Vascular Cases - HD

Introduction

I am Dr. Deborah Rubins. I'm from the University of Rochester.

And today I am gonna be talking to you about some unusual and challenging vascular cases many times where we didn't make the right diagnosis.

But I'm hoping by our examples that you will make the right diagnoses in the future.

I have no disclosures.

First Case: Abnormal Waveform in Left Common Femoral Vein

Our first case, patient being examined for rule out DVT, and you can see an abnormal waveform in the left common femoral vein compared to the normal right sided common femoral vein.

And the question is, is this an AV fistula? What's going on here?

What can you do to figure this out?

And I'm gonna give you a couple more images and you can see here when you image it a little further in the left common femoral vein, you can see that actually there is an arterial waveform sitting here as well.

And you can see over here, this is the left common femoral artery waveform.

So this is the alias left common femoral artery wave form.

So how did this vascular pattern arise?

As it turns out in this patient, the common femoral vein and common femoral artery are very close together.

And if you sample in the left common femoral vein too close to the wall adjacent to the common femoral artery, you can get this abnormal wave form.

So we repositioned the cursor and back into the middle of the vessel, more like in here, and you get the nice normal common femoral vein wave form that you have on the right.

So this is a partial volume artifact because your ultrasound thickness of your slice is not infinitely thin.

And even if you're sampling here, you may actually be sampling part of the artery as well, but not see it in your picture.

True Arteriovenous Fistula

True arterial venous fistula.

This is a patient where we are also doing a DVT study, does have an arterialized waveform.

But you can see here that there should be a communication as you can see it here coming from the artery.

And you can see here as you sample in the communication, you get artery and vein together.

You can actually get the passageway between the two, and you get this very, very high velocity, 200 centimeters per second area, with a lot of noise and vibration of the adjacent tissue.

And you can see here, the normal vein up higher, on the left, again, normal waveform low velocity, the common femoral vein on the right as you go above the area of the fistula, you can still see an arterialized waveform and much higher velocity flow.

Next Case: Shoulder Dislocation and Arm Swelling

Our next case, this is a 43-year-old man who had a shoulder dislocation and relocation and his arm was swelling.

And they asked us to exclude a deep vein thrombosis.

So the sonographer came back with these images, the right subclavian vein.

You see very, very, very poor flow in it.

It seems patent, but very slow flow.

And here in the axi there is a very, very large, dilated sort of elliptical structure, that the sonographer thought was the axillary vein.

You could see the axillary artery sitting right on top of it.

And the question is, what is the diagnosis here?

You can see he's labeled this axillary vein.

And this is critical here.

This is that it's three centimeters in size.

So your diagnosis, the sonographer thought this was a DVT.

This was carried on from the sonographer through the resident, through the faculty member, and the patient was placed on anticoagulation.

Now, a couple of days later, after anticoagulation, the pain and swelling were increasing.

So they asked us to come back.

And now this mass is about six by four and a half centimeters.

It's gotten bigger and it's more hypoechoic.

And this is almost doubled in size and a different sonographer found slow flow in basically the normal axillary vein.

So what was this? This was a very, very large hematoma.

This patient was treated unnecessarily.

He actually had a brachial plexus injury from this unnecessary anticoagulation.

So it just bears in mind that you need to be pretty certain that you've got a DVT.

You don't want to treat patients unnecessarily.

You can do harm with that.

And the pearl here is that no normal axillary vein is three centimeters in size.

If you see a vein that's that big, it must be either aneurysmal or it's probably not a vein.

And search harder to find the real vein that's there.

Another DVT Study: Leg Swelling and Hypoxia

Here's another patient. This is another DVT study.

We do a lot of these.

Patient has leg swelling and hypoxia.

And the question is, is this chronic change in the wall of the vessel or is it acute?

And the sonographer came back and thought this was clot.

But when we look carefully, you can see that there's an area here that's sort of symmetric on both sides and the vessel bulges a little bit.

And if you look even more carefully, you can see that there's a valve here.

So how did we make this fill in with color here?

And what is really the diagnosis?

So this is slow flow behind a valve leaflet.

And what you do here is actually augment the calf and you can actually increase the flow through the vessel and get the retrograde flow in behind the valve to show that there is not a clot there.

