REVIEW OF BASIC VASCULAR

ULTRASOUND: A PRACTICAL APPROACH

Michael Rico B. Mesina, MD, FPCR, FCTMRISP, FUSP

Practicing Radiology Consultant
Assistant Professor IV of Radiology
PART 1: BASIC CONCEPTS AND
KNOBOLOGY
1. DEFINITION OF TERMS
Vascular Ultrasound
• Pseudonym: Doppler
Ultrasound

• Named after Christian

Johann Doppler, an
Austrian physicist who
first described the said
effect

Picture of Christian Johann Doppler.

Source: commons.wikimedia.org
Uniplex, Duplex and Triplex
 Power Doppler vs. Color Doppler
Power Doppler Color Doppler

• More sensitive
in detecting
vascularity
• Shows direction
of flow

• Not very much • Affected by

affected by insonation angle
insonation angle
• No aliasing

• More sensitive
to motion
Color Doppler and Spectral Doppler
Examination
2. BASIC ASSESSMENT OF COLOR
DOPPLER FLOW AND SPECTRAL
DOPPLER WAVEFORMS
 a. ASSESSMENT OF COLOR DOPPLER
FLOW
 Use the color Doppler function
to check if the structure or
organ examined has color
flow/vascularity (“meron o
wala?”)

 If it does not show evidence of

color flow, use the power
Doppler function for more
sensitive detection
TIP: Check the color indicator bar at
the side of the screen.
 RED = TOWARDS the
transducer
(ANTEGRADE)
 BLUE = AWAY from the
transducer
(RETROGRADE)
 REMEMBER: It does not
always mean that:
 Red = Artery
 Blue = Vein
b. ASSESSMENT OF SPECTRAL
DOPPLER WAVEFORMS
1. Is there a wave?
• None appreciated =
APHASIC
• If there is a wave but there
is no variation in its
appearance/fluctuation =
NON-PHASIC
– Veins
• If there is a wave with note
of mild
fluctuation/undulation, or
gentle sloping: PHASIC
– Veins
– Low resistance arteries
• If there is a wave with note
of high or marked
fluctuation/undulation,
with wide vertical range
between its highest and
lowest points, as well as
steep sloping: PULSATILE
– High resistance arteries
2. Does the waveform exhibit High or
Low-resistance?
 High resistance – little/no
diastolic flow, or reversal
of diastolic flow

 Low resistance –
Continuous diastolic flow

 Quantitatively: Compare
the peak systolic and end
diastolic velocities using
the resistive index (RI).
 If RI is 0.7 or more = high
resistance waveform
Examples:
3. Some Concepts on Vascular
Resistance
• On Doppler US examinations, arteries have a physiologic tendency to favor either a
low or a high-resistance state.
• Low resistance arteries
– End-arteries
– Organs which are always “on” or need to be continually prefused
• High resistance arteries
– Transmit blood over long distances
– Arteries with multiple branches
• Normal arteries can change their resistance to divert flow toward the organs that
need it most. When an organ needs to be “on,” its arteriolar bed relaxes, the
waveform exhibits a lower resistance, and the organ is appropriately perfused.
• Changes in spectral pattern in cases of luminal narrowing
– Spectral broadening
– Loss of spectral window
– High to low resistance waveform, and vice versa
4. Direction of Flow
• Antegrade or retrograde?
5. Unidirectional vs. Bidirectional Flow
Vessels with flow in only
one direction =
unidirectional flow
(“monophasic”)
Vessels that have flow in
two directions =
bidirectional flow
May be biphasic, triphasic,
or tetraphasic (depending
on how many times blood
flows in each direction, or
crosses the baseline)
TIP:

• It is important to be aware of what vessel you are

scanning, to have an idea of its expected/usual blood
flow.
3. KNOBOLOGY AND BASIC
TROUBLESHOOTING
1. On Color Box Orientation and Color Gain

