Measurement of Radiation and Dosimetric Procedure.pptx
Doppler hepático: anatomía y patología vascular
1. US Doppler hepático
Técnica de exploración, anatomía y patología vascular
DR. ERIC KIMURA HAYAMA
Instituto Nacional de Cardiología Ignacio Chávez
CT Scanner
de México Grupo CT Scanner
Thursday, May 31, 2012
6. Objetivos
1. Describir aquellos parámetros técnicos útiles en la obtención
de un estudio diagnóstico y que pueden condicionar artificios
Thursday, May 31, 2012
7. Objetivos
1. Describir aquellos parámetros técnicos útiles en la obtención
de un estudio diagnóstico y que pueden condicionar artificios
2. Describir las características normales de los vasos hepáticos
Thursday, May 31, 2012
8. Objetivos
1. Describir aquellos parámetros técnicos útiles en la obtención
de un estudio diagnóstico y que pueden condicionar artificios
2. Describir las características normales de los vasos hepáticos
3. Describir algunas patologías donde el US Doppler es de
utilidad en su estudio
Thursday, May 31, 2012
9. 1. TÉCNICA
2. Anatomía y fisiología
3. Patología
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
10. Técnica de revisión: ventanas
• Depende del vaso, tamaño del hígado y del paciente
Transabdominal
Lóbulo izquierdo
• Porta izquierda
• VSH izq
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
11. Técnica de revisión: ventanas
• Depende del vaso, tamaño del hígado y del paciente
Transabdominal Intercostal (DLI)
Porta hepatis
Lóbulo izquierdo • Porta principal
• Porta izquierda • Art. Hepática principal
• VSH izq y ramas der e izq
• VSH der y media
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
12. Técnica de revisión: ventanas
• Depende del vaso, tamaño del hígado y del paciente
Transabdominal Intercostal (DLI) Subcostal
Lóbulo derecho (segm
Porta hepatis posteriores)
Lóbulo izquierdo • Porta principal
• VSH y su llegada a la
• Porta izquierda • Art. Hepática principal VCI
VSH izq y ramas der e izq
• • Bifurcación portal
• VSH der y media (“H”)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
13. Doppler: parámetros técnicos
Doppler color y espectral
Doppler espectral
Doppler color
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
14. Doppler: parámetros técnicos
Doppler color y espectral • Línea basal
• Escala de velocidad (PRF)
• Filtros
• Inversión de flujo
Doppler espectral
Doppler color
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
15. Doppler: parámetros técnicos
Doppler color y espectral • Línea basal
• Escala de velocidad (PRF)
• Filtros
• Inversión de flujo
Doppler espectral • Ganancia espectral
• Ángulo
• Tamaño y posición de la
muestra
Doppler color
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
16. Doppler: parámetros técnicos
Doppler color y espectral • Línea basal
• Escala de velocidad (PRF)
• Filtros
• Inversión de flujo
Doppler espectral • Ganancia espectral
• Ángulo
• Tamaño y posición de la
muestra
Doppler color • Ganancia de color
• Barra y caja de color
• Escala de velocidad de color
• Prioridad
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
17. Doppler: parámetros técnicos
Doppler color y espectral • Línea basal
• Escala de velocidad (PRF)
• Filtros
• Inversión de flujo
Doppler espectral • Ganancia espectral
• Ángulo
• Tamaño y posición de la
muestra
Doppler color • Ganancia de color
• Barra y caja de color
• Escala de velocidad de color
• Prioridad
TODOS los parámetros DEBEN individualizarse
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
18. Sobrerrango (aliasing)
• Causa: PRF “muy bajo” (los
cambios de frecuencia
superan el límite Nyquist -2
veces el PRF-)
Thursday, May 31, 2012
19. Sobrerrango (aliasing)
• Causa: PRF “muy bajo” (los
cambios de frecuencia
superan el límite Nyquist -2
veces el PRF-)
SOLUCIÓN
1. PRF
2. Mover la línea basal
3. ángulo Doppler
4. Transductor <frecuencia
Thursday, May 31, 2012
20. Doppler espectral: PRF y línea basal
¿Espectro pequeño?
Solución: mover línea
basal o PRF
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
21. Doppler espectral: PRF y línea basal
Mover línea basal
¿Espectro pequeño?
Solución: mover línea Mover PRF
basal o PRF
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
22. Ganancias color
¿Hemorragia de color?
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
23. Ganancias color
¿Hemorragia de color? Solución: ganancia color
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
24. Ganancias espectrales
id
ru o
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
25. Tamaño y posición de la muestra
Mejor definición del espectro y de la ventana espectral
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
26. Ventana espectral
Caus
Artifi
Lar
Hig
Physi
No
No
Patho
Co
Tur
vessel e
aorta. T
Figure 10. Diagrams illustrate “spectral window” andRadiología/Unidad PET-CT
incich/grupo ct scanner Departamento de
tral wa
spectral broadening. In the proximal aorta (top left),
Thursday, May 31, 2012
27. color Doppler examination includes gray-scale US (B-
Generalidades
mode imaging).
Figure 2. Spectral Doppler examination components.
Diagram at left shows the general layout of a spectral
Doppler image. The spectral waveform is displayed
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
on the lower half of the image, a color Doppler image
Thursday, May 31, 2012
28. Generalidades
Magnified view of a spectral waveform illustrates its features.