So we confirm the slow flow of the valve by augmentation.

You also should be able to see this by compression.

Unfortunately in this patient there was so much leg swelling that the sonographer wasn't able to compress this area very well.

So if you can compress in the area, then you can also prove that there's no clot.

Postoperative Leg Mass

This is another patient who had pain, has had surgery on her leg about two months ago.

And you can see a mass here that is hypoechoic, has some internal echoes, slightly irregular, and you can see a vessel behind it.

Now we always talk about is it vascular or nonvascular?

And the idea here is that you wanna be seeing vessels in the picture to be sure that you're actually imaging with the correct technique to look for vascularity.

So the sonographer came out and said, I've got a vessel here and I've got a vessel here.

This is just a hematoma and there's some through transmission, right?

The conclusion coming outta the room was it was a postoperative fluid collection.

So what's wrong with that reasoning?

Well, the problem is that this is a pretty big vessel.

And if you are seeing this vessel, you may not be optimized for very small vessels that are within this area here that even may be more superficial.

So again, we're taught that if you can see a vessel deep to something that you must have be able to see the vessels that were in it, but you really still have to optimize for slow flow.

So here's our image again and what happens when we change our frequency of our color and go up to six, we were at three.

All of a sudden you can see vessels in this mass.

And this is not a postoperative fluid collection.

This is actually a solid mass.

So this needs higher frequency for better sensitivity.

You really have to optimize for slow flow and you always wanna confirm with spectral doppler in case you're just moving your transducer a little bit and creating some noise.

So here we can see that this has got an arterial waveform.

And yes, indeed, this is actually a malignancy.

This was a melanoma recurrence just two months from the original surgery.

So proving solid masses, you have to maintain a very high index of suspicion in a patient, especially with a history of malignancy.

You wanna confirm the flow with spectral doppler.

If there's absent flow, you may have improper doppler settings or technique and or it may be a necrotic lesion.

And if you have a high index of suspicion, if the edges are irregular, if it doesn't look like a typical hematoma you wanna be using with another modality or even use ultrasound contrast off label to get better sensitivity for that slow flow in those small vessels.

Popliteal Fossa Mass

Okay, this is another patient rule out DVT.

He's a 67-year-old man and he has a 3.7 centimeter mass in the popliteal fossa.

Okay?

And you can see here it's about, it's relatively hypoechoic, and it's been labeled left popliteal artery.

So this does actually communicate with the popliteal artery and you can see it's quite irregular.

It's got a lot of calcification, there's no flow in the mass.

So what should you do next?

And the answer is you should look at the other side.

And you should look at the distal runoff.

So here is the left posterior tibial artery.

You can see that there's flow distally, but it's tardus parvus.

And here is the other side. Here is the right side.

And lo and behold, it looks identical.

So there's a big mass here in the popliteal fossa.

It is the popliteal artery.

It has absolutely no flow in it, and we're going to look distally as well here on the right side.

The tardus parvus waveform is apparent also in the anterior tibial artery.

So it's a reconstituted distal vessel.

So we've got bilateral popliteal artery occlusions with some distal runoff, but not great flow or perfusion to either foot.

What should we do next?

And the answer is you have to look up in the abdomen.

So here's this patient's aorta.

You can see he has an eight centimeter abdominal aortic aneurysm.

It is just huge. It's only a centimeter or so from the skin, but somehow nobody ever felt this guy's belly.

And he is just a disaster waiting to happen.

You can see it here on the CT, a giant aneurysm waiting to rupture and here it is as well.

So it's interesting, the aneurysms in the abdomen tend to rupture when they get big.

The popliteal artery aneurysms tend to occlude and cause their devastation by basically by limb loss.

So these are defined as one and a half times the size of the proximal vessel.

And usually they're bigger than a centimeter and a half.

They're often bilateral more than half of the time.

And if they're bilateral, there's a very high association with abdominal aortic aneurysm up to 70%.

The major risk, as I said, from popliteal artery aneurysm, ischemia and limb loss.

So the management for these is if they are patent and if they're under two centimeters, you actually do serial ultrasound and anticoagulate them.

For our patient, it was bigger than three, two centimeters, it was three centimeters.

So this patient would need repair.

