spectrum of the portal vein on color and spectral …...main causes: cirrhosis, portal hypertension,...
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Spectrum of the Portal Vein on Color and Spectral Doppler,
and Contrast Enhanced Ultrasound in both Native and
Transplanted Livers
NicholasLesleinMD;BiancaCarpen4erMD;PriyankaJha,MD;JudyYeeMD;StefanieWeinsteinMD
University of California, San Francisco
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TheAuthorsHaveNoFinancialDisclosures
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LearningObjec-ves■ ReviewrangeofnormalDopplerfindingsintheportalvein■ Reviewpathologicappearanceoftheportalvein(PV)inna4veandtransplantedliverswithuseofcolorDoppler,spectralDoppler,andcontrastenhancedultrasound
■ Topicstobediscussedinclude:■ Monophasicityvs.increasedpulsa4lity■ Flowdirec4on:antegrade/bidirec4onal/reversed/helical■ Increasedintraluminalechoes
■ PVOcclusions:Par4al/Complete/Obliterated■ Air/Rouleaux(slow)flow
■ Slowvs.highflowstates(cardiac,pregnancy,shun4ng)
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NormalPortalVein
■ Normalvelocityrange20-40cm/s■ Monophasicwaveformwithgentleundula4ons■ Antegradeflow
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IncreasedPulsa-lity
ImagesoftheMPVdemonstrateincreasedpulsa7lityinthese9ngofrightheartfailure
Alsonoteincreasedpulsa7lityinthemiddlehepa7cveinanddilata7onofthehepa7cveins
■ Pulsa4lityisthevariabilityofbloodvelocityinavessel■ Increasedpulsa4lityisusuallyseenintheseZngofelevatedrightatrialpressure:
■ Rightheartfailure■ Tricuspidregurgita4on
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IncreasedPulsa-lity■ Donotmistakearterializedflowforincreasedvenouspulsa4lity
Note the arterialized waveforms in the region of the portal vein in both images
TeachingPoint:arterializedflowinportalveinistumorthrombus,mostcommonlyhepatocellularcarcinoma,un4lprovenotherwise
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Varia-oninFlowDirec-onRetrograde(hepatofugal)-Bidirec-onal
MainCauses:Cirrhosis,PortalHypertension,CardiacDisease
Twoexamplesofspectralwaveformoftheportalveinwithflowseenbothaboveandbelowthebaselineinthesepa7entswithliverdisease
Teachingpoint:Evensmallpressurechangesrelatedtoinspira7onandexpira7oncan
causereversalofflowdirec7on
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Retrograde–Bidirec-onalFlow
S7llimagefromCINEloopdemonstra7ngbidirec7onal(alterna7ngredandbluecolor)flowinthemainportalvein–HyperlinkforCINEhostedonweb
Teachingpoint:Thiscanbemisinterpretedasunidirec7onalflowons7llimagesonly
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Varia-onsinFlowDirec-onHelicalflow
■ Disrup4oninthenormallaminarflowsecondaryto:■ Vesselgeometry■ Irregularityofthevesselwall■ Changesinflowdirec4onandspeed
■ Dopplerdemonstratesalterna4ngredandbluebandsinaspiral
■ Canbeseena\erlivertransplantorTIPSpa4entsasanormalfinding■ Abnormalifpersistent
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■ Transplant■ SecondarytochangeinPVdiameterbetweendonorandna4vevessel,mostprominentwhendiscrepancyis>50%
■ Localturbulence
■ TIPS■ ChangesinPVvelocity,flowdirec4on,andpulsa4lity
■ Reportedlyashighas28%ofTIPS1
Varia-onsinFlowDirec-onHelicalflow
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Teachingpoint:bewareofpiballs■ Rouleauxfromslowflow■ Truethrombus■ Misdiagnosisofpneumobilia
S7llimagefromCINEloop(hyperlink)demonstra7ngrapidlymovingintraluminalechogenicfociintheportalsystem
SpectralDopplerdemonstra7ngcharacteris7c“spike”likeaberra7onintheportalveinwaveform
IntraluminalEchoesPortalVeinAir
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IntraluminalEchoesAnotherexampleofPortalVeinAir
Still image from CINE loop (hyperlink) demonstrating numerous swirling internal reflectors within the main portal vein
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■ CTmaybeconfirmatory■ Unlikepneumobilia,generallyconsideredamoreominousfinding
■ Poten4alCauses■ BowelIschemia/infarc4on■ Bowelobstruc4on■ Pancrea44s■ Diver4culi4s/Appendici4s
PortalVeinAir
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CompletePVThrombus
IntraluminalEchoesPortalVeinThrombosis
Par7alThrombus
Teachingpoint:Needtoop4mizeDopplertechniquewhenevalua4ngforthrombus
