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MESENTERIC DOPPLER:

OBJECTIVES

Define and describe the clinical presentations of mesenteric ischemia including

Provide sonographic technique and protocol information

Discuss interpretation criteria

Discuss common pitfalls Describe new technologyReview good practice tips

MESENTERIC ARTERIES

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Causes:

Arterial stenosis or occlusion

Venous thrombosis

Nonocclusive disease (low flow states, hypotension, shock)

MESENTERIC ARTERIES

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Acute Mesenteric Ischemia (AMI)

Severe abdominal painN/VDiarrheaSurgical emergency

Chronic Mesenteric Ischemia (CMI)

Postprandial painNonspecific abdominal painWeight lossBloating

MESENTERIC ARTERIES

Intersocietal Accreditation Commission (IAC)

• Aorta adjacent to visceral vessel origins

• Celiac artery origin

• Common hepatic artery

• SMA origin and proximal segment

• IMA

The Society for Vascular Ultrasound (SVU)

• All the above AND

• Splenic artery

• Mid and distal SMA

• Documentation of SMV and IMV patency

PROTOCOL

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Grayscale • Vessel tortuosity• Aneurysm/dissection• Bowel wall thickening/distension• Ascites

Color Doppler • Optimize gain, PRF, wall filter• Homogeneous flow pattern• No aliasing/color bruit

Spectral Doppler • Longest axis of vessel • Angle correction • “Step” through vessel from

aorta to origin

TECHNIQUE

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PROTOCOL AORTA

• Transverse “seagull sign”

• Turn sagittal to obtain the longest axis

• Obtain angle corrected waveform

• Measure PSV during expiration

• Measure PSV during deep inspiration (R/O MALS)

• Measure PSV 1-2 cm from origin during quiet breathing

PROTOCOL CELIAC ARTERY

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PROTOCOL SMA

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PROTOCOL IMA

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Vessel Post Prandial NORMAL Response

SMA More diastolic flow Increased PSVLess pulsatility

Celiac No change

Hepatic artery

Increased pulsatiltiy

Portal vein Increased flow

INTERPRETATION CRITERIA

Celiac (fasting) SMA (fasting) IMA Aorta Ratios

> 225 cm/s indicates >70% diameter stenosis

>275 cm/s indicates>70% diameter stenosisIncreased EDV (> 45 cm/s)

also a criteria

No good criteria Celiac: Aorta 3.5

SMA: Aorta 3.5

(widely quoted)

INTERPRETATION CRITERIA DIRECT SIGNS

• Aliasing

• Bruit

INTERPRETATION CRITERIA

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INTERPRETATION CRITERIA INDIRECT SIGNS

Reversed Hepatic Artery

• Elevated PSV

• Post stenotic turbulence

• Distal parvus tardus

INTERPRETATION CRITERIA

SMA Celiac

Sensitivity: 89-100%Specificity: 91-96%

Sensitivity: 87-93%Specificity: 80-100%

INTERPRETATION CRITERIA

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• AORTIC STENOSIS.

• ANEURYSMS.

• DISSECTION.

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Common Variants:1. Replaced right hepatic artery originates from SMA2. Replaced common hepatic artery originated from SMA3. Common hepatic artery originating from aorta4. Common origin of the celiac and SMA

PITFALLS

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MALS

Expiration Inspiration

MALS

Expiration Inspiration

MALS

Expiration Inspiration

Application: Vascular Perfusion Status

Diagnosis: Complex Distal Endoleak

NEW HORIZONSCarotid bulb plaque

High velocity flow

Flow reversal

Temporary absence of flow

Flow returns to original state

NEW HORIZONS

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NEW HORIZONS

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Pathology Color Doppler

Stenosis > 50% High velocity flow, aliasing, color bruit

High velocity flow, post stenotic turbulence

Occlusion No color flow at origin Absent flow signals

MALS Increased color velocity during exhalation

Increased velocities with exhalation and decreased with inhalation

GOOD PRACTICE TIPS

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4. HTTPS://ACSEARCH.ACR.ORG/DOCS/70909/NARRATIVE.

5. HTTPS://WWW.WJGNET.COM/1007-9327/FULL/V23/I38/6931.HTM

6. HTTPS://RADIOLOGYKEY.COM/ULTRASOUND-ASSESSMENT-OF-THE-SPLANCHNIC-MESENTERIC-ARTERIES/

7. HTTPS://VASCULAR.ORG/PATIENT-RESOURCES/VASCULAR-CONDITIONS/MESENTERIC-ISCHEMIA#CAUSES

8. HTTPS://WWW.WJGNET.COM/1007-9327/FULL/V23/I38/6931.HTM

REFERENCES