And actually in this patient emergent repair, because this patient does have acute ischemia and he has it bilaterally.

Moving to the Abdomen: Renal Vein Thrombosis in a 15-Year-Old

We're gonna move now into the abdomen moving away from the limbs.

And here is a 15-year-old gentleman with proteinuria.

And the clinicians were looking for renal vein thrombosis.

And what we first noticed is that there's an asymmetric size of the kidneys on gray scale.

The left kidney is four and a half centimeters, the right is 12.

There's also some edema around this left kidney.

So we're looking for renal vein thrombosis and we looked at the resistive indices.

They're normal, they aren't particularly helpful here.

So normal diastolic flow and the renal veins were all patent.

And here's the left renal artery.

You can see here, here's the left renal vein.

You can see the waveform, the main renal vein.

So the question for you is, what are we doing wrong?

This patient clinically has renal vein thrombosis and we're not finding it.

And the trick here is to figure out what's missing.

And if you look carefully at this image, you can see the main renal vein here and you can see some vessel up here in the hilum, but you never saw the main renal vein in continuity.

So you can see here, when you look at the main renal artery, here's the main renal vein next to it and it is occluded.

You can see it here, big thrombus within it.

So it's very hard to find what's missing.

And that's sort of the key to this case.

So we actually didn't figure this out.

We knew that there had to be renal vein thrombosis.

We actually sent the patient on to CT where you can see the same things we saw in ultrasound, but you also see the clot.

And here is the enlarged atrophic kidney with delayed nephrogram.

You can see here is the thrombus heading into the IVC.

And when we look back, we could see that the area was missing over here.

And when you look at gray scale, we brought the patient back because we were sort of embarrassed and you can see on gray scale and enlarged thrombus in this left renal vein coming in towards the IVC looks identical to the CT.

So sometimes the gray scale is your clue here.

And always make sure you can see the entire renal vein in continuity.

'Cause native renal vein thrombosis is a very difficult Doppler diagnosis.

Usually the resistive indices are not affected.

Occasionally you could see reverse diastolic flow the way you do in renal transplants, but it's not the rule.

Incomplete thrombus is common.

So you're gonna look for waveform changes and absent flow in the affected veins.

So look for areas maybe where the vessel is, where the vein is narrowed.

You might find some elevated velocities there.

And also look for differences.

For example, here you can see that the waveform is quite flat out here and then whereas at the hilum where it's reflecting what's happening in the arcuate arteries, you have more pulsatility.

So that's a waveform change you might have in retrospect at least figured out.

Companion Case: Nutcracker Syndrome

In contrast it's sort of a companion case.

Here we have another young man who has gross hematuria and anemia, and I'm gonna just show you a couple of images from him.

Here is the main renal vein coming across the midline into the IVC.

And you can see again his resistive indices on that left kidney are normal.

So we know his vessels are open.

And that doesn't seem to be the problem, but when you look at his main renal vein here as it's coming outta the kidney, you have a velocity of about 10 centimeters per second.

And as it comes into this area, as it's entering towards the IVC right behind this superior mesenteric artery, the velocity takes a huge jump up to 170 centimeters per second.

And this you can see here, you can measure the diameter of the vein.

And here it is almost eight millimeters here at the area.

It's most narrowed is almost just down to one millimeter and then it opens back up again on the other side.

So this is a patient with Nutcracker syndrome and here you make the diagnosis by seeing the compression of the left renal vein between the superior mesenteric artery and the aorta.

And this can cause hematuria or proteinuria.

So the patients could come with either and you might be asked to evaluate them even for renal vein thrombosis, but in this case not renal vein thrombosis, Nutcracker syndrome.

And the diagnostic criteria are a ratio of 4.8 to one between the narrowed segment and the hilar renal vein, which our patient certainly had.

This is more like 17 to one and a normal resistive index.

So this is entrapment of the left renal vein between the SMA and the aorta.

And as I said, the clinical symptoms can be hematuria or proteinuria or even flank pain.

And the ratio is the diagnosis.

And what we do is treat them expectantly as children because the idea is as they grow and get more fat in the retroperitoneum, sometimes that area between the superior mesenteric artery and the aorta will open up.

If it doesn't or the patient is very symptomatic, they can stent this renal vein.

