Vascular

A free gallery of high-resolution, ultrasound, color doppler and 3D images

Ultrasound and color doppler images of the normal renal arteries and renal veins:

It takes patience and favourable imaging conditions (like thin abdominal wall and patient cooperation) to locate the renal arteries and veins by color doppler and even more difficult to get a spectral waveform tracing of the vessels. The upper few color doppler images show the left renal artery as it emerges from the abdominal aorta and enters the renal hilum. The lower few images show the right renal artery and right renal vein. Spectral tracing shows typical normal arterial and venous flow patterns. Ultrasound and color doppler images taken using a Toshiba Nemio XG color doppler machine by Joe Antony, MD, Cochin, India.

More ultrasound/ Color Doppler images of the origin of the Normal Right renal artery:

The above 4 ultrasound and Color Doppler images show the origin of the normal right renal artery from the abdominal aorta (Ao), just below the origin of the superior mesenteric artery. It takes careful adjustment of the wall filter settings to remove the motion artifacts from the aortic pulsations, with appropriate PRF settings to get a decent Color Flow image of the Right renal artery. The right renal artery is seen coursing behind the IVC (Inferior Vena Cava) after a antero-lateral origin from the Aorta (Ao). The left renal vein is also seen traversing anterior to the abdominal aorta (Ao) and between it and the SMA (superior Mesenteric Artery). All the above 4 images are transverse sections through the epigastrium. The liver provides a good window to view these vessels.

Ultrasound and color Doppler images of Dystrophic calcification of carotid arteries:

Calcific lesions of carotid arteries:

These ultrasound images of a young, asymptomatic adult female patient reveal multiple calcific plaques of the common carotid arteries of both sides. The intimal plaques measure 1.5 to 4mm. in size. These sonographic images are diagnostic of dystrophic calcification of the intima of the carotid arteries. Such lesions are very unlikely to cause stroke or thromboembolic events and are hence of little significance. All ultrasound images taken with a Nemio - XG ultrasound system, by Joe Antony, MD, India.

References:1) http://www.evtodayarchive.com/03_archive/0902/et0902_15.html (a good article.. free).

2) http://stroke.ahajournals.org/cgi/content/abstract/24/9/1330 (abstract)

Color Doppler imaging of the Normal Carotid and vertebral arteries:

The carotid bifurcation:

The above color Doppler images show a cross section through the bifurcation of the (Rt.) common carotid artery into its two main branches: 1) Rt. ECA- the external carotid artery 2) Rt. ICA- the internal carotid artery. The image on right shows a section just above the bifurcation. IJV= the internal jugular vein (seen in blue color). Note that the ECA is more anterior and medial to the ICA. Also, the ICA (internal carotid artery) is larger than the other branch- the ECA.

The above Color Flow images show a long section through the Rt. CCA (common carotid artery) bifurcating into the ICA (internal carotid artery) and ECA (external carotid artery). Note the wider caliber of the ICA. (arrow points to the bifurcation).

Spectral Doppler waveform of the normal Common carotid artery (CCA):

The above images (Rt. CCA) show moderately broad systolic peaks and moderate diastolic flow in diastole. The peak systolic velocity (PSV or V-max) is also in a range between that of the ICA and ECA. This is the typical appearance of the waveform of the CCA. Normal PSV for the CCA is usually less than 100cms./sec. (In this case, the PSV= 94 cms./sec.). The PSV in the CCA increases towards its proximal part (ie: towards the aorta).

Spectral Doppler waveforms of the normal ICA (internal carotid artery):

The Doppler images above show the spectral waveform of the normal ICA (Internal carotid artery-Rt.). The systolic peak in the ICA is broader than the ECA or even the CCA. Also, note the high (and persistent) diastolic flow. The normal PSV (Vmax in our image), ranges from55 to 88 cms./sec. in the ICA. This is true for the post bulbar (part distal to the carotid bulb) part of the ICA. (In our case the PSV or Vmax = 68 cms./sec).

Doppler waveform of normal ECA (External carotid artery):

The ECA (right ECA here) shows very high (compared to ICA) PSV values and hence a sharp systolic peak and rather poor flow during diastole (seen as low EDV or end diastolic velocity). The PSV (Vmax) in this case is = 105/cms./sec. The normal range of PSV (peak systolic velocity) for the ECA is from 77 cms./sec. to 115 cms./sec.

The temporal tap sign of the (ECA) External carotid artery:

An important method of differentiating the ECA from the ICA is the "temporal tap" sign. Tapping the temporal artery (a branch of the ECA) at the level of the zygomatic arch, just anterior to the external ear, produces fluctuations in the spectral waveforms of the ECA. This is seen in the above ultrasound images showing vertical dips and peaks during the diastolic flow. (Compare the Doppler images on left (without the tap) with the image on right (during temporal tap)).

Intima-media thickness (IMT) of carotid artery:

The carotid artery/ arteries consist of 3 layers- the intima (the inner most thin layer of endothelium), the middle layer or media (formed by smooth muscles) and the outermost layer- the adventitia (formed by loose connective tissue. On grey scale sonography, the long section ultrasound image produces 2 parallel lines - the inner most line is bright (echogenic), thin and corresponds to the intima; the media is the dark line just outer to the intima. The measurement of the total thickness (intima media thickness) or IMT helps assess the arterial wall for presence of plaques or thickening. Normal common carotid artery thickness should be less than 0.9 mm. In the ultrasound images above, the IMT measures 0.6 to 0.7 mm. (normal).

