Interesting Vascular Cases - HD

Introduction

We're gonna cover a balance of a couple cases you've already seen. You'll take it as unknowns and a couple pretty atypical cases that you may not have ever seen.

I do have disclosures as listed above.

Case 1: 30-Year-Old Woman with Renal Pseudoaneurysms

We're gonna start with the 30-year-old woman with renal pseudo aneurysms.

Image of the right kidney. Anything wrong with this kidney? Diffusely echogenic. That's right. Kidney that's left kidney diffusely echogenic shadowing behind.

Anybody wanna go ahead and throw out the diagnosis? Angiomyolipoma. Good. Echogenic fatty, right? What about now? Liver lesion. And then two video clips.

This is showing you that IVC with similar echogenic tracking all the way up into the IVC. And then your last video, this is through the liver. So innumerable small echogenic foci throughout the liver. Tuberous sclerosis. Good. But what else beyond tuberous sclerosis?

So these are angiomyolipomas, gigantic angiomyolipomas. You can see the pseudoaneurysm, which is bled in this one. And it's known for having multiple angiomyolipomas.

I'm gonna draw your attention to this fatty thrombus going up into the IVC and then it's showering these small little fatty lesions throughout the liver. So this is an invasive angiomyolipoma. So little pieces of the material showering into the liver.

Combination of ultrasound and CT criteria. Very rare. We've only had a couple of cases of this at UAB, but maybe three or four since I've been there. This was the patient with that bleed is what brought them here.

And so this was the selective artery angiograms showing the multiple round pseudo aneurysms. This is why they bleed. So it's not the angiomyolipoma itself, it's the small dysmorphic vessels within it that lead to the hemorrhage combination of smooth muscle adipose and blood vessels.

And then again, risk of hemorrhage in these patients.

All right, that's probably gonna be the weirdest one that we'll see today.

Case 2: 50-Year-Old Male with Renal Transplant Dysfunction

50-year-old male with a renal transplant dysfunction. And by the way, I'm not gonna go slow just to keep us here the whole time. So if we get done and you're participating well and gimme the answers, we're gonna move on through we all right.

This is transplant kidney. So if you've been in here, you should know the answer. What is the answer? So yes, the answer is renal vein thrombosis in this case, but I'd rather you had said reversal of diastolic flow because we've got a little bit of a difference here.

This is the second version, second picture from it. We've got a continuous waveform of reversal diastolic flow. So this is not just a little blip, this is continuous.

So this goes along with the original works of Buter and Covea Buter. When they first saw this very first time they ever saw this, they said This is renal vein thrombosis. That's what this is. It's always gonna be that.

Well, Veia came along and said, well, not so fast. Not so fast. It can be renal vein thrombosis, but it could be a number of other things that can also cause that very high resistance.

I will go ahead and tell you in this case it is renal vein thrombosis and here is the CT that was done with contrast, even though I would not have prefer to have it happen that way.

And you can see this round filling defect right here. Wow. Consistent with the renal vein thrombosis. So renal vein thrombosis visible clot is actually the best sign if you can see the clot in the vein. And transplant kidneys are actually very superficial. So you often can actually see the vein really well.

But reversal of diastolic flow is very common and it should be throughout diastole, not just a little blip. Transient really is not predictive at all.

So here's the difference. We looked at 5,089 renal transplant ultrasounds over a 10 year period. So we're doing about 500 a year and we looked at every single case. No predisposed, no bias, not looking up a lit search, not looking up reports, every single case.

And we identified only 59 out of 5,000 patients. Well, here's the problem. All comers, 30 of them on the final EMR path biopsy surgery, clinical follow-up. The final diagnosis was severe rejection. 25% was due to a TN and only 10% was due to renal vein thrombosis.

Now you say, well what about, maybe it's because you're anywhere from one to a year. What if it's only in the first few days? You are gonna have a higher chance of it being a renal vein thrombosis in that first 24 to 48 hours. And in that case, one of the six cases, 16% actually was a renal vein thrombosis.

So even then though, it was less than a TN. If you take less than 30 days, it goes down to around that 10 to 10% rate. Because again, even by 30 days our rejection was overwhelming renal vein thrombosis as the etiology.

