Doppler ultrasound of visceral arteries

Doppler ultrasound of visceral arteries
Samir Haffar MD
Gastroenterologist – Sonographer

Doppler ultrasound of visceral arteries
① Normal Doppler ultrasound of visceral arteries
② Doppler of proximal abdominal aorta in cardiac diseases
③ Arterial stenosis and occlusion
④ Arterial aneurysm
⑤ Arterial pseudo-aneurysm
⑥ Arteriovenous fistula
⑦ Arterial dissection
⑧ Abdominal vascular compression syndromes

① Normal Doppler ultrasound of
visceral arteries

Optimization of color and spectral Doppler
Color box Small box improved frame rate with better color resolution
Doppler gain Just below the noise level
Color scale (PRF) Low PRF more sensitive to low velocity flow
but may lead to aliasing
Beam steering Adjust to obtain satisfactory vessel angle
Sample volume Usually two thirds of vessel lumen
Wall filter Higher filter cuts out noise & slower velocity flow
Keep filter at 50–100 Hz
Focal zone Color flow optimized at level of focal zone
Bhatt S et al. Ultrasound Clin 2007;2:437–453.

Arteries scanned
• Abdominal aorta: upper & lower
• Celiac axis
• Splenic artery
• Hepatic artery
• Superior mesenteric artery (SMA)
• Inferior mesenteric artery (IMA)
• Renal arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

Aorta, celiac axis, SMA & IMA
SMA: superior mesenteric artery – IMA: inferior mesenteric artery
https://radiologykey.com/ultrasound-assessment-of-the-splanchnic-mesenteric-arteries/

All arise from anterior abdominal aorta
Celiac axis is first major branch of abdominal aorta
SMA origin is 1 – 2 cm distal to celiac axis
IMA origin is 3 – 5 cm proximal to aortic bifurcation
Aorta, celiac axis, SMA & IMA

Transducer positions for scanning AA
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Sagittal or
longitudinal
Transverse
Coronal

Normal spectral Doppler of abdominal aorta
Middle abdominal aorta
Biphasic flow pattern
Proximal abdominal aorta
Triphasic flow pattern
Antegrade systolic waveform
Early diastolic reversal
Low velocity antegrade flow
Antegrade systolic velocity
Early diastolic reversal
No antegrade diastolic flow
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.

Reverberation artefact
Longitudinal gray scale US of proximal aorta
Echogenic focus mimicking intraluminal thrombus (arrow)
Secondary to reverberation artifact
Longitudinal gray scale image of upper abdominal aorta

Duplicated aorta or duplication artifact?
Meuwly JY et al. Ultraschall Med 2011;32:233–236.
Duplication image artifact frequent in lower abdomen:
False cases of twin pregnancies
Double intra-uterine devices
Gray-scale US
Duplicated aorta
Color Doppler US
2 aortic lumen filled
with color
Tiny sliding probe to right
Only one lumen filled
with color

Normal aortic bifurcation
Transverse gray scale image Transverse color Doppler image

Normal aortic bifurcation
Longitudinal gray scale image
Longitudinal color Doppler image
Normal aortic bifurcationNormal aortic bifurcation

Normal Doppler of celiac axis
Forward flow in systole & diastole
Low-resistance flow (RI: 0.74)
Celiac axis divides into CHA & HA
Ao: aorta; IVC: inferior vena cava;
SV: splenic vein
Transverse US of celiac axis Spectral Doppler of celiac axis
RI: resistive index
https://radiologykey.com/anatomy-and-normal-doppler-signatures-of-abdominal-vessels/

CA: celiac axis – CHA: common hepatic artery – LGA: left gastric artery
White RD et al. RadioGraphics 2015;35:879–898.
Common celiac axis branching patterns
Trifurcating CA
Separate origin of
LGA from aorta
Bifurcating CA
into CHA & LGA
Quadrifurcating
of celiac axis

Normal hepatic artery waveform
Forward flow in systole & diastole
Low-resistance spectral pattern (RI: 0.67)
RI: resistive index
Swart J et al. Ultrasound Clin 2007;2:355–375.

Common variations of hepatic artery
“replaced” right hepatic
artery originating from
SMA
Common hepatic artery
originating from CA
Quadrifurcating CA
Separate left & right
hepatic artery
White RD et al. RadioGraphics 2015;35:879–898.

Right hepatic artery from SMA
Battaglia S et al. J Ultrasound 2010;13:49–56.
Common hepatic artery gives rise to GDA & LHA
Right hepatic artery originates directely from SMA
SMA
Branch of SMA
CHA
SMA
LHA
RHA
GDA

Common hepatic artery from SMA
Common hepatic artery originates
from superior mesenteric artery
SMACHA
LHARHA
SMACHA

Left hepatic artery from left gastric artery
LHA originates from LGA
Runs alongside venous ligament
LGA
LHA
CHA
RHA LHA
LGA

Normal splenic artery
Normal Doppler signal of splenic artery
PSV: 110 cm/s – EDV: 45 cm/s – RI: 0.59
Low resistance flow
PSV: peak systolic velocity – EDV: end diastolic velocity – RI: resistive index
https://radiologykey.com/anatomy-and-normal-doppler-signatures-of-abdominal-vessels/

Sagittal ultrasound of SMA
Ao: abdominal aorta
CA: celiac artery
SMA: superior mesenteric artery
Zachrisson H et al. J Med Diagn Meth 2013, 3:2.

Doppler angle for superior mesenteric artery
Doppler angle can be improved from 75° to 25°
by moving transducer distally & tilting it cranially
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

Transverse US of superior mesenteric artery
Transverse US of pancreatic body and its dorsal landmark
SMA surrounded by collar of fat (yellow arrow)
A: Aorta; P: pancreas; splenic vein: white arrow
Diagnostic ultrasound, Edited by CM Rumack, 5th edition, 2018, Elsevier

Anatomic relationships of SMA
Anterior to SMA: SV & pancreas
Posterior to SMA: aorta
Left to SMA: left renal vein
Right to SMA: Right renal vein & IVC
Surrounded by layer of echogenic fat
Revzin MV et al. Ultrasound Clin 2007;2:477–492.

Normal spectral Doppler of SMA
Sharp systolic upstroke
Variable diastolic component
Low flow, reversed flow, or both
Fasting state
High-resistance flow
Postprandial state
Low-resistance flow
Increased velocity
High diastolic velocity
Absence of reverse flow

Common origin of CA and SMA
Common origin of CA and SMA
(arrow)
Common celiac and SMA origin
Color Doppler of abdominal aorta Sagittal MRA of abdominal aorta
CA: celiac axis – MRA: magnetic resonance angiography – SMA: superior mesenteric artery

Inferior mesenteric artery
Arises 3 – 5 cm above aortic bifurcation
From left anterolateral aspect of the aorta
Transverse scan with slight pressure & moving upward from bifurcation
Scanned over length of 2 – 5 cm from its origin

Color Doppler ultrasound of normal IMA
Longitudinal view
Normal inferior mesenteric artery (arrow)
arising from anterior left lateral aspect of aorta
AO: aorta – IMA: inferior mesenteric artery

Inferior mesenteric artery and vein lying adjacent to aorta (arrows)
IMA: inferior mesenteric artery
Color Doppler ultrasound of normal IMA
Transverse view

Normal spectral Doppler of normal IMA
PSV: 150 cm/sec
Early diastolic reversed flow
Low forward diastolic flow
High resistance flow

Normal spectral Doppler of IMA
Mirk P et al. Abdom Imaging 1998;23:364–369.
High systolic peak
Early diastolic reflux
Low velocity diastolic flow
High pulsatility index: 5.46
Transverse & left sagittal
US of infrarenal aorta
IMA originates from left anterior
aspect of aorta & descends along
its left side with straight course in
its proximal portion
Doppler waveforms of IMA

Normal spectral Doppler of IMA
• Diameter: 2.8 ± 0.55 mm (1.3 – 4.3 mm)
• Pic systolic velocity: 1.41 m/s ± 0.48
• Minimal diastolic velocity: 0.10 m/s ± 0.16
• Pulsatility index: 3.49 ± 0.49 (1.60 – 6.23)
• Time-average velocity (TAV): 0.43 m/s ± 0.19
• Flow volume: 0.13 ± 0.06 L/min (0.05 – 0.29)
Study of 116 patients without splanchnic vessel pathology
Mirk P et al. Abdom Imaging 1998;23:364–369.