■ Usetheappropriatedepth■ Usetheappropriatescale
■ Highscalemaymisslowerveloci4esthatarebelowthresholdvalue
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CavernousTransforma-on
■ Sequelaeoflongstandingportalveinthrombosis
■ Thrombosedmainportalveinmaynolongerbepresent
■ Secondarysignsofchronicthrombosis■ Periportalcollateralswithmanyflowdirec4ons
■ SmallcaliberorabsentmainPV CavernousTransforma7on
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IntraluminalEchoesTumorThrombus
Grayscaleimagedemonstratesexpandedmainportalveinfilledwithintraluminalechoes
ColorandspectralDopplerimagesdemonstrateirregularvesselswitharterializedwaveformsinPV
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TumorThrombus
S7llimagefromCINEclip(hyperlink)demonstra7ngtumorthrombusinMPV
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RoleofCEUSBlandversusTumorThrombus
■ Contrast-enhancedultrasoundaddsvalueindifferen4a4ngblandthrombusfromtumorthrombus
■ CEUSimprovessensi4vityanddiagnos4caccuracy4,7
(TopLe()Grayscaleimagesshowsintraluminalfillingdefect(Bo=om)CEUSdualscreenCINEimages(hyperlink):noteenhancementinareaoffillingdefectinle(portalvein
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Slowflow
■ NormalMPVpeaksystolicvelocity(PSV)measuresbetween20-40cm/s■ PSVof<16cm/sandincreasedcaliberofMPVarediagnos4cfeaturesofportalhypertension
(Topright)Imagesdemonstrateslow,lowamplitudebidirec7onalflowintheRPV(BoTomright)PowerDopplerdemonstra7nglowamplitudeflowinLPV
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Slowflow“Rouleaux”flow
■ Imagesdemonstra4ngmobilelowlevelechoesintheMPV(a.)andmiddlehepa4cveinandIVC(b.)bejerappreciatedonCINE■ “Rouleaux”flowisduetoredbloodcellaggrega4onfromsluggishflowa. b.
a.)Hyperlinkb.)Hyperlink
a.
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Highflow■ Highveloci4es■ Causes
■ Stenosis■ Mostcommonlyseeninpost-transplant
■ Pregnancy■ Pseudoaneurysm■ ArteriovenousFistula/AVM
■ Congenital(OslerWeberRendu)■ Acquired(postbiopsy/trauma)
Images from a liver transplant showing turbulent high flow (>50 cm/s) related to a hepatic artery-portal vein fistula
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PVinLiverTransplant
Teachingpoint:bewareofpiballs■ Pseudostenosis–canbeanormalfindingsecondarytodifferenceinvesselcaliber
betweenna4veanddonor.Usuallyresolvesinimmediatepostopera4veperiod
■ Stenosis■ Typicallywithendtoendanastomosis■ 3-4xincreaseinpeaksystolicvelocity(PSV)■ Associatedfindings
■ Aliasing■ ElevatedPSV■ Spectralbroadening
Notealiasingandelevatedveloci7esatsiteofPVanastamosis
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Conclusion
■ Abdominalradiologistsshouldbefamiliarwiththespectrumofnormalvariantsandpathologyintheportalveinreflec4ngunderlyingpathologicstates,includingbutnotlimitedto,cardiacdysfunc4on,portalhypertension,stenosis,andthrombosis
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3. McNaughtonDA,Abu-YousefMM.DopplerUSofthelivermadesimple.Radiographics.2011Jan-Feb;31(1):161-88.doi:10.1148/rg.311105093.
4. RazaS,JangHJ,KimT.Differen4a4ngmalignantfrombenignthrombosisinhepatocellularcarcinoma:contrast-enhancedultrasoundAbdomImaging(2014)39:153.
5. RosenthalSJ,HarrisonLA,BaxterKG,WetzelLH,CoxGG,BatnitzkyS.DopplerUSofhelicalflowintheportalvein.Radiographics.1995Sep;15(5):1103-11.
6. RossiS,RosaL,RavejaV,CascinaA,QuareZP,AzzareZA,ScagnelliP,TinelliC,DionigiP,CalliadaF.Contrast-EnhancedVersusConven4onalandColorDopplerSonographyfortheDetec4onofThrombosisofthePortalandHepa4cVenousSystems.AmericanJournalofRoentgenology2006186:3,763-773
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Contact
■ NicholasLeslein,[email protected]
■ BiancaCarpen4er,[email protected]
■ PriyankaJha,[email protected]
■ JudyYee,[email protected]
■ StefanieWeinstein,[email protected]
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CINE Loops Hosted on Web
■ Slide8–Bidirec4onalFlow–hjps://vimeo.com/199039295■ Slide11–PortalVeinAir-hjps://vimeo.com/199039639■ Slide12–PortalVeinAir–hjps://vimeo.com/199039889■ Slide17–TumorThrombus-hjps://vimeo.com/198946303■ Slide18–CEUSTumorThrombus-hjps://vimeo.com/199041745■ Slide20–RouleauxFlowinMPV-hjps://vimeo.com/198947317■ Slide20–RouleauxFlowinHepa4cVeinsandIVC-hjps://vimeo.com/198947045