4 Tissue Harmonic Imaging and Doppler

4
Tissue Harmonic Imaging and

Doppler Ultrasound Imaging
ARASH ANVARI | XIAOZHOU MA | SOMESH LALA |
BIJAL JANKHARIA | VISHAKHA MAZUMDAR
Tissue Harmonic Imaging depth of field, (3) frame rate, (4) flow sensitivity with
TECHNICAL ASPECTS adjusted gain settings, (5) image vessel of interest at a
Doppler angle of 30 to 60 degrees, and (6) low wall filter
Fundamental frequency is the original frequency of the acoustic settings (if these are high, significant velocity information
beam emitted from the transducer. Harmonic wave generation can be lost). The recorded color flow should occupy the
is an acoustic phenomenon. Harmonic waves are integer mul- full anteroposterior diameter or cross-sectional area of the
tiples of the fundamental frequency. vessel without color flow aliasing and noise in the sur-
The second harmonic (twice the fundamental frequency) is rounding tissues.
currently used for tissue harmonic imaging (THI). With THI, • Positioning: The various positions required for imaging
the fundamental frequency is eliminated with image processing every individual vessel.
techniques. THI advantages include improved signal-to-noise
ratio and artifact reduction.1,2 PROS AND CONS OF DOPPLER IMAGING
Pros
CLINICAL APPLICATIONS
• Noninvasive
THI improves image quality and conspicuity, and has been • Readily available and cost-effective
shown to be useful in multiple clinical scenarios, including (1) • Portability: Can be done by the bedside in sick or debili-
obesity, (2) hollow structures (e.g., cysts, gallbladder, urinary tated patients
bladder) (Figure 4-1), and (3) the deep-seated major vessels • Differentiating vascular and nonvascular structures (e.g.,
(inferior vena cava [IVC] and abdominal aorta) (Figure 4-2). porta hepatis) (Figure 4-3)
• Provides information about the patency of blood vessels,
direction of flow turbulence, phasicity, jet, impedance, and
Doppler Ultrasound Imaging so on
Doppler ultrasonography is a noninvasive technique that pro- • Quantification of stenosis and direct measurement of flow
vides information about the condition of blood vessels and lumen reduction
blood flow direction. It also measures flow velocity and can be • Tissue characterization of tumors
used to evaluate the vascularity of mass lesions. Color and
pulsed-wave Doppler imaging provide complementary infor- Cons
mation, including spatial orientation and a time velocity spec- • Operator dependency.
trum, respectively.3 • Doppler imaging is technically difficult to perform in
obese patients and in those with overlying bowel gas or a
distended abdomen, especially when desiring visualization
TECHNICAL ASPECTS
of the mesenteric vessels, the portosplenic confluence, or
Doppler examination requires five technical parameters (5 Ps), renal artery origin; performing portosystemic collateral
as follows: mapping; evaluating a shunt anastomosis; and so on.
• Patient preparation: Fasting is required for a Doppler • Good spectral analysis cannot be achieved in patients who
examination of the abdomen. cannot hold their breath (e.g., acutely ill patients).
• Probes: Commonly used probes are the (1) curvilinear- • Graft surveillance at the level of the distal abdominal aorta
array probes (low frequency, 3 to 5 MHz), (2) phased- and iliac arteries is difficult.
array probes (low frequency, 2 MHz), and (3) linear-array • Abdominal aortic calcifications can be an obstacle in visu-
probes (high frequency, 4 to 10 MHz).4 alization of renal artery origin.
• Person: The sonographer should have a considerable
amount of expertise to perform a Doppler examination NORMAL ANATOMY OF ABDOMINAL VESSELS
such as understanding of the normal anatomy, pathophys-
iology, and signature patterns of abdominal vessels. The normal appearance and signature pattern of abdominal
• Picture quality (machine): To obtain good picture quality, vessels—the portal vein (Figure 4-4), hepatic vessels, mesenteric
the radiologist should consider the following operational vessels (Figures 4-5, 4-6, and 4-7), renal vessels (Figure 4-8),
parameters: (1) an appropriate anatomic window, (2) abdominal aorta (Figure 4-9), and IVC—are summarized in
24
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4 Tissue Harmonic Imaging and Doppler Ultrasound Imaging 25
0 0
GB GB
PV PV
5 5
Without harmonic With harmonic
A B
Figure 4-1 Comparison of images in the same location of the right upper quadrant without and with harmonic imaging. A, Image without harmonic
imaging: the fundus and neck areas (arrows) of the gallbladder (GB) and intraportal venous area (PV, arrow) appear echogenic and cloudy. B, With
harmonic technique, the figure shows a clear GB and portal venous structure. In addition, the tiny calcification on the anterior wall of the GB (arrow-
head) is well shown on the harmonic image in B but invisible in the blurred image in A.
0 0
5 5
Without harmonic With harmonic
A B
Figure 4-2 Comparison of image conspicuity without/with harmonic imaging in the sagittal plane of the left liver and the long axis of the inferior
vena cava (IVC). The arrows point to the intra-IVC area, which is obviously cloudy and blurring in the nonharmonic image (A) compared with the
harmonic image (B).
Figure 4-3 Transverse Doppler imaging centered at midclavicular line reveals multiple collateral vessels in the porta hepatis that mimic dilated
intrahepatic biliary radicles.
26 PART 1 Imaging Techniques
PRF 4.4KHz
-34cm/s
SMV
PV
60 PV
45
30
15
cm/s
-15
-30
Figure 4-5 Superior mesenteric vein (SMV). Long-axis view shows a

