DISCLOSURE TEST YOUR WAVEFORM IQ. Partial volume artifact. 86 yo female with right arm swelling, picc line. AVF on left? Dx?

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Evelyn Stevens
5 years ago
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1 Deborah Rubens University of Rochester Rochester, NY DISCLOSURE Neither I nor my immediate family have a financial relationship with a commercial organization that may have a direct or indirect interest in the content of this presentation. Imaging Sciences 86 yo female with right arm swelling, picc line. Partial volume artifact PSA incidentally discovered Thrombin x 3 AVF on left? Dx? 51 yo diabetic with syncope DX? 1

2 44 yo male with right monocular vision loss Gray scale image shows extensive plaque in the ICA Spectral tracing of the CCA has a normal waveform with a PSV of 51cm/sec Prox ICA normal waveform shape, velocity is 58cm/sec ICA/CCA ratio is 1.1 Distal ICA waveform is tardus parvus, velocity 14cm/sec ICA/CCA ratio (14/51) =0.3 How do you report this? Severe Stenosis Velocity increases as diameter reduction increases from 50 to 90% If stenosis is near complete, velocity will drop Diagnosis: Severe Stenosis 72 year old male with abnormal mental status Abn grayscale Low velocity flow Tardus parvus waveform 2

No diastolic flow Right ICA: Normal waveforms and

Stenosis of the LT CCA with low velocities: do a CTA

evaluate intracranial circulation Dx: Intracranial

knocking waveform is characterized by diminished

diastolic flow Knocking waveforms occur proximal to

indicating patent artery This patient had an

an acute stroke Abnormal signal indicating occlusion

irregular waveform Abnormally low peak systolic

cycle This patient suffered a traumatic aortic

arteries The waveform tends to be bizarre, highly

3 Q: What to do next? Left ICA: Small, blunt percussive waveforms Low PSV No diastolic flow Right ICA: Normal waveforms and PSV No Significant Stenosis: exam is complete Severe Stenosis of the LT CCA with low velocities: do a CTA Thorax and Neck More distal stenosis or occlusion: evaluate intracranial circulation Dx: Intracranial ICA occlusion 45 year old male with a bruit A knocking waveform is characterized by diminished peak systolic velocity and absent or even reversed diastolic flow Knocking waveforms occur proximal to an occlusion or severe stenosis Normal flow void indicating patent artery This patient had an occluded left internal carotid artery, resulting in an acute stroke Abnormal signal indicating occlusion of the artery Carotid dissection Highly variable, irregular waveform Abnormally low peak systolic velocity Bidirectional flow throughout the cardiac cycle This patient suffered a traumatic aortic dissection with extension into both common carotid arteries The waveform tends to be bizarre, highly irregular, and dampened Waveforms will vary according to the extent of the dissection and relative sizes of true and false lumen 3

63 year old male with abnormal physical exam Low velocity

CCA, ICA and vertebral arteries Waveform has 2 peaks, one

reversal at end diastole (arrow) Intra-aortic balloon pump

balloon causes 2nd peak of forward flow during early

deflation of balloon 23 year old male with chest pain and

deceleration Reversed early and enddiastolic flow,

systolic velocity Aortic regurgitation The water hammer

waveform is characterized by: sharp systolic upstroke with

4 63 year old male with abnormal physical exam Low velocity waveforms in the left and right carotid systems, involving CCA, ICA and vertebral arteries Waveform has 2 peaks, one in systole and the second in early diastole Diastolic flow reversal at end diastole (arrow) Intra-aortic balloon pump Mid systolic retraction due to pressure drop Inflation of balloon causes 2nd peak of forward flow during early diastole Flow reversal at end of diastole corresponds to deflation of balloon 23 year old male with chest pain and bruit c/o L Scoutt Sharp systolic upstroke and rapid deceleration Reversed early and enddiastolic flow, indicating a widened pulse pressure Markedly elevated peak systolic velocity Aortic regurgitation The water hammer pulse may be seen with severe aortic regurgitation This waveform is characterized by: sharp systolic upstroke with steep drop in late systole reversal of flow in diastole markedly elevated peak systolic velocity 4

