Table of Contents

1 Fundamental Principles................................................................................................. 1
1.1 Technical Principles of Diagnostic Ultrasound....................................................... 1
1.1.1 Gray-Scale Ultrasonography (B-Mode)........................................................ 1
1.1.1.1 Historical Milestones....................................................................... 1
1.1.1.2 Sound Waves.................................................................................... 1
1.1.1.3 Generating Ultrasound Waves.......................................................... 2
1.1.1.4 Physical Factors Affecting the Ultrasound Scan.............................. 2
1.1.1.4.1 Reflection and Refraction................................................. 3
1.1.1.4.2 Scattering.......................................................................... 3
1.1.1.4.3 Interference....................................................................... 4
1.1.1.4.4 Diffraction........................................................................ 4
1.1.1.4.5 Attenuation and Absorption............................................. 4
1.1.1.5 Generating an Ultrasound Image..................................................... 4
1.1.1.5.1 Pulse-Echo Technique...................................................... 4
1.1.1.5.2 Time-Gain Compensation................................................ 4
1.1.1.5.3 A-Mode............................................................................ 5
1.1.1.5.4 B-Mode............................................................................ 5
1.1.1.5.5 M-Mode............................................................................ 5
1.1.1.6 Resolution........................................................................................ 6
1.1.1.7 Beam Focusing................................................................................. 6
1.1.1.8 Types of Transducers........................................................................ 7
1.1.1.8.1 Principle of Operation...................................................... 7
1.1.1.8.2 Linear Arrays................................................................... 7
1.1.1.8.3 Curved or Convex Arrays................................................. 8
1.1.1.8.4 Sector Scanners................................................................ 8
1.1.1.8.5 Phased Arrays................................................................... 8
1.1.1.8.6 Mechanical Sector Scanners............................................. 8
1.1.1.8.7 Annular Phased Arrays.................................................... 9
1.1.1.8.8 Disadvantages of Mechanical Transducers...................... 9
1.1.1.9 Ultrasound Artifacts......................................................................... 9
1.1.1.9.1 Posterior Shadowing........................................................ 9
1.1.1.9.2 Acoustic Enhancement..................................................... 9
1.1.1.9.3 Edge Effect....................................................................... 9
1.1.1.9.4 Side Lobes........................................................................ 10
1.1.1.9.5 Reverberation Artifact...................................................... 10
1.1.1.9.6 Geometric Distortion........................................................ 11
1.1.2 Basic Physics of Doppler Ultrasound............................................................ 11
1.1.2.1 Continuous Wave Doppler Ultrasound............................................. 12
1.1.2.2 Pulsed Wave Doppler Ultrasound/Duplex Ultrasound..................... 13
1.1.2.3 Frequency Processing....................................................................... 13
1.1.2.4 Blood Flow Measurement................................................................ 14
1.1.3 Physical Principles of Color-Coded Duplex Ultrasound............................... 18
1.1.3.1 Velocity Mode.................................................................................. 18
1.1.3.2 Power (Angio) Mode........................................................................ 20
1.1.3.3 B-Flow Mode (Brightness Flow)..................................................... 21
1.1.3.4 Intravascular Ultrasound.................................................................. 22
1.1.3.5 Three-Dimensional/Four-Dimensional Ultrasound.......................... 23
1.1.4 Factors Affecting (Color) Duplex Imaging – Pitfalls.................................... 23
1.1.4.1 Scattering, Acoustic Shadowing...................................................... 23
1.1.4.2 Mirror Artifact.................................................................................. 24
1.1.4.3 Maximum Flow Velocity Detectable – Pulse Repetition Frequency.... 24
1.1.4.4 Minimum Flow Velocity Detectable – Wall Filter, Frame Rate....... 27
1.1.4.5 Transmit and Receive Gain.............................................................. 28
1.1.4.6 Doppler Angle.................................................................................. 28
1.1.4.7 Physical Limitations of Color Duplex Ultrasound........................... 28
1.1.5 Ultrasound Contrast Agents.......................................................................... 30
1.1.6 Safety of Diagnostic Ultrasound................................................................... 32
1.1.6.1 Thermal Effects................................................................................ 32
1.1.6.2 Mechanical Effects........................................................................... 33
1.1.6.3 Specific Risks of Individual Ultrasound Techniques....................... 33
1.2 Hemodynamic Principles......................................................................................... 34
1.2.1 Laminar Flow................................................................................................ 34