Aorta and renal arteries
https://radiologykey.com/ultrasound-assessment-of-the-splanchnic-mesenteric-arteries/

Anatomy of aorta and renal vessels
Lt kidney
Rt kidney
IVC Aorta
SMA
CA
LRA
LRV
RRA
RRV
CA: celiac axis – IVC: inferior vena cava – LRA: left renal artery – LRV: left renal vein
RRA: right renal artery – RRV: right renal vein – SMA: superior mesenteric artery

Number of main renal arteries
Özkan et al. Diagn Interv Radiol 2006;12:183–186.
Angiographic evaluation of 855 consecutive patients
No of vessels 1 2 3 4
Right 83% 15% 1% –
Left 86% 12% 1% 0.2%

Anatomy of main renal arteries
Japan Society of Ultrasonics in Medicine. J Med Ultrasonics 2016;43:145–162.

Branched structure of renal artery

Main renal arteries
Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.
Transverse scan with probe angulations

Norma right renal artery
Moukaddam H et al. Ultrasound Clin 2007;2:455–475.
Transverse gray scale image
Right main renal artery
Transverse color Doppler image
Right main renal artery

Normal right renal artery
Coronal image of inferior vena cava
RRA is the only vessel to course under the IVC
Often slightly indents the IVC

Longitudinal scan in left lateral decubitus
Two right renal arteries (15%)

Pre-caval right renal artery
RRA: right renal artery – IVC: inferior vena cava
Hélénon O et al. EMC-Radiologie 2005;2:367–412.
aorta
IVC
RRA

Norma left renal artery
Proximal main left renal artery Proximal main left renal artery
Color Doppler image
LRA
Gray scale image
LRA

Angle of insonation
Difficult to estimate in tortuous or curved renal artery
Correct angleIncorrect angle

Pulsed Doppler of main left renal artery
Early systolic notch
Low resistance flow (PSV 90 cm/sec)

Early systolic notch
Some normal waveforms have early systolic notch
1. Measuring to point of PSV results in prolonged acceleration time
2. Excellent negative predictive value of stenosis > 60%
Doppler of right main renal artery

Limits in visualization of main renal arteries
• Obesity
• Overlying bowel gas
• Dyspnea
• Shadowing from arterial calcifications
• Cardiac arrhythmias
• Poor angle of Doppler insonation
• Accessory renal arteries (small size)
RA: renal arteries
Expert sonographers detect 80-90% of main RA
CEUS improves success rate to 95%

Adjustment of Doppler control
Low flow settings for intra-renal arteries
• Lowest pulse repetition frequency without aliasing
• Small color box
• Greatest gain without background noise
• Lowest wall filter
• High color priority

Normal segmental & interlobar renal arteries
Normal segmental renal arteries (long arrows)
Color Doppler image of kidney
Normal interlobar renal arteries (short arrows)

Study of interlobular arteries
Perfusion study / Low PRF
Cortical perfusion

Normal pulsed Doppler waveform
Renal segmental artery
Sharp systolic upstroke
Continuous forward diastolic flow
Low resistance flow (low RI)

Measurement of resistive index
Resistive index: S – ED / S
Normal 50 – 70%
Abnormal > 80%

Measurement of acceleration time (AT)
• Length of time in second from
onset of systole to peak systole
• Normal value: < 0.07 sec (70 msec)
Acceleration time (AT) or rise time (RT)

Normal renal aortic ratio (RAR)
Left renal artery Upper abdominal aorta
PSV: 80 cm/sec PSV: 120 cm/sec
RAR: PSV of renal artery to aorta (80/120 = 0.67)
Normal value ˂ 3

Normal spectral Doppler of renal arteries
• PSV of renal artery at origin: < 180 cm/s
• RAR (PSV ratio of renal artery/aorta): < 3
• Resistive index (RI): < 0.70
• ∆ RI (right – left): < 0.15
• Acceleration time (AT): < 0.07 sec
• Acceleration index (AI): > 3.5 m/s2
PSV: peak systolic velocity – RI: resistive index

② Doppler ultrasound of proximal
abdominal aorta in cardiac diseases
Window to left heart

Abnormal spectral Doppler of proximal abdominal aorta
TVI: Time Velocity Integral
Fadel BM et al. Echocardiography 2014;00:1–5.
Severe aortic regurgitation
Holodiastolic flow reversal (arrows)
Diastolic TVI (17 cm) close to systolic TVI (20 cm)
Indicating a large regurgitant fraction

Coarctation of the aorta
Tardus Parvus wave
Prolongation of acceleration time (arrow)
Prolongation of deceleration time (arrowhead)
Prominent diastolic forward flow
No flow reversal

Aorto-iliac disease
Mid systolic notching
Notching of antegrade systolic waveform (arrow)

Left ventricular assist device
Monophasic forward flow throughout the cardiac cycle
Lack of flow reversals

Pulsus alternans
Alternating high peak velocities (arrow)
and low peak velocities (arrowhead)

Pulsus paradoxus
Significant respiratory variability in flow
Inspiration decreases systolic velocity & duration (arrows)

2D-imaging of abdominal aorta coupled with
pulse Doppler imaging of proximal abdominal
aorta adds substantially to value of TTE study
TTE: trans-thoracic echocardiography

③ Arterial stenosis and occlusion

Signs of stenosis on pulsed Doppler
Sites of pulsed Doppler Features of pulsed Doppler
Proximal to stenosis: Mid systolic notching
At stenosis: Increased PSV/EDV compared to pre-stenotic segment
Laminar flow
Beyond stenosis: Post-stenotic turbulence
Spectral broadening
Loss of well demarcated spectral edge
Distal to stenosis: Tardus-parvus wave

Atherosclerotic abdominal aorta
Luminal irregularity
Sagittal US of abdominal aorta
Marked calcification (arrow)
of abdominal aorta (AO)
Color Doppler of abd aorta

Atherosclerotic stenosis of abdominal aorta
Stenosis in middle aortic segment with significant turbulence
Peak systolic velocity: 369 cm/s
https://radiologykey.com/the-aorta-and-inferior-vena-cava/

Abdominal aortic occlusion
Kaschwich M et al. J Cardiovasc Surg 2017;58(2):313 20.
Transverse US of lower abd aorta Longitudinal US of lower abd aorta

Mid-aortic syndrome
Hypoplasia of aorta, atrophy of aorta, atypical coarctation
• Rare disease w narrowing in distal thoracic &/or abdominal aorta
• Usually found in children and young adults
• Causes: Takayasu arthritis, congenital developmental anomaly,
neurofibromatosis, Williams syndrome
• Renal artery involved in 90% of cases: arterial hypertension
• Clinic: AHT, lower extremity claudication, chronic abdominal pain
• Physical exam: abdominal bruit, reduced or absent femoral pulses,
differential blood pressure between upper & lower extremities
Han L et al. J Clin Ultrasound 2019;47:22–26.

Refractory hypertension for 18 years in a 36-year-old man
Mid-aortic syndrome
PSV: peak systolic velocity – RI: resistivity index
Han L et al. J Clin Ultrasound 2019;47:22–26.
Color Doppler US
of abdominal aorta
Spectral Doppler of
abdominal aorta
Turbulent flow in
narrowed suprarenal
aorta (arrow)
Spectral Doppler
of right kidney
Turbulent flow
with high velocity
PSV > 4.0 m/s
Tardus-parvus waveform
Low RI: 0.32

Different types of celiac trunk stenosis
* Medial Arcuate Ligament Syndrome (celiac artery compression syndrome)
Fibromuscular dysplasia
rare
Atherosclerosis
most frequent
MALS syndrome*

Grading stenosis of celiac axis
• Stenosis 50 – 69%: 43 patients
PSV: > 240 cm/s (sens 87%, spec 83%, OA 86%)
EDV: > 40 cm/s (sens 84%, spec 48%, OA 73%)
PSV ratio1: 1.5
• Stenosis 70 – 99% : 62 patients
PSV: > 320 cm/s (sens 80%, spec 89%, OA 85%)
EDV: > 100 cm/s (sens 58%, spec 91%, OA 77%)
PSV ratio1: 2.75
(1) PSV ratio of celiac axis to aorta
AbuRahma AF et al. J Vasc Surg 2012;55:428-36.
105 patients with celiac artery stenosis on angiography

Stenosis of celiac axis
Aliasing and tissue bruit around a stenotic coeliac axis origin
Longitudinal color Doppler UD of upper abdominal aorta

Atherosclerotic stenosis of celiac artery
Spectral tracing
PSV: peak systolic velocity – EDV: end diastolic velocity
PSV: 276 cm/sec – EDV: 134 cm/sec
Stenosis ≥ 50%

