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ABDOMINAL VESSELS. I. Introduction/General Information A. Uses for ultrasound 1. Screening procedure for abdominal abnormalities 2. Localize/Characterize masses 3. Measurement, rate, direction of blood flow via Doppler .

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Abdominal vessels

  • I. Introduction/General Information

  • A. Uses for ultrasound

  • 1. Screening procedure for abdominal abnormalities

  • 2. Localize/Characterize masses

  • 3. Measurement, rate, direction of blood flow via Doppler


Abdominal vessels

  • General Information, continued …

    B. Heart:

    1. CVT used on adults

    2. Ultrasound used in utero

    • C. Abdominal vessels

  • 1. Abdominal aorta

  • a. Ultrasound can delineate contour, course & size


Abdominal vessels

General Information, continued …

b. Can evaluate entire course

c. Used to diagnose, follow progress of aneurysms

d. Can distinguish between normal and aneurysm aortic pulsations


Abdominal vessels

Abdominal Vessels, continued …

2. Celiac axis (trunk, artery)

a. First unpaired branch off abdominal aorta (~ L-1)

b. Originates from ventral surface

c. Gives rise to splenic, common hepatic, & left gastric arteries



Abdominal vessels

Abdominal Vessels, continued …

3. Superior Mesenteric Artery

a. Second, unpaired branch of abdominal aorta

b. Originates ~ lower L-1 body

c. 1 – 2 cm below celiac axis

d. Supplies small intestines, pancreas, omentum, ascending and transverse colon



Abdominal vessels con t
Abdominal Vessels, con’t…

4. Inferior Mesenteric Artery

a. Arises just above the bifurcation of the aorta (~L-3/4)

b. Last unpaired branch of aorta

c. Supplies jejunum, descending and sigmoid colon, rectum



Abdominal vessels

Abdominal Vessels, continued … Arteries

4. Renal arteries

a. First major paired branches from aorta

b. Arise opposite each other 1-2 cm below SMA (~L-2)

c. Multiple renal arteries occur in 20% of patients


Renal arteries
Renal Arteries Arteries

Figure 19.11


Abdominal vessels

Abdominal Vessels, continued … Arteries

5. Common Hepatic Artery

a. Right branch of celiac a.

b. Continues to GDA, then…

6. Proper Hepatic Artery

a. Branches within liver

b. Begin at ~porta hepatis



Abdominal vessels

Abdominal Vessels, continued … Arteries

7. Inferior Vena Cava

a. Formed at ~ L-5

b. by union of Common Iliac Veins

c. Largest vein in body

d. Dilation may be due to:

1. right-sided CHF

2. Portal hypertension


Major veins of the abdomen
Major Veins of the Abdomen Arteries

L-5

Figure 19.21


Abdominal vessels

Abdominal Vessels, continued … Arteries

8. Veins of Portal Circulation

a. SMV: joins with splenic vein

1. runs parallel to SMA

2. On right side of abdomen

b. IMV: terminates in splenic vein

c. Portal Vein: enters liver


Veins of the hepatic portal system
Veins of the Hepatic Portal System Arteries

Figure 19.23


Abdominal vessels

Abdominal Vessels, continued … Arteries

d. Renal Veins – run parallel to renal arteries


Major veins of the abdomen1
Major Veins of the Abdomen Arteries

Figure 19.21


Veins of the right lower limb and pelvis
Veins of the Right Lower Limb and Pelvis Arteries

e. Femoral Veins - run parallel to femoral arteries

f. Popliteal Veins – run parallel to popliteal arteries

Figure 19.24a


Abdominal vessels

  • 1. Size:

  • a. ~ 2.5 cm – 0.5 mm

  • b. inside diameter

  • c. Arbitrary designation

  • 2. Structure: 3 coats or tunics


  • Abdominal vessels

    • Detailed Anatomy, con’t… Arteries

      • a. Tunica intima

      • 1. aka: tunica interna

      • 2. innermost layer

      • 3. = endothelium

      • 4. thin: 1 cell layer + basement membrane


    Vascular tunics tunica intima
    Vascular Tunics: Tunica Intima Arteries

    Tunica Intima

    Artery

    Capillary

    Vein


    Abdominal vessels

    Structure, Arteries, continued … Arteries

    b. Tunica media

    1. thickest layer

    2. smooth muscle & connective tissue (mostly elastic)