1.2.2 Flow Profiles and Perfusion Regulation........................................................ 36
1.2.2.1 Low-Resistance Flow....................................................................... 36
1.2.2.2 High-Resistance Flow...................................................................... 36
1.2.2.3 Blood Flow Regulation.................................................................... 37
1.2.3 Determining the Degree of Stenosis.............................................................. 38
1.3 Machine Settings..................................................................................................... 42
2 Peripheral Arteries......................................................................................................... 45
2.1 Pelvic and Leg Arteries........................................................................................... 45
2.1.1 Vascular Anatomy......................................................................................... 45
2.1.1.1 Pelvic Arteries.................................................................................. 45
2.1.1.2 Leg Arteries...................................................................................... 45
2.1.2 Examination Protocol and Technique............................................................ 47
2.1.2.1 Pelvic Arteries.................................................................................. 47
2.1.2.2 Leg Arteries...................................................................................... 48
2.1.3 Specific Aspects of the Examination from the Perspective
of the Angiographer and Vascular Surgeon................................................... 49
2.1.4 Interpretation and Documentation................................................................. 55
2.1.5 Normal Duplex Ultrasound of Pelvic and Leg Arteries................................ 55
2.1.6 Abnormal Findings: Clinically Oriented Ultrasound Examination,
Ultrasound Findings and Measurement Parameters, Diagnostic Role.......... 56
2.1.6.1 Atherosclerotic Occlusive Disease................................................... 56
2.1.6.1.1 Pelvic Arteries.................................................................. 57
2.1.6.1.2 Leg Arteries...................................................................... 60
2.1.6.2 Arterial Embolism............................................................................ 71
2.1.6.3 Aneurysm......................................................................................... 72
2.1.6.4 Rare Stenosing Arterial Diseases of Nonatherosclerotic Origin...... 73
2.1.6.4.1 Adventitial Cystic Disease............................................... 75
2.1.6.4.2 Popliteal Entrapment Syndrome...................................... 76
2.1.6.4.3 Raynaud’s Disease........................................................... 77
2.1.6.4.4 Paraneoplastic Disturbance of Acral Perfusion................ 79
2.1.6.4.5 Buerger’s Disease............................................................. 79
2.1.6.4.6 Inflammatory Conditions................................................. 80
2.1.6.4.7 Chronic Recurrent Compartment Syndrome of the Calf.. 81
2.1.7 Follow-up After Surgical and Interventional Treatment............................... 81
2.1.7.1 Thromboendarterectomy.................................................................. 81
2.1.7.2 Percutaneous Transluminal Angioplasty and Stenting..................... 81
2.1.7.3 Bypass Graft Surveillance................................................................ 83
2.1.7.3.1 Methodological Considerations and Stenosis Criteria..... 83
2.1.7.3.2 Controversy About the Benefit of Duplex Bypass
Graft Surveillance Programs............................................ 86
2.1.7.4 Ultrasound Vein Mapping Prior to Peripheral Bypass Surgery....... 88
2.1.8 Role of (Color) Duplex Ultrasound Compared with Other Modalities:
Problems and Pitfalls..................................................................................... 89
2.2 Arm Arteries............................................................................................................ 92
2.2.1 Vascular Anatomy......................................................................................... 92
2.2.2 Examination Protocol and Technique............................................................ 93
2.2.3 Clinical Role of Duplex Ultrasound.............................................................. 94
2.2.3.1 Atherosclerosis................................................................................. 94
2.2.3.2 Compression Syndromes.................................................................. 94
2.2.4 Documentation.............................................................................................. 95
2.2.5 Normal Findings............................................................................................ 95
2.2.6 Abnormal Findings, Duplex Ultrasound Measurements,
and Clinical Role........................................................................................... 95
2.2.6.1 Atherosclerosis................................................................................. 95
2.2.6.2 Compression Syndromes.................................................................. 95
2.3 Atlas: Peripheral Arteries........................................................................................ 97
3 Peripheral Veins.............................................................................................................. 165
3.1 Pelvic and Leg Veins............................................................................................... 165
3.1.1 Vascular Anatomy......................................................................................... 165
3.1.2 Examination Protocol.................................................................................... 167
