Role of Doppler in Acute Vascular Emergencies

1. Dr Rupa Ananthasivan DMRD, DNB, FRCR
Consultant Radiologist, Manipal Hospital, Bangalore.

2. Vascular Emergencies
 Prompt diagnoses
 Accurate Diagnoses
 Timely Intervention
 Quick Decision Making-Surgical vs Non-surgical

3. Tools Available
 Ultrasound with Doppler
 CT Angiography
 MR Angiography
 DSA
 Intravascular USG

4. Advantages
 Readily Available
 Portable
 Speed
 Temporal Resolution
 Spatial Resolution

5. Disadvantages
 Acoustic Impedance-Air, Bone, Soft tissue, Bowel,
tissue oedema,
 Field of View
 Operator Dependence

6. Do’s and Don’ts !!!
 Do NO Harm !!!
 Be Prepared.
 Be Meticulous but quick.
 Know your Patient –and your machine .

7. Acute Vascular Emergencies
 Ruptured Aortic Aneurysm
 Acute Carotid Thromboses
 Carotid and Vertebral dissection
 Pseudo-Aneurysm
 Acute Limb Ischemia
 Graft Failure

8. Ruptured Aortic Aneurysm
 Fatal if untreated. 50 % may not reach hospital alive
 Surgery=30-65 % survival rate
 Classical Triad- Back Pain, Hypotention, Pulsatile
Abdominal Mass- 50%
 Timely Intervention is the key

9. Propensity to Rupture
 F > M
 > 6 cm
 Increase in size > 5 mm / year (vs 2-3 mm/yr)

10. Ruptured Aortic Aneurysm
 Sensitivity= 98 %
 Specificity=95 %
( Setting of Abdominal Pain and Haemodynamic
Instability)

13. Findings
 Crescent of Intramural Hemorrhage
 Para- Aortic Haematoma
 Retroperitoneal Haematoma
 Haemoperitoeum

14. Acute Carotid Thrombosis
 Complication of endarterectomy/ stenting
 Acute progression of Carotid stenosis
“ Culprit” lesion in an acute stroke

18. Acute Carotid Thrombosis
 Thrombus is heterogenously echogenic/ or very
hypo-echoic
 Calibre of vessel is normal or expanded
 Pulsations in vessel wall but NO FLOW
 Swirling, sludge like flow in Carotid bulb

21. Thump Flow

22. Acute Carotid Thrombosis-
 Thump flow proximally
 No flow in the ICA
 Low resistance flow in the ECA

23. Free Floating Thrombus
 Broad Base towards vessel wall
 Tongue like projection
 Oscillation with blood flow

24. Carotid Dissection
 Due to hemorrhage into the intima with extension into
sub-intimal and sub-adventitial layers
 Type A Dissection of Aortic Arch

25. Carotid Dissection
 Ehler-Danlos Syndrome
 FMD
 Idiopathic
 Trauma- Hyper-extension, Penetrating
 Iatrogenic-Following Catheterization

26. Presentation
 Often delayed
 Neck pain, headache
 Tinnitus
 Focal neurological defects
 Horners Syndrome
 Blindness

27. Dissections
 20% strokes in young patients
 2.5% strokes in older patients

28. Carotid Dissection
 Intra-cranial- Rare-75% mortality -20-30 yrs
 Extra-cranial- Subtle Symptoms-40yrs
Commonly - proximal ICA just distal to bifurcation

29. Extra- cranial Carotid Dissection
 Patent Carotid Bifurcation
 Tapering of the proximal ICA
 Distal ICA stenosis /occlusion
 Intimal Flap
 Thrombosed False
Lumen bulging out

30. Carotid Dissection
 High resistance , Low velocity flow in Carotid artery
 If False lumen patent –
low velocity to and fro flow

31. Carotid Dissection
Courtsey-Dr Ullas V Acharya

32. Vertebral Dissection
 Occlusion
 Dampened Flow
 Reverse flow

37. Accuracy
 Cervical Carotid artery=70 %
 Vertebral Artery=75-86%

38. Pseudo Aneurysm
 Contained Rupture of a blood Vessel
 Absence of three layers
 Causes
Iatrogenic- Catheterization, Post-Surgical following
Anastomosis, Arterial Repair
 Penetrating Trauma

39. Femoral Pseudo-aneurym
 O.2 % of diagnostic angios
 8% 0f Interventional procedures
 CFA > EIA> SFA> DFA

40. Femoral Pseudo-Aneurysm
 Incidence=7-9 %
> Size of Catheter,
>Length of procedure,
>Use of anti-coagulants,
>Obesity,
>Hypertension

