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Intraoperative Sonogram in Mesenteric Revascularization: Spectrum of Findings

¹ Department of Radiology, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905.
² Division of Vascular Surgery, Mayo Clinic and Foundation, Rochester, MN 55905.

View larger version (20K): [in a new window]   Fig.1A. —llustrations show most common types of mesenteric arterial revascularization. Bifurcated supraceliac aorta to celiac and superior mesenteric artery (SMA) is most common type of revascularization performed.

View larger version (24K): [in a new window]   Fig.1B. —llustrations show most common types of mesenteric arterial revascularization. Endarterectomy.

View larger version (23K): [in a new window]   Fig.1C. —llustrations show most common types of mesenteric arterial revascularization. Retrograde iliac to SMA.

View larger version (20K): [in a new window]   Fig.1D. —llustrations show most common types of mesenteric arterial revascularization. Antegrade aorta to SMA.

View larger version (91K): [in a new window]   Fig. 2A. —58-year-old woman who underwent supraceliac bifurcated aorta celiac and superior mesenteric artery (SMA) bypass graft. Intraoperative sonogram findings were normal. Longitudinal gray-scale image shows no technical defect in proximal graft anastomosis (aorta = narrow arrow, graft body = wide arrow, bifurcated limbs = arrowheads).

View larger version (111K): [in a new window]   Fig. 2B. —58-year-old woman who underwent supraceliac bifurcated aorta celiac and superior mesenteric artery (SMA) bypass graft. Intraoperative sonogram findings were normal. Longitudinal gray-scale image reveals widely opened distal anastomosis of graft limb (arrow) and native SMA (arrowhead).

View larger version (60K): [in a new window]   Fig. 2C. —58-year-old woman who underwent supraceliac bifurcated aorta celiac and superior mesenteric artery (SMA) bypass graft. Intraoperative sonogram findings were normal. Subsequent color Doppler screening confirms absence of hemodynamic disturbance.

View larger version (54K): [in a new window]   Fig. 2D. —58-year-old woman who underwent supraceliac bifurcated aorta celiac and superior mesenteric artery (SMA) bypass graft. Intraoperative sonogram findings were normal. Spectral analysis confirms absence of hemodynamic disturbance.

View larger version (78K): [in a new window]   Fig. 3A. —73-year-old woman with aorta to celiac artery bypass graft. Intraoperative sonogram with longitudinal views of distal anastomosis evaluation is shown. Spectral Doppler waveform at distal graft limb shows velocity of about 0.4 m/sec.

View larger version (95K): [in a new window]   Fig. 3B. —73-year-old woman with aorta to celiac artery bypass graft. Intraoperative sonogram with longitudinal views of distal anastomosis evaluation is shown. Spectral Doppler waveform in native artery reveals significant increase in peak systolic velocity up to 2.5 m/sec associated with significant change in caliber. Elevated velocities were seen throughout vessel, and no filling defect was detected. These findings are characteristic of graft–vessel mismatch.

View larger version (74K): [in a new window]   Fig. 4. —66-year-old man with bifurcated supraceliac aorta to superior mesenteric artery (SMA) bypass. Intraoperative sonogram with spectral Doppler waveform shows elevated velocity and turbulence associated with area of angulation at proximal SMA graft anastomosis. On gray-scale image, lumen in area of angulation remains widely opened, and velocity distal and proximal to area of turbulence was not significantly lower. Therefore, findings were thought to be insignificant and attributed to mild graft kinking.

View larger version (77K): [in a new window]   Fig. 5A. —Intraoperative sonogram of 50-year-old woman with longitudinal views of distal anastomosis of supraceliac aorta to superior mesenteric artery bypass graft. Doppler interrogation of distal graft limb reveals normal waveform.

View larger version (102K): [in a new window]   Fig. 5B. —Intraoperative sonogram of 50-year-old woman with longitudinal views of distal anastomosis of supraceliac aorta to superior mesenteric artery bypass graft. Doppler sampling at distal anastomosis reveals elevated velocity and focal narrowing. This was thought to be hemodynamically significant focal narrowing that warranted revision.

View larger version (90K): [in a new window]   Fig. 5C. —Intraoperative sonogram of 50-year-old woman with longitudinal views of distal anastomosis of supraceliac aorta to superior mesenteric artery bypass graft. Postrevision image reveals resolution of abnormal findings. Graft anastomosis narrowing was found.

View larger version (112K): [in a new window]   Fig. 6A. —Intraoperative sonogram of 62-year-old man with redo bifurcated aorta to common hepatic artery and superior mesenteric artery (SMA) bypass graft. Gray-scale sonogram reveals echogenic line (small arrow) at anastomosis of new SMA graft limb (arrow) to old graft (arrowhead).