So I want, even though when you're taking a test or evaluating this and you're saying what's the most common type, yeah, it's rejection that's gonna be, but I want you to keep in mind in that first early phase, you still need to be very cognizant of renal vein thrombosis and you still have to chase it.

Here's the other problem is if it's rejection, they do terribly. Most of these kidneys will go on to failure because most of these are not caught in that first 24 hours when they're, I mean if you're monitoring them every hour and seeing every little thing and you catch it instantly they've got a chance.

But after a couple days they're not checking every few minutes. Every hour. And if it sits there for a little while, the kidneys just do not do well.

Renal vein thrombosis 80% and the only one that survived was within 24 hours. Acute rejection was 27% hematoma and kink. The good news about a TN and hematoma are kink is they do great and especially in that first 24 hours, half of the cases were due to hematoma.

They go in, they take out the hematoma just like Dr. Grant said. And it does beautifully. But if it is rejection or RVT, not so good.

Again, 5,000 cases prospective 4,000.

Case 3: 40-Year-Old Male with Scrotal Pain

Next patient is a 40-year-old male with scrotal pain. Right side, left side. Any ideas, thoughts, anything catch your eye that is a little subtle until I give you your last picture, but focals, huh? Focal zone. Focal zone is right in there and that's why you've got more flow Superficial.

What do you think of the scrotal wall skin? A little thick, right? Perhaps maybe the focal zone is causing the flow in the anterior testis to be more hyperemic. But then we get this right next door to it. Now what are we thinking? Yeah, these are bubbles of gas.

This is Fournier's gangrene, multiple bubbles of gas in the subcutaneous tissues. Scrotal wall thickening may be some inflammation of the adjacent testis. But remember the testis actually has a different blood supply. So it would be an innocent bystander effect due to the surrounding inflammation.

Occurs in diabetic. Elderly men. This person was a little younger than you'd typically see it in. This does require surgical debridement.

Ultrasound findings are scrotal, wall thickening, subcutaneous gas ed grant talked about that dirty or he used another word for it other than the dirty shadowing. But the shadowing that's not a pure clean shadow. And then looking for hyperemia on the doppler, just as another example, this patient did not have Fournier.

This one was a case where the shadows were a little darker and this was calcifications in the subcutaneous fat was the diagnosis. Dermatomyositis. So again, clinical, you're not gonna mistake these two patients. They're gonna have a clearly different symptoms set. And this was down in the knee area as opposed to the perineum.

Case 4: Patient with Right Epididymis and Testis

All right, new case. This is a patient with a picture of the right epididymus. An testis. What do we have here? Large tortuous spiral varix. Intratesticular Varix. Very good. I like it. The left side was normal. Now what? Look up at the kidney. Here's your mass right here.

So when you have an isolated right-sided varicocele, especially in someone over age 40, you need to look up top to either see is there adenopathy or some type of mass that's blocking the flow. There's actually more recently they even talk about a new onset of a left side varicocele. Then you also should look for adenopathy or retroperitoneal process.

It's more common on the left. Dilate veins are somewhere between two and three millimeters. That's still up for debate. Even among experts, increased dilatation does occur during Valsalva and it also can occur if you stand them up.

Sonographers really don't enjoy that part of the exam. So they're always hoping that they valsalva real well so we can go ahead and see it while they're laying down.

And then there's actually, I've not confirmed this myself, but there's one study that shows if you have a retro aortic left renal vein, there's probably partial compression of it because their rate of varicocele on the left was three times the normal population, which actually sort of makes sense.

Case 5: Great Saphenous Vein Thrombus

Okay, what's the diagnosis? This one's tricky. Yell it out. All right, how about now? Oh, sorry. Yeah, how about now? A few seconds later. Yeah, so had the scale, had the gain turned the wrong, not quite optimized. And now that we've got a better showing of it, now we've got focal thrombus filling the great saphenous vein, not greater saphenous vein.

Great saphenous vein since what, 2002? Somewhere like that? Yeah. So this is great saphenous vein actually going into the common femoral vein. And then this was just with some color to show it even a little bit prettier.

So what you need to understand about this thrombus that I just showed you is it's a superficial clot but even if it's not actually going into the common femoral vein, it has to be treated as a DVT study anytime it's within four centimeters.

And then there's actually the task study that suggested even if it's a little bit longer, I mean a little bit further away, but a long thrombus, then it would benefit from being anticoagulated.