Cardiac phasicity creates a phasic cycle, which is composed of phases as de-
termined by the number of times blood flows in each direction. The baseline
(x = 0) separates one direction from another. Moving from left to right along
the x-axis corresponds to moving forward in time. Moving away from the
baseline vertically along the y-axis in either direction correspondsRadiología/Unidad PET-CT
incich/grupo ct scanner Departamento de
to increas-
Thursday, May 31, 2012
29. Generalidades
trate th
used to
undula
velocity
wavefo
and no
phasic
phasic
teries b
veins. N
a phas
no velo
though
The te
out ph
is no fl
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
30. radiographics.rsna.org
Figure 6. Phase interpretation ambiguity. Schematics illustrate how different
interpretations of what constitutes a phase can affect waveform characteriza-
tion and nomenclature. D.A.M. interprets a phase as a component of the
waveform on either side of the baseline; M.M.A.Y. interprets a phase as an
inflection.
Figure 6. Phase interpretation ambiguity. Schematics illustrate how different
interpretations of what constitutes a phase can affect waveform characteriza-
tion and nomenclature. D.A.M. interprets a phase as a component of the
waveform on either side of the baseline; M.M.A.Y. interprets a phase as an
inflection.
Figure 7. Directionality and phase quantification. When phase is defined as
a component of phasic flow direction, waveforms may be described in terms
of the number of phases. All monophasic waveforms are unidirectional; bidi-
rectional waveforms may be either biphasic, triphasic, or tetraphasic.
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
31. the PI in the portal vein (V2/V1). The most fre- theless u
quently used index in the hepatic arteries is the the RI o
RI, which is calculated as
1. A h
(PSV − EDV) (V1 − V2) therefor
RI = = ,
(PSV) V1 ing than
Table 1 where PSV = peak systolic velocitycorrelates with, the number of sounds
and EDV = 2. An
audio Doppler US. With this interpretthe post
end diastolic velocity. Calculating the RI is phases (phase quantificatio
number of prob-
ably the easiest part of measuring and reporting inflection diffuse d
Internal carotid arteries
to the number of points con
Hepatic arteries
arterial impedance; most US vendors provide one cycle.wide var
Renal arteries
waveform during
Perhaps in the future, a consensusease due
software that automatically performs this calcula-
Testicular arteries addressing what constitutes a phase an
tion. What to radiographics.rsna.org is much less clear. will be3. An
do with the result ate phase quantification forthc
Note.—RI = resistive index.
This is because the normal range varies from oneto overall waveform
cially as it pertains proxima
n- institution, and publishedarteries. Schematics illustrate thatarticle, D.A.
High- versus low-resistance
article to the in this a(arteriov
ture. Nonetheless,
Table 2 artery, high-resistance artery (left) allows less blood flow during end diastole (the
nce; pretation of phase will be used for pha
e next. Furthermore,such that the
trough is lower) than does significance of (right). These visual findings severe
ization of any wave can be achieved the a low-resistance artery an abnor-
cation and subsequent waveform nom in
are confirmed by calculating an RI. High-resistance arteries normally have RIs
words usedmal result 0.7,not could be entered Therefore, it is wise to 0.7.
External carotid arteries is wave always clear.
to describe the whereas low-resistance arteries have RIs ranging from 0.55
over injury);
Extremity arteries (eg, external iliac is a low-resistance artery.
arteries,
into a computer to relyhepatic artery these measurements; rather,
- not andThe waveform recreated.
the solely on
axillary arteries)good to know that phase
Unidirectional versus Bidirectional.—
they should such as and supporting unidirectionaldirection of flow can also
Regardless, it is
Fasting mesenteric arteries be used asinferior
quantification descriptors (superior
,
data. the and
describe Flow 7)
(Fig P
mesenteric arteries)
ter- , and In general, ambiguous given arteries normally direction (whetherar
can be low-resistance flow in only one There a
Note.—RI = in the RI of 0.55–0.7. The hepatic retrograde) can be said to have un
have an index.
