Spectrum of the Portal Vein on Color and Spectral Doppler,

and Contrast Enhanced Ultrasound in both Native and

Transplanted Livers

NicholasLesleinMD;BiancaCarpen4erMD;PriyankaJha,MD;JudyYeeMD;StefanieWeinsteinMD

University of California, San Francisco

TheAuthorsHaveNoFinancialDisclosures

LearningObjec-ves■  ReviewrangeofnormalDopplerfindingsintheportalvein■  Reviewpathologicappearanceoftheportalvein(PV)inna4veandtransplantedliverswithuseofcolorDoppler,spectralDoppler,andcontrastenhancedultrasound

■  Topicstobediscussedinclude:■  Monophasicityvs.increasedpulsa4lity■  Flowdirec4on:antegrade/bidirec4onal/reversed/helical■  Increasedintraluminalechoes

■  PVOcclusions:Par4al/Complete/Obliterated■  Air/Rouleaux(slow)flow

■  Slowvs.highflowstates(cardiac,pregnancy,shun4ng)

NormalPortalVein

■ Normalvelocityrange20-40cm/s■ Monophasicwaveformwithgentleundula4ons■ Antegradeflow

IncreasedPulsa-lity

ImagesoftheMPVdemonstrateincreasedpulsa7lityinthese9ngofrightheartfailure

Alsonoteincreasedpulsa7lityinthemiddlehepa7cveinanddilata7onofthehepa7cveins

■ Pulsa4lityisthevariabilityofbloodvelocityinavessel■ Increasedpulsa4lityisusuallyseenintheseZngofelevatedrightatrialpressure:

■ Rightheartfailure■ Tricuspidregurgita4on

IncreasedPulsa-lity■ Donotmistakearterializedflowforincreasedvenouspulsa4lity

Note the arterialized waveforms in the region of the portal vein in both images

TeachingPoint:arterializedflowinportalveinistumorthrombus,mostcommonlyhepatocellularcarcinoma,un4lprovenotherwise

Varia-oninFlowDirec-onRetrograde(hepatofugal)-Bidirec-onal

MainCauses:Cirrhosis,PortalHypertension,CardiacDisease

Twoexamplesofspectralwaveformoftheportalveinwithflowseenbothaboveandbelowthebaselineinthesepa7entswithliverdisease

Teachingpoint:Evensmallpressurechangesrelatedtoinspira7onandexpira7oncan

causereversalofflowdirec7on

Retrograde–Bidirec-onalFlow

S7llimagefromCINEloopdemonstra7ngbidirec7onal(alterna7ngredandbluecolor)flowinthemainportalvein–HyperlinkforCINEhostedonweb

Teachingpoint:Thiscanbemisinterpretedasunidirec7onalflowons7llimagesonly

Varia-onsinFlowDirec-onHelicalflow

■ Disrup4oninthenormallaminarflowsecondaryto:■ Vesselgeometry■ Irregularityofthevesselwall■ Changesinflowdirec4onandspeed

■ Dopplerdemonstratesalterna4ngredandbluebandsinaspiral

■ Canbeseena\erlivertransplantorTIPSpa4entsasanormalfinding■ Abnormalifpersistent

■ Transplant■ SecondarytochangeinPVdiameterbetweendonorandna4vevessel,mostprominentwhendiscrepancyis>50%

■ Localturbulence

■ TIPS■ ChangesinPVvelocity,flowdirec4on,andpulsa4lity

■ Reportedlyashighas28%ofTIPS1

Varia-onsinFlowDirec-onHelicalflow

Teachingpoint:bewareofpiballs■  Rouleauxfromslowflow■  Truethrombus■  Misdiagnosisofpneumobilia

S7llimagefromCINEloop(hyperlink)demonstra7ngrapidlymovingintraluminalechogenicfociintheportalsystem

SpectralDopplerdemonstra7ngcharacteris7c“spike”likeaberra7onintheportalveinwaveform

IntraluminalEchoesPortalVeinAir

IntraluminalEchoesAnotherexampleofPortalVeinAir

Still image from CINE loop (hyperlink) demonstrating numerous swirling internal reflectors within the main portal vein

■ CTmaybeconfirmatory■ Unlikepneumobilia,generallyconsideredamoreominousfinding

■ Poten4alCauses■ BowelIschemia/infarc4on■ Bowelobstruc4on■ Pancrea44s■ Diver4culi4s/Appendici4s