Ultrasound and Color Doppler imaging of vertebral artery:

The vertebral arteries course through the foramen of the transverse processes of the cervical vertebrae (from C-6 upwards). The vertebral artery is seen sonographically, between the transverse processes of the cervical vertebrae, as segments. The part within the transverse processes is hidden by the bone. The normal vertebral artery (see color Doppler images above) shows the same direction of flow (and hence the same color as the common carotid artery anterior to it).

Reference: http://emedicine.medscape.com/article/1155193-overview (free article and images).

Ectasia of Internal Jugular vein:

(Phlebectasia of Internal jugular vein):

Case-1:

This was a young adult male with complaint of small swelling in the left side of neck and mild dysphagia. On Color Doppler examination of the vessels of the neck, the right side showed normal diameter and flow in the right internal jugular vein and common carotid artery (see image on top left). However the left jugular vein showed a fusiform dilatation of the lower part of the vessel (close to its origin, ie: the proximal portion). Here, the vessel measured almost 12 to 14 mm. in diameter at rest. On deep inspiration and Valsalva maneuver, the rise in intrathoracic pressure resulted in diameter of the Internal jugular vein measuring 15 to 17 mm. (see image at bottom left). Compared to the the IJV on the right side the left IJV (internal jugular vein) also showed marked turbulence of flow both on Color Doppler imaging (see images on bottom left) and spectral Doppler waveform. The ultrasound/ Color Doppler images/ findings suggest Ectasia of the left Internal Jugular vein.

Reference: http://www.jultrasoundmed.org/cgi/reprint/18/6/411.pdf (free article and images).

Article on Phlebectasia of Internal Jugular vein (free article)

Color and Spectral Doppler Examination of the veins of the Lower limb:

Color Doppler images and imaging of normal deep veins of Lower limb:

1) Normal phasic changes in venous flow during respiration:

During respiration there are phasic changes seen in the venous flow of the lower limb veins. This is best studied using Triplex imaging, and especially by spectral pattern of venous flow. Upper left image shows changes in flow (in superficial femoral vein), with increase during inspiration, caused by lower intra-thoracic pressure and vise versa during expiration. The Doppler image on right side shows similar changes in the popliteal vein of the same limb. This suggest continuity of flow with transmission of pressure all the way upto the vena cava and the right atrium.

2) Normal compressibility of the lower limb veins:

The above 2 Doppler images show the normal superficial femoral vein (Left) and the Normal popliteal vein (Right). Compression of the veins by the Doppler probe causes the normal veins to collapse COMPLETELY (compressibility). Presence of thrombus would cause poor or absent compression of the vessels. Note that the arterial flow is not hampered by the probe pressure. However, the veins disappear in the right half of each image.

3) Flow augmentation:

On applying pressure to the lower limb, distal to the veins being assessed, there is increase in flow (spectral Doppler trace). Both the superficial femoral vein (image on Left) and popliteal vein (Right) show marked increase ( flow augmentation) on applying pressure below. This suggests absence of thrombosis in the intervening parts of both veins.

4) Cessation of flow on Valsalva maneuver:

Another technique to assess the patency and absence of thrombus in the part of the venous system above the point of examination is to use the Valsalva maneuver. During deep inspiration and holding of breath, there is normal abrupt cessation of flow in the vein. In image above, the superficial femoral vein shows total cessation of flow. This is therefore, normal.

Chronic venous insufficiency (Incompetence of great saphenous vein):

This male patient underwent Color Doppler evaluation of the veins of both lower limbs for chronic venous insufficiency. Color flow imaging and Spectral Doppler images of the great saphenous veins showed-1) reversal of flow in the great saphenous veins of both sides. This is seen as red color (Doppler flow images) on inspiration, and followed by blue colored flow on expiration. Similar changes are seen on Valsalva maneuver. 2) On spectral Doppler trace, the images show typical reversal of flow on inspiration and expiration. This is seen as flow below the baseline, followed by flow above the baseline on expiration or Valsalva maneuver. Both sides thus show incompetence or insufficiency of the sapheno-femoral junction valves. There were also multiple varicose veins seen in the thigh (the topmost row (left) and bottom-most row images shows large veins with poor flow). All ultrasound and Color Doppler images of the Varicose veins and venous insufficiency of great saphenous veins, were taken using a Toshiba Nemio-XG color Doppler machine.

Reference: http://ves.sagepub.com/cgi/content/abstract/39/4/341 (abstract)

http://www.jultrasoundmed.org/cgi/reprint/26/2/163 (free article)--- excellent

Sapheno-femoral junction and sapheno-femoral incompetence:

The color Doppler image on top left shows the typical Mickey mouse appearance of the cross section through the Common femoral artery, the Common femoral vein and the Long saphenous vein (great saphenous vein) as it joins the Common femoral vein at the Sapheno-femoral junction. The image (top right) shows typical insufficiency of the sapheno-femoral junction valves, resulting in reversal of flow on Valsalva manoever. (This is seen as blue color on rest and red colored flow on Valsalva). Spectral Doppler trace (images in lower row) show flow reversal on Valsalva. The period of reversal of flow is measured (lower X-axis) and lasts more than 0.5 seconds (here it lasts 1.1 second). This is significant flow reversal s/o insufficiency at this valve.

Celiac Artery and its branches:

The celiac artery arises from the anterior surface of the abdominal aorta and immediately divides into 3 branches: the common hepatic, the splenic and the left gastric arteries. The above ultrasound and Color Doppler images show the normal celiac artery with the 2 main branches, the splenic and common hepatic arteries. The left gastric is not visualized usually on sonography, being a small branch.

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This page was last edited on: Thursday March 11, 2010 03:24 PM

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Contact: joe@ultrasound-images.com or drjoea (at) gmail.com