this differenceresistivedefinition of phase. Another or artery is Causes of Spectral Bro flow (no
e- point to keeplow-resistance vessel; however, wider normalonly be monophasic
a in mind is that nonphasic waves do flow, which can Artificial
not actually lack phasicity; rather, they have one
lent flow
High- versus low-resistance arteries
earlier). Vessels thatLarge samplein twofl
have flow PET-CT
m- volume
incich/grupo ct scanner
ranges of 0.55–0.81 have been reported to have bidirectional flow, of
phase (ie, are monophasic) without any inflec- for
high-resistance artery (left) allows less blood
effect wh
Departamento de Radiología/Unidad
ion
Thursday, May 31, 2012 trough issaid than does a low-resistance arter
are lower) High gain
32. Parvus tardus
incich/grupo ct scanner Diagram illustrates upstream stenosis
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
33. 1. Técnica
2. ANATOMÍA Y FISIOLOGÍA
3. Patología
Thursday, May 31, 2012
36. Anatomía (Couinaud)
SEGMENTO NOMBRE
I Caudado
II Lateral sup
III Lateral inf
IV Medial
V Anterior inf
VI Posterior inf
VII Posterior sup
VIII Anterior sup
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
37. Couinaud
ESTRUCTURA LOCALIZACIÓN UTILIDAD
Separa segmentos
VSHD Cisura intersegmentaria derecha
anterior/posterior
Separa lóbulos
VSHM Cisura lobular principal
derecho/izquierdo
Separa segmentos
VSHI Cisura intersegmentaria izquierda
medial/lateral
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
39. VSH normales
• Abordaje: variable
• Morfología trifásica:
• Suprabasal (1): sístole
atrial
• Infrabasal (2): fases de
llenado auricular
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
40. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
and waveform. The direction of normal flow is predominantly antegrade, PET-CT
incich/grupo ct scanner Departamento de Radiología/Unidad
Thursday, May 31, 2012
41. Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
tracing, and hepatic venous (HV) waveform (4). The
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough
42. Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
Contracción auricular
(fin de diástole)
Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
tracing, and hepatic venous (HV) waveform (4). The
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough
43. Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
Contracción auricular
(fin de diástole)
Efecto “succión” post
contracción auricular
y tricúspide cerrada
Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
tracing, and hepatic venous (HV) waveform (4). The
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough
44. Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
Contracción auricular
(fin de diástole)
Efecto “succión” post
contracción auricular
y tricúspide cerrada
Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
Aumento presión intraauricular
con válvula tricúspide cerrada (telesístole) (HV) waveform (4). The
tracing, and hepatic venous
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough
45. Espectro normal vena suprahepática
Figure 18. Diagram illustrates normal hepatic venous flow direction
a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
Contracción auricular
(fin de diástole)
Efecto “succión” post
contracción auricular
y tricúspide cerrada
Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
Aumento presión intraauricular Fase de llenado
con válvula tricúspide cerrada (telesístole) (HV) waveform (4). The
tracing, and hepatic venous rápido ventricular
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough
46. Espectro NORMAL vena suprahepática
D
v
Figure 18. Diagram illustrates normal hepatic venous flow direction
and waveform. The direction of normal flow a predominantly antegrade,
1) Relaciones normales: is
S
which corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The term , which refers to the a, S, and D inflection
points, is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
47. Espectro NORMAL vena suprahepática
D
v
Figure 18. Diagram illustrates normal hepatic venous flow direction
and waveform. The direction of normal flow a predominantly antegrade,
1) Relaciones normales: is
a>v a >D S
which corresponds to S waveform that is mostly below the baseline at spectral
Doppler US. The term , which refers to the a, S, and D inflection
points, is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
48. Espectro NORMAL vena suprahepática
D
v
Figure 18. Diagram illustrates normal hepatic venous flow direction
and waveform. The direction of normal flow a predominantly antegrade,
1) Relaciones normales: is
a>v a >D S
which corresponds to S waveform that is mostly below the baseline at spectral
Doppler US. The term , which refers to the a, S, and D inflection
points,2) commonly Valsalva:
is Efecto de used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
Pérdida de pulsatilidad
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
49. Espectro NORMAL vena suprahepática
D
v
Figure 18. Diagram illustrates normal hepatic venous flow direction
and waveform. The direction of normal flow a predominantly antegrade,
1) Relaciones normales: is
a>v a >D S
which corresponds to S waveform that is mostly below the baseline at spectral
Doppler US. The term , which refers to the a, S, and D inflection
points,2) commonly Valsalva:
is Efecto de used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
Pérdida de pulsatilidad
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
3) ¿Cómo revisarla?:
tetraphasic (bottom right).
Inspiración ligera
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
50. Venas hepáticas: anomalías espectro
176 January-February 2011 radiographics.rsna.org
• Alta pulsatilidad:
corresponds to maximal retrograde hepatic ve-
nous flow. In physiologic states, the peak of the
Table 6
Causes of Pulsatile Hepatic Venous Waveform
a wave is above the baseline, and the a wave is
• Origen: cardiaco
wider and taller than the v wave (the other po- Tricuspid regurgitation
Decreased or reversed S wave
tentially retrograde wave). Even in pathologic
states, the a wave remains wider than the v wave, Tall a and v waves
which represents the best way to initially orient Right-sided CHF
oneself on the waveform. The only time this rule Maintained S wave/D wave relationship
breaks down is in cases of severe tricuspid regur- Tall a and v waves
gitation, when the S wave becomes retrograde
and merges with the a and v waves to form one
large retrograde a-S-v complex.
The S wave is the next wave encountered grade diastolic velocity is maximal. The subse-
on the waveform. Its initial downward-sloping quent rising portion results from increasing right
portion is generated by decreasing right atrial atrial pressure generated by the increasing right
pressure, as a result of the “sucking” effect cre- ventricular blood volume.
ated by the downward motion of the atrioven- It is almost unheard of to describe flow in the
tricular septum as it descends toward the cardiac hepatic veins as hepatofugal, since the term is
apex during early to midsystole. Note that the reserved for describing the state of pathologic
tricuspid valve remains closed. If it were open flow in the portal veins. However, it is important
(tricuspid regurgitation), the result would be to remember that physiologic flow in the hepatic
pathologic retrograde flow. The S wave corre- veins is hepatofugal (ie, away from the liver and
sponds to antegrade hepatic venous flow and is toward the heart). In summary, the hepatic ve-
the largest downward-pointing wave in the cycle. nous waveform is normally phasic and predomi-
The lowest point occurs in midsystole and is the nantly antegrade.
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
point at which negative pressure is minimally op- Abnormal (pathologic) hepatic venous flow
Thursday, May 31, 2012velocity is maximal. After
posed and antegrade may manifest in one of several basic ways.
