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B-Flow Imaging of the Hepatic Vasculature: Correlation with Color Doppler Sonography

¹ Department of Radiology, University Hospital, New Jersey Medical School, 150 Bergen St., C-320, Newark, NJ 07103.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —47-year-old woman with cirrhosis. Color Doppler sonogram optimized for detection of slow flow fails to display flow signal in portal vein.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —47-year-old woman with cirrhosis. On B-flow image, portal vein lumen is filled with mobile echoes (arrowheads), best appreciated on movie clip (Fig. S1C). Portal vein was patent at liver transplantation 1 week later. Slow blood flow and large beam–vessel angle made Doppler sonography detection of slow portal flow difficult, whereas B-flow imaging performs well at large beam–vessel angles.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —44-year-old woman with poor graft function 2 days after liver transplantation. Gray-scale sonogram shows complex intrahepatic collection.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —44-year-old woman with poor graft function 2 days after liver transplantation. Color Doppler sonogram optimized for slow-flow detection shows questionable flow straddling margin of this collection (arrow).

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —44-year-old woman with poor graft function 2 days after liver transplantation. B-flow image shows "puff of smoke" appearance (arrowheads) indicating flowing blood within collection. This appearance can be better appreciated on movie clip (Fig. S2D). Active venous bleeding into intrahepatic pseudoaneurysm was identified and repaired at laparotomy.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —37-year-old woman with Budd-Chiari syndrome who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) procedure. Spectral Doppler sonogram reveals what appears to be flow signal within hypoechoic structure adjacent to TIPS, suspicious for iatrogenic pseudoaneurysm.

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —37-year-old woman with Budd-Chiari syndrome who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) procedure. B-flow image reveals flow within TIPS and inferior vena cava (IVC) but not inside lesion. This finding resolved on follow-up, supporting diagnosis of iatrogenic hematoma.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —38-year-old woman with cirrhosis. Transverse color Doppler sonogram of hilar portal vein displays color signal filling entire vascular lumen (arrowhead).

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —38-year-old woman with cirrhosis. B-flow image in same plane as A reveals flowing echoes in medial half of portal vein but no flow in lateral half (arrowheads).

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —38-year-old woman with cirrhosis. Contrast-enhanced CT scan shows nonocclusive thrombus (asterisk), confirming B-flow imaging findings. This case illustrates how high color gain setting can cause oversaturation and potentially obscure intravascular thrombus.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —45-year-old man with cirrhosis. All images are sagittal sections of left lobe obtained near midline. Color Doppler sonogram obtained with color gain increased until just below development of color noise reveals what appears to be normal patency of left hepatic vein.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —45-year-old man with cirrhosis. All images are sagittal sections of left lobe obtained near midline. B-flow image reveals curvilinear intravascular channels within left hepatic vein lumen, consistent with neovascularization within tumor thrombus rather than patent lumen.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —45-year-old man with cirrhosis. All images are sagittal sections of left lobe obtained near midline. Color Doppler sonogram, repeated with gain significantly lower than in A and other parameters unchanged, now also reveals intrathrombus neovascularity. CT scan confirmed hepatocellular carcinoma invading left hepatic vein. This case shows that widespread practice of maximizing color gain until noise develops can lead to color oversaturation and obscuration of nonocclusive thrombus.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —37-year-old male liver transplant recipient. Color Doppler sonogram of liver hilum depicts relatively slow flow in portal vein (PV) and aliased flow in hepatic artery (star). Note regions of focal widening of arterial flow signal in porta hepatis (arrowheads), suggesting looped vessel or pseudoaneurysm.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —37-year-old male liver transplant recipient. B-flow image reveals tangles of small collateral vessels (arrows), which developed after hepatic arterial occlusion.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —37-year-old male liver transplant recipient. Contrast-enhanced CT scan confirms hepatic artery collaterals (arrow).