Celiac axis stenosis
PSV: 318 cm/s
indicating ≥ 70% stenosis
Color Doppler of celiac axis Pulsed Doppler at stenotic site
Color aliasing at CA origin (stenosis)
Post-stenotic dilatation
CA: celiac axis – PSV: peak systolic velocity

Grading of SMA stenosis
• Stenosis 50 – 69%:
PSV > 280 cm/s
EDV > 45 cm/s
PSV ratio of SMA/aorta > 3.6
• Stenosis 70 – 99%:
PSV > 395 cm/s
EDV > 74 cm/s
PSV ratio of SMA/aorta > 3.6
PSV: peak systolic velocity – EDV: end diastolic velocity – SMA: superior mesenteric artery
Bird S et al. J Clin Ultrasound. 2019;47(5):267–271.
65 patients with SMA stenosis on CT angiography

Severe stenosis of superior mesenteric artery
PSV 390 cm/s indicating ≥ 70% stenosis
Color and spectral Doppler of SMA
PSV: peak systolic velocity
https://thoracickey.com/clinical-evaluation-and-treatment-of-mesenteric-vascular-disease/

Color & spectral Doppler
at stenotic site
Color bruit outside vessel
High PSV > 500 cm/s
Stenosis ≥ 70%
Post-stenotic
color & spectral Doppler
Post-stenotic turbulence:
Typical “spike hairdo” waveform
Mirror-image artifact
“flow below baseline” at top of tracing
Diagnostic ultrasound, Edited by Rumack CM, 5th edition, 2018, Elsevier

Pulsed Doppler at origin of SMA
PSV: 422 cm/s
Stenosis ≥ 70%
Low-velocity rounded waveforms:
tardus-parvus in post-stenotic zone
Pulsed Doppler of mid-distal SMA

Occlusion of superior mesenteric artery
Thump artifacts
Focal retrograde flow in
collateral vessel (straight arrow)
Occlusion of proximal SMA
(straight arrow)
Reconstitution by collaterals
from CA (wavy arrow)
US Doppler of SMA origin US Doppler of occluded segment

Grading of IMA stenosis
based on angiography
IMA: inferior mesenteric artery – PSV: peak systolic velocity – EDV: end diastolic velocity
AbuRahma AF et al. Vascular 2012; 20(3):145–149.
Stenosis PSV
cm/s
EDV
cm/s
IMA/aortic
systolic ratio
Normal2 1051
< 50% stenosis3 ≥ 210 no flow or ≥ 20 ≥ 2.5
50 – 69% stenosis4 ≥ 250 ≥ 90 ≥ 4.5
≥ 70% stenosis5 ≥ 270 ≥ 100 –
(1): mean – (2): 45 patients – (3): 12 patients – (4): 8 patients – (5): 15 patients

Severe stenosis of inferior mesenteric artery
Color aliasing at origin of IMA (arrow)
Pulsed Doppler of stenotic region: 332 PSV cm/s
Consistent with hemodynamically severe stenosis (≥ 70%)
Pellerito JS et al. J Ultrasound Med 2009;28:641–650.

Mesenteric ischemia
• Acute mesenteric ischemia: high morbidity and mortality
Causes: SMA embolism, SMA thrombosis, non-occlusive ischemia
Abdominal pain out of proportion to physical examination
Differentiate from other common causes of acute abdominal pain
Laboratory findings of little value: metabolic acidosis, high lactate,…
• Chronic mesenteric ischemia: less common
Severe stenosis or occlusion of 2 of 3 mesenteric vessels
Complete occlusion of single artery may cause intestinal angina
Clinical triad: postprandial abd pain, weight loss, food avoidance
ACR: American College of radiology
Expert Panels on Vascular Imaging and Gastrointestinal Imaging.
J Am Coll Radiol 2018;15:S332-S340.

Acute mesenteric ischemia
Extent of intestinal necrosis varies with level of occlusion
Main trunk Vasa recta
Non occlusive
intestinal ischemia
Ileo-colic artery/
Right colic artery
2nd & 3rd
order branches

Imaging of suspected acute mesenteric ischemia
ACR Appropriateness Criteria
ACR: American College of radiology – CTA: computed tomography angiography
Procedures Appropriateness category
CTA abdomen & pelvis with IV contrast Usually appropriate
CT abdomen & pelvis with IV contrast May be appropriate
Arteriography abdomen May be appropriate (disagreement)
MRA abdomen & pelvis w/o & with IV contrast May be appropriate (disagreement)
Radiography abdomen May be appropriate
US duplex Doppler abdomen May be appropriate
CTA of abdomen and pelvis is the most appropriate choice

Doppler US in acute mesenteric ischemia
ACR appropriateness criteria
• Detecting proximal celiac axis & SMA stenosis with high Se & Sp
• Detecting proximal mesenteric arterial thrombosis
• Detecting superior mesenteric or portal venous thrombosis
• Challenges: bowel gas, obesity, vascular calcifications
• Limited role: distal arterial embol, nonocclusive mesenteric ischemia
• Length of examination and pain associated with applied pressure to
abdomen during imaging may be limiting factors

Acute superior mesenteric artery occlusion
Longitudinal US of SMA Transverse US of SMA
https://radiopaedia.org/cases/acute-superior-mesenteric-artery-occlusion-on-ultrasound

Superior mesenteric artery thrombosis
Thrombus demonstrated within an expanded SMA (arrows)
https://radiopaedia.org/cases/superior-mesenteric-artery-thrombosis-1
Longitudinal US of SMA Transverse color Doppler of SMA

Mesenteric vein thrombosis
https://www.pinterest.com/pin/767652698957432844/
Sagittal color Doppler US of superior mesenteric vein

Imaging of suspected chronic mesenteric ischemia
ACR Appropriateness Criteria
Procedures Appropriateness category
CTA abdomen & pelvis with IV contrast Usually appropriate
MRA abdomen & pelvis w/o & with IV contrast Usually appropriate
Arteriography abdomen May be appropriate (disagreement)
CT abdomen and pelvis with IV contrast May be appropriate
MRA abdomen and pelvis without IV contrast May be appropriate
US duplex Doppler abdomen May be appropriate
ACR: American College of radiology – CTA: computed tomography angiography
CTA of abdomen and pelvis is the most appropriate choice

Doppler US in chronic mesenteric ischemia
ACR appropriateness criteria
• Useful initial screening tool for chronic mesenteric ischemia
• Best performed in fasting state & early in the day to avoid bowel gas
• Peak systolic velocity used for diagnosing stenosis
SMA: 295 cm/s and 400 cm/s for 50% and 70% respectively
Celiac artery: 240 cm/s

Doppler of renal artery stenosis
Gray scale imaging first
• Kidneys Maximum renal length
Echogenicity of renal cortex
Thickness of renal cortex
Masses – hydronephrosis – renal calculi
• Aorta Plaque – thrombus – dissection – aneurysm
• Adrenal glands

Measurement of parenchymal & cortical thickness
Cortical thickness: normal 8 – 10 mm
Parenchymal thickness: normal 14 – 18 mm
Tuma J et al. European course book: Genitourinary ultrasound.
European Foundation of Societies of Ultrasound in Medicine & Biology.
parenchyma
cortex

Sites for pulsed Doppler of renal arteries
Aorta
Ostium of main renal arteries
Trunk of main renal arteries
Hilum of both kidney
Upper pole of both kidney
Middle pole of both kidney
Lower pole of both kidney

• Aorta: PSV
• Ostium of renal arteries: PSV
• Renal aorta ratio: PSV ratio of renal artery to aorta
• Trunk of renal arteries: PSV
• Segmental or interlobar arteries: RI and AT
Upper, middle and lower poles of both kidney
Doppler of renal artery stenosis
Ultrasound protocol
AT: acceleration time –PSV: peak systolic velocity – RI: resistive index

Two main causes of renal artery stenosis
Atherosclerosis (> 90%) FMD (< 10%)
Age ˃ 50 years young
Gender more common in males more common in females
Location proximal 1 cm of main RA
branching points
middle of renal artery
others (carotids)
Post-stenotic
dilatation
rare frequent
FMD: fibromuscular dysplasia

Doppler features of renal artery stenosis
Main renal artery Intra-renal arteries
Focal color aliasing AT > 0.07 sec2
Color bruit Flat blood flow waveforms
Turbulence beyond stenosis Δ RI (right – left) > 15%
RAR > 3.5
PSV > 180 cm/sec1
EDV > 90 cm/sec
1 PSV >180 cm/s: ≥ 50% diameter reduction
PSV > 300 cm/s: ≥ 60% diameter reduction
2 AT > 0.07 sec: > 85% diameter reduction
AT: acceleration time – EDV: end diastolic velocity
PSV: peak systolic velocity – RAR: renal aortic ratio – RI: resistive index

Renal artery stenosis
Renal aortic ratio (RAR)
Left renal artery Upper abdominal aorta
PSV: peak systolic velocity
PSV: 410 cm/s PSV: 50 cm/s
RAR: 410/50 = 8.20 (normal ˂ 3)
Renal artery stenosis ≥ 60%

PSV: 293 cm/sec – RI : 0.91
Controversial indication of PTA2
Aliasing in left renal artery
Retro-aortic course of LRV
LRV: left renal vein – PSV: peak systolic velocity – RI resistive index – PTA: angioplasty
1 Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin, 2nd edition, 2011.
2 Jaeger KA et al. Ultraschall in Med 2007;28:28–31.