5 49 year old male undergoing heart transplant evaluation Marked tardus parvus waveforms in all vessels Low peak systolic velocity No flow below the baseline Findings should be reproducible in the femoral arteries Left ventricular assist device Blood is diverted from the left ventricular apex and propelled by a pump through a graft into the aorta Most devices in current use provide continuous, forward flow throughout the cardiac cycle Abnormality? Left portal vein antegrade, right portal vein retrograde. Portal Hypertension with Collateral 48 y.o. male, GI bleed Transverse midline 5

6 Diagnosis: Tumor Thrombus Tumor Thrombus Hepatic artery Portal vein with thrombus Tumor artery Often has visible flow within thrombus Don t mistake residual flow in nonocclusive clot (portal vein wave form) with true vascularized clot (hepatic artery wave form) Tumor within portal vein CT shows occlusion of the portal vein with tumor. Histology demonstrated tumor throughout the liver and in the portal vein CHF 45 yo M with weight loss and diarrhea, r/o mes. ischemia Increased RA pressure reflected in TIPs, IVC, PV PV pulsatility of greater than 50% Severe cases have systolic flow reversal 45 yo M with weight loss and diarrhea, r/o mes. ischemia Dx Criteria: PSV Celiac >200cm/sec SMA > 275 cm/sec IMA > 200cm/sec Ratio > 2.5/3:1 ACR guidelines 2012, Pellerito JUM 2009 Diagnosis? Low resistance in CA Prominent IMA Color bleed over stenosis Dx pancreatic CA invading mesentery 6

7 Low RI s- HAS? False Positive: Intraparenchymal Shunting Reperfusion Injury First 48 hours post op High velocity diastolic flow May also have tardus parvus waveform Reverses on its own Post Operative Day 0 Post Operative Day 1 Assymptomatic Patient Low RI s Dx: HA-PV Fistula HA- PV Fistula Common Complication Most Asymptomatic Seen in up to 50% of patients within 1 week post biopsy Less than 10% persist beyond a week Most close spontaneously Saad WEA, Lin E, Ormanoski M, Darcy MD, Rubens DJ. Noninvasive Imaging of Liver Transplant Complications.Tech Vasc Interventional Rad 10: , PORTAL VEIN THROMBOSIS? HEMATOMA COMPRESSES MPV No detectable flow in the MPV with reversed flow in R and LPVs? Doesn t make sense. What to do? Get a CT. 7

8 FOLLOWING DECOMPRESSION S/P liver Txp, poor fxn Post Coiling Immediate 24 hours later Arterial Steal Syndromes? Consequence of excess PV flow Dx by arteriography-low flow into allograft US shows elevated RI s with low velocity or loss of HA flow signal, loss of diastolic flow most specific Angiography demonstrates increased flow to the splenic a. or gastroduodenal a. Rx includes splenic artery embolization Garcia-Criado AJR 2009;193(1): Sanyal and Shah JUM 2009:28: Day 0 45 yo M, Rising LFT s p/bmt Very poor flow in the parenchyma with tardus parvus waveforms 3:1 ratio Dx? Arterial compression syndrome Following revision returns to normal VOD? Portal Hypertension? PV Stenosis? Thrombosis? 8

9 Bilateral Leg Swelling CHF Waveform extremely pulsatile Large extent above baseline (towards feet) Conclusions THANK YOU Waveform shape and velocity both contribute to diagnoses Technique important to insure proper waveform Waveforms reflect local disease as well as proximal, distal or systemic abnormalities Waveform expertise makes you a Doppler star!! 9

Ultrasound Imaging of The Posterior Circulation

Ultrasound Imaging of The Posterior Circulation Michigan Sonographers Society 2 Nd Annual Fall Vascular Conference Larry N. Raber RDMS-RVT Clinical Manager General Ultrasound/Neurovascular Laboratory Cleveland