So if you see a great saphenous vein thrombus within four centimeters of the insertion, it's still gonna be treated. So you still ought to let your doctors know that it is classified more as A DVT.

Case 6: External Carotid Artery with Reversed Flow

Alright, new patient, right? External carotid artery longitudinal view. Internalized, Okay, internalized flow. Alright, internalized flow. I think I heard someone going to an answer, but what's the way, what's interesting about the waveform other than it's collateralized, it's low resistance tardus and it's flowing in reverse.

It's above baseline going down toward the feet. So reversed collateralized flow of the ECA. So you say well how did that happen? Here's the ICA. Mm-hmm I, so the ICA is going antegrade toward the brain.

So now we've got reversed ECA antegrade ICA and then here's your CCA no flow in the CCA. And then if you didn't believe it, obviously you know more sensitive with power doppler. So we put on the power doppler and again we show no flow within this common carotid artery.

So how does the flow get there? It finds its way from the other side to it and usually it's either gonna be the ophthalmic branches or thyroidal branches causing collateral flow from the contralateral side.

Alright, any questions on that? We good?

Case 7: Main Renal Artery with High Resistance Waveform

Alright, you've had a suggestion of how to get to the answer of this one, but we'll see if you get there. So main renal artery, this is in the hilum. What's wrong with the waveform? Yeah, actually I appreciate everybody's actually chiming in and answering. Thank you. 'cause I've had talks like this before and it's just silence and I would have to pay somebody over there to yell out something.

So high resistance, very high. I mean this is zero diastolic flow. So this is a resistive index of one that's in the main, this is the upper pole, same kidney swollen, so it looks like rejection, right? And then again, no diastolic flow. Mid portion, same thing. Lower pole normal resistive index is 0.66.

So why do we have high resistance throughout the kidney? But the lower pole is actually normal pushing too hard's a good thought. Not in this case though, but two arteries. So an accessory artery.

So say you had a lower pole artery with a stenosis so that you had high resistance everywhere else, but the low post stenotic flow was allowing it to come down to normal. Is there another way that you could bypass all that resistance of the rejection? Maybe after some procedure that I may have AV fistula, right?

So I asked the sonographer for Karen to go back in, she gave me the vein and here we have a low resistance arterialized waveform in this lower pole branch. So we had diffuse rejection but the fistula allowed it to come back down into the normal range, which is sort of what Dr. Grant showed you in a similar fashion with his case K 10 to 15% frequently in the lower pole because that's where we biopsy.

And then if it's bad enough it can actually cause allograft dysfunction like he was talking about. It can steal blood from the rest of the kidney. You wanna look for that arterialized venous flow and also that tissue reverberation that that he showed you.

Case 8: 38-Year-Old Female with Carotid Bruits and Hypertension

Alright, all right. 38-year-old female with carotid bruits and hypertension. Here's another one that you should get. Say it again. Arteritis, smooth diffuse wall thickening. I can go with that. Pretty normal flow there, right? Pretty normal waveform. Still pretty normal waveform.

So even though we've got this wall thickening, we're our waveforms are pretty good. But look at this wall, I mean that is absolutely impressive. And notice it's a little bit echogenic.

So what type of arteritis? Takayasu arteritis. So yes, this is Takayasu, it's a granulomatous vasculitis younger age group. Strong female pre predilection about nine to one ratio.

Look for the smooth it can be actually a little hypoechoic, but more typical in the literature is that macaroni sign with the echogenic linear appearance. Often long segment, not very regular. It's a nice smooth long segment.

And then the velocities, if you're not too tight, your velocities will actually have normal waveforms on the color and spectral doppler.

Case 9: 20-Year-Old Male with Progressive Weight Loss and Severe Pain After Eating

Alright, 20-year-old male with progressive weight loss and severe pain after eating this, it's just showing you the aorta so that it's not some inflow. Cardiac problem, the aorta looks nice and normal.

This is celiac artery and SMA celiac SMA because why are you saying that? And not a stenosis 20 years old, right? Okay, they're 20 years old, so who's gonna get, I guess they could have had a dissection, but you know, who's gonna really get arterial atherosclerotic disease that bad in 20 years old.

