SSS, BCS, Avf, Mal

Subclavian Steal
• The subclavian steal phenomenon occurs when there is high grade

stenosis or occlusion of the proximal subclavian or innominate arteries.
• Patent vertebral arteries bilaterally
• The artery of the ischemic limb “steals” blood from the vertebrobasilar
circulation through retrograde vertebral artery flow
• symptoms of vertebrobasilar insufficiency.
Subclavian
Steal
Hemodynamic Pattern in
Subclavian Steal Syndrome
Subclavian Steal
Causes
• Atherosclerotic disease (Most common)
• Traumatic, embolic, surgical, congenital, and neoplastic
Subclavian Steal
COMPLETE SUBCLAVIAN STEAL
• Reversal of flow within vertebral artery ipsilateral to stenotic or occluded
subclavian or innominate artery
INCOMPLETE OR PARTIAL SUBCLAVIAN STEAL
• Transient reversal of vertebral artery flow during systole
• May be converted into a complete steal using provocative maneuvers
• Suggests stenotic, not occlusive, lesion
Subclavian Steal
PRESTEAL PHENOMENON
• “Bunny” waveform: systolic deceleration less than diastolic flow
• May be converted into partial steal by provocative maneuvers
• Seen with proximal subclavian stenosis
TARDUS-PARVUS (DAMPENED) WAVEFORM
• Seen with vertebral artery stenosis
Click icon to add picture
Subclavian Steal
Reversal of Vertebral Artery Flow in
Subclavian Steal.
Incomplete Subclavian Steal
presteal (“bunny”) waveform
Incomplete Subclavian Steal and Provocative Maneuver.

Median Arcuate Ligament Syndrome
• Median arcuate ligament (MAL) is a fibrous arch that connects the

diaphragmatic crura to form the anterior margin of the aortic hiatus.
Clinical features
• intermittent abdominal pain, typically epigastric and usually postprandial.
• weight loss, nausea and diarrhea.
Examination
• mild epigastric tenderness
• midabdominal systolic bruit on auscultation
Radiologic findings
• MAL thickness of more than 4 mm is considered abnormal
• Focal narrowing of the proximal celiac axis with a characteristic hooked
appearance caused by the inferior displacement of the celiac artery by the
MAL.
• Sagittal axis for visualizing the “hooking” of the proximal celiac trunk
• Associated findings include poststenotic dilatation or collateral vessel
formation from the SMA branches.
Sagittal arterial volume-rendered
phase CT image 3D
reconstruction
• Percutaneous angiography is the reference standard for the diagnosis of

MAL syndrome and shows findings similar to CT such as superior
indentation, hooking, and poststenotic dilatation of the celiac axis.
• A useful additional finding on angiography is the ability to assess the
stenosis in both end-inspiration and end-expiration
Doppler ultrasound
• noninvasive
• A peak systolic velocity of greater than 200 cm/s has a reported sensitivity
and
• flow turbulence, accentuated during the expiratory phase
AV Fistula
AV Fistula
A.Radiocephalic fistula at
the wrist
B. Brachiocephalic fistula
at the antecubital fossa
C. Brachiobasilic vein
transposition
D.The forearm loop graft
E. Upper arm straight graft
F. Axillary loop graft
Pre op
Peripheral arteries
• Diameter at least 1.6mm
• Patent palmar arch
Peripheral veins
• Diameter at least 2.5mm with tourniquet,
>2mm without tourniquet.
• Course - linear (for a distance of at least 8–
10 cm) and should lie < 6 mm below the skin
surface. Thin, regular walls and a completely
anechoic lumen.
Reactive hyperemia test
Left ischemic phase with fist closed and corresponding

Doppler spectrum, Right Doppler spectrum during the reactive
hyperemia phase with the hand opened.
AV Fistula
PRACTICAL TIPS
• Upper extremity vessel mapping should be performed with the patient
sitting upright, The nondominant forearm is the preferred site for AVF
placement.
• If the radial or ulnar artery at the wrist meets size criteria the cephalic vein
is evaluated for size and patency along its course to the subclavian vein.
• The subclavian and IJ veins are evaluated for the presence of stenotic
lesions, occlusions, or thrombus.
Post op
Criteria for mature fistula (at 6 to 8
weeks)
• flow volume of 500 ml/min
• out-flow vein diameter of >4 mm
• out-flow vein depth of <5 mm below the skin surface.
Routine surveillance
• AP diameter of draining
vein
• Distance from skin
• Veins branching off within
first 10cms.
• Flow volume
Anastomotic stenosis
feeding artery 2 cm Aliasing (arrow) PSV of 4.91 m/s at site of

upstream from the immediately beyond the stenosis.
arteriovenous anastomosis.
anastomosis PSV
1.35m/s
Arterial steal
Calculation of the AVF flow scanner software (‘‘Flow by
volume diameter’’)
Budd- Chiari syndrome
Budd- Chiari syndrome
• Budd-Chiari syndrome is a heterogeneous group of disorders
characterized by hepatic venous outflow obstruction at the level of the
hepatic veins, the inferior vena cava (IVC), or the right atrium .
• Budd-Chiari syndrome is not a primary condition of the liver parenchyma;
it is the result of partial or complete obstruction of hepatic venous
outflow.
Causes
• Hematologic diseases, especially myeloproliferative disorders, are the
most common cause.
• thrombotic diathesis
• Metastatic invasion of the hepatic vein, IVC, or right atrium.
Imaging Characteristics
• Duplex Doppler ultrasonography (US): easy assessment of hepatic venous
flow and detection of hepatic parenchymal
• Computed tomography (CT) and magnetic resonance (MR) imaging also
can depict hepatic venous flow or thrombosis and IVC compression or
occlusion.
Right hepatic vein is seen as a Abnormal intrahepatic collaterals
thrombosed cord.Middle hepatic vein
does not reach the inferior vena cava.
Left hepatic vein is not seen.
Budd-Chiari Syndrome With Extensive Color Doppler image,anomalous right
Inferior Vena Cava Thrombosis hepatic vein is distended with
thrombus. There is flow in the vein
proximal to the thrombus
anomalous left hepatic vein shows flow to the inferior vena cava
(normal direction) and aliasing and very high abnormal velocity of
approximately 140 cm/sec,
USG showing enlarged liver and Contrast material–enhanced abdominal
heterogeneity of the hepatic CT image shows ascites and stronger
parenchyma. enhancement in the caudate lobe and
central portion of the liver parenchyma
than in the periphery.
Contrast-enhanced abdominal CT show
patchy enhancement of the liver
parenchyma, hypertrophy of the left hepatic
lobe, and thrombosis of the hepatic veins
and IVC
multiple regenerative nodules
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SSS, BCS, Avf, Mal

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Subclavian Steal

• The subclavian steal phenomenon occurs when there is high grade

Incomplete Subclavian Steal and Provocative Maneuver.

• Median arcuate ligament (MAL) is a fibrous arch that connects the

• Percutaneous angiography is the reference standard for the diagnosis of

Left ischemic phase with fist closed and corresponding

feeding artery 2 cm Aliasing (arrow) PSV of 4.91 m/s at site of

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