3.1.2.1 Thrombosis....................................................................................... 167
3.1.2.2 Chronic Venous Insufficiency and Varicosis.................................... 170
3.1.3 Normal Findings............................................................................................ 173
3.1.4 Documentation.............................................................................................. 174
3.1.4.1 Deep Vein Thrombosis of the Leg................................................... 174
3.1.4.2 Chronic Venous Insufficiency and Varicosis.................................... 174
3.1.5 Clinical Role of Duplex Ultrasound.............................................................. 174
3.1.5.1 Thrombosis and Postthrombotic Syndrome..................................... 174
3.1.5.2 Varicosis........................................................................................... 178
3.1.6 Duplex Ultrasound – Diagnostic Criteria, Indications, and Role.................. 181
3.1.6.1 Thrombosis....................................................................................... 181
3.1.6.2 Chronic Venous Insufficiency.......................................................... 192
3.1.6.3 Varicosis........................................................................................... 195
3.1.6.4 Varicophlebitis................................................................................. 198
3.1.7 Rare Venous Abnormalities........................................................................... 199
3.1.7.1 Venous Aneurysm............................................................................ 199
3.1.7.2 Tumors of the Venous Wall.............................................................. 201
3.1.7.3 Venous Compression........................................................................ 201
3.1.7.4 Adventitial Cystic Disease of Veins................................................. 201
3.1.7.5 Differential Diagnosis: Lymphedema, Lipedema............................ 201
3.1.8 Vein Mapping................................................................................................ 202
3.1.9 Diagnostic Role of Ultrasound...................................................................... 202
3.1.9.1 Thrombosis....................................................................................... 202
3.1.9.2 Chronic Venous Insufficiency.......................................................... 206
3.1.9.3 Varicosis........................................................................................... 208
3.2 Arm Veins and Jugular Vein.................................................................................... 209
3.2.1 Vascular Anatomy......................................................................................... 209
3.2.2 Examination Protocol and Technique............................................................ 209
3.2.3 Normal Findings............................................................................................ 209
3.2.4 Documentation.............................................................................................. 209
3.2.5 Clinical Role.................................................................................................. 210
3.2.6 Duplex Ultrasound Findings and Their Diagnostic Significance.................. 210
3.2.7 Diagnostic Role of Duplex Ultrasound Compared with Other Modalities... 211
3.3 Atlas: Peripheral Veins............................................................................................ 213
4 Shunts............................................................................................................................... 267
4.1 Clinical Role of Shunt Diagnosis............................................................................ 267
4.1.1 Background................................................................................................... 267
4.1.2 Diagnostic Tasks in Patients with Spontaneous and Therapeutic Shunts...... 267
4.2 Examination Protocol, Technique, and Diagnostic Role......................................... 269
4.2.1 Congenital and Acquired Fistulae................................................................. 269
4.2.2 Dialysis Access............................................................................................. 269
4.3 Typical Shunt-Related Changes in the Doppler Waveform..................................... 271
4.4 Shunt Maturation and Flow Volume Measurement................................................. 271
4.5 Documentation......................................................................................................... 272
4.6 Vascular Mapping Prior to AV Fistula Creation...................................................... 272
4.7 Abnormal Findings (Inadequate Dialysis)............................................................... 273
4.7.1 Shunt Stenosis...................................................................................................273
4.7.2 Peripheral Ischemia....................................................................................... 275
4.7.3 Shunt Aneurysm............................................................................................ 275
4.7.4 Abnormal Shunt Flow................................................................................... 276
4.8 Diagnostic Role of Duplex Ultrasound Compared with Other Modalities.............. 276
4.9 Atlas: Shunts............................................................................................................ 278
5 Extracranial Cerebral Arteries..................................................................................... 291
5.1 Normal Vascular Anatomy and Important Variants................................................. 291