Waveform of intra-renal blood flow
AT: acceleration time
Normal flow patternIntra-renal artery Renal artery stenosis

Acceleration time (AT)
Normal ˂ 70 msec
AT: 40 msec AT: 65 msec AT: 140 msec
Normal AT Normal AT Prolonged AT

Tardus Parvus wave
• Mimics Aortic/mitral valve disease
Aortic coarctation
William syndrome
Left ventricle dysfunction
CV medications: after-load reducers
• Exaggerating 25 mg captopril 1 hour before exam
• Minimizing Age – HTN – DM (vessel compliance)
CV: cerebrovascular – DM: diabetes mellitus – HTN: hypertension

Moniliform aspect of RRA
Typical FMD in middle third of RRA
PSV: 250 cm/sec
No parallelism of RRA walls

Indications of PTRA in renal artery stenosis
Still controversial
• Hemodynamically significant renal artery stenosis and:
Resistant hypertension despite use of ≥ 3 antihypertensive drugs
Exacerbating hypertension
Malignant hypertension
Hypertension with idiopathic unilateral kidney atrophy
Idiopathic pulmonary edema that suddenly develops
Repeated heart failure
Unstable angina
• Patients with bilateral renal artery stenosis
• Progressive chronic kidney disease in a single functioning kidney
PTRA: percutaneous transluminal renal angioplasty

Renal artery thrombosis (complete)
Irshad A et al. Semin Ultrasound CT MRI 2009;30:298–314.
Transplanted kidney
Absence of flow within kidney
Power Doppler US Power Doppler US more medially
Flow in iliac artery
& proximal anastomotic artery

Partial acute renal infarction
Gray scale image Power Doppler image

Aneurysms, false aneursysm & arterial dissection
Normal artery
Arterial wall
components
True aneurysm
Components of arterial
wall "stretched"
Hole in arterial wall
with confined collection
of blood
False aneurysm Arterial dissection
Hematoma between
components of wall
Zwiebel JW. Ultrasound assessment of aorta, iliac arteries and inferior vena cava.
In: Introduction to vascular ultrasonography. Zwiebel JW ed, 5th edition, Elsevier Saunders, 2005.

Selective screening for AAA
• Selective screening
3 important risk factors: Males
Age > 65 years
History of smoking
• Effectiveness of screening
4 RCTs including more than 125,000 men
Reported results for up to 5 – 10 years of follow-up
Reduction in mortality from 68% to 21%
RCT: randomized controlled trial
Lederle FA. Ann Intern Med 2003 ; 139 : 516 – 22.

Abdominal aortic aneurysm (AAA)
• Normal size of abdominal aorta 1.5 – 2.5 cm
• Ectatic aorta 2.5 – 3 cm
• Aortic aneurysm > 3 cm
• Annual growth rate of aneurysms 0.33 cm/year
measuring between 4 & 5.5 cm

Abdominal aortic aneurysm (AAA)
• Measurement
• Location
• Morphological evaluation
• Possible evaluation of iliac arteries
• Complications: rupture, thrombosis, dissection, embolization
What to evaluate?

Measurement of widest part
Measurement technique of aneurysm

Measuring diameter of AAA
Incorrect measurement Correct measurement
AAA: abdominal aortic aneurysm
Correct diameter measured by rotating transducer clockwise
until round image of aorta comes into view

Battaglia S et al. J Ultrasound 2010:13:107–117.
Abdominal aortic aneurysm (swirling flow)
Pseudo ‘‘Yin-Yang sign’’
Similarity in appearance to pseudo-aneurysm finding

Classification of abdominal aortic aneurysms
Classification Categories
By location Suprarenal: Above origin of renal areteries (very rare)
Juxtarenal: Where renal arteries originate
Infrarenal: Below origin of RA (most common)
By morphology Fusiform (most common)
Hourglass
Saccular
By etiology Atherosclerotic (most common)
Inflammatory (5% – 10%)
Mycotic (1%): saccular, salmonella & SA, high mortality

Classification of AAA by location
Based on relation to renal arteries
Suprarenal
Suprarenal: Aneurysm involves origins of one or more visceral arteries
Pararenal: RAs arise from aneurysm but aorta at level of SMA not aneurysmal
Juxtarenal: Aneurysm originates just beyond origins of RAs
Infrarenal: Aneurysm originates distal to renal arteries.
Pararenal Juxtarenal Infrarenal

Supra-renal abdominal aortic aneurysm
Schuster H et al. Ultraschall Med 2009;30:528–543.
Transverse US viewLongitudinal US view
Inclusion of visceral & renal
arteries
Perfused lumen
& narrow circular thrombus

Infra-renal abdominal aortic aneurysm
Distance between renal vein & upper limit of aneurysm
LRV: left renal vein – SMA: superior mesenteric artery
SMA
LRV

Classification of AAA by shape
Fusiform Saccular
Most frequent
Double aneurysm
Hourglass aorta

Abdominal aortic aneurysm (fusiform)
Transverse image
Anteroposterior diameter
from outer wall to outer wall
Sagittal image
Diameter measured in transverse
image larger due to obliquity

Abdominal aortic aneurysm (hourglass)
Bhatt S et al. Ultrasound Clin 2007;2 437–453.
Two discontinuous focal segments of aneurysmal dilatation
Aortic diameter in between is normal in caliber

Abdominal aortic aneurysm (saccular)
Saccular or mycotic aneurysm
Thrombus seen as low-level echoes within aneurysm
Longitudinal image of abdominal aorta
Abraham D et al. Emergency medicine sonography: Pocket guide.
Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.

Complications of abdominal aortic aneurysm
• Thrombosis
• Dissection
• Rupture
• Embolization

Partial thrombus
Infrarenal AAA with thrombus occluding
approximately two thirds of the lumen
Longitudinal color Doppler US Transverse color Doppler US

Abdominal aortic aneurysm (thrombus liquefaction)
Area of thrombus liquefaction may be confused with dissection
Large thrombus separate area of liquefaction from lumen

Longitudinal color Doppler Transverse color Doppler
Accorci F. Ultrasound in abdominal aorta and iliac artery atherosclerotic diseases.
http://www.echodoppler-lessons.com/en/pathology-of-the-aorta-and-the-peripheral-arteries/
ultrasound-in-abdominal-aorta-and-iliac-arteries-atherosclerotic-disease
Complete thrombus

Longitudinal gray-scale US
Echogenic band in aortic lumen Echogenic band in aortic lumen
Transverse gray-scale US
Transverse color Doppler US
Anterior false lumen (blue)
Posterior true lumen (red)
Longitudinal color Doppler US
Entry point (arrowhead) of
intimal tear causing dissection
Complications of AAA (dissection)

AAA with peripheral thrombus
Small hypoechoic area (wall rupture)
Hypoechoic structure at upper end
Presence of active bleeding
No further imaging confirmation
Taken directly to OR
AAA: abdominal aortic aneurysm – OR: operating room
Rupture (high mortality rate: 90%)

Stent-graft expands to make firm
circumferential contact with
 ‘neck’ of relatively normal aorta
between RA & upper end of AAA
 each CIA below aneurysm
Endovascular aortic aneurysm repair (EVAR)
First performed by Parodi from Argentina in 1990 1
AAA: abdominal aortic aneurysm – CIA: common iliac artery –RA: renal arteries
1 Parodi JC et al. Ann Vasc Surg 1991;5:491–499.
2 Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Stent-graft

Endoleak after EVAR
Persistent flow in aneurysm lumen after procedure
• Increase in aneurysmal diameter with risk of rupture
• 20 – 40% at any time after graft placement1
• Lifelong surveillance 1st month, 6th month, yearly2
• Modalities CTA: gold standard
CDUS/CEUS: acceptable alternative
MRA – DSA
CDUS: color Doppler ultrasound – CEUS: contrast-enhanced ultrasound
CTA: computed tomography angiography – MRA: magnetic resonance angiography
1 Demirpolat G et al. J Clin Ultrasound 2011;39:263–269.
2 Stavropoulos SW et al. Radiology 2007;243:641.
Determination of endoleak & aneurysmal size

Endoleak following EVAR
Type I Type II Type III Type IX
Failure of proximal or
distal attachment sites
Flow through aortic
or iliac branches
common
Perforation & tear
in graft material
rare
Porosity of graft
material
resolved in 1 month
EVAR: endo-vascular abdominal aneurysm repair
White GH et al. J Endovasc Surg 1996 ;3:124–5.
Carrafiello G et al. Cardiovasc Intervent Radiol 2006;29:969–974.

