Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Note: A dissecting aneurysm may occur without luminal enlargement.
– False aneurysm (“pulsating hematoma”; see above)
– Arteriovenous fistula without luminal enlargement; see above
x
Sonographic criteria:
– Circumscribed or diffuse dilatation (aorta i30 mm)
– Atherosclerotic plaques (see p. 203)
– Thrombi
ab
Fig. 265a, b a Serpentine aneurysm (cursors, AN) arising from a normal-sized
aorta (AO) and forming a largely asymmetrical series of dilatations. b CDS
appearance of a typical small, asymmetrical anterior wall protrusion (arrow)
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
a
Fig. 266a, b Dissecting aneurysm. a Intraluminal echogenic intima (arrows). b TEE
demonstrates the intimal flap in the aortic lumen of the thoracic aorta, longitudinal
scan
ab c
Fig. 267a–c “Aneurysmosis” involving all of the infradiaphragmatic aorta with
ectasia, thromboses, and apparent intimal dissection (prebifurcation, cranial?)
with a thin flap (arrow) extending into the gallbladder bed.
b
199
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
Fig. 268 Aneurysm (AN) of the right
renal artery (RA) posterior to the vena
cava (VC)
Displacement, Compression, and Infiltration
..............................................................................................................
n
Benign masses (such as cyst or abscess ) : These lesions tend to displace arteries
rather than compress them. Infiltration does not occur.
n
Malignant masses (such as malignant lymphoma and carcinoma, Figs. 269, 270):
Lymphomas tend to displace and compress vessels, whereas carcinomas infiltrate
them.
Fig. 269 High-grade non-Hodgkin
lymphoma of the pancreas (T) causing
convex displacement and slight compression of the splenic artery. CDS
shows no turbulence, indicating a small
stenosis. AO = aorta
Fig. 270 Inoperable
pancreatic carcinoma (T)
infiltrating the celiac
trunk. CDS and spectral
analysis show irregular
vascular calibers and
increased flow velocities
i 240 cm/s.
ST = stomach, AO = aorta
200
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Overview: Classification of Changes by Location (Table 32):
..............................................................................................................
Table 32.Classification of sonographic findings by location
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Wall changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hypoechoic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Thrombotic plaques (p. 201)
Luminal changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hypoechoic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Embolus (p. 203)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Echogenic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Atherosclerotic plaques (p. 201)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Echogenic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Intimal flap, prosthesis (p. 205)
Thrombus (p. 204) Protuberant calcifying plaques (p. 205)
Floating thrombi (p. 204)
Combined changes (involving the lumen and wall)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Malignant
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Metastases (p. 205)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Benign
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Retroperitoneal fibrosis (p. 205)
Lymphoma (p. 205) Abscess (p. 206)
Periprosthetic infection, anastomotic leak (p. 206)
Hypoechoic Wall Changes
..............................................................................................................
n
Atheromatous plaques (see Figs. 261 and 263, pp. 197 and 198).
n
Hypoechoic, protuberant intraluminal platelet thrombi (Figs. 271 and 272):
x
Sessile or pedunculated, occasionally laminar
x
Rarely with an echogenic cap, sometimes with associated intimal dissection.
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
Fig. 271 Protuberant intraluminal
atheromatous plaques (arrows) with
echogenic atherosclerotic wall thickening of the descending aorta (AO).
