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The radiologist’s guide to duplex ultrasound assessment of chronic mesenteric ischemia

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Abstract

Objective

This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications.

Results

Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of “imaging wisely” raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia.

Conclusion

Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.

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Acknowledgements

The authors thank Henry Douglas for their help with images, Lei Wang for his help with video-recording, Alexandria Brackett for the assistance with literature searches, Melody Polio, Victoria Clifford, Crystal Piper, and Jennifer Smith for their help with obtaining images, and Mary Jo Smallwood for her help in education on new ultrasound vascular platforms.

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Authors and Affiliations

  1. Department of Radiology and Biomedical Imaging, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA

    Margarita V. Revzin

  2. Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, 300 Community Drive, Manhasset, NY, 11030, USA

    John S. Pellerito

  3. Department of Diagnostic Radiology and Biomedical Imaging, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA

    Nariman Nezami

  4. Department of Radiology, University of Washington Medical Center, Seattle, WA, USA

    Mariam Moshiri

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Correspondence to Margarita V. Revzin.

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Movie 1. The celiac artery landmark.

The celiac artery is best recognized in short axis, where is has a characteristic “seagull sign” or T-shaped appearance that describes the bifurcation of the main celiac artery into the common hepatic artery and splenic artery (MP4 2619 kb)

Movie 2 The SMA landmarks.

The SMA can be quickly identified by scanning in the transverse plane via an anterior epigastric approach. The SMA lies just posterior to the splenic vein, anterior to the left renal vein and the abdominal aorta, and to the right of the SMV. It is surrounded by retroperitoneal fat that is seen on ultrasound as an “echogenic halo sign” (red arrows) (MP4 6671 kb)

Movie 3. IMA Landmarks.

The IMA originates from the left anterolateral aspect of the abdominal aorta and can be seen either on gray-scale imaging (red arrow) or on color Doppler (yellow arrow). It can be either identified on transverse and sagittal planes. On color Doppler blood flow in IMA is demonstrated moving away from the transducer due to the caudad course of the artery toward the left colon, and is thus assigned a blue color (arrow) (MP4 8938 kb)

Movie 4. Grays scale evaluation of the mesenteric arteries.

The mesenteric Doppler examination is preferentially performed in the fasting state. Patients are examined in the supine position, utilizing an anterior epigastric approach that helps to visualize the origins of the mesenteric arteries. Gradual compression technique usually helps to improve visualization of the vasculature by displacing bowel gas away from the transducer . B-mode or gray-scale imaging is imperative in the initial evaluation of the aorta and the mesenteric arteries. Atherosclerotic plaque burden, the presence of a dissection flap, vascular wall thickening, and the presence of either abdominal aortic or mesenteric aneurysm or pseudoaneurysm can all be accurately identified on gray-scale imaging (MP4 12,550 kb)

Movie 5. Color Doppler Evaluation of the mesenteric arteries.

The color Doppler mode aids in determination of vessel patency, flow disturbance and flow direction, and provides average estimation of blood velocity. The identification of disturbed flow on color Doppler, represented by color aliasing, may signify the presence of luminal narrowing or a flow-limiting lesion. Color Doppler images should be initially optimized for laminar flow in the abdominal aorta by adjusting the velocity scale, gain, and wall filter. This aids in detection of abnormalities within the arteries Color Doppler serves as a road map for placement of the spectral gate within an area of abnormality when acquiring quantitative estimation of blood velocity (MP4 14,234 kb)

Movie 6 SMA stenosis and aliasing.

Cine clip through the celiac and mesenteric artery obtained in sagittal plane demonstrates color aliasing at the focal site of narrowing within the SMA (green arrow). Spectral Doppler interrogation obtained at a later time showed high peak systolic velocity at the area of aliasing (not shown) (MP4 7241 kb)

Movie 7. Spectral Doppler evaluation of the mesenteric arteries.

Spectral Doppler mode allows quantitative and qualitative assessment of vascular hemodynamics via calculation of peak systolic velocities throughout the mesenteric arteries, and also via analysis of the waveform pattern. Peak systolic velocities are obtained with mesenteric arteries and the aorta positioned in sagittal plane, using epigastric approach as an acoustic window. Attention is made to the size of the mesenteric arteries, and the size of the aorta at the level of the mesenteric arteries origin. Any areas of narrowing or widening should be interrogated. Peak systolic velocities are performed by placement of the spectral gate in the center of a vessel. Optimization of parameters such as velocity scale, gain and angle correction are important for accurate estimation of the velocities. Preferable angle of insonation should be 60 degrees or less. Manual angle correction can be used to achieve more optimal angles. After obtaining waveforms and velocities at the origin of a mesenteric artery, the cursor is then moved to its proximal, mid and distal segments. Each mesenteric artery is assessed sequentially in the same order, including celiac, superior and inferior mesenteric arteries. In a case of a visible flow disturbance on color Doppler, the area of interest should be careful interrogated with spectral Doppler. The waveform pattern should be analyzed with respect to the presence of a brisk or delayed upstroke and the presence or absence of diastolic flow. An assessment should be also made in regards to flow direction and the presence of collateral vessels. Peak systolic velocities in the celiac artery should be obtained on both inspiration and expiration. Mesenteric-to-aortic PSV ratio is calculated for each mesenteric artery and should be stated in the study report (MP4 14,972 kb)

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Revzin, M.V., Pellerito, J.S., Nezami, N. et al. The radiologist’s guide to duplex ultrasound assessment of chronic mesenteric ischemia. Abdom Radiol 45, 2960–2979 (2020). https://doi.org/10.1007/s00261-019-02165-2

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