Figure 4-4 Normal portal vein (PV). Pulsed Doppler image of the
normal SMV becoming confluent with the portal vein (PV).
portal vein shows normal undulating signature pattern with phasic flow.
Peak systolic velocity = 15 cm/s.
L5 Se: 0001/1 2
Ex: Im: 0006/11
SMA POST MEAL
20 4
Se: 0001/1 Mag: 1.0x
Im: 0002/11
6
Mag: 1.0x
-17 8
cm/s AC 49
-20 +1 200
cm/s 10
SMA FASTING AC 22 150
+1 150 100
+1
50
100
[cm/s]
50
+1 1Vs 195.83 cm/s -50
Vd 65.38 cm/s
[cm/s] RP 0.67 -3 -2 -1 0
1 Vs 151.47 cm/s
Vd 37.13 cm/s Figure 4-7 Superior mesenteric artery (SMA). Postprandial Doppler
RP 0.75 -3 -2 -1 0 image reveals low-resistance waveform pattern with increase in peak
Figure 4-6 Superior mesenteric artery (SMA). Long-axis view shows systolic velocity. Resistive index = 0.6.
normal high-resistance waveform patterns of artery in fasting. Peak
systolic velocity = 151 cm/s; resistive index = 0.75.
Im: 0005/11
5
Mag: 1.0x
-23
cm/s 10
AC 43
AB AO 150
100
+1
50
[cm/s]
Figure 4-9 Abdominal aorta (AB AO). Long-axis view of the proximal
abdominal aorta shows high-resistance flow with brief flow reversal.
Doppler angle = 43 degrees.
Figure 4-8 Normal right renal artery. Right coronal oblique view with
anterolateral transverse approach shows the course of the renal artery
from the hilum to the origin.
TABLE
4-1
Normal Appearance and Signature Patterns of Abdominal Vessels
Vessel Identification Normal Signature Pattern
Portal vein: normal caliber = Anechoic structure, which runs in transverse plane and Undulating continuous waveform
13 mm (quiet respiration) converges on the porta hepatis pattern with subtle phasic variation
Surrounded by a sheath of echogenic fibrous tissue Hepatopetal flow (toward the liver)
Hepatic vein: normal caliber = Longitudinally oriented sonolucent structures within Triphasic pulsatile waveform pattern
3 mm (measured 2 cm from liver parenchyma with hepatofugal flow
inferior vena cava) Best visualized with transverse subxiphoid approach to Naked margins
see the three main trunks with the inferior vena cava
Hepatic artery: normal velocity = Vascular structure anterior to portal vein Low-resistance flow with spectral
30-60 cm/s broadening
Inferior vena cava: normal caliber = Anechoic structure in the midline to the right of the Pulsatile flow near the heart: “sawtooth
2.5 cm aorta and anterior to the spine pattern”
Upper part best visualized using liver as an acoustic Phasic flow distally
window
Abdominal aorta: Normal caliber = Hypoechoic tubular pulsatile structure with echogenic High-resistance waveform pattern with
2.3 cm (men), 1.9 cm (women) walls best seen by longitudinal midline approach a brief period of reversed flow (see
Figure 4-9)
Mesenteric vessels: normal caliber Superior mesenteric artery is surrounded by a Superior mesenteric artery fasting
<10 mm triangular mantle of fat. It is to the right of the view: High-resistance waveform
superior mesenteric vein, which runs parallel to the pattern with sharp systolic peaks
superior mesenteric artery (see Figures 4-6 and 4-7) with absent late diastolic flow
Postprandial shows low-resistance
waveform pattern.
Celiac artery Best visualized in transverse plane, in which the Low-resistance type of waveform
T-shaped bifurcation of vessel into hepatic and
splenic artery is characteristic
Renal artery and vein Origin of artery is slightly caudad to superior Artery: Low-resistance flow with broad
mesenteric artery and best seen by transverse systolic waveform and forward flow
midline approach. Left renal vein is seen between during diastole
superior mesenteric artery and aorta. Right renal Vein: Phasic with velocity varying with
vein can be traced from inferior vena cava respiration and cardiac activity
(Table 4-1).5 Portosystemic collateral vessels (Figures 4-10) and Portal Vein
splenorenal collateral vessels (Figure 4-11) are explained in • Thrombosis: Absence of flow; malignant thrombus
detail in Table 4-2.6,7 causes pulsatile flow, whereas bland thrombus does
not (Figure 4-14).
• Continuous monophasic flow is seen.
Clinical Applications • Reduction in velocity is from 7 to 12 cm/s.
PORTAL HYPERTENSION • Abnormal hepatofugal flow may be the only sign
(Figure 4-15).7,8
Common Causes • Gallbladder varices may be associated with portal
• Prehepatic: Portal vein thrombosis (idiopathic, hyperco- vein thrombosis (spontaneous portosystemic shunt)
agulable states, pancreatitis), portal vein compression (Figure 4-16).
(tumor, trauma, lymphadenopathy) • Chronic: Echogenic/nonvisualized portal vein occurs with
• Intrahepatic: Cirrhosis cavernoma formation (Figure 4-17).7
• Posthepatic: Budd-Chiari syndrome (idiopathic, hyperco- • Aneurysmal dilatation of the portal vein occurs
agulable states, trauma, web, and tumor). (Figure 4-18).
Hepatic Artery
Diagnostic Criteria • The hepatic artery is dilated with increased resistance
Gray-Scale Imaging Findings (resistive index > 0.78).
• Portal vein dilatation is greater than 13 mm. Hepatic Vein (Budd-Chiari Syndrome)
• Superior mesenteric vein and splenic vein are greater than • Thrombus formation occurs (Figure 4-19).
10 mm. • The vein cannot be visualized.
• Lack of caliber variation in splanchnic veins is less than • Stenosis and size reduction are noted as less than 3 mm
20%. (Figure 4-20).
• In thrombosis, there may be partial visualization or failure • Decreased, absent, or reversed flow occurs in hepatic vein.
to visualize the portal vein (chronic) or echogenic material • Communicating intrahepatic venous collateral vessels can
within distended lumen (acute) (Figures 4-12 and 4-13). be seen.
Doppler Imaging Findings Text continued on p. 32
TABLE
4-2
Portosystemic Collateral Vessels: Diagnostic Criteria
Site Portosystemic Appearance
Gastroesophageal junction. Between coronary/short gastric veins and Coronary veins >7 mm are abnormal. Prominent
Normal coronary vein systemic esophageal veins cephalad-directed vessel arising from portal vein
diameter <6 mm opposite superior mesenteric vein
Paraumblical vein (falciform Between left portal vein and systemic Solitary vein originating from left portal vein courses
ligament) epigastric veins near umbilicus inferiorly through falciform ligament and anterior
Normal = 2 mm abdominal wall to umbilicus, demonstrating
hepatopedal flow hepatofugal flow
Gastroepiploic (see Between gastroepiploic and esophageal/ Cephalad directed vessel along the inferior border of the
Figure 4-6) paraesophageal veins left lobe
Splenorenal and gastrorenal Between splenic, coronary, short gastric, Splenorenal (see Figure 4-11). Tortuous, inferiorly directed
(splenic and renal hilum) and left adrenal or renal veins vessels between spleen and upper pole of left kidney
Intestinal Veins of ascending/descending colon, Collateral pathways identification on ultrasonography
duodenum, pancreas, liver anastomosis depends on the amount of air in the bowel at the time
with renal, phrenic and lumbar veins of study
(systemic tributaries)
Hemorrhoidal (perianal Superior rectal vein anastomoses with Rectal/pararectal varices can be detected with
region) systemic middle and inferior rectal veins transvaginal or transrectal ultrasonography, cannot be
visualized on transabdominal ultrasonography