51. Venas hepáticas: anomalías espectro
OJO: NO aplica en
casos de cirrosis
176 January-February 2011 radiographics.rsna.org
• Alta pulsatilidad:
corresponds to maximal retrograde hepatic ve-
nous flow. In physiologic states, the peak of the
Table 6
Causes of Pulsatile Hepatic Venous Waveform
a wave is above the baseline, and the a wave is
• Origen: cardiaco
wider and taller than the v wave (the other po- Tricuspid regurgitation
Decreased or reversed S wave
tentially retrograde wave). Even in pathologic
states, the a wave remains wider than the v wave, Tall a and v waves
which represents the best way to initially orient Right-sided CHF
oneself on the waveform. The only time this rule Maintained S wave/D wave relationship
breaks down is in cases of severe tricuspid regur- Tall a and v waves
gitation, when the S wave becomes retrograde
and merges with the a and v waves to form one
large retrograde a-S-v complex.
The S wave is the next wave encountered grade diastolic velocity is maximal. The subse-
on the waveform. Its initial downward-sloping quent rising portion results from increasing right
portion is generated by decreasing right atrial atrial pressure generated by the increasing right
pressure, as a result of the “sucking” effect cre- ventricular blood volume.
ated by the downward motion of the atrioven- It is almost unheard of to describe flow in the
tricular septum as it descends toward the cardiac hepatic veins as hepatofugal, since the term is
apex during early to midsystole. Note that the reserved for describing the state of pathologic
tricuspid valve remains closed. If it were open flow in the portal veins. However, it is important
(tricuspid regurgitation), the result would be to remember that physiologic flow in the hepatic
pathologic retrograde flow. The S wave corre- veins is hepatofugal (ie, away from the liver and
sponds to antegrade hepatic venous flow and is toward the heart). In summary, the hepatic ve-
the largest downward-pointing wave in the cycle. nous waveform is normally phasic and predomi-
The lowest point occurs in midsystole and is the nantly antegrade.
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
point at which negative pressure is minimally op- Abnormal (pathologic) hepatic venous flow
Thursday, May 31, 2012velocity is maximal. After
posed and antegrade may manifest in one of several basic ways.
52. Venas hepáticas: anomalías espectro
OJO: NO aplica en
casos de cirrosis
176 January-February 2011 radiographics.rsna.org
• Alta pulsatilidad:
corresponds to maximal retrograde hepatic ve-
nous flow. In physiologic states, the peak of the
Table 6
Causes of Pulsatile Hepatic Venous Waveform
a wave is above the baseline, and the a wave is
• Origen: cardiaco
wider and taller than the v wave (the other po- Tricuspid regurgitation
Decreased or reversed S wave
tentially retrograde wave). Even in pathologic
states, the a wave remains wider than the v wave, Tall a and v waves
which represents the best way to initially orient Right-sided CHF
oneself on the waveform. The only time this rule Maintained S wave/D wave relationship
breaks down is in cases of severe tricuspid regur- Tall a and v waves
gitation, when the S wave becomes retrograde
and merges with the a and v waves to form one
large retrograde a-S-v complex.
• Baja pulsatilidad:
The S wave is the next wave encountered
on the waveform. Its initial downward-sloping
grade diastolic velocity is maximal. The subse-
quent rising portion results from increasing right
portion is generated by decreasing right atrial atrial pressure generated by the increasing right
• Origen: pérdida de
pressure, as a result of the “sucking” effect cre- ventricular blood volume.
distensibilidad venosa (por
ated by the downward motion of the atrioven-
tricular septum as it descends toward the cardiac
It is almost unheard of to describe flow in the
hepatic veins as hepatofugal, since the term is
aumento en la presión
apex during early to midsystole. Note that the
tricuspid valve remains closed. If it were open
reserved for describing the state of pathologic
flow in the portal veins. However, it is important
intraparenquimatosa
(tricuspid regurgitation), the result would be
pathologic retrograde flow. The S wave corre-
to remember that physiologic flow in the hepatic
veins is hepatofugal (ie, away from the liver and
hepática)
sponds to antegrade hepatic venous flow and is
the largest downward-pointing wave in the cycle.
toward the heart). In summary, the hepatic ve-
nous waveform is normally phasic and predomi-
The lowest point occurs in midsystole and is the nantly antegrade.
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
point at which negative pressure is minimally op- Abnormal (pathologic) hepatic venous flow
Thursday, May 31, 2012velocity is maximal. After
posed and antegrade may manifest in one of several basic ways.
53. Venas hepáticas: anomalías espectro
OJO: NO aplica en
casos de cirrosis
176 January-February 2011 radiographics.rsna.org
• Alta pulsatilidad:
corresponds to maximal retrograde hepatic ve-
nous flow. In physiologic states, the peak of the
Table 6
Causes of Pulsatile Hepatic Venous Waveform
a wave is above the baseline, and the a wave is
• Origen: cardiaco
wider and taller than the v wave (the other po- Tricuspid regurgitation
Decreased or reversed S wave
tentially retrograde wave). Even in pathologic
states, the a wave remains wider than the v wave, Tall a and v waves
which represents the best way to initially orient Right-sided CHF
oneself on the waveform. The only time this rule Maintained S wave/D wave relationship
breaks down is in cases of severe tricuspid regur- Tall a and v waves
S wave becomes retrograde
gitation, when the 178 January-February 2011 radiographics.rsna.org
and merges with the a and v waves to form one
large retrograde a-S-v complex.