 If the study is done

using a linear probe, the
orientation of the color
box should be
approximately parallel
to the course of the
vessel to be examined
 Should be as high as
possible without
causing color aliasing
 Remedy - adjust the
color gain
• ALIASING IN SPECTRAL
DOPPLER ULTRASOUND
– Remedy: Adjust the
scale/PRF
2. On Spectral Doppler Ultrasound
Imaging
 Spectral Doppler US images
are displayed with the spectral
waveform at the bottom of the
screen and a color Doppler
image at the top
 Make the sample
volume/Doppler indicator line
as small as possible
 Place the sample volume in
the center of the vessel
 Make sure the angle theta is
less than 60 degrees
THANK YOU!
 REVIEW OF CAROTID AND LOWER
EXTREMITY DOPPLER ULTRSOUND: A
PRACTICAL APPROACH
Michael Rico B. Mesina, MD, FPCR, FCTMRISP, FUSP
Practicing Radiology Consultant
Assistant Professor IV of Radiology
 CAROTID DOPPLER ULTRASOUND
• MAIN INDICATION: to detect the
presence of occlusion and stenosis in
the neck arteries (especially the ICA)
caused by atherosclerotic vascular
disease in symptomatic patients who
had a TIA or completed stroke

• Other indications:
– Patients with non-focal symptoms
which may have a vascular etiology
– Post-endarterectomy patients
– Pulsatile neck masses
– Neck trauma
– Screening for atherosclerotic disease
 Indications
• MAIN INDICATION: to detect the
presence of occlusion and stenosis in
the neck arteries (especially the ICA)
caused by atherosclerotic vascular
disease in symptomatic patients who
had a TIA or completed stroke

• Other indications:
– Patients with non-focal symptoms
which may have a vascular etiology
– Post-endarterectomy patients
– Pulsatile neck masses
– Neck trauma
– Screening for atherosclerotic disease
Preparation
• 5 to 10 minutes rest before the examination

• No fasting is required

• Avoid taking caffeinated drinks and stimulants

a day before the procedure
Equipment
• Ultrasound machine
with Doppler
capabilities

• High-frequency
transducer (linear) – 5
MHz or more
Neck Artery Anatomy Review
1. Common Carotid Artery
B-mode Features
• Lateral to the thyroid
lobe
• Medial to the IJ vein
• Fairly straight course
Features of the Common Carotid
Artery vs. the Internal Jugular Vein

Features CCA IJV

Location More medial More lateral
Caliber Fairly uniform Varies in response to
respiration
Wall Relatively thicker Very thin/imperceptible
Response to Transducer Firm Collapses with slight
Pressure pressure
Intima-Medial Thickness
• Arterial wall
– Intima (hyperechoic)
– Media (hypo)
– Adventitia (hyper)

• Measured using the CCA at

the level of the base of the
neck (longitudinal view)

• Increases with age

• Normal: Less than or equal

to 1 mm
2. Color Doppler Features
• Antegrade / Forward
flow
 3. Spectral Doppler Features
• Appearance of its waveform is a
combination of that of the ICA
and ECA
– Slightly pulsatile
– Diastolic waveform is
between the ICA and ECA
– RI is borderline

• Where to measure the PSV:

around 2-4 cm below its
bifurcation
Before we go to the branches – Carotid
Bulb
Internal Carotid Artery

• Takes 70 to 80 % of the net blood flow from

the CCA
• Supplies the anterior circulation of the brain.
1. B-mode Features
• Almost parallel in course
relative to the carotid
bulb

• Postero-laterally situated
relative to the ECA

• Cervical segment almost

always has NO branches
2. Color Doppler Features
• Antegrade/Forward
Flow
3. Spectral Doppler Features

• Uniphasic

• Low resistance
waveform

• Measured at its
visualized proximal
segement
The ICA-CCA Ratio
• To check for the presence of
and degree of ICA stenosis

• Divide the measured Peak

Systolic Velocity of the ICA
with that of the CCA

• Hemodynamically
significant stenosis: ICA-CCA
ratio of 2.0 or more
C. External Carotid Artery
1. B-mode Features
• More anteriorly and
medially located
relative to the ICA

• Has several branches

2. Color Doppler Features
• Antegrade/Forward
flow

• Color intensity varies

(appears to “flicker”)

• Exhibits branches
3. Spectral Doppler Ultrasound
• Very pulsatile, due to
reflected arterial waves
from its branches