TEE was used to locate the source of
the emboli
201
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
ab
Fig. 272a, b Hypoechoic, protuberant thrombotic lesion filling the arterial lumen.
a Protuberant atherosclerotic lesion of the aorta (AO) extending into the right iliac
artery (IA). All criteria of atherosclerosis are present: significant bandlike wall
thickening, luminal narrowing (arrows), a hypoechoic thrombus with a fibrous cap,
a broad band of calcification, and an acoustic shadow (S). b Occlusion of the
mesenteric artery (MA): absence of arterial flow. TR = thrombus
Echogenic or Sonodense Wall Changes
..............................................................................................................
n
Echogenic wall thickening, complex wall thickening:
x
Hypoechoic = thrombus (see Fig. 272a), p. 202)
x
Echogenic = calcification (see Fig. 263c), p. 198)
n
Atherosclerotic plaques (Fig. 273): see classification in Table 33.
x
Simple plaques (Fig. 274):
– Segmental or circumscribed wall thickening with no acoustic shadowing
– Echogenic plaques without calcification, cholesterol deposits
x
Complicated plaques (Fig. 273; see also Fig. 272a, p. 202, and Fig. 271, p. 201):
atherosclerotic plaques with calcification, necrosis, and ulceration (the latter
cannot be detected sonographically)
ab
Fig. 273a, b Atherosclerosis. a Simple atherosclerotic lesion of the aorta (AO).
Atheromatosis: echogenic wall thickening without an acoustic shadow (arrows).
b Complicate d atherosclerotic lesion: slightly raised, echogenic lesion with
significant wall thickening (arrows), a faint bandlike acoustic shadow, and irregular
vessel contours
202
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 274a, b Mönckeberg sclerosis. a B-mode image shows diffuse, patchy wall
calcification (arrows) of the popliteal artery (PA) with partial acoustic shadowing
(S). b CDS shows no significant stenosis. The patient had diabetic neuropathy with
pedal ulcers and a palpable pedal pulse, Doppler pressure i300 mmHg
Table 33.Classification of atherosclerotic plaques
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Simple plaques Complicated plaques
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Focal echogenic intimal thickening
Smooth protuberances I 5 mm Protuberances extending i 5 mm into the lumen
n
Mönckeberg sclerosis (Fig. 274): diffuse calcific deposits in the media of diabetic
patients with symptoms of arterial occlusive disease (AOD) (severe occlusive
symptoms are rare, however)
x
Extremely high Doppler wedge pressures
x
Diffuse, patchy echogenic wall calcification, sometimes with acoustic shadowing
Hypoechoic Luminal Changes
..............................................................................................................
n
Embolus (Fig. 275): hypoechoic intraluminal flow void. B-mode imaging is less
rewarding than CDS, which can confirm the absence of flow.
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Irregular surface, disruptions, ulceration,
(secondary) calcifications
– Sessile
– Pedunculated (prone to embolism)
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
Fig. 275 Embolus (arrow) straddling
the bifurcation of the aorta (AO). The
patient presented clinically with acute
bilateral leg pain and other manifestations of AOD
203
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
7
7
7
n
Conglutination thrombus in aortic or arterial aneurysms (Figs. 276–278):
x
Eccentric or concentric, weakly echogenic material on the vessel wall
x
Frequent lamination
x
Doppler ultrasound occasionally shows an anechoic crescent devoid of flow
n
Floating thrombi, “erythrocyte noise ”: pulsating, swaying hypoechoic structure
or erythrocyte clusters in slow-moving flow
Arteries and Veins
Arteries and Veins
Arteries and Veins
Fig. 276 Circumferential thrombus
(arrows) in an aortic aneurysm. CDS
shows color reversal indicating zones of
turbulent flow
Fig. 277 Saccular aneurysm: circumferential thrombosis surrounding a central residual lumen (AO). The aneurysm
occludes the proximal portions of the
iliac arteries (IA). Typical features:
size i 10 cm, balloon-like shape
ab
Fig. 278a, b Conglutination thrombi in a saccu lar aortic aneurysm, visualized in
upper abdominal transverse scans. a Peripheral laminar thrombus (TH) and a
central whorled thrombus (arrows) with a crescent-shaped, anechoic residual
lumen. Both are enveloped by an echogenic intimal flap (dissecting aneurysm).
b Scan at a more distal level shows a regular central aortic lumen (AO) alternately
surrounded by conglutination thrombi and serosanguinous fluid (S)
204
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Echogenic Luminal Changes
..............................................................................................................
