evaluarea echo-doppler a arterelor membrului superior
DESCRIPTION
sunt prezentate succint si scolastic aplicatiile ecografiei Doppler in evaluarea normala si patologica a arterelor membrului superiorTRANSCRIPT
Evaluarea Doppler a Evaluarea Doppler a AA membrului AA membrului
superiorsuperior
Alexandru AndritoiuESC, Artery Research (Cambridge)
Background
Anatomie vasculara• Topografie• Raporturi AA-VV
• Doppler• Color• Spectral (PWD)• Power-angio• B-flow• Contrast (CEUS)
ANATOMIEANATOMIE
Common upper extremity arterial anatomy: Common upper extremity arterial anatomy: The ulnar artery supplies the superficial palmar arch, The ulnar artery supplies the superficial palmar arch,
the major source of blood flow to the digitsthe major source of blood flow to the digits
Stepansky F et al. Radiographics 2008;28:e28-e28
Fig. Common upper extremity arterial anatomy: The ulnar artery supplies the superficial palmar arch, the major source of blood flow to the digits. The radial artery supplies the deep palmar arch, which in turn supplies the dorsal arches of the hand.
The superficial palmar arch is formed mainly by the ulnar The superficial palmar arch is formed mainly by the ulnar artery and is completed by the superficial branch of the artery and is completed by the superficial branch of the
radial artery.radial artery.
Stepansky F et al. Radiographics 2008;28:e28-e28
Fig. The superficial palmar arch is formed mainly by the ulnar artery and is completed by the superficial branch of the radial artery. A complete arch is not always present. The superficial palmar arch provides the arterial supply to the digits via the digital palmar arteries.
B-modeB-mode
• Perete fin-ecogen• Calibru normal• Pulstatilitate
Elementele de semiologie patologica
• placi• stenoza• tromboza• ocluzie• anevrism
Doppler colorDoppler color
• Permebilitate• Calibru normal• Directia de curgere• Velocitatea • Amplitudinea
Elemente patologice• Flux turbulent• Absenta fluxului• Fistula AA-VV• Stenoza/ocluzie• Disectie
VELOCIMETRIEVELOCIMETRIE
• AA de rezistenta• Profil trifazic• Difera topografic
Elemente patologiceElemente patologice• Cuantificarea stenozei• Ocluzie• HemodinamiceHemodinamice• Incarcarea din colaterale• Amonte/aval de stenoza• Sdr. Furt S-V (sten. AS)• Sdr. defileului toracic
INDICATIIINDICATII
• Stenoza TBC• Stenoza AS• Cateterizarea AB• Ocluzia AB• Embolie distala (Fi A, • Sdr. Defileului toracic• Evaluarea Fct. Endoteliale• Arterite (TAO, B. Raynaud)• Fistule AA-VV (dializa)• By-pass (patenta/stenoza graftului)
TBCTBC
• Crosa Ao• ACC dr-AS dr• Rar: stenoza
semnificativa
A SubclavieA Subclavie
• Abord: spatiul supra/subclavicular
• Raporturi cu V Subclavie
• Flux pulsatil
• Sediul stenozei ATS
• Consecinte hemodinamice aval/amonte
ATENTIE: AS ABERANTA IN CAZURI PEDIATRICE Se asociaza cu sdr. compresiv al cailor aeriene
Stenoza ASStenoza AS
• Prevalenta: 2-7%• Diferenta TAS >15 mm
dr/stg
CAUZE:• ATS – placa• B. Takayasu• Dispazia fibromusculara• Radioterapie
Relatia cu:• Fumatul, • HDL-C • ATS (BCI, stenoza ACI,
BOAP, stroke)
Shadman R et al. J Am Coll Cardiol, 2004; 44:618-623 Gutierrez GR et al. Angiology. 2001;52:189–194English JA et al.Cathet Cardiovasc Intervent. 2001;54:8–11
• CAD – 0.5-4%
• PAD – 18.7%
Stenoza AS - DiagnosticStenoza AS - Diagnostic
• Clinic:
difer TAS dr/stg >15-20 mmHg
claudicatia bratului• FRCV
ImagisticaImagistica• US US • Angio CT/RMNAngio CT/RMN• Angio-standardAngio-standard
Angiografie Angio-CT
HemodinamicaHemodinamica
• In relatie cu localizarea/severitatea stenozei
• Local: V max S ampla • Amonte: sdr. Furt S-V• Aval: flux redus:• A axilara• A brahiala• A mamara interna
Stenoza ASStenoza AS
Flux distal: tardut et parvus
Subclavian steal Subclavian steal syndromesyndrome
• Stenoza/ocluzia AS ipsilaterala cu devierea retrograda a fluxului in AV
• Stenoza situata proximal de originea AV
• Asimptomatic
• Simptome neurologie (ischemie cerebrala)
Contorni, 1960;Fisher, 1961;Parrott, 1964
UNILATERAL/BILATERAL DOBANDIT/CONGENITAL
Subclavian steal syndromeSubclavian steal syndrome
Stepansky F et al. Radiographics 2008;28:e28-e28
Fig. Subclavian steal syndrome. (a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.