Also, it's got a little bit of that angulation that we worry about the shepherd's crook type of picture. And again, this I think shows it a little better with the post stenotic dilatation and no shadowing plaques in that region.

So yes, median arcuate stenosis, median arcuate ligament is a good thought on this. This is just showing the flow beyond the narrowing where you've got a low, I'm sorry, high velocity low resistance waveform going into that redundant dilated segment.

Younger patients, usually thin females, so, and especially people who have lost a lot of weight. So that angle of the SMA and the celiac artery can change worsen symptoms with exertion.

You're gonna get a J shape appearance because the top edge of the celiac artery is being touched by your median arcuate ligament. So if the artery is like this, if you breathe in real deep, the lung comes down and straightens out the artery.

If you blow your breath all the way out the lung rises and that artery angulation is accentuated. So that's why we do the inspiration expiration to look for the two to one ratio because if the velocity stays the same, then you're thinking fibrotic stricture, right? But if that changes now it's a functional positional effect.

It's formed where the diaphragmatic crura fuse at the crura of fuse at T 12 to L one. It's usually a centimeter above the celiac artery, so causes no problem. And then it may compress in a subset of patients, so many of you're ultrasound specialists, but I still wanted to show you the ct.

So you can see this median arcuate ligament coming across here. And then as we come down, you'll see it touching this anterior surface of the celiac artery with the focal narrowing. And if you don't believe me on that, we'll show you the coronal.

Here's the right crura, here's the left crura and it's touching right on top of it. And if you still don't believe me, here's that shepherd's crook angulation and touching at the level where it's coming out.

Another thing is, if you fix this, a lot of times the velocities get better. Now not everybody gets better clinically, so that's why there's controversy on it. But the actual mechanical velocities, you can fix this.

So three different studies all looked at the velocities before a repair and after. And you can see in every case the average velocity was above the threshold that you were told for celiac artery stenosis, right? 200 above.

And every time after the repair, it was backed down to a normal value. In a series of 18 patients who had a surgical repair, 73% had complete resolution of symptoms after the repair. And this with a mean follow up for at least three years controversial because you can see some of that effect even on a normal patient.

Now if you see, you're not gonna see post anoc dilatation, but you may see a little angulation there, even in a normal patient. Plus it's not involving the SMA. So if you're considering single vessel disease is unlikely to cause symptoms, you're not sure why would it therefore cause symptoms if only one vessel is being involved?

And also the success rate varies. One meta-analysis literature review though showed from the studies 82% success. So there is something there.

Case 10: Hematuria with Nutcracker Syndrome

All right, hematuria, this is I think one of my last cases, not cracker syndrome. Yes. So here is the artery immediately past where it crosses, I mean, sorry, here's the left renal vein where it crosses behind the SMA and the aorta right as it's about to come into the IVC. And then here it is a little more to the left.

So this is coming from the kidney before it gets to the SMA and you have this dilated vein coming to a very tapered vein. Then we can look at the velocities. And again, if you look at that inflow vessel here, only 12.6 centimeters per second, and then we have like eight to 10 to one ratio once we get to the area where it's coming behind the SMA.

So this elevated velocity and the difference in the size goes along with Nutcracker syndrome as you said. Here's the slow flow coming into the level of aliasing at the transition point.

Here's the CT for those who don't love ultrasound, which I hope you've already gone out to enjoy the day. It can be an etiology for hematuria. You should not really call it if there's no renal vein dilatation or no beaked appearance.

And then it can really solidify the diagnosis on CT if there is a delay of enhancement of the left kidney compared to the right. But that beak like appearance ultrasound criteria would be the dilated compared to the com collapsed of a four to five one ratio, peak velocity ratio of the two of greater than four to five.

And if you use both of those with a cutoff of five, sensitivity of 90% and a hundred percent specificity. And the three studies are listed here, some people look at the angle of the SMA takeoff because what's gonna happen is as you lose weight and that SMA angle drops, there's not as much space for the renal vein to go through.

So if you're less than 45 degrees upright, or if you're supine less than 23 degrees, these are criteria that can help you diagnosis.

Summary

So in summary, not every case is black and white. If you keep your eyes open, you're gonna eventually find a colorful gemstone. And so turn that doppler on, use that spectral, you're gonna find more vascular structures, especially if you're looking for 'em.

Thank you for your attention.