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Role of doppler in acute vasclar emergencies dr.rupa

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Role of Doppler in Acute Vascular Emergencies

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Role of doppler in acute vasclar emergencies dr.rupa

  1. 1. Dr Rupa Ananthasivan DMRD, DNB, FRCR Consultant Radiologist, Manipal Hospital, Bangalore.
  2. 2. Vascular Emergencies  Prompt diagnoses  Accurate Diagnoses  Timely Intervention  Quick Decision Making-Surgical vs Non-surgical
  3. 3. Tools Available  Ultrasound with Doppler  CT Angiography  MR Angiography  DSA  Intravascular USG
  4. 4. Advantages  Readily Available  Portable  Speed  Temporal Resolution  Spatial Resolution
  5. 5. Disadvantages  Acoustic Impedance-Air, Bone, Soft tissue, Bowel, tissue oedema,  Field of View  Operator Dependence
  6. 6. Do’s and Don’ts !!!  Do NO Harm !!!  Be Prepared.  Be Meticulous but quick.  Know your Patient –and your machine .
  7. 7. Acute Vascular Emergencies  Ruptured Aortic Aneurysm  Acute Carotid Thromboses  Carotid and Vertebral dissection  Pseudo-Aneurysm  Acute Limb Ischemia  Graft Failure
  8. 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. 9. Propensity to Rupture  F > M  > 6 cm  Increase in size > 5 mm / year (vs 2-3 mm/yr)
  10. 10. Ruptured Aortic Aneurysm  Sensitivity= 98 %  Specificity=95 % ( Setting of Abdominal Pain and Haemodynamic Instability)
  11. 11. Findings  Crescent of Intramural Hemorrhage  Para- Aortic Haematoma  Retroperitoneal Haematoma  Haemoperitoeum
  12. 12. Acute Carotid Thrombosis  Complication of endarterectomy/ stenting  Acute progression of Carotid stenosis “ Culprit” lesion in an acute stroke
  13. 13. 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
  14. 14. Thump Flow
  15. 15. Acute Carotid Thrombosis-  Thump flow proximally  No flow in the ICA  Low resistance flow in the ECA
  16. 16. Free Floating Thrombus  Broad Base towards vessel wall  Tongue like projection  Oscillation with blood flow
  17. 17. Carotid Dissection  Due to hemorrhage into the intima with extension into sub-intimal and sub-adventitial layers  Type A Dissection of Aortic Arch
  18. 18. Carotid Dissection  Ehler-Danlos Syndrome  FMD  Idiopathic  Trauma- Hyper-extension, Penetrating  Iatrogenic-Following Catheterization
  19. 19. Presentation  Often delayed  Neck pain, headache  Tinnitus  Focal neurological defects  Horners Syndrome  Blindness
  20. 20. Dissections  20% strokes in young patients  2.5% strokes in older patients
  21. 21. Carotid Dissection  Intra-cranial- Rare-75% mortality -20-30 yrs  Extra-cranial- Subtle Symptoms-40yrs Commonly - proximal ICA just distal to bifurcation
  22. 22. Extra- cranial Carotid Dissection  Patent Carotid Bifurcation  Tapering of the proximal ICA  Distal ICA stenosis /occlusion  Intimal Flap  Thrombosed False Lumen bulging out
  23. 23. Carotid Dissection  High resistance , Low velocity flow in Carotid artery  If False lumen patent – low velocity to and fro flow
  24. 24. Carotid Dissection Courtsey-Dr Ullas V Acharya
  25. 25. Vertebral Dissection  Occlusion  Dampened Flow  Reverse flow
  26. 26. Accuracy  Cervical Carotid artery=70 %  Vertebral Artery=75-86%
  27. 27. Pseudo Aneurysm  Contained Rupture of a blood Vessel  Absence of three layers  Causes Iatrogenic- Catheterization, Post-Surgical following Anastomosis, Arterial Repair  Penetrating Trauma
  28. 28. Femoral Pseudo-aneurym  O.2 % of diagnostic angios  8% 0f Interventional procedures  CFA > EIA> SFA> DFA
  29. 29. Femoral Pseudo-Aneurysm  Incidence=7-9 % > Size of Catheter, >Length of procedure, >Use of anti-coagulants, >Obesity, >Hypertension
  30. 30. Femoral Pseudo-aneurysm  Often 1-10 days post-procedure  Swelling in Groin  Pulsatile mass  Thrill
  31. 31. 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
  32. 32. Femoral Pseudoaneurysm  Swirling pattern within pseudo-aneurysm-----Yin- Yang  To and Fro flow in the neck  Rarely only neck show flow
  33. 33. 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
  34. 34. 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
  35. 35. Haemotoma  Initially Echogenic / hypo-echoic well/ill defined area  Later becomes more well-defined and anechoic  Initial scan –exact measurements and even skin marking
  36. 36. 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
  37. 37. Acute Interventions  Limb Saving-Embolectomy, Bypass, Thrombolysis  Life Saving- Amputation
  38. 38. Acute Limb Ischemia  Gray Scale  Colour Doppler  Spectral Tracing
  39. 39. Acute Limb Ischemia  Case 1--- Gangrene left Foot  Case 2- Acute Pain Right hand, Impending Gangrene  Case 3- Gangrene right Thumb
  40. 40. Left Superficial Femoral Artery-1
  41. 41. Brachial Artery – Case 2
  42. 42. Acute Limb Ischemia  Acute Thrombosis - hetero-echoic/ hypoechoic  Expansion of Vessel  Retrograde Propagation  Use Accompanying veins to track artey  Identify reconstituted area
  43. 43. Acute Limb Ischaemia  Upstream- High Resistance, Biphasic, Reversed Diastolic  Downstream-Monophasic, Low resistance, Decreased Velocity
  44. 44. Case 2- Impending Gangrene-Right Hand
  45. 45. Case 2
  46. 46. Case 1- Gangrene Left Foot
  47. 47. Case 3- Gangrene Left Thumb
  48. 48. Case 1- Left Foot Gangrene Leg arteries
  49. 49. Case 2- Impending Gangrene-Right Hand
  50. 50. Case 3- Gangrene Left Thumb
  51. 51. 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
  52. 52. Case 2- Acute Subclavian Occlusion
  53. 53. Failed Inguino Bypass Graft  > 1 month ---------Surgical technique  1month-2 years---Fibrio-intimal Hyperplasia  > 2 years-------------Atherosclerosis
  54. 54. Bypass Graft Failure  Graft thrombosis  Absent Flow  Poor flow in run –off vessels
  55. 55. Impending Failure  Low flow velocity within the graft  Average velocity < 45 cm/sec  Interval decrease in ankle- brachial index
  56. 56. -Alert -Quick -Accurate -Calm The Eyes do not see what the mind does not know !!!!
  57. 57. Dr Pramesh Reddy Mr. Mahesh Mahadev
  58. 58. Carotid Stenosis  Candidates for Acute Carotid Endarterectomy / Acute Carotid Stenting  Cresendo TIA  Stroke In Evaluation  Fluctuating defficiets  Free floating thrombosis
  59. 59. Intra-operative USG  Intimal flaps  Ulcerative plaques  Retained Thrombi
  60. 60. Acute Limb Ischaemia  ? Segmental Pressure Gradients  Entire limb artery Examination
  61. 61. AVF (Graft ) Thrombosis  Loss of thrill  Inability to dialyze  Swelling  Usually Venous portion
  62. 62. Other Complications  A-V Shunting through unligated veins  Anastomotic Pseudoaneurysm  Perigraft Abcess

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