And lastly, if it still is a problem, vascular surgery bypass can be performed in adults.

Optimizing Technique: Complex Renal Cyst

Alright, back to our theme of optimizing technique.

So this is a patient who comes to us from CT, has an area, a mass that has a little bit higher Hounsfield units.

And the question is, is this a complex renal cyst?

And you can see here the sonographer's got the color on and you've got the box on and you might say, well, I don't see any vessels in here, so this is not optimized.

And you would be correct. However, the sonographer couldn't really get any better imaging there.

This patient was let go because nobody noticed that at the time and it looked pretty anechoic, right?

So when the patient comes in and the next time we actually put on a different transducer.

And just a reminder, you don't have to save your high frequency transducers just for superficial studies, they can actually do quite well sometimes in thinner patients in the abdomen.

So if you wanna optimize your technique, go to higher frequency transducer.

And sure enough, lo and behold, this is a solid renal mass.

So this is a cystic renal cell carcinoma.

And again, you really, really need to optimize your technique.

All we did was we got our color frequency up just a little bit, enabled us to lower our scale, lower the wall filter slightly, and all of a sudden you can see the flow within it.

And as I said, you always wanna confirm with spectral doppler and yet those are renal arteries in this mass.

That's not a simple cyst.

This is a cystic renal cell carcinoma.

Preoperative Liver Transplant: Portal Vein Thrombosis

Again, optimizing technique.

This patient preoperative for liver transplant and you can see that he's got a cirrhotic liver, a lot of ascites so already know we're in trouble because the liver is deep and we're gonna have trouble seeing things with doppler, but we need to know whether he has a portal vein thrombosis or not.

So we try lowering our scale and you can see we're getting color noise here in the background in the gallbladder.

Our hepatic artery here is full of color and aliasing like crazy and we still don't have any flow in this portal vein, but when we look in the left lobe, you can see that there is reversed flow in the left portal vein and antegrade flow of course in the hepatic artery.

So does this make sense?

How can you have flow in one part of the system and not in another or is there just slow such slow flow that it's zero flow?

What can we do to make this better?

So we had no flow in the portal vein, but and a low scale cause noise and reverse flow in the left.

So what happens if we increase the gain?

Well, if we wanna increase the gain, we can really only increase it to the point where the background tissue shows color and then we have to turn it back.

So we're already there.

We've lowered our scale and increase our gain as much as we can.

So to optimize for slow flow, just remember that the flow is slowest as it begins to reverse.

And sometimes things reverse in the more distal, if you will, portal veins out in the liver before they reverse in the main portal vein.

So our technical options are decreasing the scale, we already did that, minimize the wall filter, not sure if we've done that yet, increase the transducer frequency if possible, but sometimes we need to decrease the frequency to penetrate better and you really don't know which one it's gonna be.

I usually increase the frequency first.

And if that doesn't work, then I try going lower.

So in our case, here's the solution.

We were starting with this transducer, which gave us this color Doppler frequency 1.7.

And by changing transducers we actually increased our color Doppler frequency, we became more sensitive to flow, it allowed us to lower our scale more.

And our wall filter is nice and low here and lo and behold, yeah, we have a patent portal vein, no clot within it.

Yes, it is reversed flow, so no thrombosis.

And you wanna switch your transducer frequency after you've optimized your other parameters first.

Another Portal Vein Thrombosis Case

Okay, here's another patient is this portal vein thrombosis.

And you can see here are some vessels here anterior to it.

Both the wall filter and the scale are high.

And here we've dropped our scale, our wall filter is lower, we're still not seeing flow.

But again now with a frequency that we've actually dropped, we penetrate better and we see the slow reversed flow so that, as I said, you can't always tell which one's gonna work.

Sometimes it's increasing the frequency, sometimes decreasing.

Have to try both to make sure that you have no flow.

Hepatic Surgery Patient: Elevated Liver Function Tests

Okay, I'm moving on to a patient who's had hepatic surgery and has elevated liver function tests.

And the question is, is there portal vein thrombosis?

So in this case we don't see a portal vein main portal vein area is always a bad sign.

If you see anything that says area, you know, your sonographer or your sonologist is in trouble and you can see lots of vessels here.