This is because the waveform is affected not only
• Baja pulsatilidad:
The S wave is the next wave encountered grade diastolic velocity is maximal. The subse-
by the cardiac cycle, but also by respiratory varia-
on the waveform. Its initial downward-sloping
Table 7
quent rising portion Causes of Decreased Hepatic Venous Phasicity
tion. It has been shown that inspiration and expi-
results from increasing right
portion is generated by decreasing right atrial atrial pressure generated by the increasing right
• Origen: pérdida de
ration both affect the systolic/diastolic ratio, and
pressure, as a result of the “sucking” effect cre-
Cirrhosis
ventricular blood volume. vein thrombosis (Budd-Chiari syndrome)
that the Valsalva maneuver can markedly reduce Hepatic
distensibilidad venosa (por
ated by the downward motion of the atrioven- It is almost unheard of toveno-occlusive disease
pulsatility, even to the point of nonphasicity (1).
tricular septum as it descends toward the cardiac
Hepatic describe flow in the
hepatic veins as hepatofugal, since outflow obstruction from any cause
Hepatic venous the term is
The ideal time to acquire the spectral waveform
aumento en la presión
apex during early to midsystole. Note that the reserved for describing the state of pathologic
is during a small (incomplete) inspiratory breath
tricuspid valve remains closed. If it were open flow in the portal veins. However, it is important
hold. Once proper technique has been confirmed,
intraparenquimatosa
(tricuspid regurgitation), the result would be to remember that physiologic flow in the hepatic
pathologic causes of nonphasicity may be consid-
pathologic retrograde flow. The S wave corre- veins is hepatofugal (ie, away from the liver and
ered, including cirrhosis, hepatic vein thrombosis literature indicates that approximately 25% of
hepática)
sponds to antegrade hepatic venous flow and is toward the heart). In summary, the hepatic ve-
(Budd-Chiari syndrome), hepatic veno-occlusive
the largest downward-pointing wave in the cycle.
patients with Budd-Chiari syndrome also have
nous waveform is normally phasic and predomi-
disease, and hepatic venous outflow obstruction portal vein thrombosis (23).
The lowest point occurs in midsystole and is the nantly antegrade.
incich/grupo ct scanner from any cause (Table 7). As disease severity Budd-Chiari Departamento de Radiología/Unidad PET-CT
syndrome is typically classified
point at which negative pressure is minimally op- Abnormal (pathologic) hepatic venous flow
progresses and the veins become more com- into one of three types on the basis of the loca-
Thursday, May 31, 2012velocity is maximal. After
posed and antegrade may manifest in one of several basic ways.
55. Diagnóstico????
Insuficiencia tricuspídea
moderada (S < D, >>> a/v)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
56. Diagnóstico????
Insuficiencia tricuspídea
moderada (S < D, >>> a/v)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
57. Diagnóstico????
Insuficiencia tricuspídea grave
Insuficiencia tricuspídea
moderada (S <onda S) a/v)
(inversión D, >>>
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
58. “a” o “v”, como identificarlas????
a v
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
59. Insuficiencia cardiaca derecha sin IT grave
Figure 21.
incich/grupo ct scanner
Thursday, May 31, 2012
Right-sided CHF without tricuspid re-
Departamento de Radiología/Unidad PET-CT
60. Insuficiencia cardiaca derecha sin IT grave
Insuficiencia cardiaca derecha
(relación S/D conservada, y >>>> a/v)
Figure 21.
incich/grupo ct scanner
Thursday, May 31, 2012
Right-sided CHF without tricuspid re-
Departamento de Radiología/Unidad PET-CT
61. Baja pulsatilidad: aplanamiento a inversión “a”
Figure 22. Decreased hepatic venous
phasicity. Diagrams illustrate varying
degrees of severity of decreased phasicity
in the hepatic vein. Farrant and Meire (5)
first described a subjective scale for quan-
tifying abnormally decreased phasicity in
the hepatic veins, a finding that is most
commonly seen in cirrhosis. The key to
understanding this scale lies in observing
the position of the a wave relative to the
baseline and peak negative S wave excur-
sion. As the distance between the a wave
and peak negative excursion decreases, pha
sicity is more severely decreased.
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
62. Baja pulsatilidad: aplanamiento a inversión “a”
178 January-February 2011 radiographics.rsna.org
This is because the waveform is affected not only
Table 7
by the cardiac cycle, but also by respiratory varia- Causes of Decreased Hepatic Venous Phasicity
tion. It has been shown that inspiration and expi-
ration both affect the systolic/diastolic ratio, and Cirrhosis
that the Valsalva maneuver can markedly reduce Hepatic vein thrombosis (Budd-Chiari syndrome)
pulsatility, even to the point of nonphasicity (1). Hepatic veno-occlusive disease
The ideal time to acquire the spectral waveform Hepatic venous outflow obstruction from any cause
is during a small (incomplete) inspiratory breath
hold. Once proper technique has been confirmed,
pathologic causes of nonphasicity may be consid-
ered, including cirrhosis, hepatic vein thrombosis literature indicates that approximately 25% of
(Budd-Chiari syndrome), hepatic veno-occlusive patients with Budd-Chiari syndrome also have
disease, and hepatic venous outflow obstruction portal vein thrombosis (23).