41. Femoral Pseudo-aneurysm
 Often 1-10 days post-procedure
 Swelling in Groin
 Pulsatile mass
 Thrill

45. Femoral Pseudoaneurysm
 “Bubble like Anechoic /hypoechoic structure attached
to artery
 Cylindrical neck along needle track
 Bubble measures 1-3 cms
 Neck variable length and width

46. Femoral Pseudoaneurysm
 Swirling pattern within pseudo-aneurysm-----Yin-
Yang
 To and Fro flow in the neck
 Rarely only neck show flow

55. Treatment
 USG guided compression- Upto 75% success
> Ihr compression
> painful
Thrombin Injection-99% success
0.5-1ml 0f 1000 IU/ml
Inadvertent injection into artery/vein very rare

56. Hematoma
 Natural Outcome of Vascular Disruption
 Due to poor Compression
 Ecchymosis and Discomfort
 Rarely large compressing the artery and nerve roots
 Retroperitoneal and pelvic extention, Compartment
syndrome

60. Haemotoma
 Initially Echogenic / hypo-echoic well/ill defined area
 Later becomes more well-defined and anechoic
 Initial scan –exact measurements and even skin
marking

61. Acute Limb Ischemia
 Embolic- Heart, Aorta, Iliac arteries, Aneurysm
 Thrombosis over an existing plaque
Symptom onset is usually rapid-severe claudication, rest
pain, sensory loss and colour change
Depends upon collaterals

62. Acute Interventions
 Limb Saving-Embolectomy, Bypass, Thrombolysis
 Life Saving- Amputation

63. Acute Limb Ischemia
 Gray Scale
 Colour Doppler
 Spectral Tracing

64. Acute Limb Ischemia
 Case 1--- Gangrene left Foot
 Case 2- Acute Pain Right hand, Impending Gangrene
 Case 3- Gangrene right Thumb

65. Left Superficial Femoral Artery-1

68. Brachial Artery – Case 2

69. Acute Limb Ischemia
 Acute Thrombosis - hetero-echoic/ hypoechoic
 Expansion of Vessel
 Retrograde Propagation
 Use Accompanying veins to track artey
 Identify reconstituted area

70. Acute Limb Ischaemia
 Upstream- High Resistance, Biphasic, Reversed
Diastolic
 Downstream-Monophasic, Low resistance, Decreased
Velocity

71. Case 2-
Impending
Gangrene-Right
Hand

72. Case 2

73. Case 1- Gangrene
Left Foot

74. Case 3- Gangrene Left
Thumb

75. Case 1- Left
Foot
Gangrene
Leg arteries

77. Case 2- Impending
Gangrene-Right
Hand

78. Case 3-
Gangrene
Left Thumb

79. Diagnoses
 Case 1- Superficial Femoral artery occlusion due to
atherosclerosis with significant small vessel disease
 Case 2- Acute Distal Subclavian Artery Occlusion
 Case 3-Significant Radial Artery Compromise

80. Case 2- Acute
Subclavian
Occlusion

81. Failed Inguino Bypass Graft
 > 1 month ---------Surgical technique
 1month-2 years---Fibrio-intimal Hyperplasia
 > 2 years-------------Atherosclerosis

82. Bypass Graft Failure
 Graft thrombosis
 Absent Flow
 Poor flow in run –off vessels

85. Impending Failure
 Low flow velocity within the graft
 Average velocity < 45 cm/sec
 Interval decrease in ankle- brachial index

86. -Alert
-Quick
-Accurate
-Calm
The Eyes do not see what the
mind does not know !!!!

87. Dr Pramesh Reddy
Mr. Mahesh Mahadev

88. Carotid Stenosis
 Candidates for Acute Carotid Endarterectomy / Acute
Carotid Stenting
 Cresendo TIA
 Stroke In Evaluation
 Fluctuating defficiets
 Free floating thrombosis

89. Intra-operative USG
 Intimal flaps
 Ulcerative plaques
 Retained Thrombi

90. Acute Limb Ischaemia
 ? Segmental Pressure Gradients
 Entire limb artery Examination

95. AVF (Graft ) Thrombosis
 Loss of thrill
 Inability to dialyze
 Swelling
 Usually Venous portion

137. Other Complications
 A-V Shunting through unligated veins
 Anastomotic Pseudoaneurysm
 Perigraft Abcess