Role of CEUS in Imaging of the Abdominal Aorta - SD

Normal Abdominal Aortic Imaging Without Contrast

Starting with the first image, we see that normally.

The question is whether we really need every time contrast science ultra ultrasound.

If we look at the atomic area here, the order we are starting with a gray scale image.

And this image everything is clear.

We see no plaques, we see no movement membrane.

So otic dissection, no aneurysm.

And also in the long term view we see this nice shape of the aortic of theorum.

So in this case there is no need to use scent ultrasound.

Also we use the next step.

The next step will be car dolar information.

We see a nice filling of the ter. We see also the IVC.

Here we see a normal curve from the TER and also long to view here of the TER we see no turbulence.

So also major information already exists in this image.

There's no need to use contrast.

But if we think about pathologies for example, the aneurysm there, we have to use contrast.

If we think about how much contrast is necessary to get a good contrast, we use only one C of contrast and followed by 10 of the lean solution.

The amount of contrast is a little bit different on the different system.

So sometimes you need a bit more contrast, but an average you use only one CCC of contrast.

Aortic Aneurysm: General Information and Case Example

Starting with aneurysm, of course an aneurysm is called an aneurysm if the diameter is more than three centimeters.

We also know that in the western Union we have got a higher risk to develop an aneurysm in comparison to the other areas in the world.

And unfortunately also most of the men have got the risk to develop an aneurysm.

And of course, depending on the diameter, the risk that this an, this risk that the aneurysm aneurysm could rupture will be increased depending on the diameter.

So starting with the first patient that's an 85-year-old patient, no trauma history, he find position AB the tumor and pain.

So we see a huge aneurysm test called diameter about 10 centimeter or also in the longitudinal view we see it partial changed in the aneurysm but we could not exclude any rupture in this case by using the next step using color doppler information, we see that there is still a flow inside some turbulences inside that the iliac arteries right and the left iliac arteries and also in the long term view we see here part of the iliac artery.

But we could not exclude eruption in this case.

So therefore it's helpful to use contrast.

So by using contrast we see contrast stays in the aneurysm.

It doesn't leave the aneurysm.

So only a huge tic aneurysm with a diameter about 10 centimeter with thrombotic changes but no sign of rupture.

This patient will in the most time treated by other stent grafts.

Unfortunately a stem graft implantation was not possible.

Couple of days later this patient died.

Aortic Dissection: Case Example

If you think about TER section, often we find in the gray scale the movement of the membrane.

Sometimes the question is whether both lumen has still flow inside yes or not.

And what about the perfusion of the kidney?

You have to look really carefully at the kidney because most of the time and either the right or the left side of the um, aneurysm of the dissection for entire from the fourth lumen.

So starting with a gray scale image that's a 70-year-old patient with pain for two days come to this ultrasound examination.

The diagnosis is clear, it's an auto dissection we see here in the long review the movement and the membrane.

But could we answer the question where true lumen, where the fourth lumen, of course we see it also on the vu here.

Probably if we have experience, you see the flap moves more in this direction in comparison to the other probably this will be true lumen, this will be the fourth lumen.

So we look at the car doppler, we see there's still a flow in both lumen, but we see also that the color settings is a little different.

So there must different flows in both lumen.

So where are the additional information by using contrast in this patient?

First of all we look at the timer we inject contrast that the dual mode, first of all the contrast arrive in the true lumen then in the fourth lumen.

And if you look very carefully here we see the right renal artery also here.

That's the true lumen, fourth lumen.

And here is the right renal artery.

But where are the left renal artery? Could we see it really hard? I couldn't find it.

Next step I look at the perfusion of the kidney and compare to part of the liver.

The perfusion of the kidney is nice, no infarction and if you compare from the complete side of this kidney all over nice perfusion.

So the question is why we only find the right renal opery because this patient has got only one kidney.

Here we see the dissection of the aorta that the fourth lumen and the right wing artery entered from the fourth lumen.

Therefore it's very important to look very, very carefully on the right kidney because he has got only right kidney with entire from the fourth lumen

Covered Rupture: Case Example

covered rupture is a very rare case, therefore it's very important to see maybe a hematoma or a active bleeding in this hematoma.

But are we able to see these bleedings or not starting with this case that's a 57-year-old female with un abdominal pain in the last four days we starting with the gray scale and the long drew view, we see a calcification plug.

We see the XI view a little bit, unlucky shape of theor here.