And we do see again, reverse flow in the left portal vein, nothing in the main portal vein except for hepatic arteries.

Here's the right portal vein, it's reversed as well.

So we've got, again, reversed flow out in the parenchyma of the portal system, but no main portal vein.

So what should we do next?

And if we can't see a vein, well you have to look harder for extrinsic clot or something that's compressing the vein that you just can't see it.

So when you look carefully here, there's actually a mass in the region of the porta hepatis, you can see it here as well if you look with gray scale.

So there's this ill-defined mass hematomas can be difficult to see immediately because they have lots of internal echoes and they tend to blend in with the background soft tissue.

So this patient did go on to CT and I've got arrows pointing to the compressed portal vein.

This portal vein is just tiny here, it's obliterated here.

There's a large hematoma you can see here adjacent to the liver.

This is the area where the portal vein should be.

And then down here is the confluence.

So the portal vein is still open, it's just so small and compressed that you can't see it.

So this patient does need to go to the operating room.

He went back in and they decompressed his portal vein by evacuating the hematoma and after decompression, here's the main portal vein wide open, good flow within it.

And you can see here on CT that it's being reconstituted as well.

Portal Vein Case: 60-Year-Old Man with Acute Myelogenous Leukemia

Another portal vein case for you, a 60-year-old man with acute myelogenous leukemia.

He's had a bone marrow transplant six weeks ago.

And the findings here are again, the right portal vein is reversed, but here we can see a main portal vein and it's still forward but with very, very slow flow.

And you can see here on the CT portal vein is completely open.

So what is your diagnosis here?

Well, this is actually abnormal flow.

This is sort of a focal area of portal hypertension.

Here's four weeks later, I'm gonna give you a follow up.

He got treated and now his right portal vein is now normal in direction and his main portal vein remains normal in direction, but also the flow is increased.

So what's the difference between the two?

Well, this patient has hepatic veno-occlusive disease and that involves basically the venules and bone marrow transplant patients.

They basically are obliterated or clotted.

The major veins will be normal.

So the hepatic veins will be normal and usually the diagnosis has to be made by liver biopsy.

However, they've been noted to have rapid development of patent um portal venous flow.

So this patient who previously we would assume would've had normal flow, has reverse flow in his portal veins.

Clinically he has occlusive disease, he gets treated for it.

And actually then it becomes normal after therapy.

You can see here his hepatic vein is completely normal with a normal waveform.

So the problem is out here in the liver, not actually in the central draining veins or hepatic veins.

So if you make the diagnosis with doppler, it's an unusual diagnosis to make, but you can make it and it saves the patient a liver biopsy, which is great because these people are really sick, have poor platelets and you'd like to avoid sticking their livers.

Cancer Patient with Bone Marrow Transplant: Rising Liver Function Tests

All right, another cancer patient has bone marrow transplant and rising liver function tests.

And what you see here is the main portal vein is going into the liver this direction.

But then you see an area with is this reversed flow?

Is this thrombus in the portal vein?

There's some hypoechoic material here.

Is it a partial thrombus with an area of narrowing or is this actually a stenosis?

Is this veno-occlusive disease? He's had lymphoma.

Is this something else?

The question is can you make the diagnosis?

So need to think about what could possibly happen in these folks.

So here's the main portal vein.

When you look at the waveform here, it's very, very, very, very, very flat, right?

And when you look at the area of narrowing here, or blueness if you will, it's not reversed at all.

It's actually high velocity flow.

So this is in essence a stenosis.

But then the question becomes why would there be a stenosis in this patient?

He's had no surgery, he's had no instrumentation of his portal vein.

So I think you have to think next about what can give you narrowing.

And the next thing to think about is, is there something extrinsic?

So I'll just remind you that when we're using color, sometimes the color tends to bleed over our images a little bit and we tend to forget to look in the surround.

We're so busy looking at the vessel that we don't look at what's around it.

And when you look carefully at this patient, there's a large hypoechoic mass in the porta and actually around the margins of this vessel.

The other thing to see in this patient is some mildly dilated ducts.

So that makes you think again that there is probably some kind of an obstructive process going on at the porta hepatis.

So is it clot or something else?

I'm sort of leading you here.

You can see again this mass around this portal vein.