• High-resistance

• Triphasic
ICA vs. ECA
Features ICA ECA

Size Larger of the 2 Smaller of the 2

Branches Very rarely Always

Orientation/Position Proceeds deep and slightly Proceeds antero-medially

posteriorly towards the (towards the face)
mastoid

Flow Antegrade Antegrade

Spectral Doppler waveform Low-resistance High-resistance

D. Vertebral Artery
1. B-mode Findings
• Seen between the
transverse processes of
the cervical vertebral
bodies (“ilog sa pagitan
ng 2 bundok”)

• Fairly straight course

2. Color Doppler Findings
• Antegrade/forward and
consistent flow
3. Spectral Doppler Findings

• Uniphasic

• Low resistance
DISCUSSION OF SOME BASIC
PATHOLOGIES
A. Atherosclerotic Changes
• Elevated IMT (greater
than 1mm) – predictive
of future vascular
events

• Presence and
characteristics of
atherosclerotic plaques
Plaque Characterization
• Location and extent (longitudinal)
• Thickness (transverse)
• Degree of luminal reduction it causes (transverse)

• When reporting plaque severity, use generic terms

– Minimal
– Moderate
– Severe
Plaque Type International Bluth Classification
Classicification
System

1 Uniformly Heterogeneous Predominantly

sonolucent with a sonolucent (>50%),
thin echogenic cap with a thin
echogenic cap
2 Predominantly Heterogeneous >50% sonolucent
<50% echogenic
sonolucent (>50%) Calcification may be present

3 Predominantly Homogeneous >50% echogenic

<50% sonolucent
echogenic (>50%) Calcification may be present

4 Uniformly echogenic Homogenous Uniformly echogenic

5 Unclassified due to poor Unable to classify

visualization; calcifications
causing inadequate
visualization
Significance of Plaque Characterization
• Types 1 and 2
– Associated with intraplaque
hemorrhage and/or
ulceration
– “vulnerable”
– Subject to abrupt increase in
plaque size following
hemorrhage and
embolization
– Usually found in symptomatic
patients with stenoses greater
than 70% of diameter
• Types 3 and 4 plaque
– Generally composed of
fibrous tissue and/or
calcification
– Generally more benign and
stable
– Common in asymptomatic
individuals
– Type 4 is more commonly
seen
• Type 5 – with
calcification; difficult to
visualize its other
portions
B. Arterial Stenosis
• Most stenotic lesions are
seen in the proximal ICA

• Up to 30% of all major

hemispheric events
(stroke, TIA, amaurosis
fugax) are thought to
arise from pathology at
the carotid bifurcation

• NASCET and ECST

methods
Main Doppler UTZ Parameters used for
detection of Stenosis
• Peak systolic velocity
– Most commonly used (easily
obtained and reproducible)
– Obtained at the B-mode
determined area of stenosis
• ICA-CCA ratio
– Compensates for interpatient
and instrument variability
• End diastolic velocity
– Obtained at the B-mode
determined area of stenosis
Results of Society of Radiologists in Ultrasound Consensus Conference on the Diagnosis
of Internal Carotid Stenosis

ICA PSV Plaque/ ICA-CCA PSV ICA EDV

(cm/sec) Diameter Ratio (cm/sec)

Normal < 125 None < 2.0 < 40

< 50% < 125 < 50% < 2.0 < 40

50 – 69% 125 – 230 >/= 50% 2.0 to 4.0 40 – 100

70% to near >230 >/= 50% > 4.0 >100

occlusion

Near occlusion High, low or Visible Variable Variable

undetectable

Total occlusion Undetectable Visible; no N/A N/A

detectable
lumen
Example:
• Answer: Approximately
50-69% stenosis

• PSV = 180.5 cm/sec

• EDV = 89.6 cm/sec
Near Occlusion
• String Sign on color
Doppler ultrasound

• Plaque occupies almost

the entire lumen of the
vessel
Complete Occlusion

• Plaque occupies the

entire lumen of the
vessel

• No color flow nor

spectral Doppler
waveform identified in
the occluded segment
Classification of Patients into the following
Main Groups based on the assessed
Degree of Stenosis:
• Those without significant disease