Types of endoleak
Type I: Distal attachment site
Type II: Patent lumbar artery
Thrush A et al. Peripheral vascular ultrasound. Elsevier, London, 2nd edition, 2005.
Hartshorne T. Ultrasound 2006;14:34–42.
Type II: Inferior mesenteric artery
Type I: Proximal attachment site

Endoleak type II over mesenteric artery
Zimmermann H et al. Clin Hemorheology Microcirculation 2014;58:247–260.
Aortic aneurysm with graft
No endoleak seen in B-mode
Type II endoleak (yellow arrow)
over mesenteric artery
Color Doppler ultrasoundGray scale ultrasound

Zimmermann H et al. Clin Hemorheology Microcirculation 2014;58:247–260.
Gray scale ultrasound Color Doppler ultrasound
Aortic aneurysm with graft
No endoleak seen in B-mode
Endoleak type II over lumbar artery
Type II endoleak (yellow arrow)
over right lumbar artery

Endovascular aortic aneurysm repair
Mirror artifact
Demirpolat G et al. J Clin Ultrasound 2011;39:263–269.
Synchronous pulsatility with flow in patent graft
Changing position while examining from different aspects
Spectral analysis aids in reducing false positive
Mirror image behind patent limbs of stent graft

Iliac artery aneurysm
• Most iliac artery aneurysms associated w distal aortic aneurysms
Aortic aneurysm is the source of clinical concern
• Isolated iliac artery aneurysm uncommon but may be deadly:
Not palpated on physical examination even when large
Rupture generates nonspecific abdominal or pelvic symptoms
Nor recognized until patient becomes hypotensive or dies
• Located in proximal or distal portion of common iliac arteries
• Surgical repair or percutaneous stenting recommended if >3 cm

Aortic and iliac artery aneurysms
Aortic aneurysm & common iliac artery aneurysm
Separated by relatively normal segment of proximal CIA (arrow)
Longitudinal view of lower abdominal aorta

Isolated common iliac artery aneurysm
Transverse ultrasound of abdominal aortic bifurcation
Left iliac artery aneurysm
Pseudo Yin Yang flow pattern

Isolated internal iliac artery aneurysm
Flow in the mass (arrows)
and apparent communication
with IIA
Gray scale ultrasound Color Doppler ultrasound
Hypoechoic mass in pelvis
near EIA (arrows)
Initially thought to be nodal mass

• Definition:
Arterial dilatation > 1.5 times the size of original vessel
with loss of parallelism of vascular walls
• Size of visceral arteries:
Celiac trunk: 0.79 ± 0.06 cm
Common hepatic artery: 0.50 ± 0.04 cm
Proper hepatic artery: 0.45 ± 0.03 cm
Splenic artery: 0.46 ± 0.03 cm
Visceral artery aneurysms
Ibrahim F et al. Curr Treat Options Cardio Med 2018;20:97–111.

Sites of visceral artery aneurysms
Rare – discovered incidentally – high mortality in rupture
Jesinger RA et al. Radiographics 2013;33:E71–96.
Piasek E et al. J Ultrason 2018;18:148–151.
Splenic artery:
Hepatic artery:
Superior mesenteric artery:
Celiac artery:
Inferior mesenteric artery:
Gastric, intestinal, pancreatic, gastroduodenal:
Renal artery
60%
20%
5%
4%
1%
rare
1 – 10 %
Splenic artery & hepatic artery most commonly involved

Celiac artery aneurysm
Transverse gray scale US of upper abdomen
Aneurysm of celiac axis

Celiac artery aneurysm
Lumen of celiac axis dilated (arrow)
Disturbed flow on color Doppler (pseudo Yin Yang flow)

Celiac axis aneurysm with dissection
52-year-old male - CT for workup of testicular seminoma
Celiac axis aneurysm
13 mm
Aneurysmal dissection
w true & false lumen
PSV: peak systolic velocity – EDV: end diastolic velocity
Errigo A et al. J Vascular Ultrasound 2018;42(2):82–84.
Doppler of false lumen
PSV: 402 cm/s
EDV: 142 cm/s

Extra-hepatic artery aneurysm
Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005
Extrahepatic sacular hepatic artery aneurysm
Pseudo Yin-Yang flow pattern

Ignee A et al. Z Gastroenterol 2002;40:21–32.
Gray-scale US Color & duplex US
Pseudo Yin-Yang flow pattern
Arterial flow on spectral Doppler
Ovoid mass in porta hepatis
Extra-hepatic artery aneurysm

Intra-hepatic artery aneurysm
O’Driscoll D et al. Br J Radiology 1999;72:1018–1025.
26-year-old man – abdominal pain after abdominal blunt trauma
Hypoechoic lesion in right lobe
Arterial flow on spectral Doppler
Contrast-enhanced CTPulsed Doppler US
Large aneurysm in right
hepatic lobe

• 3rd common intra-abdominal aneurysm after aorta & iliac arteries
• Abnormal dilatation of splenic artery > 1 cm in diameter
• Risk factors: pregnancy, portal hypertension, trauma, arterial
degeneration (medial fibrodysplasia), atherosclerosis
• Majority asymptomatic (80%) & discovered incidentally
• Symptomatic in 20%: epigatric or LUQ pain
• Spontaneous rupture: frequency 3% – mortality 25%
• Risk of rupture: pregnancy, PHT, > 2 cm, liver transplantation
Splenic artery aneurysm
LUQ: left upper quadrant – PHT: portal hypertension
Al-Habbal Y et al. Surgeon 2010;8:223–231.

Gray-scale US of splenic hilum Color Doppler US of splenic hilum
Splenic artery aneurysmCystic mass in splenic hilum

Gray scale ultrasound
Wakui N et al. J Med Ultrasonics 2011:38:167–171.
Color Doppler ultrasound
2.2-cm cystic mass at
splenic hilum (arrow)
Color Doppler: pseudo Yin-Yang pattern
Pulsatile waveform in cystic lesion

Atherosclerotic splenic artery aneurysm
Badea R et al. J Med Ultrasonics 2013;40:487–490.
Turbulent color signal
suggesting splanchnic
aneurysm
4-cm hypoechoic mass
on splenic artery trajectory
with wall calcification
Presence of splenic
artery aneurysm
CT angiographyGray scale US Color Doppler US

Multiple splenic artery aneurysms
Bagga B, Das CJ. BMJ Case Rep 2019;12:e228705.
Transverse abdominal US Color spectral Doppler US
Dilated splenic artery (asterisk)
Multiple aneurysms (arrow)
likely arising from it
Arterial waveform in
aneurysms confirming them to
be arising from splenic artery

Thrombosed splenic artey aneurysm
mimicking pancreatic adenocarcinoma
Round hypoechoic solid mass
appears as aneurysmatic thrombosed
dilatation arising from splenic artery
Casadei R et al. JOP (Online) 2007;8(2):235-239.
Transverse color Doppler US Non-contrast-enhanced CT scan
Hypodense round solid mass of
pancreatic body w calcified periphera
spot simulating pancreatic neoplasm

Splenic vein aneurysm
• Splenic vein aneurysms are rare
• Etiology: portal hypertension, congenital weakness in vein wall
• Clinic: asymptomatic – usually incidental findings
• Complication: rupture, thrombosis, compression adjacent structures
• Appropriate management: unknown
Noninvasive follow-up, plication, and aneurysm excision
Torres G et al. J Vasc Surg 1999;29:719–21.