Modificari precoce ale anvelopei Modificari precoce ale anvelopei spectrale a spectrale a
AV in furtul S-VAV in furtul S-V
• Tipul I (20%)
• Tipul II (40%)
Kliewer MA et al. Am J Radiol 2000;174:815-819
• Tipul III (12.5%)
• Tipul IV (27.5%)
Kliewer MA et al. Am J Radiol 2000;174:815-819
Furt S-V patent (total)Furt S-V patent (total)
Flux inversat (retrograd)
TratamentTratament
InterventionalInterventional• angioplastie
ChirurgicalChirurgical• By-pass Car-AS• By-pass AS-AS• By-pass axilo-axilar
Angioplastie cu balonasAngioplastie cu balonas
By-passBy-pass
Rolul USRolul US
• DiagnosticDiagnostic – necesita confirmare Angio!• Supraveghere post-interventionalaSupraveghere post-interventionala• Restenoza post-stentare• Tromboza graftului
Kablak-Ziembicka A et al. Cardiovasc Intervent Radiol 2007;30:894-900
Tromboza ASTromboza AS
Cauze:Cauze:
• Lezarea endoteliului
• Stari protrombotice
• Efort fizic (compresie musculara)
• Sdr. de defileu toracic
AS in defileul toracicAS in defileul toracic
Coronary-Subclavian steal Coronary-Subclavian steal syndromesyndrome
DefinitieDefinitie
Sdr. coronarian (anginos) aparut la pacientii revascularizati prin by-pass cu a. mamara interna la care se dezvolta stenoza proximala de AS
HemodinamicaHemodinamica
• Flux retrograd in A. mamara interna stg.
• Ischemie miocardica in zona revascularizata
TratamentTratament
• Interventional
• Angioplastie-dilatarea stenozei AS + stentare
• By-pass:
• Transpozitie-sunt Car-Subcl distala
Proteza vascularaProteza vasculara
• Perete ecogen• Material sintetic• Lumen• Tipuri diferite
US – metoda ideala de supraveghere a evolutiei post-operatorii (permeabilitatea/ocluzia trombotica)
Hematom periproteticHematom periprotetic
Artera BrahialaArtera Brahiala
AB – Doppler colorAB – Doppler color
AB – anvelopa spectralaAB – anvelopa spectrala
IndicatiiIndicatii
TrombozaTromboza CercetareCercetare• Remodelare arteriala• Evaluarea fct. endoteliale
Tromboza ABTromboza AB
CAUZE
• Lezarea endoteliului• Cateterizarea AB
• Conditii protrombotice:• Trombofilie• Anticonceptionale orale
Tromboza ABTromboza AB(post-angiografie)
Doppler color - Power-angio lipsa semnal vascular
Anevrism de a. brahialaAnevrism de a. brahiala