n
Intimal flap (see Fig. 266, p. 199): e.g., in aortic dissection
x
Hyperechoic intraluminal membrane, usually showing an irregular thickness
n
Intraluminal aortic prosthesis (Fig. 279): smooth, echogenic intraluminal mem-
brane
n
Protuberant echogenic plaques (see Fig. 263), p. 198; Fig. 274, p. 203)
ab
Fig. 279a, b Intraluminal aortic prosthesis and intimal dissection. a Intraluminal
aortic prosthesis : fine, echogenic intraluminal walls of the prosthesis in an aortic
aneurysm (41 mm in diameter, cursors). b Almost identical intraluminal structure
as in a. The entry tear of the intimal dissection (arrows) can be identified
Paravascular Changes
..............................................................................................................
n
Metastases, lymphadenopathy (Fig. 280; see also Fig. 658, p. 438; Fig. 152, p. 112;
Fig.
158, p. 115):
x
Well-defined masses or bulky, hypoechoic perivascular structures
x
Increased aorto-spinal distance (i 5 mm)
x
Sandwich sign (vessel “sandwiched” between conglomerates of lymph nodes,
suggestive of high-grade lymphoma)
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
ab
Fig. 280a, b Differentiation of an aortic aneurysm from a perivascular tumor.
a Initial sonographic diagnosis: dissecting aortic aneurysm (AO, AO A) with an
intimal flap (IN). b CDS : anechoic lymphomatous tumors (T) around the aorta and
vena cava (AO, VC). The renal artery (RA) passes through the tumor masses.
Diagnosis: high-grade NHL
n
Retroperitoneal fibrosis:
x
Diffuse, hypoechoic periaortic structures
x
Usually associated with urinary tract obstruction
205
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
7
7
7
n
Para-aortic or para-arterial abscess (see also Figs. 124 and 125, p. 95): hypoe-
choic mass with irregular margins:
x
Hypoechoic, irregular, bandlike structure surrounding the prosthesis
x
Perivascular mass in the area of the prosthetic anastomosis, often manifesting
arterial flow (by CDS).
n
Graff infection, suture-line breakdown (Fig. 281a, b): hypoechoic mass sur-
rounding the graff
Arteries and Veins
Arteries and Veins
Arteries and Veins
ab
Fig. 281a, b Postoperative perivascular masses. a Infected popliteal
prosthesis (arrows, AP) with extensive
purulent material (cursors).
The patient presented clinically with unexplained fever and suspected popliteal
vein thrombosis. b Anastomotic leak (arrow) with a perivascular hematoma (H)
following the insertion of an aortofemoral vascular prosthesis (P). FA = femoral
artery
Interpretation and Further Testing
..............................................................................................................
n
Sonography: Ultrasound is a mainstay for the initial evaluation and postoperative
follow-up of all aortic and arterial diseases.
x
Classification of an aneurysm: according to type (true, dissecting, or false)
x
Preoperative planning : Ultrasound aids in treatment planning based on the location (infrarenal, iliac) of an aortic aneurysm. The sonographic criteria for extension above the origins of the renal arteries are as follows :
– Direct visualization of the renal artery arising from the aortic aneurysm
– Superior border of the aneurysm is above a horizontal line drawn from the
renal hilum to the aorta
ab
Fig. 282a, b Sonographic determination of intima-media thickness in the
common carotid artery. a Normal finding (0.6 mm) in a healthy 68-year-old man.
b Intima-media thickness of 1.4 mm in a 53-year-old man with a high
cardiovascular risk profile
206
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
– The distance from the aortic bifurcation to the superior border of the aneu-
rysm is i 9.5 cm.
n
New sonographic techniques: US contrast agents have been shown to be highly
effective in enhancing Doppler signals within the macrovasculature and the
microvasculature. Contrast enhanced US increases the accuracy in detection of
abnormalities in periferal arteries and portal veins.