And if you look carefully here, it is crawling all the way up into the portal and there's a huge mass, it's sitting right here, but you might not be paying attention to it if I don't point it out to you.

So this patient was referred on for CT and you can see this mass of lymphadenopathy, you can see it nicely here compressing the portal vein.

So he actually presents with elevated liver function tests from this sort of an extrinsic narrowing, if you will, of the portal vein.

And he needed, he had relapsed his lymphoma.

You can see this adenopathy in here as well.

Another Portal Vein Case: Alcoholic with Esophageal Bleeding

Another portal vein case for you.

This is a patient who is an alcoholic, comes in with esophageal bleeding and he's had variceal banding and he presents with a GI bleed.

And on the CT, they said there was they suspected portal vein thrombosis.

I'm just gonna show you the images from the CT liver here.

Here's gallbladder.

And you really don't see any normal portal vein.

Here's the aorta back here, IVC back here.

So the sonographer comes out of the room and says, yep, I see the portal vein and there's flow in it and it's going opposite the direction of the hepatic artery.

Here's the hepatic artery over here with an antegrade waveform.

Here's the portal vein, it's got a retrograde waveform.

This is a recanalized portal vein with cavernous transformation.

I'm done with the case.

And the question to you is, is your sonographer done with the case and is that the answer?

And if you look carefully at this waveform, it doesn't really look like a typical portal vein waveform.

It has some variability to it.

And so you have to be suspicious that you could be dealing with actually an hepatic artery in the portal vein.

So here what we did was we went back in, here's the hepatic artery for comparison, sent the sonographer back in the room and said, no, I don't think so.

And when you work at it a little bit, get me a better waveform.

And sure enough that looks like a hepatic artery.

So what's a hepatic artery doing in the portal vein?

Well, not anything good and it only gets there by having some tumor bringing it in.

So this is tumor thrombus in this portal vein and you can see here on CT, here is the portal vein and these are obviously had arterial signal if you will, or CT attenuation vessels that match that of the aorta.

So this was an enlarged hepatic arterial mass, if you will in the portal vein.

Notice that we don't see any other mass in the liver and that's not uncommon to have diffuse sort of infiltrating hepatocellular carcinoma, which is invading the portal vein and giving you a tumor thrombus.

So the next step for this patient is actually a biopsy.

You can biopsy that portal vein and this is tumor thrombus and it's a stage four hepatocellular carcinoma.

Mesenteric Vessels: Patient with Weight Loss and Diarrhea

Similar theme, we're gonna move to the mesenteric vessels.

Here is a patient with weight loss and diarrhea.

And the question is, is their mesenteric ischemia?

So I've given you a bunch of images here.

We start out sagittally with celiac artery in the SMA.

They both look wide open, don't they? They do due to me.

Here's the celiac axis here.

You can see the aorta in the back.

Here's the celiac with the hepatic and the splenic and we get measurements in the aorta.

It's 78 proximal to the vessels and the celiac, we got a velocity of 169 and the SMA velocity of 174.

And here is the IMA and velocity down here is 182.

So we say no stenosis, right, because here are our diagnostic criteria and they're supposed to be celiac greater than 200 SMA greater than 275 IMA greater than 200 ratio greater than three to one.

None of these are true in our case, right?

Everything is, the ratios are all less than two and a half to one.

And the velocities are all under 200.

So, but the patient still has symptoms.

So what else can we see in this? Where is the abnormality?

Well look at the waveforms.

Here's the aorta that's got nice reverse diastolic flow right here.

The SMA has a pretty good dichotic notch.

It has reasonable flow here, but it has some diastolic flow.

Celiac has a lot of diastolic flow, maybe more than it should have.

And this of course was not recognized by us.

This patient had his symptoms, we didn't answer it by ultrasound and he went on to have a CT scan.

So our diagnosis, we have low resistance in celiac.

And the other thing to mention is usually it's not so easy to see the IMA.

So the IMA is relatively prominent, but again, we get so hung up looking at the vessels and the velocities that we forget to look at the tissue around.

And if you look here, there's a hypoechoic mass, there's a hypoechoic mass sitting around this celiac artery and here it is on CT.

You can see this is the aorta, here is the celiac, here is the hepatic and the splenic.

