CAHE VASCULAR II- RENAL, MALE & FEMALE PELVIS

uterine artery doppler findings during luteal stage

RI about 0.84

uterine artery doppler findings during proliferative stage

RI about 0.88

doppler waveform of ovarian artery of early postmenopausal phase

RI about 0.92

duplex values of normal renal artery stenosis classification

1. RAR = < 3.5 2. PSV = < 120 cm/s 3. post stenotic turbulence (PST) = absent

less than 60% renal artery stenosis values

1. RAR = <3.5 2. PSV = >180 cm/s 3. PST = absent

over 60% renal artery stenosis values

1. RAR = > 3.5 2. PSV = > 180 cm/s 3. PST = present 4. EDV = >150 cm/s (over 80% stenosis) 5. RI = 0.8

occlusion of renal artery values

1. RAR = low velocity & low amplitude parenchymal signals 2. PSV = N/A 3. PST = N/A

varicocele

1. abnormal dilation of peritesticular veins 2. more common on left side 3. visualized better when pt in upright position/during valsalva maneuver

doppler spectral waveforms of renal vein thrombus

1. absence of flow 2. lack of phasic flow proximal to obstructed segment 3. minimal phasicity in distal venous segments (if thrombus segment = recanalized/venous collaterals developed)

renal hilar evaluations method of calculations

1. acceleration time (AT) 2. acceleration index (AI)

ovarian blood supply (dual)

1. aorta 2. ovarian (gonadal) branches of uterine arteries

pathway of blood flow through kidney

1. aorta 2. renal artery 3. segmental artery (5) 4. interlobar artery 5. arcurate artery 6. interlobular artery 7. afferent arteriole 8. glomerulus 9. efferent arteriole

normal intrarenal vasculature

1. arteries = red coursing towards periphery of kidney 2. veins = blue 3. PRF = low level for slow flow in kidney

etiology of renal artery disease

1. atherosclerosis = 90% for cause of renal artery stenosis 2. men affected more 3. bilateral lesions occur 30% times

centripetal arteries

1. branch of capsular artery 2. curve backward & form centrifugal arteries

female pelvis vasculature

1. common iliac artery 2. internal iliac artery (hypogastric) 3. uterine artery 4. arcuate artery (myometrium) 5. radial artery (straight arteries = stratum basalis & spiral arteries = stratum functionalis

doppler waveform of ovarian artery of periovulatory phase

1. days 12-14 2. decrease in resistance 3. RI about 0.86

normal waveform of ovarian artery of pre-menopausal female

1. decrease in RI compared with post-menopausal 2. increase in diastolic flow from high need blood supply

doppler waveform of ovarian artery of luteal phase

1. decrease in resistance 2. RI about 0.83

ovarian torsion waveform findings

1. decreased, absent of reversed diastolic flow in ovarian artery 2. always abnormal increase in RI (low velocity)

clinical findings in renovascular HTN

1. difficult to contorl with treatment 2. severe HTN = diastolic BP >120 mmHg 3. onset before 30 or after 50 4. abdominal bruit heard

3 things classification of renal artery stenosis relies on

1. doppler-derived systolic velocity (PSV) 2. comparison with systolic velocity recorded in proximal abdominal aorta (RAR) 3. flow patterns along length of renal artery (RI)

normal intrarenal arterial waveform

1. early systolic peak seen as small notch in systole 2. systolic upstroke = rapid 3. AT = 0.07 seconds or less

acute inflammation of scrotum

1. epididymitis & epididymo-orchitis 2. most common cause of painful scrotal swelling over 18 3. acutely inflamed part = hypervascular

normal waveform ovarian arteries of postmenopausal female

1. increase in RI compared with pre-menopausal 2. decrease in diastolic flow from diminished need for constant blood supply

acute inflammation of scrotum spectral tracing

1. increases PSV 2. RI decrease in testicular (< 0.5) & epididymal (< 0.7) branches

right and left testicular arteries

1. infrarenal branches of aorta 2. primary source of blood flow to testis 3. along posterior surface of testicles 4. form capsular arteries 5. give rise to centripetal arteries

renal aneurysms

1. involves main segment of renal artery 2. identified with color flow 3. intervention recommended if 2 cm or greater diameter

indirect findings of main renal artery occlusion

1. kidney length = < 8cm 2. significant over 2cm difference in length compared with contralateral kidney

renal artery occlusion

1. lack of flow in lumen 2. cortical flow <10 cm/s with low amplitude waveform throughout renal parenchyma 3. result of collateral flow to kidney (ureteral/adrenal)

renal arterial blood supply

1. lateral branch of abdominal aorta 2. arise inferior to origin SMA

left renal vein

1. left adrenal vein branch = superior 2. left gonadal vein branch = inferior 3. 1 or 2 lumbar veins empty into posterior wall