from any cause (Table 7). As disease severity Budd-Chiari syndrome is typically classified
progresses and the veins become more com- into one of three types on the basis of the loca-
pressed by fibrotic constriction or parenchymal tion of the obstruction. Type 3, also called hepatic
Figure 22. Decreased hepatic venous
edema, they lose their ability to accommodate veno-occlusive disease, is rare and involves dif-
retrograde flow. This is the one case in which phasicity. Diagrams illustrate varying
fuse narrowing at the venule level. Types 1 and 2
our model for understanding the hepatic venous are the mostof severity of decreased phasicity
degrees common and involve obstruction at
waveform in terms of right atrial pressure breaks the level of the hepatic vein or vena and Meire (5)
in the hepatic vein. Farrant cava. The ob-
down. Decreased venous compliance is seen as struction is usually secondary to bland thrombus
first described a subjective scale for quan-
a waveform with a proportional loss of phasicity. related to a hypercoagulable state; however, the in
tifying abnormally decreased phasicity
A quick and reliable way to grade the severity list of causes of hepatic vein occlusion is long and
of decreased phasicity is to visually assess the the hepatic veins, a finding that is most
is traditionally divided into primary (eg, congeni-
waveform, focusing on how far the a wave drops talcommonly seen in cirrhosis. The key to
webs) and secondary (eg, benign or malignant
below the baseline (Fig 22). As long as the a wave thrombosis) causes. this scale lies in observing
understanding
remains above the baseline, there is normal pha- Overall, hepatic the a wave relative to the
the position ofvein thrombosis is much less
sicity; once the a wave goes below the baseline, common than portal vein thrombosis. Malignant
baseline and peak negative S wave excur-
there is at least mildly decreased phasicity, which hepatic vein thrombosis (ie, tumor thrombus) is
has been observed in less than 10% of healthy
sion. As the distance between the a wave
usually the result of direct invasion from an adja-
patients (1). Once the peak of the a wave is at and peak negative excursion decreases, pha
cent parenchymal hepatocellular carcinoma; how-
least halfway between the baseline and the peak ever, anyis more severely decreased.
sicity other malignant vena cava thrombosis,
negative excursion of the waveform, there is at such as renal cell carcinoma, adrenal cortical car-
incich/grupo ct scanner least moderately decreased phasicity. This degree cinoma, or Departamento de Radiología/Unidad PET-CT
primary inferior vena cava (IVC) leio-
Thursday, May 31, 2012 of decreased phasicity is never normal. When the myosarcoma, may also cause Budd-Chiari syn-
63. Arteria hepática (AH) normal
• Abordaje: intercostal
• 20% flujo hepático
• Baja resistencia (flujo
diastólico anterógrado)
• IR: 0.5-0.7
• VPS: 30-60 cm/seg
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
64. Cómo se clasifica a la anatomía de la AH
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
65. Cómo se clasifica a la anatomía de la AH
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
66. Clasificación de Michels AH
AJR 2004;183:145
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
67. Arteria hepática: IR normal
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
68. Arteria hepática: IR alto
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
69. Arteria hepática: IR alto radiographics.rsna.org
Table 4
Pathologic (microvascular compression or disease)
Chronic hepatocellular disease (including cirrhosis)
Hepatic venous congestion
Acute congestion diffuse peripheral vasoconstriction
Chronic congestion fibrosis with diffuse peripheral compression
(cardiac cirrhosis)
Transplant rejection (any stage)
Any other disease that causes diffuse compression or narrowing of
peripheral arterioles
Physiologic
Postprandial state
Advanced patient age
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
70. Diagnóstico????
373 cm/seg 362 cm/seg
168 cm/seg
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
71. Diagnóstico: ????
T12-L1
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
72. Diagnóstico: ????
T12-L1
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
73. Inspiración Espiración
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
76. Arteria hepática
Advanced patient age
Proximal arterial narrowing
Transplant stenosis (anastomosis)
Atherosclerotic disease (celiac or hepatic)
Arcuate ligament syndrome (relatively less common than transplant
stenosis or atherosclerotic disease)
Distal (peripheral) vascular shunts (arteriovenous or arterioportal fistulas)
Cirrhosis with portal hypertension
Posttraumatic or iatrogenic causes
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
77. Arteria hepática... conclusiones
• IR alto = inespecífico
• IR bajo = más específico (cortocircuitos o
estenosis)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
78. Vena porta
• 70-80% flujo hepático
• Ventanas
• Intercostal oblicua derecha
• Oblicua subxifoidea con angulación craneal
• Intrasegmentarias (excepto porción ascendente de
VPI, que es intersegmentaria)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
79. Porta principal
• Unión de esplénica y
mesentérica sup
• Orden (post a ant)
• Porta-Colédoco-Arteria
• Diámetro 11 +/- 2 mm
• Visibles por colágena
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
81. Porta izq
• Más corta, craneal y
anterior
• Su unión con la porta
común indica la porta
hepatis
• “H” reclinada 4 3
• Subdivisión med/lat
2
1
Thursday, May 31, 2012
82. Porta derecha
• Más larga, caudal y
posterior
• División ant/post
• 10% VPD inferior
8 5 accesoria
• “H” reclinada
7 6
Thursday, May 31, 2012
83. Clasificación Nakamura
• Variantes anatómicas 10%
• Generalmente afectan a la VP derecha
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
84. Porta normal
• Abordaje: variable, en general
intercostal
LAMINAR: petal y ligeramente ondulante