Figure 4-10 Portosystemic collateral vessels. Long-axis view shows large, tortuous, left gastric vein collateral vessels along the inferior border of
the left lobe of the liver.
Figure 4-11 Splenorenal collateral vessels. Transverse image of the left kidney shows tortuous collateral vessels between the splenic and
renal hila.
Figure 4-12 Partial portal vein occlusion. Transverse imaging of the portal vein shows echogenic thrombus within the vein with incomplete filling
on color flow Doppler imaging.
Figure 4-13 Acute portal vein occlusion. Transverse image of the intrahepatic portal vein shows distended portal vein with thrombus within.
Mag: 1.0x
–15
ASC
cm/s
–10
Figure 4-14 Tumor thrombus from renal mass. Transverse image of the liver reveals echogenic material within the portal vein with peripheral flow
along its walls. ASC, Ascites.
20. 1
CG18
D2. 5
R1. 96
SV3. 8
SV4
e 0
DG18
CN4
11cn
DR54
G 98
Figure 4-15 Cirrhosis. Long-axis view of the liver shows hepatofugal flow (away from the liver) in the portal vein. Note that the signature pattern
is below the baseline.
Figure 4-16 Gallbladder varices. Transverse imaging of the liver shows hepatopetal collateral vessels involving the gallbladder wall.
Figure 4-17 Chronic portal vein thrombosis. Serpiginous tortuous collaterals along the portopancreatic axis suggestive of cavernoma
formation.
Figure 4-18 Portal vein aneurysm. Long-axis view of the liver shows aneurysmal dilatation of the portal vein with to-and-fro flow within.
Figure 4-19 Budd-Chiari syndrome. Right coronal oblique view shows echogenic thrombus partially obstructing the right hepatic vein.
8.6KHz cm/s 40
S
MHV
40
80
120
160
200
240
280
RI 1 = 0.00
320
PS 1 = 255.7cm/s
MD 1 = 255.7cm/s 4Sec
S/D1 = 1.00
A xx B
Figure 4-20 Budd-Chiari syndrome. A and B, Gray-scale and color Doppler imaging. Transverse subxiphoid approach shows focal narrowing and
significant increase in peak systolic velocity in middle hepatic vein (MHV).
The reader is referred to Table 4-3 for the specifics of diag- Doppler Imaging Findings. Post-TIPS spectral analysis
nostic imaging for portal hypertension. should show high-velocity turbulent flow (90 to 110 cm/s) and
uniform flow at the portal and IVC ends. Abnormal findings
Transjugular Intrahepatic Portosystemic Shunt include generalized decrease in shunt velocity to less than
Transjugular intrahepatic portosystemic shunt (TIPS) refers to 60 cm/s, localized increase in shunt velocity, irregular filling
portal decompression through a percutaneously established defects, and absence of flow in the shunt.
shunt between the hepatic and portal veins with an expandable
metallic stent (Figure 4-21).9 It is done for esophageal and Liver Transplantation
gastric variceal hemorrhage or refractory ascites in advanced Doppler imaging plays an important role in assessing vascular
liver disease with portal hypertension. complications of liver transplants, which is the most frequent
cause of graft loss. Most of the complications involve the IVC,
portal vein, and hepatic artery (Figure 4-22). The complications
are commonly seen as a result of discrepancy in vessel caliber
TABLE
4-3 Ultrasound Imaging of Portal Hypertension between the donor and the recipient, faulty surgical technique,
and hypercoagulable states. The diagnostic criteria are listed in
Prehepatic Hepatic Posthepatic Table 4-4.
Portal vein flow Hepatopedal Hepatofugal Hepatofugal
direction Mesenteric Ischemia
Portal vein caliber Increased Increased Normal or Mesenteric ischemia may be classified as occlusive or nonoc-
(>13 mm) increased clusive. Occlusion accounts for 75% of acute intestinal ischemia
Liver texture/size Normal Altered Altered (Figure 4-23). Mesenteric artery embolus and plaque secondary
Caudate lobe — + + to rheumatic heart disease or atherosclerosis and venous occlu-
hypertrophy sion resulting from infection or hypercoagulability states are the
Hepatic wedge Normal High High common causes (Figure 4-24). The diagnostic criteria are listed
pressure in Table 4-5.10-13
Secondary signs + + +
of portal Renal Artery Stenosis
hypertension
(splenomegaly, Atherosclerosis accounts for 75% of the causes of renal artery
ascites, stenosis, whereas fibromuscular dysplasia accounts for 15%.
portosystemic Renal artery stenosis is hemodynamically significant when the
collateral luminal narrowing is 50% to 60% (Figure 4-25). The diagnostic
vessels)
criteria are listed in Box 4-1.14-19
Figure 4-21 Transjugular intrahepatic portosystemic shunt (TIPS). Right coronal view of liver shows a TIPS between the portal and hepatic veins.
0 + 15.3
TABLE Vascular Complications of Liver Transplant:
SV Angle –60˚ 4-4
Dep 9.1 cm Diagnostic Criteria
5
Size 2.0 mm
Freq 2.5 MHz Complication Diagnostic Criteria
10 WF Low Anastomotic narrowing of Thinned-out portal vein with
Dop 93% C1 portal vein/inferior vena cava poststenotic dilatation
15 - 15.3
PRF 3731 HZ Thrombus/stenosis in portal Filling defect in portal vein
cm/s
vein Focal narrowing at anastomotic
-120 site with increase in velocity
-90 Thrombus/stenosis in inferior Focal increase in velocity at
vena cava stenotic/anastomotic site
-60 Dilatation of inferior vena cava
-30 proximal to stenosis
Damped waveform with absent
cm/s periodicity in subanastomotic
HA 30 inferior vena cava
I NTRAH E PATI C 60 Hepatic artery stenosis Increase in peak systolic
velocity >200-300 cm/s and
poststenotic turbulence
Figure 4-22 Liver transplant. Post-transplant image of hepatic artery
Intrahepatic tardus parvus
(HA) shows a normal low-resistance spectral waveform pattern with a
distal to stenosis
renal resistive index of 0.57.
Hepatic artery thrombosis Absence of flow
57
AC 35
+1 250
200 TABLE
5 4-5 Ultrasound Imaging of Mesenteric Ischemia
-57
cm/s Acute Ischemia Chronic Ischemia
150
Gray-scale findings: Bowel Doppler findings: Stenosis
wall thickening (normal, (≥70%); superior mesenteric
100 <2 mm)11 artery shows increase in peak
Doppler findings: systolic velocity >275 cm/s
Arterial: Mesenteric artery not and end-diastolic velocity
10 always well visualized, >45 cm/s with poststenotic
50
absence of arterial flow in turbulence (see Figure 4-23).14
the wall of the ischemic Celiac artery shows increase in
colon12 peak systemic velocity
[cm/s]
Venous: Dilated vein with >200 cm/s and end-diastolic
1 Vel 251.45 cm/s -3 -2 -1 0 echogenic thrombus and no velocity >55 cm/s.
flow within (see Figure Low-resistance pattern in fasting
Figure 4-23 Superior mesenteric artery stenosis. Atherosclerotic nar- 4-24)13 is diagnostic of mesenteric
rowing of the artery reveals significant increase in peak systolic velocity ischemia.
(251 cm/s) at its origin suggestive of moderate stenosis.
Figure 4-24 Superior mesenteric vein thrombus. Transverse and long-axis epigastric views show distended vein with thrombus within.
v V
LT. KIDNEY SEGHN
53 26.3
CG 18
CG22
D2.5
D2. 5
R10. 4
R1. 13
SV6. 1
SV2. 3
SV4
SV4
e 39
e 37
DG24
DG26
CN0
CN13
14cn
10cn
DR54
DR54
D 54
RT. KIDNEY MAIN ORIGXX G 74
STEN
A x 3.582n/s
R0.52n/s B R. 164n/s
Figure 4-25 Renal artery stenosis. A and B, Color Doppler image and spectral analysis at the level of right renal artery origin show significant
increase in peak systolic velocity (251 cm/s) with poststenotic turbulence in the segmental artery.
BOX 4-1 ULTRASOUND IMAGING OF RENAL 80

