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Doppler Ultrasound of the Mesenteric Vasculature

Introduction Color and pulsed Doppler evaluation of the mesenteric arteries is performed to assess for compromise of intestinal blood flow in patients presenting with chronic, unexplained, and atypical abdominal pain. This examination includes evaluation of the abdominal aorta and the celiac, superior mesenteric (SMA), and inferior mesenteric (IMA) arteries. Doppler ultrasonography can accurately assess anatomic and physiologic features that are important for patient management including vessel…

Ultrasound Assessment Following Endovascular Aortic Aneurysm Repair

Introduction Endovascular aneurysm repair (EVAR) uses endografts, also called endovascular grafts, covered stent-grafts, or transluminally placed endovascular grafts to isolate an aortic aneurysm from the circulation. EVAR is preferred to open abdominal aortic aneurysm (AAA) repair. Patients undergoing EVAR will probably require routine, lifelong follow-up, and imaging surveillance. Frequent assessment and objective follow-up are critical following EVAR. Color Doppler ultrasound has been used for aortic endovascular…

Ultrasound Assessment of the Abdominal Aorta

Introduction The abdominal aorta is the continuation of the thoracic aorta and the major conduit artery distributing blood to the abdominal organs and then to the lower extremities. Pathologic processes that affect the abdominal aorta, in order of decreasing incidence, are: atherosclerosis (mostly nonhemodynamic significant plaques), abdominal aortic aneurysm formation, various forms of vasculitis, genetically based degenerative disease of the aortic wall, and the extension of…

Anatomy and Normal Doppler Signatures of Abdominal Vessels

Introduction In this chapter, we will review the normal anatomy and sonographic appearances of the abdominal arteries and veins. We will include an analysis of the normal Doppler waveforms of the abdominal vessels. Of course, recognition of the normal vascular anatomy is essential for the investigation of any abdominal vascular problem. Doppler studies of the abdominal vessels demand an understanding of normal and abnormal blood flow…

Nonvascular Findings Encountered During Venous Sonography

Introduction It is not unusual to encounter incidental findings during the course of a venous examination. Some of these findings may be the cause of extremity pain or swelling apart from venous disease. Recognition of the sonographic features associated with different pathologies is critical for accurate diagnosis. Many of these diagnoses are common, such as edema, hematoma, lymph nodes, or popliteal (Baker) cysts. Other findings are…

Ultrasound Diagnosis of Venous Insufficiency

Introduction The term chronic venous insufficiency most often refers to venous valvular incompetence in the superficial, deep, perforating and/or the nonsaphenous veins of the lower limb. Although it is thought to affect approximately 40% to 50% of the population and has been widely researched, this form of venous dysfunction remains poorly understood. Incompetence of the vein valves permits retrograde flow (reflux), which is opposite to the…

Risk Factors and the Role of Ultrasound in the Management of Extremity Venous Disease

Introduction Duplex sonography can effectively diagnose the presence of acute and chronic venous thrombosis in the extremity veins. Most commonly, duplex sonography is used when acute deep vein thrombosis is suspected, but it is also a reliable means for determining the extent of chronic venous disease and the accompanying physiologic alterations in venous hemodynamics. Performance of the diagnostic venous ultrasound examination is also tailored to current…

Ultrasound Diagnosis of Lower Extremity Venous Thrombosis

Introduction Venous thromboembolism is a major health problem, especially among the hospitalized, the elderly, and the patient with underlying hypercoagulable states such as cancer. Deep vein thrombosis (DVT), defined as coagulated blood or clot within a deep vein of the body, constitutes one end of the spectrum of venous thromboembolism. The other end of the spectrum, and a direct sequela of both upper and lower extremity…

Extremity Venous Anatomy and Technique for Ultrasound Examination

Introduction Venous structure and function are different from their arterial counterparts. Although they both transport blood, the veins perform multiple different functions. Their tasks include transporting blood back to the heart, helping to regulate body temperature and cardiac output, and providing a storage reservoir for blood. Depending on certain conditions, the storage of blood can induce the formation of clots and the possibility of venous thrombosis…

Ultrasound in the Assessment and Management of Arterial Emergencies

Introduction Vascular emergencies require a prompt diagnosis, as timely intervention is often critically important. Delays of minutes or hours in diagnosis may mean the difference between life and death, or limb preservation or loss. Ultrasound plays an important role in the diagnosis and management of many vascular emergencies. Because vascular emergencies are often managed nonoperatively, an accurate diagnosis is needed for appropriate patient triage. Several diagnostic…