    3. in lamina

    4. fibers circularly arranged around lumen


    Vascular tunics tunica media
    Vascular Tunics: Tunica Media Arteries

    Tunica Media


    Abdominal vessels

    Structure arteries, continued … Arteries

    c. Tunica externa

    1. thinner than media

    2. thicker than intima

    3. white fibrous C. T.

    4. A few smooth muscle fibers, arranged longitudinally


    Vascular tunics tunica externa
    Vascular Tunics: Tunica Externa Arteries

    Tunica Externa


    Abdominal vessels

    Arteries, continued … Arteries

    3. Variability of arteries

    a. larger elastic arteries:

    1. aorta, pulmonary, carotids

    2. have thicker tunica intima

    3. increased elastic tissue


    Abdominal vessels

    Arteries, variability, continued … Arteries

    4. very thick tunica media

    a. smooth muscle

    b. obscured by elastic tissue

    5. tunica externa is

    a. thin but strong

    b. limits stretch


    Abdominal vessels

    Structure, arteries, continued Arteries

    6. Serve as “shock absorbers”

    a. expand & contract

    b. accommodate the pressure from pumping of the heart

    c. Maintain blood flow


    Abdominal vessels

    Structure, arteries, continued Arteries

    7. arteriosclerosis leads to:

    a. decreased elasticity

    b. increased blood pressure

    c. High B.P., aneurysm, rupture of vessels


    Abdominal vessels

    Variability, Arteries, continued … Arteries

    b. Muscular arteries

    1. farther from the heart

    2. tunica media

    a. more smooth muscle

    b. Less elastic tissue

    c. controlled by ANS


    Elastic vs muscular arteries
    Elastic vs. Muscular Arteries Arteries

    Elastic Artery

    Muscular Artery


    Abdominal vessels

    Variability, Muscular Arteries, continued … Arteries

    3. actively influence blood flow, pressure

    4. ANS:

    a. triggers smooth muscle contraction

    b. Sympathetic and parasympathetic responses


    Abdominal vessels

    Variability, arteries, continued … Arteries

    5. have capacity to establish collateral circulation

    6. Especially coronary arteries

    7. contract when injured

    a. ANS reaction

    b. Prevents blood loss


    Abdominal vessels

    • Detailed anatomy, continued … Arteries

      • B. Arterioles: small arteries < 0.5 mm

      • 1. Lie close to capillary beds

      • 2. Muscular

      • 3. Primary function: regulate capillary blood flow

      • 4. Allows for exchange of materials between blood and tissues


    Abdominal vessels

    • Detailed anatomy, continued … Arteries

      • C. Capillaries (sinusoids)

    • 1. Size: 1 mm long x 10 micrometers diameter

    • 2. Structure

    • a. Wall: 1 cell layer thick (endothelium)

    • b. inner surface contacts blood



    Abdominal vessels

    Capillaries, continued … Arteries

    c. outer surface rests on basement membrane

    d. Beyond basement membrane:

    1. loose connective tissue

    2. contains tissue fluid ( = plasma outside of blood stream)


    Abdominal vessels

    • Capillaries, continued … Arteries

      • 3. Organization of capillaries:

    • a. Form vast, complex networks

    • b. Penetrate to reach most tissues

    • c. Pre-capillary sphincter:

    • 1. smooth muscle rings

    • 2. regulate blood flow between arterioles & capillary beds


    Abdominal vessels

    • Capillaries, continued … Arteries

      • d. Capillary beds: (~ 60,000 miles)