• Flujo normal (petal)
• Hacia el transductor (rojo)
(excepto rama posterior der –
azul -)
• Variante: flujo helicoidal
Thursday, May 31, 2012
85. Porta normal
• Abordaje: variable, en general
intercostal
LAMINAR: petal y ligeramente ondulante
• Flujo normal (petal)
• Hacia el transductor (rojo)
(excepto rama posterior der –
azul -)
• Variante: flujo helicoidal
Thursday, May 31, 2012
86. Porta normal
• Abordaje: variable, en general
intercostal
LAMINAR: petal y ligeramente ondulante
• Flujo normal (petal)
• Hacia el transductor (rojo)
(excepto rama posterior der –
azul -)
• Variante: flujo helicoidal
15-40 cm/seg
Thursday, May 31, 2012
88. Variante normal: flujo HELICOIDAL
HELICOIDAL: petal/fugo (espiral)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
89. Flujo helicoidal: causas
1. Normal: 2.2% población
2. Shunts portosistémicos patológicos (20% pacientes
hepatópatas con HP) o quirúrgicos
3. Invasión o desplazamiento tumoral
4. PO inmediato TOH: 43%
• Desproporción diámetros de
la anastomosis (>50%)
5. Post TIPS: 28%
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
90. Flujo helicoidal: causas
1. Normal: 2.2% población
2. Shunts portosistémicos patológicos (20% pacientes
hepatópatas con HP) o quirúrgicos
3. Invasión o desplazamiento tumoral
}
4. PO inmediato TOH: 43%
• Desproporción diámetros de
Transitorio. Si persiste,
la anastomosis (>50%)
descartar estenosis portal
(anastomosis/stent)
5. Post TIPS: 28%
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
91. Flujo portal normal: índice pulsatilidad
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
92. Flujo portal normal: índice pulsatilidad
La pulsatilidad depende de la transmisión del flujo venoso
de forma trans-sinusoidal, en particular de la contracción
auricular (onda a, contracción auricular, telediástole)
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
93. Análisis de la pulsatilidad portal: IP alta
180 January-February 2011
Spectral Doppler US image shows
tile waveform with flow reversal in the right por
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
0 January-February 2011 radiographics.rsna.org
Figure 24. Normal and abnormal portal FigureSpectralSlow portalimage shows a pulsa-
26. Doppler US venous flow. Spectra
incich/grupo ct scanner tile waveform with flow reversal in the right portal vein.
Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012 The waveform may be systematically characterized as
94. Análisis de la pulsatilidad portal: IP alta
180 January-February 2011
NORMAL Spectral Doppler US image shows
tile waveform with flow reversal in the right por
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
0 January-February 2011 radiographics.rsna.org
NORMAL
Figure 24. Normal and abnormal portal FigureSpectralSlow portalimage shows a pulsa-
26. Doppler US venous flow. Spectra
incich/grupo ct scanner tile waveform with flow reversal in the right portal vein.
Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012 The waveform may be systematically characterized as
95. Análisis de la pulsatilidad portal: IP alta
180 January-February 2011
Anormal: IP Doppler US image shows
elevado
NORMAL Spectral
tile waveform with derreversal in the right por
= Falla flow o IT
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
0 January-February 2011 radiographics.rsna.org
NORMAL Anormal: IP elevado
= Falla der o IT
Figure 24. Normal and abnormal portal FigureSpectralSlow portalimage shows a pulsa-
26. Doppler US venous flow. Spectra
incich/grupo ct scanner tile waveform with flow reversal in the right portal vein.
Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012 The waveform may be systematically characterized as
96. blue on the color Doppler US image and is displayed
the
below the baseline on the porta: waveform. Hepa-
Análisis espectral spectral IP alta
tofugal flow is due to severe portal hypertension from the
any cause. sati
scri
pre
Table 8
por
Causes of Pulsatile Portal Venous Waveform side
tran
Tricuspid regurgitation
arte
Right-sided CHF
ver
Cirrhosis with vascular arterioportal shunting
her
Hereditary hemorrhagic telangiectasia–arteriove- this
nous fistulas I
am
red
usu
Findings That Are Diagnostic for Portal Hy- tion
pertension
incich/grupo ct scanner
by
Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012
97. Análisis de la pulsatilidad portal: IP normal
Spectral Doppler US image shows a pulsa-
tile waveform with flow reversal in the right portal vein.
The waveform may be systematically characterized as
predominantly antegrade, pulsatile, biphasic-bidirec-
Spectral Doppler US image shows
tional, and di-inflectional.flow reversal in the right por
tile waveform with
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
Figure 24. Normal and abnormal portal Figure 26. Slow portal venous flow. Spectral Dop-
venous phasicity. Images show a spectrum pler US image shows slow flow in the main portal vein.
of increasing pulsatility (bottom to top). Slow portal venous flow is a consequence of portal hy-
Note that increasing pulsatility corresponds pertension. In this case, the peak velocity is 9.0 cm/sec,
to a decrease in the calculated PI. Although which is well below the lower limit of normal (16–40
normal phasicity ranges widely in the portal cm/sec). Although portal hypertension may cause a
pulsatile-appearing waveform as venousthis case, the
Figure 26. Slow portal seen in flow. Spectra
Figure 24. PI should and abnormal 0.5
veins, the Normal be greater than portal
incich/grupo ct scanner and bottom). When the PI is less
(middle slow flow helps differentiate this condition from hyper-
Departamento de Radiología/Unidad PET-CT
venous phasicity.the waveform may spectrum
Images show a be called pler US image shows such as CHF and tricuspidpo
pulsatile high-velocity states
slow flow in the main
Thursday, May 31, (top),
than 0.5 2012
98. Análisis de la pulsatilidad portal: IP normal
Spectral Doppler US image shows a pulsa-
tile waveform with flow reversal in the right portal vein.