But could we exclude a rupture here If we compare with contrast, we see that below this plug it's still contrast the long review so there must be rupture.

Otherwise the contrast could not be below this plug.

Also in the al view we see the shape and the hematoma here without contrast uptake.

And if we compare this now to the CT examination, we see here the rupture covered rupture of theor.

Also here in the sagal view and this was bet treated by an OR stent graft

Aorto-IVC Fistula: Case Example

in very uncommon case is a rupture from the orta in the IVC as a sign of a fistula.

So this patient 60-year-old patient suspicion of a symptomatic abdominal tic and rhythm.

We started with gray scale.

We see this allis here next to the aorta.

So there's suspicion of an IV fistula but could we see this fistula must be somewhere here.

Yeah. Also in the long view we can see that must be here in this area.

But how many fistula exist in this case?

Starting with contrast, our order, there's a channel between the order and the IVC and the second channel here Again one channel and here is second channel.

So two fistulas from the IVC in the I, from the order in the IVC and of course we have done dynamic MRA examination and also CT examination.

If we look at the dynamic MRI examination, we see this filling of the aorta, we see this aneurysm, we see the aneurysm of the iliac arteries, we see the filling of the iliac arteries but we could not see any filling in the YA veins but we have still contrast in the IVC.

So the contrast must take this way from the order direct directly in the IVC.

Otherwise it makes no sense that these contrast arrives so early in the IVC we compare to the CT examination, we see it also similar.

We see here the aneurysm, the IAC arteries, no IAC grains and we could see here I received filled with contrast due to the fact that that a fistula but in CT on also MI there was a suspicion only of one fistula but there was two fistula at the end.

Therapy of this patient was also a stent graft.

Inflammatory Aortic Aneurysm: Case Example

An inflammatory a andry is a very rare case.

This first was described by walker in the year 90 72.

So it's about two to 50% of this aneurysm could be inflammatory ans and often we see an enlargement of the aortic wall of course with more small vessels inside

This patient was already treated the aneurysm by antic stent graft.

We see here the otic stent graft.

We see that normally aortic wall and then we see this enlargement of the anter and ventral and lateral and ventral part of the a wall by car dola.

We see that the stand graft is fine.

We could not see any endo leak but this session will be coming later but we could not see any flow here, no major vessel.

Also if we use the power dola settings, we can see here the stand graft is nice perfused but we could not see any flow here in this enlarged otic wall.

So are this technique sensitive enough to detect the perfusion of the otic wall?

We inject contrast, we see the perfusion of the stem graft.

It's fine. Take a little bit while and then we see this filling of the inflammatory A aneurysm here especially on the ventral part and on the lateral part due to the fact that an inflammatory a aneurysm, these aneurysm will be often treated and therefore the next step for contrast ultrasound.

You can monitor this treatment if you do this examination before treatment and use this time intensive curve as a baseline examination and then compared over time you can say whether your treatment are successful or not.

This the same patient.

This was uh, CTA mip so we couldn't see it but we see the part of the aneurysm before and we see here the aneurysm and this wall uptake and this was a stent graft.

If I compare it, you can see and make measurements inside here and here.

And then you get this nice curve which you have already seen in the kidney diagnostics and then you compare side by side the changes.

Conclusion

So in conclusion, for the first we can say the use of contrast and ultrasound is very helpful to detect all the major pathologies in the abdominal order.

TIC order is also possible but that's a special part and even more difficult we have additional information like perfusion of the ween of the real and forest lumen and dissection and also perfusion of the kidneys, which is really very important.

If there's less perfusion you need an intervention And it's addition examination to C and MIA.

Of course if we find in the gray scale image in tic dissection we need the CTA because we wanna know how far does the dissection go.

The tic dissection next to the heart does go the carotid artery.

So this patient also received a ct.

But in the follow up on intensive care unit, you can look at this patient on the bedside examination and compare whether both lumen has the contrast uptake or not or what about the perfusion of the kidney.

And there's no need to bring this patient again to the C or the MID department.

You can do this on the intens care unit next to the patient and the bedside examination.

And of course this technique is also very helpful for the pre planning.

If we think about the covered rupture or the covered rupture where the question was how far are the renal RV away from the covered rupture, we could answer the question very, very clearly and say this patient need a special stent graft.

Normal ST stand graft will not work here.

And this also was confirmed by the CT examination and therefore for the preoperative planning, this tool is also very helpful to find the correct or best treatment for your patient.

Thank you much for your attention.