• Mild disease (< 50% diameter reduction) – will benefit from medical
therapy if symptomatic

• More severe disease (50-70% diameter stenosis) – treated

medically and followed-up to assess progression of disease,
particularly if symptomatic

• Severe disease (> 70% diameter reduction) –will benefit from

surgery if symptomatic

• Complete occlusion – not candidates for surgery

LOWER EXTREMITY DOPPLER
ULTRASOUND
ARTERIAL STUDY
Indications
• To screen for atherosclerotic vessel disease
• To determine the presence and degree &
extent of arterial stenosis, as well as arterial
occlusion
• Part of work-up in patients who are
candidates for possible lower extremity
amputation
Additional Indications
Preparation
• No special preparation needed
Equipment (Transducer)
• High-frequency
transducer (linear)
Patient Position
• Supine
• Initial position: the knee is slightly flexed and
the extremity is oriented laterally
• Other positions: the knee is extended, with
the patient at the supine and lateral positions
Basic Anatomy of the Lower Extremity
Arteries
Recommended Protocol
• Arteries to assess:
– Common femoral artery
– Superficial femoral artery (proximal, middle and distal)
– Deep femoral artery
– Posterior tibial artery (proximal, middle and distal)
– Anterior tibial artery (proximal, middle and distal)
– Dorsalis pedis artery
– Peroneal artery (proximal, middle and distal)
– Popliteal artery
The Ankle-Brachial Index
• Gives a general
assessment of the
adequacy of perfusion
of the lower extremities
Ankle-Brachial Index Interpretation
B-mode Study
• Check for the presence of wall thickening and
calcifications
• Check for abnormal dilatation and luminal
narrowing
Artery vs. Vein
• Transverse compression
technique
Normal Color and Spectral Doppler
Appearance of the Lower Extremity
Arteries
• Color Flow
– Forward flow
– Pulsatile
• Waveform Appearance
– Above the baseline
– High resistance
– Triphasic or biphasic
Color Doppler Ultrasound of the
Leg Arteries
Spectral Doppler Ultrasound of the
Lower Extremity Arteries
Common Arterial Pathologies
Arterial Stenosis based on Velocity
Measurements
Case

Answer: PSV Ratio = 5; thus, % stenosis is > 75%

VENOUS STUDY
Indications
• To check for the presence and severity of
varicose veins
• To determine the presence and extent of
venous thrombosis
• To assess for the presence of venous reflux/
insufficiency
Basic Anatomy of the Lower Extremity
Veins
Recommended Protocol
• Veins to assess:
– Common femoral vein
– Proximal segment of the greater saphenous vein
– Superficial femoral vein (proximal, middle and distal)
– Above knee, below knee and ankle level segments of
the greater saphenous vein
– Posterior tibial vein
– Anterior tibial vein (in passing only)
– Peroneal vein
– Lesser saphenous vein
– Popliteal vein
B-mode Study
• Assess for the presence
of intraluminal
thrombus formations
• Best way: Serial manual
compressions
• Check for abnormal
dilatations as well as
the presence of
adjacent varicosities
(serpetine structures)
Color Doppler Ultrasound of the
Leg Veins
Color and Spectral Doppler
Appearance of the Lower Extremity
Veins
• Color Flow
– Backward/Retrograde
flow
• Waveform Appearance
– Low resistance
– Monophasic or phasic
Augmentation Techniques
• Done to check for patency as well as for reflux
and insufficiency
• For proximal veins – Valsalva maneuver
• For leg veins – Compression of the more distal
segment
Common Lower Extremity Vein
Pathologies
1. Venous Thrombosis
• Non-compressibility
Acute vs. Chronic Thrombosis
• Acute – hypoechoic
• Chronic – hyperechoic
2. Venous Insufficiency
• Presence of significant
flow within the vein on
Valsalva or compression
maneuver
REVIEW OF HEPATIC, RENAL AND AV
ACCESS DOPPLER ULTRAOSUND: A
PRACTICAL APPROACH
Michael Rico B. Mesina, MD, FPCR, FCTMRISP, FUSP
Practicing Radiology Consultant
Assistant Professor IV of Radiology
HEPATIC DOPPLER ULTRASOUND
Indications
• To assess the hepatic vasculature, commonly the
following conditions:
– Portal hypertension
– Venous thrombosis
– Arterial stenosis
Preparation
• At least 8 hours fasting
Equipment and Patient Positioning
• 2-5 MHz curved array
transducer