ARTERY STENOSIS
+1 60
DIRECT SIGNS
-11
• Peak systolic velocity greater than 180 to 200 cm/s with post- cm/s
stenotic turbulence: Significant stenosis (see Figure 4-25)16 5 40
• Renal aortic ratio greater than 3.5
• No flow detected: Arterial occlusion
20
INDIRECT SIGNS
• Dampened appearance: Tardus parvus pulse +1 [cm/s]
• Loss of early systolic peak
• Acceleration time >80 ms (0.08 s) (see Figure 4-25, B)17
• In mild stenosis <50% intrarenal Doppler is normal18 -20
1 Vs62.13 cm/s
• Difference in renal resistive index between normal and abnor-
mal kidney Vd 0.00 cm/s
RI 1.00 10
-2.0 -1.5 -1.0 -0.5 0.0
Figure 4-26 Renal parenchymal disease. Spectral analysis of renal
artery at the hilum reveals high-resistance waveform pattern with absent
end-diastolic flow. Resistive index = 1.00.
Renal Vein Thrombosis. The common causes of renal vein
thrombosis are dehydration (in neonates) and low flow states,
trauma, and tumor (in adults). The thrombotic process begins
BOX 4-2 ULTRASOUND IMAGING OF RENAL
in the small intrarenal veins, reducing venous flow. In the acute VEIN THROMBOSIS
stage, hemorrhagic renal infarction occurs from ruptured
vessels and capillaries. Formation of collateral vessels begins at GRAY SCALE
24 hours and peaks 2 weeks after onset of occlusion. The diag- • Enlarged kidney with focal or generalized areas of increased
nostic criteria are listed in Box 4-2. echogenicity
• Loss of corticomedullary differentiation
Renal Parenchymal Disease • Thrombus within distended renal vein/inferior vena cava
Flow resistance within the renal parenchyma may be increased DOPPLER