n
Angiography: Other tests can reduce the need for conventional angiography but
cannot replace it. Angiograms are essential for preoperative planning and for
selecting the optimum therapeutic procedure (catheter-directed thrombolysis
and atherectomy, stent graft, patch graft, operative thrombectomy).
n
MR angiography: has already become a standard tool for surveying the arterial
vascular system to verify stenoses, especially in patients who are poor candidates
for conventional angiography (renal failure). It can be particularly useful as a
prelude to interventional angiography.
x
Advantages: less contrast medium, single sitting
x
Disadvantage: cannot adequately quantify stenoses
n
CT: Better than sonography for defining the extent of supradiaphragmatic aortic
aneurysms and evaluating the dissection
n
Echocardiography: establishes the presence of a dissecting aneurysm (e.g., involv-
ing the aortic root)
n
Staged protocol for art erial studies:
x
History (e.g., walking distance)
x
Vascular physical examination (palpable pulses, stress tests)
x
Doppler examination with pressure measurement, determination of Doppler
index
x
Duplex or CDS
x
Angiography
n
Procedure for aortic aneurysms:
x
Diagnostic workup: begins with ultrasound, which may be done as a routine
examination (lesion detected incidentally), a selective examination for suspected disease, or an emergency examination (dissection, perforation)
x
Follow-ups: at 3–6 month intervals for aneurysms that do not require acute
operative treatment (see below)
x
Indications for operative treatment:
– Aneurysm size is the main criterion. Aneurysms I 5 cm have a 5–15 % like-
lihood of rupture within 5 years, and this increases to 75 % for aneurysms
i 8 cm. Aneurysms i 5 cm should therefore be treated operatively.
– Another criterion is the sonographically determined growth rate. Aneurysms
i 5 cm grow by an average of 0.6 cm in 1 year, whereas smaller aneurysms
grow by 0.2 cm. Rapid growth noted at 4–6-month ultrasound follow-ups
strengthens the indication for early operative treatment.
7
7
7
Arteries and Veins
Arteries and Veins
Arteries and Veins
207
7.3 Vena Cava and Peripheral Veins
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
7
7
7
7.3 Vena Cava and Peripheral Veins
Overview (Table 34):
..............................................................................................................
Table 34.Venous changes detectable by ultrasound
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Luminal/flow changes Intraluminal
Arteries and Veins
Arteries and Veins
Arteries and Veins
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Congestion (p. 208)
Vascular collapse (p. 209) Tumor invasion
Chronic venous insufficiency, saphenous
incompetence (p. 209)
Luminal Changes
..............................................................................................................
n
Congestion (Figs. 283 and 284): e.g., vena cava–hepatic venous congestion; sys-
temic venous congestion
x
Clinical signs: unexplained dyspnea or lower-extremity edema. In this case a
simple evaluation of the vena cava can quickly furnish a diagnosis or exclude
heart failure. Severe vena caval congestion due to right-sided heart failure is
characterized by pulsatile reflux into the hepatic veins.
x
Sonographic criteria:
– Vascular dilatation: vena cava i 20 mm, hepatic veins i 10 mm. This is not a
definitive sign.
– Decreased inspiratory collapse. This is a reliable sign.
– Decreased compressibility
– Absence of soft double pulsations
changes
yyyyyyyyyyyyyyyyyyyyy
Thrombosis
(p. 210)
(p. 210)
Associated
effects
yyyyyyyyyyyyyyyyyyyyy
Compression
(p. 211)
Infiltration
(pp. 211 and
449)
Anomalies
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Duplication of the vena cava
or popliteal vein (p. 211)
ab
Fig. 283a, b Vena caval congestion (cursors) due to right heart failure. The caliber
of the vena cava does not expand during inspiration (paramedian upper abdominal
longitudinal scan). a Expiration, b inspiration
208