View larger version (27K): [in a new window]   Fig. 6B. —Intraoperative sonogram of 62-year-old man with redo bifurcated aorta to common hepatic artery and superior mesenteric artery (SMA) bypass graft. Color and spectral Doppler sonogram reveals associated focal elevated velocity and turbulence in proximal SMA graft.

View larger version (135K): [in a new window]   Fig. 6C. —Intraoperative sonogram of 62-year-old man with redo bifurcated aorta to common hepatic artery and superior mesenteric artery (SMA) bypass graft. Postrevision sonogram reveals resolution of echogenic line found to be thrombus.

View larger version (26K): [in a new window]   Fig. 6D. —Intraoperative sonogram of 62-year-old man with redo bifurcated aorta to common hepatic artery and superior mesenteric artery (SMA) bypass graft. Postrevision color and spectral Doppler reveals normalization of waveform.

View larger version (122K): [in a new window]   Fig. 7A. —75-year-old woman who had intraoperative sonogram after transaortic endarterectomy of superior mesenteric artery (SMA). Gray-scale image shows echogenic material within proximal SMA (arrow).

View larger version (46K): [in a new window]   Fig. 7B. —75-year-old woman who had intraoperative sonogram after transaortic endarterectomy of superior mesenteric artery (SMA). Color and spectral Doppler sonogram reveals associated turbulent flow with elevated velocity.

View larger version (98K): [in a new window]   Fig. 7C. —75-year-old woman who had intraoperative sonogram after transaortic endarterectomy of superior mesenteric artery (SMA). Postrevision Doppler with spectral analysis reveals resolution of echogenic material and normalization of velocity.

View larger version (64K): [in a new window]   Fig. 7D. —75-year-old woman who had intraoperative sonogram after transaortic endarterectomy of superior mesenteric artery (SMA). Postrevision color Doppler image reveals widely patent proximal anastomosis and resolution of thrombus found to be associated with intimal flap.

View larger version (88K): [in a new window]   Fig. 8A. —59-year-old woman with supraceliac bifurcated aorta to celiac and superior mesenteric artery (SMA) bypass graft. Longitudinal gray-scale image at distal graft to SMA anastomosis shows echogenic line in lumen (arrow).

View larger version (33K): [in a new window]   Fig. 8B. —59-year-old woman with supraceliac bifurcated aorta to celiac and superior mesenteric artery (SMA) bypass graft. Color spectral Doppler confirms hemodynamic disturbance with turbulent flow and focally elevated velocity greater than 4 m/sec.

View larger version (62K): [in a new window]   Fig. 8C. —59-year-old woman with supraceliac bifurcated aorta to celiac and superior mesenteric artery (SMA) bypass graft. Postrevision image reveals resolution of echogenic line, thought to be intimal flap that resolved after dilator was passed.

View larger version (68K): [in a new window]   Fig. 8D. —59-year-old woman with supraceliac bifurcated aorta to celiac and superior mesenteric artery (SMA) bypass graft. Color and spectral analysis Doppler shows resolution of hemodynamic abnormality. Abnormality on gray-scale image associated with elevated velocity was significant, and revision was recommended.

View larger version (65K): [in a new window]   Fig. 9. —78-year-old man with supraceliac bifurcated aorta to celiac and superior mesenteric artery bypass graft. Intraoperative sonogram with color Doppler reveals occlusive thrombus (arrow) in proximal common hepatic artery, 2 cm beyond distal graft anastomosis. Embolectomy was performed, and completion sonogram was normal. Occlusive thrombus is significant finding that should prompt revision.

View larger version (123K): [in a new window]   Fig. 10A. —73-year-old man with supraceliac bifurcated aorta to splenic artery and superior mesenteric artery bypass graft. Gray-scale image reveals linear bright echo (arrow) at distal anastomosis with splenic artery (arrowhead).

View larger version (76K): [in a new window]   Fig. 10B. —73-year-old man with supraceliac bifurcated aorta to splenic artery and superior mesenteric artery bypass graft. Spectral Doppler waveform was abnormal with minimal flow distally and high resistance, indicating distal occlusion or significant stenosis. Surgeon elected not to revise this abnormality because of prolonged operating and clamping time and significant patient comorbidities. Graft occluded the following day and patient underwent additional operation.

View larger version (114K): [in a new window]   Fig. 11. —Intraoperative sonogram of 78-year-old man after supraceliac aorta to celiac and superior mesenteric artery bypass graft. Longitudinal sonogram with spectral Doppler analysis reveals intraluminal flap (arrow) associated with elevated velocity consistent with a flow-limiting dissection in native common hepatic artery just beyond distal anastomosis. These findings are consistent with major abnormality and should prompt revision. After revision with repair of intimal flap, repeat sonogram was normal.

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