by a variety of acute and chronic parenchymal disorders (Figure • Main renal vein not traceable into inferior vena cava
4-26).20 The diagnostic criteria are listed in Box 4-3.21 • Steady, less-pulsatile venous flow compared with contralat-
eral renal vein
Renal Transplantation • Renal resistive index greater than 0.7 or reversed end-diastolic
arterial flow
Baseline ultrasound and Doppler imaging are mandatory 2 days
after renal transplantation surgery. Doppler imaging plays an
important role in assessing transplant-related complications.
The normal renal resistive index in the parenchyma should not there is an increase in the renal resistive index to
exceed 0.7 (Figure 4-27). more than 0.7. Renal biopsy is required to confirm the
diagnosis.
Parenchymal Complications • Acute interstitial rejection: This occurs secondary to edema
• Acute tubular necrosis: On gray-scale imaging, there is with lymphocytic infiltration. In vascular rejection, prolif-
increased cortical echogenicity. On Doppler imaging, erative endovasculitis and thrombosis occur.
BOX 4-3 ULTRASOUND IMAGING OF RENAL BOX 4-4 ULTRASOUND IMAGING OF THE
PARENCHYMAL DISEASE INFERIOR VENA CAVA
GRAY SCALE GRAY SCALE
• Hyperechogenicity with or without loss of corticomedullary • Distention of inferior vena cava
differentiation • Echogenic material within the lumen
• Acute: Enlarged/normal kidney
• Chronic: Small shrunken kidney DOPPLER
• Absence of flow
DOPPLER • Loss of triphasic waveform pattern
• Acute: Increase in renal resistive index greater than 0.7 • Flow reversal in distal segment secondary to collateralization
• Chronic: Increased renal resistive index with or without absent
end-diastolic Doppler
(see Figure 4-26)
31.4/100
A X X
X
TX CORTEX
Figure 4-28 Longitudinal midline color flow image shows a large