venous drainage of kidney

1. left renal vein longer than right vein

right renal artery

1. longer than left 2. posterior to IVC

normal spectral tracings of scrotal arterial supply

1. low impedance 2. high diastolic intratesticular flow

normal doppler waveforms in main renal artery & segmental renal artery

1. low resistance 2. sharp systolic upstroke

normal ultrasound appearance of scrotum

1. low resistance, broad systolic component 2. RI - 0.6 (ranging from 0.5-0.7) 3. PSV = less than 15 cm/sec 4. epididymis = no vascularity

spermatic cord torsion

1. no detectable flow within testicular parenchyma 2. diagnosis established by color or power doppler

color display of intratesticular tumor nodules

1. nonspecific appearance 2. hypervascularity 3. irregular, chaotic branching patterns

4 diagnostic categories of renal artery stenosis

1. normal 2. less than 60% stenosis 3. greater than 60% stenosis 4. occlusion

venous drainage of scrotum

1. occurs through veins of pampiniform plexus exiting from mediastinum testis & courses in the spermatic cord 2. right and left testicular veins

segmental infarction

1. rare condition 2. appearance = hypoechoic wedge shaped area in testicular parenchyma 3. absence of doppler signal (rules out tumors)

venous thrombosis in scrotum

1. rare condition 2. associated with trauma/severe infection 3. can pass unnoticed from multiplicity of veins

what does RI reflect?

1. reflects degree of vascularity 2. high RI = low degree vascularity 3. low RI = high degree vascularity

fibromuscular dysplasia (FMD)

1. second most common cause of renal artery stenosis 2. unknown etiology 3. females aged 25-50 years olf 4. involved middle and distal portion of main renal artery 5. 50% of times = bilateral 6. nonatherosclerotic disease process 7. appears ONLY in females as "string of beads"

normal renal artery doppler spectral waveforms

1. sharp (rapid) systolic upstroke 2. PSV 90-120 cm/s (< 150 cm/s) 3. renal-aortic velocity ratio (RAR) = 3.5 4. constant forward diastolic flow 5. low resistance 6. RI = <0.7 (range = 0.56-0.7)

testicular fracture

1. shown by indentation 2. hypoechoic fracture line in parenchyma 3. loss of vascular signals in lower half of testis

varicocele ultrasound criteria for diagnosis

1. single vein diameter above 3mm 2. more than 1 mm increase diameter during valsalva

renal size difference greater than 2 cm length

1. suggestive of renal artery occlusion 2. on side of smaller kidney

> 80% renal artery stenosis

1. systolic upstroke of waveform = delayed 2. decreased PSV (tardus-parvus waveform)

renal vein thrombus

1. thrombosis can lead to acute renal failure 2. dilated vein = acute thrombus 3. contracted vein = chronically thrombused

indications of renal duplex ultrasound

1. uncontrolled HTN 2. new onset HTN at young age 3. atrophic kidney

ovarian torsion doppler findings

1. variable presentation dependent on severity 2. venous flow = first one compromised 3. presence of arterial flow to ovary does NOT exclude torsion

normal ovarian & uterine arterial waveforms

1. vary with phase of menstrual cycle & age of patient 2. low resistance

evaluation of renal parenchymal blood flow

1. zero degrees angle of insonation 2. spectral waveforms recorded throughout

abnormal renal hilar AI value

< 3 m/s2

abnormal renal hilar AT value

> 0.07 seconds

accessory renal arteries

1. 20% population have multiple renal arteries 2. arise from lateral aortic wall 3. occur more on left compared to right

left renal artery

arises higher than right

renal artery & vein at renal hilum

artery posterior to vein

normal renal parenchymal flow characterization

constant forward diastolic flow

atrophic kidney

defined as less than 8 cm length

female venous drainage

drained by 1. uterine veins 2. internal iliac veins

right ovarian vein drainage

drains directly into IVC

right testicular vein drainage

drains into IVC

left ovarian vein drainage

drains into left renal vein

left testicular vein

drains into left renal vein

scrotal trauma

focal absence of vascularity suggestive for rupture

normal adult kidney measurements

length = 9-12 cm width = 4-6 cm parenchyma width = 13-25 mm

normal renal artery blood flow in proximal right renal artery

low resistance pattern

indirect findings of renal vein thrombus

renal artery displays reversed flow during diastole

vascular supply of scrotum

right/left testicular arteries

normal main renal vein spectral doppler waveform

shows continuous efferent blood flow

acceleration index (AI)

slope of systolic upstroke / transmitted frequency

acceleration time (AT)

time interval from onset of flow to initial peak (compliance)