The waveform may be systematically characterized as
NORMAL predominantly antegrade, pulsatile, biphasic-bidirec-
Spectral Doppler US image shows
tional, and di-inflectional.flow reversal in the right por
tile waveform with
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
NORMAL
Figure 24. Normal and abnormal portal Figure 26. Slow portal venous flow. Spectral Dop-
venous phasicity. Images show a spectrum pler US image shows slow flow in the main portal vein.
of increasing pulsatility (bottom to top). Slow portal venous flow is a consequence of portal hy-
Note that increasing pulsatility corresponds pertension. In this case, the peak velocity is 9.0 cm/sec,
to a decrease in the calculated PI. Although which is well below the lower limit of normal (16–40
normal phasicity ranges widely in the portal cm/sec). Although portal hypertension may cause a
pulsatile-appearing waveform as venousthis case, the
Figure 26. Slow portal seen in flow. Spectra
Figure 24. PI should and abnormal 0.5
veins, the Normal be greater than portal
incich/grupo ct scanner and bottom). When the PI is less
(middle slow flow helps differentiate this condition from hyper-
Departamento de Radiología/Unidad PET-CT
venous phasicity.the waveform may spectrum
Images show a be called pler US image shows such as CHF and tricuspidpo
pulsatile high-velocity states
slow flow in the main
Thursday, May 31, (top),
than 0.5 2012
99. Análisis de la pulsatilidad portal: IP normal
Spectral Doppler US image shows a pulsa-
tile waveform with flow reversal in the right portal vein.
The waveform may be systematically characterized as
NORMAL predominantly antegrade, pulsatile, biphasic-bidirec-
Spectral Doppler US image shows
tional, and di-inflectional.flow reversal in the right por
tile waveform with
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
Anormal:
IP normal PERO baja velocidad
= hipertensión portal
NORMAL
Figure 24. Normal and abnormal portal Figure 26. Slow portal venous flow. Spectral Dop-
venous phasicity. Images show a spectrum pler US image shows slow flow in the main portal vein.
of increasing pulsatility (bottom to top). Slow portal venous flow is a consequence of portal hy-
Note that increasing pulsatility corresponds pertension. In this case, the peak velocity is 9.0 cm/sec,
to a decrease in the calculated PI. Although which is well below the lower limit of normal (16–40
normal phasicity ranges widely in the portal cm/sec). Although portal hypertension may cause a
pulsatile-appearing waveform as venousthis case, the
Figure 26. Slow portal seen in flow. Spectra
Figure 24. PI should and abnormal 0.5
veins, the Normal be greater than portal
incich/grupo ct scanner and bottom). When the PI is less
(middle slow flow helps differentiate this condition from hyper-
Departamento de Radiología/Unidad PET-CT
venous phasicity.the waveform may spectrum
Images show a be called pler US image shows such as CHF and tricuspidpo
pulsatile high-velocity states
slow flow in the main
Thursday, May 31, (top),
than 0.5 2012
100. Análisis de la pulsatilidad portal: no flujo
Spectral Doppler US image shows
182 tile waveform with2011 reversal in the right por
January-February flow
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
Figure 28. Portal vein thrombosis (acute bland
thrombus). On a spectral Doppler US image, the
interrogation zone shows no color flow in the main
portal vein. The spectral waveform is aphasic, which
indicates absence of flow. An aphasic waveform may
be produced by either obstructive or nonobstructive
Figure 24. Normal and abnormal portal disease.
Figure 26. Slow portal venous flow. Spectra
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012
101. Análisis de la pulsatilidad portal: no flujo
NORMAL Spectral Doppler US image shows
182 tile waveform with2011 reversal in the right por
January-February flow
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
NORMAL
Figure 28. Portal vein thrombosis (acute bland
thrombus). On a spectral Doppler US image, the
interrogation zone shows no color flow in the main
portal vein. The spectral waveform is aphasic, which
indicates absence of flow. An aphasic waveform may
be produced by either obstructive or nonobstructive
Figure 24. Normal and abnormal portal disease.
Figure 26. Slow portal venous flow. Spectra
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012
102. Análisis de la pulsatilidad portal: no flujo
NORMAL Spectral Doppler US image shows
182 tile waveform with2011 reversal in the right por
January-February flow
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.
Anormal:
flujo lento/trombosis
NORMAL
Figure 28. Portal vein thrombosis (acute bland
thrombus). On a spectral Doppler US image, the
interrogation zone shows no color flow in the main
portal vein. The spectral waveform is aphasic, which
indicates absence of flow. An aphasic waveform may
be produced by either obstructive or nonobstructive
Figure 24. Normal and abnormal portal disease.
Figure 26. Slow portal venous flow. Spectra
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012
104. Trombosis e hipertensión portal (HP)
• Presión >30 mm de Hg
(gradiente >10)
• Causas: del flujo o de
resistencia
US, TC y RM dan información sobre permeabilidad vascular y
colaterales; PERO sólo el US Doppler aporta información sobre la
dinámica del flujo
incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT
Thursday, May 31, 2012