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —33-year-old male liver transplant recipient. Color Doppler sonogram of porta hepatis depicts pulsatile vascular structure containing high-amplitude blue and red flow signals (arrow), suspicious for pseudoaneurysm.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —33-year-old male liver transplant recipient. B-flow image reveals looping hepatic artery of normal caliber (large arrow). Small arrows indicate direction of blood flow.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —33-year-old male liver transplant recipient. Color Doppler sonogram obtained in different liver transplant recipient reveals hepatic artery pseudoaneurysm (arrow), which was confirmed on arteriography. Note similarity to looped artery in A.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —68-year-old woman with cirrhosis and apparently spontaneous fistulous connection between right portal and right hepatic veins. Sagittal color Doppler sonogram of inferior right hepatic lobe shows region of color aliasing (asterisk) supplied by portal vein (red signal) and drained by hepatic vein (blue signal). Arrows indicate direction of flow. Note that vessels within fistula are not individually discernible.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —68-year-old woman with cirrhosis and apparently spontaneous fistulous connection between right portal and right hepatic veins. B-flow image depicts abnormal blood vessels in exquisite detail.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —54-year-old woman with focal nodular hyperplasia. Power Doppler sonogram reveals incomplete spoke-wheel vascular pattern.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —54-year-old woman with focal nodular hyperplasia. B-flow image depicts spoke-wheel pattern to better advantage.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —42-year-old woman with arterioportal fistula. LHA = left hepatic artery, LPV = left portal vein. Color Doppler sonogram reveals large "perivascular color bruit" (arrow) generated by fistulous connection between LHA and LPV.

View larger version (50K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —42-year-old woman with arterioportal fistula. LHA = left hepatic artery, LPV = left portal vein. B-flow image reveals that fistula (arrow) is much smaller than suggested on color Doppler sonogram (A).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —42-year-old woman with arterioportal fistula. LHA = left hepatic artery, LPV = left portal vein. Contrast-enhanced CT scan indicates that true size of fistula (arrow) is similar to B-flow imaging findings.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —32-year-old male liver transplant recipient with intractable ascites. Color Doppler sonogram reveals color aliasing in hilar portal vein, with threefold focal velocity acceleration (from 45 to 149 cm/s).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —32-year-old male liver transplant recipient with intractable ascites. B-flow image shows slight waist at portal anastomosis (arrowheads) but no significant luminal narrowing.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —32-year-old male liver transplant recipient with intractable ascites. Transhepatic portogram confirms absence of significant luminal narrowing or pressure gradient across portal anastomosis (arrow). False-positive Doppler sonography diagnosis was presumably caused by anastomotic turbulence.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —53-year-old man with hilar cholangiocarcinoma. Color Doppler sonogram of porta hepatis reveals apparent stenosis of hilar portal vein (arrowhead) with color aliasing. Spectral Doppler sonogram (not shown) revealed angle-corrected velocity measuring 163 cm/s flow jet at this level.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —53-year-old man with hilar cholangiocarcinoma. B-flow image confirms color Doppler sonogram (A) impression of portal vein stenosis (arrowhead).

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —53-year-old man with hilar cholangiocarcinoma. Contrast-enhanced CT scan confirms tight stenosis of portal vein (arrow).

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —36-year-old man with cirrhosis and hemorrhage from esophageal varices treated with transjugular intrahepatic portosystemic shunt (TIPS). Oblique transverse color Doppler sonogram reveals focal flow jet (arrowhead) within TIPS. Angle-corrected velocity at this location revealed localized 60 cm/s acceleration of flow velocity, suspicious for stenosis.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —36-year-old man with cirrhosis and hemorrhage from esophageal varices treated with transjugular intrahepatic portosystemic shunt (TIPS). B-flow image in same plane as A reveals normal luminal diameter without evidence of stenosis (arrowhead).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —36-year-old man with cirrhosis and hemorrhage from esophageal varices treated with transjugular intrahepatic portosystemic shunt (TIPS). Coronal curved multiplanar reformat of contrast-enhanced CT scan reveals nonstenotic TIPS lumen, confirming B-flow imaging findings.

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