There's a complete almost obliterated celiac.

The CT was done about a day after this ultrasound, so there was really no time lag here.

And this patient has pancreatic carcinoma, is invading the mesentery.

You can see it's hypermetabolic here, hypermetabolic here.

And that is why this patient has his symptoms and he actually does have some mesenteric ischemia being caused by this compression of these vessels.

So just a reminder to look at the waveforms as well.

Patient with CVA Tenderness: Hepatic Artery Changes

So here's a patient. This is a patient who has CVA tenderness rule out obstruction.

So we're looking for renal things and we happened to look at all of her vessels and her main hepatic artery look like this.

Now she comes in and a week later her main hepatic artery looks like this.

So based on the case I just showed you, you'd say, oh, okay, there's a problem somewhere with the main, with the hepatic arteries.

Maybe it's at the level of the celiac and you would be right because this has got very, very high diastolic flow, way higher than it should be.

The resistive index is low.

So this is a patient who's got some ischemia and is being caused by a central problem.

You can see here is the splenic artery as well.

Again, very low resistance waveform.

Usually this is well above 0.5, usually 0.6 0.7.

And so this diastolic flow should tell you that we've got a problem with the celiac.

So we looked at the celiac and there is absolutely no flow here at the celiac.

The SMA in this patient, very, very low velocity flow here as well.

Waveform is still okay, but this flow velocity is way too low.

And this is basically trickle flow through the superior mesenteric artery.

So we don't do very well with acute mesenteric ischemia.

This patient had presented a week before and we really didn't pick up anything in the hepatic artery.

It wasn't until she completely occluded her celiac that we picked it up.

So you can see here as the occluded celiac here is actually thrombus, there's thrombus in the SMV as well as partial occlusion here of the SMA.

And actually this is enough.

This patient just had very, very low flow in the SMA at the time of the ultrasound on our angiogram.

You can see a very narrowed SMA again didn't manifest as high velocity but as very low velocity 'cause it's just trickle flow now.

And then later in the run of the angiogram you can see reconstituted flow here coming through the celiac and out into the hepatic artery and the splenic artery.

So we're seeing these collaterally fed vessels, reconstituted, retrograde filling of the celiac.

Testicular Cases: Importance of Waveforms

I wanna sort of finish up with a few testicular cases.

Again, importance of waveforms.

I'm not sure everybody uses spectral doppler in, they're looking at the testes, but I wanna encourage you to do that.

Here's a patient who comes in with left testicular pain, rule out torsion and this is our typical buddy shot, right?

Testis here. Left testis is here.

Maybe slightly decreased flow in the left testis, but certainly nobody is really worried about torsion.

Here you can see some hyperemia in the epididymis compared to the testis versus sort of symmetric perfusion here on the right.

And when we look at the body and tail of the left epididymis, again, more flow in the epididymis than there is in the testis.

So you might just say, well the patient has got epididymitis, right?

What about spectral tracings?

Well when we looked at the spectral, we were shocked because here's the right test, this is the normal side and you really do need to see the normal side for comparison.

Here is the left testis and notice that you have reverse diastolic flow.

So this patient not only has epididymitis, he also has vascular compromise to this testis.

So this was his story. He had seven days of pain.

He has a UTI on his urinalysis and he's work, he works as a heavy lifter so he's probably straining and refluxing urine backwards from his bladder.

And so they gave him oral antibiotics for three weeks and sent him home.

And on a follow-up clinical exam, his testis was smaller, his urine was clear, but he still had pain.

So he came back for another ultrasound and this was four weeks later and his, this is his testis now.

And you can see there's some hyperemia around it.

But the testis itself is irregular, heterogeneous and has absolutely no flow within it.

So we went to the OR because there was no testis left actually.

And this was an abscess with acute and chronic inflammation and the parenchyma was almost entirely replaced by an abscess.

So the moral of the story here is you've got a patient with a testis that's in trouble.

Reverse diastolic flow is from severe venous compromise and it can be from parenchymal edema as it probably was in this case.

It can be from venous thrombosis extrinsic to the testis, it can be from torsion and it can even be from extrinsic compression.

But I just wanna make sure that you turn on that spectral doppler and look for this in your patients with testicular pain.