Splenic vein aneurysm
Cystic round mass in
pancreatic tail
Enhancing mass in left
mid-abdomen
Torres G et al. J Vasc Surg 1999;29:719–21.
Transverse US image Abdominal CT (venous phase)

Inferior mesenteric artery aneurysm
Momin AA et al. J Clin Ultrasound 2008;36:42–44.
Transverse color US of
middle abdominal aorta
Longitudinal US of middle
abdominal aorta
IMA aneurysm parallel to
lower part of abdominal aorta
AO: aorta
VC: inferior vena cava
Aneurysm: IMA aneurysm

Renal artery aneurysm
Ultrasound of kidney
Cystic mass at hilum
Color Doppler US
Renal artery aneurysm
Pulsed Doppler US
Low resistance arterial
flow

Indications to treat visceral aneurysms
• Clinical symptoms: pain, embolism, rupture
• > 2 cm in size or twice the size of the artery by consensus
• Rapid increase in diameter of aneurysm
• Specific location: duodenopancreatic arcades
• Pregnant women or women of childbearing age
• Non-atherosclerotic etiology (ie: connective tissue disease)
• Patient requiring a liver transplant
• Portal hypertension for splenic artery aneurysm
Chiaradia M et al. Diag Inter Imaging 2015:96:796–806.

Endovascular or open surgery approaches
for visceral artery aneurysms
• Endovascular approach:
Used more often by surgeons
Shorter hospital stay
Lower rates of cardio-vascular complications
Higher rates of re-intervention
Low access site complication (<5%)
Post-embolization syndrome: from 9% (renal) to 38% (splenic)
Coil migration: from 8% (splenic) to 29% (renal)
• Difference in mortality of 2 approaches not statistically significant
Barrionuevo P et al. J Vasc Surg. 2019 May 21. doi: 10.1016/j.jvs.2019.02.024.
Systematic review
80 observational studies – 2845 visceral aneurysms

Pulsed Doppler of pseudo-aneurysm
Middleton WD et al. Ultrasound Quarterly 2005;21:3–17.
To-and-fro flow
Typical triphasic flow

“to-and-fro” flow of pseudo-aneurysm
During systole
“to”
Flow enters PA via the neck
Pseudo-aneurysm lumen enlarges
During diastole
“fro”
Flow exits PA via the neck
Pseudo-aneurysm lumen contracts

Variations in ‘‘to-and-fro’’ flow in pseudoaneurysm
Limited systolic flow
More pronounced diastolic flow
Diastolic flow decreases progressively
Diastolic flow increases progressively
Diastolic flow relatively limited
Two distinct phases of diastolic flow
Variations in duration & velocities of
systolic & diastolic flow due to arrhythmia

Pseudoaneurysm of abdominal aorta
Ertürk H et al. J Clin Ultrasound 1999;27:202–205.
“to-and-fro” flow pattern
in neck of aortic pseudoaneurysm
Turbulent flow in pseudoaneurysm
Anterior displacement of
normal-sized aorta (arrows)
Transverse color Doppler US Longitudinal color duplex US

Pseudoaneurysm of hepatic artery
PSC: primary sclerosis cholangitis
Parlak S et al. J Belg Society Radiology 2015;99(2):61–4.
50-year-old male, liver transplant for PSC, abnormal liver tests
Pseudoaneurysm originating from hepatic artery (arrow)
Classic Yin and Yang flow pattern in pseudoaneurysm
Peripheral partial thrombus in pseudoaneurysm (arrowhead)

Pseudoaneurysm of SMA
Communication between SMA (arrow) & pseudoaneurysm
Classic Yin and Yang flow pattern in pseudoaneurysm
AO: aorta – SMA: superior mesenteric artery – SV: splenic vein
66-year-old male, chronic alcoholic pancreatitis, upper abd pain
Săftoiu A et al. J Pancreas (Online) 2005; 6(1):29–35.

Pseudoaneurysm of the kidney
Secondary to renal biopsy
https://iame.com/online/duplex_and_color_doppler_of_the_kidney/content.php
Color Doppler US of kidney Puled Doppler at the neck
“to-and-fro” flow patternPseudoaneurysm
Yin and yang low pattern

External iliac arteriovenous fistula
Normal left external iliac artery
Right external iliac artery
Low resistance arterial flow
Right external iliac vein
Arterialized venous flow
Normal left external iliac vein

Kidney arterio-venous fistula
First described in 1962 1
• Cause Iatrogenic (percutaneous procedure) –Trauma
• Clinic Asymptomatic (80%)
Gross hematuria – High output cardiac failure
Thrombo-embolic episodes – RF – HTN
• Evolution Most regress spontaneously in 6 months
Some progress to life-threatening complication
• Rx Asymptomatic: follow-up by Doppler
Symptomatic: embolization
Routine post-biopsy Doppler US & 6 months later
1 Fernstrom I et al. J Urol 1962;88:709.
2 J Clin Ultrasound 2008;36:377–380.

Kidney arterio-venous fistula
Feeding artery
PRF:pulse repetition frequency
Perivascular artifact in inferior pole
“confetti phenomenon”
Color Doppler US (high PRF)
Low resistance arterial flow
Arterialized venous flow
Feeding artery & draining vein

Arterio-portal fistula syndrome
APFS
• Fistula involving one or several arteries & the portal
vein or one of its tributaries
• Hepatic artery: 65% of cases
Splenic artery: 10% of cases
SMA or IMA: 25% of cases
• Up to 1996, 75 cases of splenic arterio-venous fistula
reported in the medical litterature
Z Gastroenterol 1996;34:234–249.

• Asymptomatic
• Heart failure: Rare
Protection of heart by liver
• Intestinal ischemia: Steal phenomenon
20 % Abdominal pain, diarrhea, bleeding
• Portal hypertension: Splenomegaly – varices – ascites
20 – 40%
Clinical presentation

Dilated splenic artery (14 mm) Low RI in splenic artery: 0.42
Arterialized flow in splenic vein Dilated SV behind pancreas (20 mm)

Intimal dissection of abdominal aorta
Change in color coding due to
position of re-entry site
Color Doppler US
Longitudinal & transverse scan
Gray-scale US
Longitudinal & transverse scan
Intimal flap seen if sound beam
strikes at perpendicular angle
Search for involvement of visceral & iliac arteries

Spontaneous isolated visceral arterial dissection
• Dissection of CA, SMA, IMA or renal artery w/o aortic dissection
• Artery: SMA – CA Less frequent – Both arteries: very rare
• Dominant baseline profile: male smokers with hypertension
• Causes: arterial wall pathology, connective tissue diseases, atherosclerosis
• Clinic: severe sudden abdominal pain, vomiting
• Diagnosis: CT angiography or digital subtraction angiography
• Misdiagnosis: common & may lead to intestinal ischemic necrosis
CA: celiac axis – CT: computed tomography – SMA: superior mesenteric artery
Kim YW. Vascular Specialist International 2016;32(2):37–43.

Aortic & superior mesenteric artery dissection
Intimal flap in abdominal aorta & superior mesenteric artery
Huang CY et al. J Med Ultrasound 2019;27:47–9.
Longitudinal ultrasound of upper abdominal aorta

Extension of aortic dissection to renal artery
Aortic dissection with true lumen (red) and false lumen (blue)
Right renal artery dissection with 2 lumens (double arrows)
Japan Society of Ultrasonics in Medicine. J Med Ultrasonics 2016;43:145–162

Types of SMA dissection
Yun WS et al. Eur J Vasc Endovasc Surg 2009;37: 572–577.
Type I: Patent true & false lumens, visible entry and re-entry
Type II-a: Patent true & false lumens, visible entry, no visible re-entry
Type II-b: Patent true lumen, thrombosed false lumen, no visible re-entry
Type III: Occluded true & false lumens, no visible entry & re-entry

Type I spontaneous isolated SMA dissection
Bao S et al. Exper Ther Med 2019;17:3489–4494.
Long axis Color Doppler of SMA
48 year-old male with sudden abdominal pain for 4 h
Short axis Color Doppler of SMA
Perforation between true
and false lumen
Entry site & thrombosis in false lumen
Perforation between true
and false lumen
Less blood flow & thrombosis
in false lumen

57 year-old female with sudden abdominal pain for 8 h
Transverse US of SMALongitudinal US of SMA
Ventral false lumen
Dorsal true lumen
Only entry site is visible
Pepsi color flow in false lumen
Spontaneous isolated SMA dissection (type II-a)

Color Doppler USLongitudinal US of SMA
Intimal flap in SMA
(arrow)
Thrombosis of false
lumen (type II-b)
Spontaneous isolated SMA dissection (type II-b)
Huang CY et al. J Med Ultrasound 2019;27:47–9.
46-year-old male with epigastric pain for 3 days
Transverse US of SMA
Increased diameter
of SMA: 16.8 mm

57 year-old male with sudden abdominal pain for 5 h
Spontaneous isolated SMA dissection (type II-b)
Thrombotic false lumen
Narrowed true lumen
PSV in true lumen: 404 cm/sec
Indicating severe stenosis