      • 1. Specialized for exchange of materials

      • 2. each pound of adipose tissue contains 200 miles of capillaries


    Capillary networks
    Capillary Networks Arteries

    • Capillaries connect arterioles to venules

    • Blood flow is from the arterial to the venous vessels

    • Every millimeter of tissue has capillary blood supply


    Abdominal vessels

  • 1. Vessels closest to capillary beds

  • 2. carry deoxygenated blood

  • 3. Small venules: structurally similar to large capillaries

  • 4. Medium venules: contain a few circular muscle fibers

  • 5. Large venules: have a tunica externa


  • Abdominal vessels

  • 1. Structure: same tunics, but not as distinct

  • a. Tunica media may be absent

  • b. Tunica externa: usually thickest

  • 1. Provides strength to outer wall

  • 2. Lots of smooth muscle fibers

  • 3. Less elastic tissue


  • Vascular tunics veins
    Vascular Tunics: Veins Arteries

    Tunica Externa

    Tunica Media

    Tunica Interna


    Abdominal vessels

  • a. Folds of tunica intima

    • b. Prevent backflow

    • c. Absent in venae cavae, pulmonary & portal veins


  • Valves in veins
    Valves in Veins Arteries

    Venous Valve


    Abdominal vessels

    • Valves, continued … Arteries

      • 2. Internal jugular veins have valves

      • a. are “upside down”

      • b. blood is flowing back to heart c. when heart contracts, pushes blood up into SVC

      • d. valves keep -O2 blood from going back up into brain


    Valves assisted by skeletal muscles
    Valves Assisted by Skeletal Muscles Arteries

    • Skeletal muscle contraction, especially in the extremities, assists the flow of blood back to the heart

    • Varicose Veins…..


    Abdominal vessels


    Abdominal vessels

    Pathways of Major Vessels Arteries

    F. Path of major vessels

    1. Abdominal aorta

    a. Continuous with thoracic aorta @ diaphragm.

    b. Passes through @ T-12/L-1

    c. Most inferior hiatus in diaphragm


    Abdominal vessels

    Pathway of Major Vessels, continued … Arteries

    d. Anterior & to the left of vertebral bodies

    e. Decreases in external diameter caudally

    1. 3.0 cm @ left ventricle

    2. 1.5 cm @ bifurcation

    f. Moves toward midline distally


    Path of aorta
    Path of Aorta Arteries

    • Parasagittal section through the thorax and abdomen showing the path of the aorta


    Abdominal vessels

    Pathway of Major Vessels, continued … Arteries

    g. Bifurcates into R/L common iliac arteries @ L-3/L-4

    h. Courses posterior to IVC near diaphragm

    i. Curves anteriorly along lumbar curvature


    Abdominal vessels

    • Pathway of Major Vessels, continued … Arteries

      • 2. Celiac Artery

    • a. First unpaired branch of abdominal aorta (~T-12)

    • b. Gives rise to:

    • 1. Splenic Artery:

    • a. largest on left

    • b. supplies spleen, pancreas fundus of stomach


    The celiac trunk and its branches
    The Celiac Trunk and its Branches Arteries

    • The celiac trunk is the first unpaired artery of the abdominal aorta

    • It arises ~T-12/L-1 disc

    Celiac Trunk


    Abdominal vessels

    Major Paths of Vessels, Celiac Artery, continued Arteries

    c. L. Gastroepiploic Artery

    1. Largest branch of splenic artery

    2. supplies greater curvature of stomach


    Abdominal vessels

    Celiac artery, continued … Arteries

    2. Left Gastric Artery:

    a. smallest of 3 branches

    b. Supplies: 1. Cardiac region

    2. lesser curvature of stomach

    3. Lower esophagus


    Abdominal vessels

    Celiac artery, continued … Arteries

    3. Common Hepatic Artery:

    a. courses toward right

    b. supplies pyloric region of stomach & duodenum

    c. gives rise to gastroduodenal artery

    d. Continues as proper hepatic artery


    Hepatic artery
    Hepatic Artery Arteries

    Proper Hepatic Artery

    Common Hepatic Artery


    Abdominal vessels

    • Path of major vessels, continued … Arteries

      • 4. SMA

    • a. Second unpaired branch

    • b. Arises 1 – 2 cm below celiac artery

    • c. May have common origin

    • d. After ~6”,

    • 1. courses parallel to aorta

    • 2. then turns oblique toward right iliac fossa


    Abdominal vessels

    • SMA, continued … Arteries

      • d. Numerous branches that sometimes anastomose

      • e. Supplies:

      • 1. small intestines

      • 2. cecum

      • 3. appendix

      • 4. ascending & transverse colon 5. pancreas


    Superior mesenteric artery
    Superior Mesenteric Artery Arteries

    Superior mesenteric artery

    SMA gives rise to the inferior pancreaticoduodenal artery


    Path of major vessels continued
    Path of major vessels, continued … Arteries

    5. Renal Arteries/Veins: a. First major paired branch of abdominal aorta

    b. Arise ~L-2

    c. more later


    Abdominal vessels

    Path of major vessels, con’t… Arteries

    6. IVC: arises ~L-5

    a. lies to right of lumbar vertebrae

    b. Largest vein

    c. Occupies a fossa on posterior surface of liver

    d. Receives hepatic veins

    IVC


    Abdominal vessels

    IVC, continued … Arteries

    e. Penetrates diaphragm at T-10

    f. passes through pericardium

    g. empties into right atrium

    h. IVC receives blood from lower extremities, lumbar v., renal v., adrenal v.


    Abdominal vessels

    IVC and its Tributaries Arteries

    Pathway of IVC and its major contributing veins


    Abdominal vessels

  • a. Receives blood from digestive organs

  • b. Is high in nutrients  enters portal vein  then to liver sinusoids

  • c. then to hepatic veins  into IVC



  • Abdominal vessels

    Portal system, continued … Arteries

    d. Portal Vein:

    1. formed ~L-2 by union of SMV & splenic vein

    2. travels superiorly surrounded by lesser omentum

    3. Enters liver at porta hepatis


    Portal vein formation
    Portal Vein Formation Arteries

    L-2


    Abdominal vessels

    • III. Gray Scale Anatomy Arteries

    • A. Abdominal aorta

    • 1. Circular in T.S.

    • 2. Tubular in L.S.

    • 3. Differences from IVC:

    • a. IVC lies to the right


    Abdominal vessels

  • d. Aorta pulsates

  • 4. Slopes anteriorly to L-3/4


  • Abdominal vessels

    Gray scale anatomy, continued … Arteries

    B.SMA

    1. Extends from ~3 cm below diaphragm to umbilicus

    2. Horizontal course on L.S.

    3. Origin is 1 – 2 cm below celiac

    4. Lies anterior to aorta


    Abdominal vessels

    SMA, continued … Arteries

    4. In T.S.:

    a. sonolucent circular structure

    **b. posterior to body of pancreas

    5. Surrounding fat  collar

    a. Different from SMV

    b. SMV larger & to the right


    Abdominal vessels

    • Gray scale anatomy, continued … Arteries

      • C. Celiac trunk/axis/artery

      • 1. ID-ed on T.S. as tubular branching structure

      • 2. Originates from anterior aorta

      • 3. Short, “vertical” (really anterior) course superior to lesser curvature

      • 4. Hepatic and splenic artery branches produce “seagull” sign


    Abdominal vessels

    The “Seagull” Sign Arteries

    Splenic Artery

    Hepatic Artery

    Celiac Trunk


    Abdominal vessels

    IV. Vascular Pathology Arteries

    A. Tortuosity of abdominal aorta

    1. Aorta becomes elongated, dilated & less elastic with age

    2. Due to plaque & calcification

    3. May become tortuous

    4. May lie to right of midline

    5. May mimic an aneurysm


    Abdominal vessels

  • 1. Definitions:

  • a. circumscribed dilation of an artery

  • b. blood-containing tumor connecting with lumen of artery

  • 2. Fusiform or saccular dilations

  • 3. Usually appear distal to renal arteries


  • Abdominal vessels

    Aneurysms, continued … Arteries

    4. Measurements abnormal if:

    a. External A-P diameter >3.5 cm in upper abdomen

    b. > 2.5 cm in distal aorta

    5. Patent vessel lumen contains blood, is echolucent


    Abdominal vessels

    Aneurysms, continued … Arteries

    6. Thrombus-filled lumen is echogenic

    7. Ectatic (dilated) aorta difficult to depict on single scan

    8. Associated with arteriosclerotic plaque


    Abdominal vessels

    Aneurysms, continued … Arteries

    9. Excess plaque causes:

    a. loss of elasticity

    b. weakening in tunica media

    c. Tears in tunica interna


    Abdominal vessels

    Aneurysms, continued … Arteries

    10. Fusiform aneurysms

    a. usually project anterior & to the left

    b. path of least resistance

    c. Laminar blood flow absent in dilation

    d. Eddy currents increase likelihood of thrombus


    Abdominal vessels

    Aneurysms, continued … Arteries

    11. Ultrasound is > 95% accurate in identifying AAA

    a. Presence/location & serial growth

    b. Diameter determination

    c. Thrombus presence

    d. Incidence of rupture of aneurysm increases after 7.0 cm


    Abdominal vessels

  • 13. Less common to find aneurysm above renal arteries

  • 13. If dilation is above renal arteries, suspect dissecting thoracic aneurysm

  • 14. If dilation extends distally, survey common iliac arteries


  • Abdominal vessels

    • Aneurysms, continued … Arteries

      • B. Aortic Dissection

    • 1. Usually secondary to dissecting thoracic aortic aneurysm

    • 2. Dilation of abdominal aorta with double lumen

    • 3. Characteristics:

    • a. Intimal flap

    • b. Diffuse dilation


    Abdominal vessels

    Aortic dissection, continued … Arteries

    4. Pulsations of flap are visible

    5. Aneurysms of ascending aorta enlarge anterior and to the right

    a. May extend to mediastinum

    b. May erode sternum


    Abdominal vessels

  • 1. Atherosclerosis (reversible)

  • a. deposits of fatty materials b. in tunica intima of arteries

  • c. Genetic predisposition-- leads to 


  • Abdominal vessels

  • 2. Arteriosclerosis (irreversible)

  • a. infiltration of intima by plaque

  • b. reduces lumen size

  • c. Reduces blood supply

  • d. “hardening of the arteries”



  • Abdominal vessels

    Vascular Pathology, con’t… Arteries

    • E. Types of aneurysms

      • Axial – involves entire circumference of artery

      • Compound –some tunics ruptured, some intact

      • Dilation – axial or fusiform; general enlargement

      • a. Active – growing in diameter

      • b. Passive – wall is stretching


    Abdominal vessels

    Types of aneurysms, continued … Arteries

    4. Dissecting – splitting, tearing of intima

    a. Rarely encircles entire lumen

    b. Usually one side only

    c. May involve entire length to bifurcation

    d. Usually originates from thoracic aorta (high B.P.)


    Abdominal vessels

    Aneurysms Arteries

    Berry Aneurysm

    AAA

    Dissecting Aneurysm


    Abdominal vessels

    Types of aneurysms, continued … Arteries

    5. Ectatic – axial or dilating, but unruptured

    6. Endogenous – stretched tunica

    7. Exogenous – due to trauma

    8. Fusiform – long skinny expansion


    Abdominal vessels

    Types of aneurysms, continued … Arteries

    9. False

    a. bleeding from another source

    b. pulsating encapsulated hematoma

    c. fused with aneurysm

    d. communicates with lumen of artery


    Abdominal vessels

    Types of aneurysms, continued … Arteries

    10. Saccular – sac like bulge

    a. tunica externa expanded

    b. tunica intima intact

    11. Tubular –

    a. AKA axial; passive dilation

    b. Uniform dilation of entire vessel


    Abdominal vessels

    Types of aneurysms, continued … Arteries

    12. Varicose –

    a. result of varicose veins

    b. blood containing sac connecting artery & vein

    c. seen in antecubital fossa

    d. due to repeated IV sticks