• Main position – patient

is lying down supine
Review of Hepatic Anatomy
• Largest intra-abdominal
organ

• Right lobe, left lobe and

caudate lobe

• BS: 75% - portal vein;

25% hepatic artery
Fissures and Ligaments
• Major fissure – divides
the right and left lobes
(at its superior portion)

• Gallbladder (or GB
fossa) – divides the
right and left lobes (at
its inferior portion)
• Ligamentum teres –
divides the medial and
lateral segments of the
left lobe
• Ligamentum venousum
– separates the left lobe
from the caudate lobe
Vascular Landmarks: The Couinaud
Classification
• Hepatic Veins
– Commonly used in
dividing the superior
segments
– Intersegmental

• Portal Veins
– Commonly used in
designating the inferiorly
located segments
– Intrasegmental
RECOMMENDED SCANNING GUIDE
1. B-mode Study
• Size and configuration; relative size of the
lobes.
• Borders
• Parenchymal echogenicity and the presence of
parenchymal lesions
2. B-mode, Color and Spectral
Doppler Ultrasound Study of the
Hepatic Vessels
2.1. Portal Veins
2.1.1. Main Portal Vein
• Best seen in: Right lateral
intercostal view

• B-mode:
– Anechoic
– Slightly thick wall
– Normal diameter = up to 1.3
cm

• CDI: Antegrade

• SDI:
– Antegrade, monophasic or
phasic waveform
– Normal PSV: 10-40 cm/sec
2.1.2. Right Portal Vein
• Best view: Right lateral
intercostal view (slightly
oblique)

• Anterior branch (to S8

and S5 branches) and
posterior branch (to S7
and S6 branches)
2.1.3. Left Portal Vein
• Axial view (“Recumbent
H” view)

S4 S2

LPV S3
2.2. Hepatic Veins (including the
intrahepatic portion of the IVC)

• Best view: “Crow’s foot

appearance”

• Common variant: The

LMV and MHV forming
a common trunk before
entering the
intrahepatic portion of
the IVC
Hepatic Veins
• B-mode
– Anechoic
– Normal measurements:
• HVs = up to 1.0 cm
• Intrahepatic IVC = up to
1.8 cm (on inspiration)

• CDI: Retrograde

• SDI: Retrograde, pulsatile, tri- or

tetraphasic
2.3. Main Hepatic Artery
• Best view: Same as with
the main portal vein
• Measurement = 4-6 mm

• CDI: Antegrade, and

“flickers”

• SDI: Antegrade, high

resistance/pulsatile
– PSV: 60-80 cm/sec
Waveform of Main Portal Vein vs. Main
Hepatic Artery
COMMON PATHOLOGIES
ENCOUNTERED IN PRACTICE
1.1 Portal Hypertension (Case #1:
B-mode)
• Dilated portal vein ( >
1.3 cm)

• “Parallel tract sign”

 1.2. Portal Hypertension Case #2
(Color Doppler Study)
• Dilated MPV

• Reversal of flow
(hepatofugal)
1.3. Portal Hypertension Case #3
(CDI and SDI)
Portal HPN and Varices
• Varices – sign of
chronicity
(decompensation)
 1.4. Portal Hypertension Case #4
(CDI)
• Dilated coronary vein
1.5. Portal Hypertension Case #5
(CDI)
• Splenic varices
1.6. Portal Hypertension Case #6
(CDI)
• Recanalization of the
umbilical vein
1.7. Portal Hypertension Case #7
(CDI)
• Caput Medusae
(Paraumbilical varices)
2. Portal Vein Thrombosis
2.1. Portal Vein Thrombosis Case
#1
2.2. Portal Vein Thrombosis Case
#2
• Cavernous
Transformation of the
Portal Vein
3. Passive Congestion of the Liver
• Can be seen in CHF and
tricuspid regurgitation