abdominal aortic aneurysm (A) with peripheral thrombus.
-31.4
Rl
Vol1 A cm/s Vol2 A cm/s Ratio A
Vmax A 13.2cm/s Vmin A 4.3cm/s Rl A 0.07
Vol B cm/s Vol2 B cm/s Ratio B imaging, it can resemble a cyst, but on Doppler imaging
Vmax B 13.0cm/s Vmin B 20.0cm/s Rl B there is a to-and-fro waveform with a high-velocity jet at
Figure 4-27 Renal transplant. Color Doppler imaging at the level of the aneurysm neck.
the cortex using a high-frequency probe (7.5 to 10 MHz) shows normal
low-resistance waveform pattern. Resistive index = 0.67. TX, Transplant Abdominal Aorta
kidney cortex.
Aneurysm. The common causes of aortic aneurysm are
atherosclerosis, trauma, infection, and hypertension. Aortic
aneurysms can be associated with visceral, iliac, and femoral
• Diagnostic criteria: On gray-scale imaging, increased size aneurysms and stenosis (Figures 4-28 to 4-29). On ultrasonog-
and echogenicity of the graft with prominent pyramids are raphy, there is focal widening of the aorta more than 3 cm.
seen. On Doppler imaging, a renal resistive index greater Analysis of the aneurysm should include its dimension, shape,
than 0.9 is said to have a 100% positive predictive value.22 location, and extent and documentation of thrombus and
involvement of any branches.
Vascular Complications
• Allograft renal artery stenosis occurs at the allograft artery Dissection. The common causes of aortic dissection are hyper-
origin (short segment), which is almost always the result tension, Marfan’s syndrome, and Ehlers-Danlos syndrome.
of a surgical complication. A later complication (long Usually, dissection begins in the thorax; less than 5% occur in
segment stenosis) commonly results from intimal hyper- the abdomen. An intimal defect results in separation of the
plasia or scarring. The findings are similar to those of renal intima and adventitia by blood flow having gained access to the
artery stenosis.23 media of the aortic wall, splitting it into two.
• Vascular occlusion (rare, arterial and venous) occurs as a On gray-scale imaging, there is a thin echogenic membrane
result of rejection or faulty surgical technique. The find- (intimal flap) “fluttering” in the lumen. On color Doppler
ings are similar to those of renal arterial occlusion and imaging, blood flow is seen in both true and false channels, with
renal vein thrombosis, respectively. higher velocity in the true lumen and retrograde flow being
• Arteriovenous fistula occurs most commonly as a result of common in the false lumen (Figure 4-30).
biopsy trauma. There is a high-velocity, low-resistance
flow in the feeding artery, a pulsatile “arterialized wave- Inferior Vena Cava
form” in the draining vein, and exaggerated focal color The common causes of the IVC obstruction are neoplastic,
around the lesion, called the visible bruit. idiopathic, thrombotic extension from femoroiliac veins and
• Pseudoaneurysm is commonly seen as a result of biopsy, IVC filters, congenital webs, and extrinsic compression. The
mycotic infection, or anastomotic leakage. On gray-scale diagnostic criteria are listed in Box 4-4.24
SMA SMA
Figure 4-29 Superior mesenteric artery (SMA) aneurysm. Transverse midline imaging shows an aneurysm (A) in the distal artery with turbulent flow
within on color Doppler imaging.
Figure 4-30 Longitudinal midline gray scale and color Doppler imaging show an abdominal dissection with an intimal flap and flow within true
and false lumens.
Summary Key Points