PortalVeinAir

CompletePVThrombus

IntraluminalEchoesPortalVeinThrombosis

Par7alThrombus

Teachingpoint:Needtoop4mizeDopplertechniquewhenevalua4ngforthrombus

■ Usetheappropriatedepth■ Usetheappropriatescale

■ Highscalemaymisslowerveloci4esthatarebelowthresholdvalue

CavernousTransforma-on

■  Sequelaeoflongstandingportalveinthrombosis

■ Thrombosedmainportalveinmaynolongerbepresent

■  Secondarysignsofchronicthrombosis■ Periportalcollateralswithmanyflowdirec4ons

■ SmallcaliberorabsentmainPV CavernousTransforma7on

IntraluminalEchoesTumorThrombus

Grayscaleimagedemonstratesexpandedmainportalveinfilledwithintraluminalechoes

ColorandspectralDopplerimagesdemonstrateirregularvesselswitharterializedwaveformsinPV

TumorThrombus

S7llimagefromCINEclip(hyperlink)demonstra7ngtumorthrombusinMPV

RoleofCEUSBlandversusTumorThrombus

■  Contrast-enhancedultrasoundaddsvalueindifferen4a4ngblandthrombusfromtumorthrombus

■  CEUSimprovessensi4vityanddiagnos4caccuracy4,7

(TopLe()Grayscaleimagesshowsintraluminalfillingdefect(Bo=om)CEUSdualscreenCINEimages(hyperlink):noteenhancementinareaoffillingdefectinle(portalvein

Slowflow

■ NormalMPVpeaksystolicvelocity(PSV)measuresbetween20-40cm/s■ PSVof<16cm/sandincreasedcaliberofMPVarediagnos4cfeaturesofportalhypertension

(Topright)Imagesdemonstrateslow,lowamplitudebidirec7onalflowintheRPV(BoTomright)PowerDopplerdemonstra7nglowamplitudeflowinLPV

Slowflow“Rouleaux”flow

■  Imagesdemonstra4ngmobilelowlevelechoesintheMPV(a.)andmiddlehepa4cveinandIVC(b.)bejerappreciatedonCINE■ “Rouleaux”flowisduetoredbloodcellaggrega4onfromsluggishflowa. b.

a.)Hyperlinkb.)Hyperlink

a.

Highflow■ Highveloci4es■ Causes

■ Stenosis■ Mostcommonlyseeninpost-transplant

■ Pregnancy■ Pseudoaneurysm■ ArteriovenousFistula/AVM

■ Congenital(OslerWeberRendu)■ Acquired(postbiopsy/trauma)

Images from a liver transplant showing turbulent high flow (>50 cm/s) related to a hepatic artery-portal vein fistula

PVinLiverTransplant

Teachingpoint:bewareofpiballs■  Pseudostenosis–canbeanormalfindingsecondarytodifferenceinvesselcaliber

betweenna4veanddonor.Usuallyresolvesinimmediatepostopera4veperiod

■ Stenosis■ Typicallywithendtoendanastomosis■ 3-4xincreaseinpeaksystolicvelocity(PSV)■ Associatedfindings

■ Aliasing■ ElevatedPSV■ Spectralbroadening

Notealiasingandelevatedveloci7esatsiteofPVanastamosis

Conclusion

■  Abdominalradiologistsshouldbefamiliarwiththespectrumofnormalvariantsandpathologyintheportalveinreflec4ngunderlyingpathologicstates,includingbutnotlimitedto,cardiacdysfunc4on,portalhypertension,stenosis,andthrombosis

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Contact

■ NicholasLeslein,MD-Nicholas.Leslein@ucsf.edu

■ BiancaCarpen4er,MD-Bianca.Carpen4er@ucsf.edu

■ PriyankaJha,MD-Priyanka.Jha@ucsf.edu

■ JudyYee,MD-Judy.Yee@ucsf.edu

■ StefanieWeinstein,MD-Stefanie.Weinstein@ucsf.edu

CINE Loops Hosted on Web

■  Slide8–Bidirec4onalFlow–hjps://vimeo.com/199039295■  Slide11–PortalVeinAir-hjps://vimeo.com/199039639■  Slide12–PortalVeinAir–hjps://vimeo.com/199039889■  Slide17–TumorThrombus-hjps://vimeo.com/198946303■  Slide18–CEUSTumorThrombus-hjps://vimeo.com/199041745■  Slide20–RouleauxFlowinMPV-hjps://vimeo.com/198947317■  Slide20–RouleauxFlowinHepa4cVeinsandIVC-hjps://vimeo.com/198947045