• Findings:
– Dilated hepatic veins and
inferior vena cava
4. Hepatic Veno-occlusive Disease
(Budd-Chiari Syndrome)
• Different types

• May cause hepatic

congestion
NATIVE RENAL DOPPLER
ULTRASOUND
 Indications

Source: Allan, Paul, et.al. Clinical Ultrasound, 3rd edition, 2011

Available Imaging Modalities

Source: Allan, Paul, et.al. Clinical Ultrasound, 3rd edition, 2011

 Sensitivities

Source: Allan, Paul, et.al. Clinical Ultrasound, 3rd edition, 2011

Preparation
• Fasting for 8 hours prior
to the procedure
Equipment and Patient Positioning
• 2.5 to 3 MHz transducer

• Ideal: stretcher with a

reverse Trendelenburg
position (feet down)

• Main position of the

patient: lying down,
supine
 Review of Anatomy
• Kidneys
• Main Renal Arteries
• Intrarenal Arteries
– Segmental
– Interlobar
– Arcuate
– Cortical
1. B-mode Study
• Renal size and configuration
– Criteria for small kidneys:
• Right > 2.5 cm smaller than left
• Left > 1.5 cm smaller than right
– Less than 8 cm – atrophic; poor
outcome in revascularization therapy

• Renal parenchymal thickness (Normal = at

least 1 cm), echogenicity and presence of
focal lesions

• Check for:
– Renal calculi
– Hydronephrosis
Renal Calcifications and the
“Twinkle” Artifact

• Twinkle artifacts – seen

posterior to
calcifications on color
Doppler imaging
2. Power Doppler Imaging
• To check for renal
perfusion

• More sensitive than CDI

3. Color and Spectral Doppler
Imaging
3.1. Abdominal Aorta
• Get the color and
spectral Doppler tracing
of a segment of the
abdominal aorta (at the
suprarenal level)

• Pulsatile flow
Spectral Doppler Waveform of the
Abdominal Aorta at Different
Levels
• Pulsatile and antegrade

• Suprarenal level – with mild

diastolic component, due to the
renal arteries being one of its
more distal branches

• Infrarenal level – no or reversed

diastolic flow

• Aortic PSV – typically in the range

of 40 to 100 cm/sec
3.2 CDI of the Origin of the Main
Renal Arteries
3.2.1. Right Main Renal Artery CDI
• Passes posterior to the
IVC
3.2.2. Left Main Renal Artery CDI
• Passes posterior to the
left renal vein
3.3 Spectral Doppler Waveform of
the Origin of the MRA
• Phasic and antegrade
• Low-resistance
• Brisk systolic phase

• Normal PSV = less than 180

cm/sec

• If there is difficulty in obtaining a

waveform in the origin,
assessment of the distal segment
(pre-renal) may be done
 3.4 Renal Artery – Aortic Ratio
• PSV Renal Artery / PSV
Aorta

• Normal is < 3.5

Source: Zierler, R. Strandness’ Duplex Scanning

in Vascular Disorders, 4th edition. 2010.
3.5 Segmental Artery
• Superior, middle and
inferior

• Antegrade, Phasic, Low-

resistance.
3.6 Main Renal Vein
• Retrograde
• Phasic waveform
1. Main Renal Artery Stenosis
• Most common indication for renal native Doppler ultrasound study.
1.1 RAS Case #2
1.3 RAS Case #3 – CDI Only
• (+) Color bruit
1.4. RAS Case #4
1.5. RAS Case #5
• MRA PSV = 199 cm/sec

• RAR = 3.72
2. Renal Infarction
3. Fibromuscular Dysplasia
• Common cause of HPN
in children and
adolescents

• “String of beads”
appearance
5. Renal Artery Aneurysm
• Round/ovoid anechoic
structure

• Presence of turbulent
flow on CDI (Yin and
yang sign)
6. Renal Vein Thrombosis
• Causes:
– Membranous
glomerulonephritis
– Hypercoagulability states
– Dehydration
– Compression by fibroses
or tumor
THANK YOU!