Differential diagnosis of spontaneous
isolated visceral arteries dissection
• Atherosclerosis:
More common in elderly
Plaque at origin of artery w narrowed lumen & increased velocity
• Embolism:
Cardiac causes: atrial fibrillation or myocardial infarction
Intra-luminal hypo-echoic solid tissue filling without blood flow
• Abdominal aortic dissection involving visceral artery:
Dissection between beginning & distal end of artery
Normal abdominal aorta

⑧ Abdominal vascular compression syndromes

Syndromes Also known as
Celiac artery compression syndrome Median arcuate ligament syndrome
Dunbar syndrome
Superior mesenteric artery syndrome Wilkie syndrome
Cast syndrome
Aorto-mesenteric syndrome
Nutcracker renal syndrome Left renal vein compression syndrome
May-Thurner syndrome Iliac vein compression syndrome
Cockett syndrome
Abdominal vascular compression syndromes

Celiac artery compression syndrome

Median arcuate ligament in relation to celiac artery
Kim EN et al. JAMA Surgery 2016;151(5):471–7.
Low-riding median arcuate ligament
compared with normal anatomy

• Patients undergo extensive evaluation for other diagnoses:
Abdominal ultrasonography
Abdominal computed tomography with 3D reconstruction
Magnetic resonance angiography
Upper gastrointestinal endoscopy
Hepatobiliary iminodiacetic acid scanning
• Duplex US used as preliminary assessment:
Celiac axis tracks cephalad during expiration, leading to external
compression and elevated velocities with post-stenotic dilatation
Kim EN et al. JAMA Surgery 2016;151(5):471–7.
Commonly considered a diagnosis of exclusion

• Spectral Doppler of compressed segment of celiac axis:
During quiet respiration, inspiration & expiration
In supine position & upright positions
• Spectral Doppler of abd aorta at diaphragmatic level
• Deflection angle of celiac axis in supine during expiration
Ultrasound protocol
US: ultrasound – PSV: peak systolic velocity – EDV: end diastolic velocity
Gruber H et al. Medical Ultrasonography 2012;14 (1):5– 9.

Ultrasound features
• Pulsed Doppler:
PSV of celiac axis in supine during expiration ˃ 200 cm/s 1
PSV ratio (celiac axis in expiration/upper abdominal aorta) ˃ 3:1 1
Decreased PSV of celiac axis in supine during inspiration
Normal PSV of celiac axis in upright position
• Deflection angle:
Celiac axis deflection angle in supine during expiration ˃ 50° 2
1 Ozel A et al. Medical Ultrasonography 2012;14 (2):154–157.
2 Gruber H et al. Medical Ultrasonography 2012;14 (1):5– 9.

PSV: 155 cm/s
EDV: 45 cm/s
PSV: 128 cm/s
EDV: 35 cm/s
PSV: 170 cm/s
EDV: 56 cm/s
Quiet respiration Inspiration Expiration
Normal Doppler ultrasound of celiac artery
PSV:peak systolic velocity – EDV: end diastoliv velocity
Wang XM et al. Ultrasound Med Biol 2018;44(1):243-250.
PSV < 200 cm/s at rest, during inspiration and expiration

PSV: 345 cm/s
EDV: 134 cm/s
PSV: 147 cm/s
EDV: 55 cm/s
PSV: 470 cm/s
EDV: 160 cm/s
Quiet respiration Inspiration Expiration
Wang XM et al. Ultrasound Med Biol 2018;44(1):243-250.
Triplex Doppler ultrasound
Elevated PSV during quiet respiration, decreases in inspiration
and increases in expiration

Triplex Doppler of hepatic artery
Elwertowski M et al. J Ultrasonography 2015;15: 85–95.
Low-resistance flow in
hepatic artery
Normalization of flow
during inspiration

Triplex Doppler in splenic artery
Elwertowski M et al. J Ultrasonography 2015;15: 85–95.
Low-resistance flow
in splenic artery
Normalization of flow
during inspiration

Gruber H et al. Medical Ultrasonography 2012;14 (1):5– 9.
Deflection angle of celiac axis
Deflection angle of about 80°
Normal ˂ 50°
Maximum expirationMaximum inspiration

CT angiography
Normal celiac axis
Wang XM et al. Ultrasound Med Biol 2018;44 (1):243–250.
Inspiration
Severe stenosis of celiac artery
Expiration

Superior mesenteric artery syndrome

• Loss of mesenteric fat pad between aorta and SMA:
Narrow angle between 2 vessels & compression of 3rd duodenum
• Causes: severe weight loss (trauma, burns, anorexia nervosa)
• Rare causes: scoliosis surgery, congenital short ligament of Treitz
• Clinic: epigastric pain, abdominal distension, nausea, vomiting
• Diagnosis: abdominal ultrasound or abdominal CT
Reduced aorta-mesenteric angle (normal 45° – 60°)
Reduced aorta-mesenteric distance: normal (10 – 20 mm)
• Treatment: electrolytes correction, NG tube, nutritional support,
naso-jejunal tube beyond 3rd duodenum, surgery if no improvement
Kothari TH et al. Can J Gastroenterol 2011;25(11): 599–600.

Duodenum surrounded by adipose tissue
Loss of fatty cushion results in narrowing of aorto-mesenteric angle
Angle < 22° is diagnostic of SMA syndrome

Mathenge N et al. Clinical Anatomy 2014;27:1244–1252.
Duodenal compression between
aorta & middle colic artery
Duodenal compression between
aorta & superior mesenteric artery

Kothari TH et al. Can J Gastroenterol 2011;25(11): 599–600.
Aorta-SMA angle: 18°
Longitudinal US of upper abdominal aorta
Aorta-SMA distance: 6 mm
Measured at level of duodenum

CECT: contrast-enhanced computed tomography
Fong JKK et al. AJR 2014;203:29–36.
Dilated stomach & duodenum
Narrowed as it travels under SMA
Aorto-mesenteric distance 5 mm
17-year-old girl with of abdominal distention and vomiting
CECT
Aorto-mesenteric
angle of 15°
CECT Barium meal
Vertical compression of mucosal
folds & proximal dilatation of
duodenum & stomach from
vascular compression

Nutcracker renal syndrome (NCRS)

Schematic representations of main types of LRV
Anterior LRV Posterior LRV Circumaortic LRV
Most frequent Less frequent
0.8 – 7.1 %1
Rare
LRV: left renal vein
1 Skeik N et al. Vasc Endovascular Surg. 2011;45:749-755.
2 Orczyk K et al. BioMed Research International 2017, article ID 1746570, 7 pages

Types of LRV compression syndrome
• Anterior LRV compression syndrome: most frequent
Pre-aortic LRV compressed between SMA & abdominal aorta
• Posterior LRV compression syndrome: rare
Retro-aortic LRV compressed between aorta & lumbar vertebral body
Rare: 11 reported patients with posterior NCS by 20111
• Circumaortic LRV compression syndrome: very rare
Compression of both anterior and posterior LRV
1 Skeik N et al. Vasc Endovascular Surg 2011;45:749-755.
2 Lemasle P et al. Phlebolymphology 2017;24(2):79 – 87

• Nutcracker phenomenon: compression of LRV between aorta & SMA
Nutcracker syndrome: clinical manifestations of this phenomenon
• Higher in females, 30-40 years, low BMI, increased hight
• Manifestations: hematuria, proteinuria, left-sided flank pain, variocele
• Diagnosis: Doppler US – CTA – MRA – phlebography
• Conservative treatment: ACE inhibitors (Alacepril) – aspirin
•
• Endo-vascular treatment: stenting
• Surgery: spleno-renal venous bypass - left renal vein transposition
Nutcracker renal syndrome ( NCRS)
CTA: computed tomography angiography – MRA: magnetic resonance angiography
He Y et al. Urology 2014;83:12–17.

Recommended US protocol in suspected NCS
• Angle between aorta & SMA origin in longitudinal plane
• AP diameter of LRV lumen at renal hilum and compressed portion
• Flow velocity of LRV at renal hilum and compressed portion
• Assess surrounding structures for causes of LRV compression
• Assess & measure both kidneys looking for any pathology
• Assess vasculature within inguinal region looking for incompetence
• Scrotal varicocele in male & ovarian vein incompetence in female
AP: antero-posterior – LRV: left renal vein – SMA: superior mesenteric artery
Englund KM et al. AJUM 2018;21(2):75–78.