5.2 Examination Technique and Protocol...................................................................... 294
5.2.1 Carotid Arteries............................................................................................. 294
5.2.2 Vertebral Arteries.......................................................................................... 297
5.3 Documentation......................................................................................................... 299
5.4 Normal Findings...................................................................................................... 299
5.4.1 Carotid Arteries............................................................................................. 299
5.4.2 Vertebral Arteries.......................................................................................... 299
5.5 Clinical Role of Duplex Ultrasound........................................................................ 299
5.5.1 Carotid Arteries............................................................................................. 299
5.5.1.1 Defining the Degree of Stenosis....................................................... 301
5.5.1.2 Plaque Morphology.......................................................................... 305
5.5.2 Vertebral Arteries.......................................................................................... 306
5.6 Ultrasound Criteria, Measurement Parameters, and Diagnostic Role..................... 306
5.6.1 Carotid Arteries............................................................................................. 306
5.6.1.1 Plaque Evaluation and Morphology................................................. 306
5.6.1.2 Stenosis Quantification/Stenosis Grading........................................ 314
5.6.1.3 Occlusion......................................................................................... 324
5.6.1.4 Postoperative Follow-Up.................................................................. 326
5.6.2 Vertebral Arteries.......................................................................................... 330
5.6.2.1 Stenosis............................................................................................ 330
5.6.2.2 Occlusion......................................................................................... 330
Contents xix
5.6.2.3 Dissection......................................................................................... 330
5.6.2.4 Subclavian Steal Syndrome.............................................................. 331
5.7 Diagnosis of Brain Death......................................................................................... 332
5.8 Rare (Nonatherosclerotic) Vascular Diseases of the Carotid Territory.................... 332
5.8.1 Dissection...................................................................................................... 332
5.8.2 Inflammatory Vascular Diseases (Takayasu’s Arteritis)................................ 334
5.8.3 Fibromuscular Dysplasia............................................................................... 335
5.8.4 Aneurysm...................................................................................................... 335
5.8.5 Arteriovenous Fistula.................................................................................... 336
5.8.6 Idiopathic Carotidynia................................................................................... 336
5.8.7 Vasospasm..................................................................................................... 336
5.8.8 Compression by Tumor, Carotid Body Tumor.............................................. 337
5.9 Diagnostic Role of Duplex Ultrasound in Evaluating the Extracranial
Cerebral Arteries...................................................................................................... 337
5.10 Atlas: Extracranial Cerebral Arteries....................................................................... 341
6 Visceral and Retroperitoneal Vessels............................................................................ 377
6.1 Abdominal Aorta, Visceral and Renal Arteries....................................................... 377
6.1.1 Vascular Anatomy......................................................................................... 377
6.1.1.1 Aorta................................................................................................. 377
6.1.1.2 Visceral Arteries............................................................................... 377
6.1.1.3 Renal Arteries.................................................................................. 378
6.1.2 Examination Protocol and Technique............................................................ 378
6.1.2.1 Aorta................................................................................................. 378
6.1.2.2 Visceral Arteries............................................................................... 378
6.1.2.3 Renal Arteries.................................................................................. 380
6.1.3 Normal Findings............................................................................................ 380
6.1.3.1 Aorta................................................................................................. 380
6.1.3.2 Visceral Arteries............................................................................... 380
6.1.3.3 Renal Arteries.................................................................................. 382
6.1.4 Interpretation and Documentation................................................................. 383
6.1.5 Clinical Role of Duplex Ultrasound.............................................................. 383
6.1.5.1 Aorta................................................................................................. 383