Ultrasound Assessment During and After Carotid and Peripheral Interventions

Introduction Noninvasive imaging during and following carotid artery and peripheral arterial interventions can improve procedural and patient outcomes. Duplex ultrasound imaging alone or in conjunction with extremity systolic blood pressure measurements provides accurate diagnostic information sufficient to identify technical problems and occlusive lesions that can occur following open surgical procedures and endovascular therapy. Color and pulsed Doppler imaging can be performed during interventions with the goal…

Ultrasound Assessment of Lower Extremity Arteries

Introduction Noninvasive testing for lower extremity arterial disease provides objective information that can be combined with the clinical history and physical examination to serve as the basis for decisions regarding further evaluation and treatment. One of the most critical decisions relates to whether a patient requires therapeutic intervention and should undergo additional imaging studies. Catheter contrast arteriography has historically been the definitive examination for lower extremity…

Ultrasound Evaluation Before and After Hemodialysis Access

Introduction Doppler ultrasound is extremely useful in the evaluation of the many problems facing the hemodialysis patient. It is a noninvasive technique that demonstrates vascular detail without the risk of phlebitis or contrast reaction associated with contrast venography. Current Dialysis Outcome Quality Initiative (DOQI) guidelines encourage the placement of arteriovenous fistulas (AVFs) rather than grafts because of their greater longevity and decreased incidence of infection. Detailed…

Assessment of Upper Extremity Arterial Disease

Introduction The upper extremity arterial system requires a different diagnostic approach than that used in the lower extremity. Although progression of focal atherosclerosis or acute arterial emboli are almost always the cause of symptomatic disease in the lower extremity, upper extremity arterial disease is more complex. Mechanical compression in the thoracic outlet region, vasospasm of the digital arteries, trauma-related thrombi in the hand or wrist, arteritis,…

Physiologic Testing of Lower Extremity Arterial Disease

Introduction Atherosclerosis of the peripheral arteries is recognized as a major cause of death and disability. It has been estimated that at least 8 million people in the United States have stenosis or occlusion of one or more of their lower limb arteries. Of this group, approximately 4 million are symptomatic, while a similar number of individuals have asymptomatic disease and are at future risk for…

Anatomy of the Upper and Lower Extremity Arteries

Introduction A solid familiarity of the anatomy of the upper and lower extremity arteries is required for the evaluation of arterial disease. This chapter provides an overview of the upper and lower extremity arterial anatomy. Normal anatomy, common variants, and major collateral routes are depicted by representative arteriograms and illustrations and supplemented with computed tomography (CT) and magnetic resonance (MR) angiography. Noninvasive imaging is the preferred…

Ultrasound Assessment of the Intracranial Arteries

Introduction In 1965, Miyazaki and Kato first reported the use of continuous-wave Doppler ultrasound for the assessment of extracranial cerebral vessels. Despite its rapid development in other medical fields, this technique was not applied to the intracranial vessels until 1982. At that time, Aaslid and colleagues developed a transcranial Doppler (TCD) device with a pulsed-wave sound emission of 2 MHz that could successfully penetrate the skull and…

Ultrasound Assessment of the Vertebral Arteries

Introduction The association of carotid atherosclerotic disease with symptomatic cerebrovascular disease (i.e., transient ischemic attacks), amaurosis fugax, and stroke, is well established. Carotid endarterectomy and stenting are also effective in managing symptomatic patients with high-grade carotid stenosis. However, the implications and management of vertebral artery disease are less well studied. There are no consistently successful diagnostic or management techniques for vertebral artery disease. Patients often present…

How to Assess Difficult and Uncommon Carotid Cases

Introduction Carotid occlusion is one of the most important diagnoses that is made in the vascular laboratory or imaging department. The distinction between carotid occlusion and near-total occlusion or high-grade stenosis is critical as treatment options remain available for severe carotid stenosis. In this chapter, we discuss the significant findings associated with carotid occlusion and provide insights to distinguish between high-grade stenosis and occlusion. We also…

Ultrasound Assessment of Carotid Stenosis

Introduction The identification of carotid artery stenosis is the most common indication for cerebrovascular ultrasound. The majority of stenotic lesions occur in the proximal internal carotid artery (ICA); however, other sites of involvement in the carotid system may or may not contribute to significant neurologic events. Up to 30% of all major hemispheric events (stroke, transient ischemic attacks [TIA], or amaurosis fugax) are thought to originate…