US features of nutcracker renal syndrome
• Reduced angle between aorta and SMA < 35°
• Diameter ratio of LRV (hilum/aorto-mesenteric) > 5.0
• Velocity ratio of LRV (aorto-mesenteric/hilum) > 5.0
• Left-sided varicocele with vein diameter > 3 mm
LRV: left renal vein – NCRS: nutcracker renal syndrome
He Y et al. Urology 2014;83:12–17.
NCRS may exist in non-distended or distended LRVs
Normal flow can exist in a distended LRV

Diagnostic accuracy of Doppler ultrasound
in nutcracker syndrome
Diameter ratio of LRV (hilum/aorto-mesenteric) > 5.0
+
PSV ratio of LRV (aorto-mesenteric/hilum) > 5.0
Sensibility 80%
Specificity 94%
Diagnostic accuracy 83%
LRV: left renal vein – PSV: peak systolic velocity
Kim SH et al. Radiology 1996;198:93–97.

Nutcracker renal syndrome
Reduced aortic/SMA angle
Angle between aorta and SMA: 18.8°
Proposed aorta-SMA angle for diagnosis: usually < 35°

Compression of LRV between aorta & SMA
LRV stenosed at aorto-mesenteric portion & dilated at hilar portion
Proposed diameter ratio of LRV for diagnosis 4:1
Normal diameter of LRV: 4 – 5 mm

Tight stenosis of LRV in aorto-mesenteric space
Compression of LRV between aorta & SMA
Lemasle P et al. Phlebolymphology 2017;24(2):79 – 87

Renal Doppler ultrasound of left renal vein
Peak velocity in aorto-mesenteric stenosed portion: 194.8 cm/s
Peak velocity in hilar portion: 21.3 cm/s
Velocity ratio: 9.1
Nutcracker syndrome
Velocity ratio of left renal vein
Shin JI et al. Eur J Pediatr 2007;166:399–404.
Entrapped portion of LRV Hilar portion of LRV

Varicocele
Antero-posterior diameter of vein: 3.3 mm

Pelvic congestion syndrome
Up to 30% of women w pelvic pain without clear cause
• Mostly premenopausal multiparous women
• Chronic pelvic pain lasting > 6 months:
Not related to menstrual cycle
Pain worsens when sitting or standing
Pain relieved with lying down
In some patients: pain with urination (dysuria)
or during sexual activity (dyspareunia)
https://vein.stonybrookmedicine.edu/disease/pelvic-congestion-syndrome

Ultrasound features of pelvic congestion syndrome
• Large vein crossing the uterine body
• Presence of tortuous and dilated pelvic venous plexuses
• Increased diameter & flow reversal of varicoceles in Valsava
• Dilated arcuate veins communicating with pelvic varicose veins
• Dilatation of left ovarian vein with reversed caudal flow
Higher sensitivity when performed in upright position
Poor correlation with venography for pelvic varices

US of pelvic congestion syndrome
Systematic review
• Vein > 5 mm crossing the uterine body:
Specificity: 91% (95% CI: 77–98%)
• Pelvic varicoceles:
Sensitivity: 100% (95% CI: 89–100%)
Specificity: 83–100% (95% CI: 66–93%)
Steenbeek MP et al. Acta Obstet Gynecol Scand 2018;97:776–786.
Trans-vaginal ultrasound
Trans-abdominal ultrasound
• Reversed caudal flow in ovarian vein:
Sensitivity: 100% (95% CI: 84–100%)

Ultrasound in pelvic congestion syndrome
Large vein crossing uterine body
Large vein crossing uterine body from left to right
with dilated pelvic varicocele
Transvaginal ultrasound
Park SJ et al. AJR 2004;182:683–688.

Ultrasound in pelvic congestion syndrome
Tortuous & dilated pelvic venous plexuses
48-year-old woman with chronic pelvic pain
Multiple tubular structures Flow in tubular structures
compatible with multiple
tortuous dilated pelvic veins
Transvaginal ultrasound image Color Doppler of same image
Johnson NR. Pelvic congestion syndrome. UpToDate May 08, 2017.

Ovarian vein anatomy
Right ovarian vein:
Drains directly into IVC
Courses inferiorly in relation to
pelvic venous plexus
Left ovarian vein:
Drains into left renal vein
Courses inferiorly in relation to
pelvic venous plexus
Internal iliac veins:
Communicate with pelvic
venous plexus
Knuttinen MG et al. AJR 2015; 204:448–458

Transverse scan of normal ovarian vein
Lemasle P et al. Phlebolymphology 2017;24(2):79–87
Ovarian vein located on
medial side of psoas muscle
Psoas muscle is the best anatomical landmark
Ovarian vein located on
anterior side of psoas muscle
Lower part of ovarian vein Upper part of ovarian vein
Psoas
Psoas
Iliac vessels
Iliac vessels
Ovarian vein
Ovarian vein

Longitudinal scan along left ovarian vein
Labropoulos NL et al. Phlebology. 2017;32(9):608–619.

Normal left ovarian vein
Normal left ovarian vein
Duameter of 5.4 mm
Longitudinal view of left ovarian vein
Normal antegrade flow

Reflux in left ovarian vein
Normal flow after compression
distal to imaging site
Retrograde flow after release of
compression
Retrograde flow in left
ovarian vein
Color duplex US of left ovarian vein

Anatomy of May-Thurner syndrome
LCIV: left common iliac vein – RCIA: right common iliac artery
https://www.ardms.org/may-thurner-syndrome-what-sonographers-should-know/
Normal anatomy of iliac veins May-Thurner syndrome
Compression of LCIV by RCIA

• Stage 1: asymptomatic
Iliac vein compression without structural vein changes
• Stage 2: can also be asymptomatic
Venous spur formations which restrict blood flow and increase
risk for edema and deep vein thrombosis.
• Stage 3: symptoms begin to emerge
Obstruction causing deep vein thrombosis, edema, & formation
of varicose veins
Stages of May-Thurner syndrome

May-Thurner syndrome
Compression of left
CIV by right CIA
Stage 1 Stage 2 Stage 3
Diffuse atrophy
of left CIV
Cordlike obliteration
of left CIV
CIA: common iliac artery – CIV: common iliac vein
Narese D et al. Transl Med UniSa 2015;12(5):19–28.

• Second or third decade of life – More common in women
• Acute presentation: left CIV thrombosis, iliac vein rupture, PE (rare)
• Chronic presentation: chronic venous insufficiency, chronic leg
pain, skin pigmentation, phlegmasia cerulea dolens, skin ulcers
• Noninvasive diagnostic tests: color Doppler US – CT – MRI
• Invasive diagnostic test: contrast venography – intravascular US
• Medical therapy: anticoagulation with compression bandages
• Endovascular therapy: percutaneous transluminal angioplasty + stent
• Surgical therapy: failure of endovascular therapy
Narese D et al. Transl Med UniSa 2015;12(5):19-28.

40-year-old woman with left lower extremity pain and swelling
Acute May-Thurner syndrome
Mathur M et al. Circulation 2014;129:824–825.

Phlegmasia cerulea dolens (PCD)
Surgical emergency
Thrombosis involves deep, superficial, & collateral veins
Thrombosis extends into capillaries in 40 – 60 % of patients
Irreversible ischemia, necrosis & gangrene
https://www.grepmed.com/images/489/phlegmasia-clinical-cerulea-dolens-liftl-dvt-im

• Features of color Doppler US:
- Small LRV in transverse view at level of crossing by right ICA
- Asymmetry in comparison to contralateral vessel
- Elevated velocity& continuous flow in stenotic segment
- Diminished responses during valsalva & compression maneuvers
• Study of iliac veins challenging in some patients: obesity – gas
• Higher diagnostic accuracy of CT/MRI for venous compression
Doppler US in May-Thurner syndrome
Murphy EH et al. J Vasc Surg 2009;49:697–703.
If diagnosis suspected by US: cross-sectional imaging is needed

Compression of LCIV at level
of RCIA (blue)
Increased velocity near site of
compression (51 cm/s)
Continuous flow in normal respiration
Murphy EH et al. J Vasc Surg 2009;49:697–703.

Compression of left common iliac vein (LCIV)
by right common iliac artery (RCIA)
May-Thurner syndrome stage 1
Color Doppler ultrasound Power Doppler ultrasound
RCIA
LCIV
LCIV

Huynh N et al. J Vasc Surg Cases 2016;2:46–9.
Venous color Doppler US
Same flow direction in left common
femoral artery and vein
Complete reversal of flow toward
lower extremity in the vein
Severe left lower extremity edema
Two areas of skin ulceration
on left anterior calf
Cyanosis in left toes
May-Thurner syndrome stage 3
Lower limbs

Treatment of May-Thurner syndrome
Self-expanding stent in
left common iliac vein
Narese D et al. Transl Med UniSa 2015;12(5):19-28.
Palma operation with autologous
saphenous vein graft
Endo-vascular treatment Surgical treatment

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