6.1.5.2 Visceral Arteries............................................................................... 385
6.1.5.3 Renal Arteries.................................................................................. 386
6.1.6 Measurement Parameters, Diagnostic Criteria, and Role of Ultrasound...... 387
6.1.6.1 Renal Arteries.................................................................................. 387
6.1.6.1.1 Renal Artery Occlusion.................................................... 392
6.1.6.1.2 Transplant Kidney............................................................ 392
6.1.6.2 Visceral Arteries............................................................................... 394
6.1.6.3 Aorta................................................................................................. 399
6.2 Visceral and Retroperitoneal Veins.......................................................................... 404
6.2.1 Vascular Anatomy......................................................................................... 404
6.2.1.1 Vena Cava......................................................................................... 404
6.2.1.2 Renal Veins...................................................................................... 404
6.2.1.3 Portal Venous System and Hepatic Veins........................................ 405
6.2.2 Examination Technique................................................................................. 405
6.2.2.1 Vena Cava......................................................................................... 405
6.2.2.2 Renal Veins...................................................................................... 406
6.2.2.3 Portal Vein and Superior Mesenteric Vein....................................... 406
6.2.3 Clinical Role of Duplex Ultrasound.............................................................. 407
6.2.3.1 Renal Veins...................................................................................... 407
6.2.3.2 Portal Venous System....................................................................... 407
6.2.4 Normal Findings............................................................................................ 408
xx Contents
6.2.4.1 Vena Cava and Renal Veins.............................................................. 408
6.2.4.2 Portal Venous System....................................................................... 408
6.2.5 Documentation.............................................................................................. 408
6.2.6 Abnormal Ultrasound Findings, Measurement Parameters,
and Diagnostic Role...................................................................................... 408
6.2.6.1 Vena Cava......................................................................................... 408
6.2.6.2 Renal Veins...................................................................................... 409
6.2.6.3 Superior Mesenteric Vein................................................................. 410
6.2.6.4 Portal and Hepatic Veins.................................................................. 411
6.3 Atlas: Visceral and Retroperitoneal Vessels............................................................ 415
7 Penile and Scrotal Vessels............................................................................................... 473
7.1 Vascular Anatomy.................................................................................................... 473
7.1.1 Penile Vessels................................................................................................ 473
7.1.2 Scrotal Vessels............................................................................................... 473
7.2 Examination Technique........................................................................................... 474
7.2.1 Erectile Dysfunction...................................................................................... 474
7.2.2 Scrotal Vessels............................................................................................... 475
7.3 Normal Findings...................................................................................................... 475
7.3.1 Penile Vessels................................................................................................ 475
7.3.2 Scrotal Vessels............................................................................................... 475
7.4 Documentation......................................................................................................... 475
7.5 Clinical Role of Duplex Ultrasound........................................................................ 476
7.5.1 Erectile Dysfunction...................................................................................... 476
7.5.2 Acute Scrotum............................................................................................... 476
7.5.3 Varicocele...................................................................................................... 477
7.6 Abnormal Findings: Role of Duplex Ultrasound Parameters.................................. 477
7.6.1 Erectile Dysfunction...................................................................................... 477
7.6.2 Acute Scrotum...................................................................................................478
7.6.3 Varicocele...................................................................................................... 479
7.7 Atlas: Penile and Scrotal Vessels............................................................................. 480
References.............................................................................................................................. 485
Subject Index......................................................................................................................... 513