E2449. Adventures in the Labyrinth: Imaging Role of Mesenteric Doppler in Evaluation and Management of Mesenteric Vascular Disease
  1. Anne Sailer; Yale
  2. Nadia Solomon; Yale
  3. John S. Pellerito; Zucker School of Medicine at Hofstra/Northwell Health System
  4. Douglas S. Katz; New York University Long Island School of Medicine
  5. Mariam Moshiri; University of Washington Medical Center
  6. Margartia Revzin; Yale
Duplex sonography plays an important role in the diagnosis and management of mesenteric pathology. Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient understanding of image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive imaging modalities, such as computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive modalities (digital subtraction angiography (DSA) imaging modalities for assessment of the mesenteric vasculature, Doppler ultrasound evaluation is a valuable noninvasive imaging modality that does not expose the patient to any ionizing radiation. Mesenteric sonography is a valuable tool both screening and diagnosis of a myriad of mesenteric vasculature pathologies.

Educational Goals / Teaching Points
Familiarize radiologists with mesenteric vascular anatomy and hemodynamics of the mesenteric arteries. Review Doppler technique, image optimization and protocol for evaluation of the mesenteric vasculature. Recognize characteristic imaging findings of various mesenteric vascular pathologies diagnosed on ultrasound and review sonographic diagnostic criteria for mesenteric arterial stenosis. Describe step-wise approach in management of patients with mesenteric disease and briefly review the role of Doppler sonography in post treatment evaluation.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Mesenteric vascular anatomy (aorta, celiac artery, superior and inferior mesenteric artery, mesenteric and portovenous system) and major collateral circulation pathways. Physiology and hemodynamics of aorta and the mesenteric arterial system in pre- and post-prandial states. Ultrasound imaging techniques (role of gray scale, color, power, and spectral Doppler) with specific emphasis on image optimization and recognition of common Doppler artifacts. Protocol for assessment of mesenteric vascular pathologies. Natural history of bowel ischemia. Mesenteric vascular pathologies are subdivided into 2 main categories (acute and chronic forms): acute mesenteric ischemia: arterial (thromboembolism of mesenteric arteries, dissection, spontaneous and extension from the aorta); pseudoaneurysm formation, arteritis, venous (SMV occlusion, mesenteric congestion). Chronic mesenteric ischemia (diagnostic criteria (primary and secondary signs of stenosis, 2 vessels and 3 vessels disease), atherosclerotic disease versus fibromuscular dysplasia (FMD). Management of CMI and role of imaging in post intervention assessment and surveillance (in-stent restenosis, stent occlusion, mesenteric bypass grafts). Pitfalls in diagnosis (cardiac arrhythmia, high and low cardiac output states and role of mesenteric to aortic ratio. Median arcuate ligament syndrome (MULS), nutcracker syndrome.

Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system after revascularization.