15-Year-Old with Right-Sided Pain

So here's a patient, 15-year-old with one day of right-sided pain, nausea and vomiting, right testis, reverse diastolic flow, left testis normal.

There's flow here, but this is torsion 360 degree twist.

80-Year-Old Man with Pain, Swelling, and Fever

Here's an 80-year-old man who has pain, swelling and fever, again absent diastolic flow in the right testis.

They thought he had epididymo-orchitis, they gave him antibiotics, he didn't respond and so he did surgery for pain control and on pathology he actually had venous thrombosis and no infection and he actually was worked up and found to have protein S deficiency.

So venous thrombosis causing absent diastolic flow.

Patient with Big Hydrocele

Here's a patient with a big hydrocele, but notice also that the testis is a little bit deformed.

You wanna turn on the spectral tracing and you can see here that this right testis with the hydrocele has reverse diastolic flow compared to the normal left side.

So this patient does need to be decompressed and relatively soon and after his hydrocelectomy, his waveforms return to normal.

So diastolic flow reversal is a testis in trouble.

Another Waveform: 15-Year-Old with Minor Trauma

Okay, I wanna show you one more waveform that I wanna be sure you're comfortable with and that you use in your diagnoses.

This is a 15-year-old with minor trauma and has persistent right-sided pain.

And here we see the right testis is a little bit bigger than the left.

On the transverse midline shot, it's a little bit bigger, but you can see flow in both.

But you need to turn on the doppler because this is instead of reverse diastolic flow, this is a tardus parvus waveform and you can see the slow upstroke here, low amplitude flow.

Here's the comparison to the normal side.

You can see here is what we call a positive whirlpool sign.

And in this case it's intrascrotal.

So this is sort of a snail sign.

This is another case of torsion.

14-Year-Old with Left-Sided Pain

Here's another patient, 14-year-old, he had left sided pain that got better, but now he still has swelling and pain on the left.

So you can see here's his right testis, left testis, what's this waveform?

Tardus parvus again.

So you wanna look around and you can see again this torsed cord.

Here it is here is the flow in part of the cord.

And you can see here in the portion that's closer to the testis, there's no flow.

This is another case of torsion that is partially occlusive, but there is some ischemia beyond this area of compromise.

And so the patient is presenting with an ischemic testis.

This was not recognized at the time, unfortunately patient was sent home and he came back 11 days later and you can see here now the testis is infarcted and you've got hyperemia and hydrocele.

So this testis was lost, could have been salvaged here, lost here.

Man with Right Testicular Pain

Here's another man with right testicular pain.

You can see here on the left side, there's more flow than there is on the right and the right side again has the sort of slightly tardus parvus dampened waveform, low amplitude.

Notice our settings of the same here.

Our setting goes from one to three and one to three over here.

And the left side much more robust flow.

Even though these are not angle corrected, you can see that there's much easier to detect and better flow on the left.

So 20 minutes later, now the tracing is normal.

So the question for you is, is there real pathology here or is this something artifactual?

Am I trying to trick you?

Did the sonographer learn how to do something different?

So my differential diagnosis is this epididymitis with decreased perfusion.

This is what we started out with.

This is what we ended with.

Is this technical or is there something else like partial testicular torsion detorsion.

So for epididymitis, it should be the same all the way through the exam.

Technical variability, well you can check that by looking at your color boxes and your distance from the skin and so forth.

So this is partial testicular torsion and detorsion and we actually looked at the testicle again with color after he detorses.

And you can see that there's marked hyperemia.

So partial testicular torsion, it's a, I've shown you three cases a cord twist without complete occlusion.

And you can have high resistance as we had in this patient.

You can have low tardus parvus as we had in this patient.

And if you have detorsion, you will get hyperemia when compared to the normal side.

This is another case you can see here is actually a patient who detorses before his exam and you can see a little infarct here in the back.

So this is actually probably more common than we expect and it's really important to make the diagnosis because you don't want your patient to come back with infarction.

Conclusion

So in conclusion, waveform shape and velocity both contribute to vascular diagnoses.

Technique is really important to ensure proper waveforms and to detect flow and waveforms reflect local disease as well as proximal systemic distal or even systemic abnormalities.

And with that I wanna say thank you.