Although most abdominal vessels have a common origin, • Harmonic ultrasound imaging reduces image artifacts.
they have different signature patterns on Doppler ultrasound • Doppler imaging is useful in portal hypertension, chronic
imaging. It is important to understand normal and abnormal mesenteric ischemia, and renal transplants.
flow patterns and know the importance and limitations of • There are technical limitations in performance of the
Doppler imaging to arrive at a definitive diagnosis. examination owing to respiratory variation, obesity, and
poor patient preparation.
SUGGESTED READINGS
Foley DW, Erickson SJ: Color Doppler flow imaging. Hoskins P, Martin K, Thrush A, editors: Diagnostic Ponziak M, Zagzebski J, Scanlan KA: Spectral and
AJR Am J Roentgenol 156:3–13, 1991. ultrasound: physics and equipment, ed 2, Cam- color Doppler artifacts. Radiographics 12:35–44,
bridge, 2010, Cambridge University Press. 1992.
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4 Tissue Harmonic Imaging and Doppler

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4 Tissue Harmonic Imaging and Doppler

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Tissue Harmonic Imaging and

Without harmonic With harmonic

Without harmonic With harmonic

Figure 4-5 Superior mesenteric vein (SMV). Long-axis view shows a

BOX 4-1 ULTRASOUND IMAGING OF RENAL 80

Flow resistance within the renal parenchyma may be increased DOPPLER

Figure 4-28 Longitudinal midline color flow image shows a large

Summary Key Points

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