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Splanchnic Arterial Stenosis or Occlusion: Diagnosis at Doppler US¹

¹ From the Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul, Korea 135-710. From the 1996 RSNA scientific assembly. Received May 20, 1998; revision requested July 14; revision received August 25; accepted November 20. Address reprint requests to H.K.L.

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To determine the diagnostic accuracy of Doppler ultrasonography (US) in the detection of high-grade stenosis or occlusion of the celiac artery (CA) and superior mesenteric artery (SMA) and validate the previously reported Doppler US criteria.

MATERIALS AND METHODS: During a recent 36-month period, 82 patients were prospectively examined with Doppler US of the splanchnic arteries and with lateral abdominal aortography, regardless of their abdominal symptoms. The previously reported diagnostic criteria with the fasting peak systolic velocity measurement were prospectively used in all patients. The results of Doppler US were compared with those of lateral aortography.

RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Doppler US for the detection of 70% or greater CA stenosis or occlusion were 100%, 87%, 57%, 100%, and 89%, respectively; for 70% or greater SMA stenosis or occlusion, these values were 100%, 98%, 93%, 100%, and 99%, respectively.

CONCLUSION: Owing to its high accuracy in the diagnosis of high-grade splanchnic arterial stenosis or occlusion, Doppler US can be used as a screening method to help detect CA or SMA stenosis or occlusion and can reduce the use of unnecessary, invasive angiography.

Index terms: Aortography, 951.121, 955.121 • Arteries, stenosis or obstruction, 951.721, 951.761, 955.721, 955.761 • Arteries, US, 951.12983, 955.12983 • Ultrasound (US), Doppler studies, 951.12983, 955.12983

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Chronic intestinal ischemia is a rare disease, and the clinical diagnosis of this entity has traditionally been one of exclusion. Although postprandial abdominal pain and weight loss are frequent presentations in patients who have chronic intestinal ischemia, no pathognomonic clinical findings have been known. In addition to its rarity and lack of specific clinical features, chronic intestinal ischemia is mimicked by more frequently occurring gastrointestinal diseases, including peptic ulcer, chronic cholecystitis, and pancreatic cancer, and this has resulted in the late diagnosis of this entity. Although not all patients with high-grade stenosis or occlusion of the splanchnic (celiac and mesenteric) arteries have symptoms that suggest chronic intestinal ischemia, atherosclerotic stenosis or occlusion of the proximal portions of the splanchnic arteries in elderly patients is responsible for most cases of this disease (1). Angiographic demonstration of stenosis or occlusion of at least two of the major vessels is the examination used to confirm this entity (1,2). Most physicians, however, are reluctant to use angiography early in the examination of patients with abdominal pain because of its invasiveness.

Since the report by Jäger et al in 1984 (3), several investigators (4–8) have suggested that duplex Doppler ultrasonography (US) can be clinically useful as a screening examination to help detect high-grade stenoses of the celiac artery (CA) and superior mesenteric artery (SMA). Among the different Doppler criteria proposed in previous studies (6,7), measurement of the fasting peak systolic velocity has been known to be simple and accurate. In 1991, Moneta et al (6), in a retrospective study with 34 patients, postulated that the fasting peak systolic velocity was a potentially accurate predictor of high-grade splanchnic arterial stenosis. They suggested that a peak systolic velocity of 200 cm/sec or greater or no flow signal in the CA or a peak systolic velocity of 275 cm/sec or greater or no flow signal in the SMA enabled the prediction of the presence of 70% or greater angiographic stenosis or occlusion in the CA or SMA, respectively. With the same criteria, they conducted a prospective study (7) with 100 patients and reported that the overall accuracy of Doppler US for the detection of 70% or greater SMA stenosis was 96%, and that for the detection of 70% or greater CA stenosis was 82%. To our knowledge, however, no other report has duplicated the results obtained by Moneta et al.

The purpose of our study was to determine the diagnostic accuracy of Doppler US in the detection of high-grade stenosis or occlusion of the splanchnic arteries and to validate the previously reported Doppler US criteria with the fasting peak systolic velocity measurement.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Patient Selection
Between October 1994 and September 1997, 168,068 patients visited the gastrointestinal service at our institution. Thirty-two of these patients were clinically suspected of having chronic intestinal ischemia after a long series of diagnostic examinations at the outpatient clinic to exclude other common diseases. These patients were admitted to the study for evaluation of possible chronic intestinal ischemia. All patients had abdominal symptoms, including postprandial abdominal pain (n = 32), change in bowel habits (n = 21), weight loss (n = 16), and epigastric bruit (n = 7).

Another group of 50 patients were admitted to the vascular surgery service for aortography and treatment of symptomatic peripheral atherosclerotic vascular disease. These patients had no abdominal symptoms at the time of the study. Thus, this study included a total of 82 patients (44 men, 38 women; age range, 55–74 years; mean age, 64 years). All patients were examined with Doppler US of the splanchnic arteries. The study protocol was approved by the committee for clinical investigation at our institution, and written informed consent was obtained from all patients.

Doppler US Examination
All Doppler US examinations of the splanchnic arteries were performed by one experienced radiologist (H.K.L.) without knowledge of the angiographic findings. All patients were examined after they had fasted overnight. Doppler US examinations were performed with the patient in a supine position, and color Doppler scanners with either a 2–4-MHz (HDI UM-9 or HDI-3000; Advanced Technology Laboratories, Bothell, Wash) or 3.5-MHz (model 128 XP-10; Acuson, Mountain View, Calif) convex-array transducer were used. We did not attempt to fill the stomach with water in any of the patients. At longitudinal scanning, the CA, SMA, and supraceliac aorta were imaged with color Doppler US.

The presence or absence of flow signal in the abdominal aorta, proximal CA, and SMA was checked first. If no flow signal in these vessels was detected, the absence of flow was confirmed with the use of duplex Doppler US. When the CA and SMA had flow signal in their proximal portion, spectral waveforms were obtained. Doppler spectral waveforms were obtained with a Doppler angle of less than 60°. The Doppler sample volume was set at 1.5 mm. At least three Doppler spectral waveforms were obtained from the proximal CA and proximal SMA within 3 cm from the orifice. If there was no color signal or waveform from the CA or SMA, the artery was considered to be occluded. The maximum peak systolic velocity was measured from the spectral waveform. When the CA or SMA had severe stenosis or occlusion, we examined the inferior mesenteric artery with color Doppler US to check the possible collateral pathway. For the diagnosis of stenosis or occlusion of the CA or SMA, we used the criteria that was proposed by Moneta et al (6,7); the patients were considered to have 70% or greater stenosis or occlusion when they had a peak systolic velocity greater than 200 cm/sec or no flow in the CA or greater than 275 cm/sec or no flow in the SMA.

Angiographic Examination and Data Analyses
Forty-seven patients underwent aortography before the Doppler US examination, and the remaining 35 patients underwent aortography after the Doppler US examination. Each study was performed by one of the authors (H.S.P., Y.S.D., S.W.C., I.W.C.). The intervals between the two examinations were within 2 days in all patients. All lateral abdominal aortograms were obtained with an intraarterial digital subtraction technique. Angiographic stenosis of the CA and SMA was recorded as the percentage of diameter reduction at the point of maximal narrowing compared with the widest portion of the contrast material column.

Two authors (H.K.L., Y.S.D.) compared the results of Doppler US with those of aortography. The diagnostic accuracy of Doppler US to enable the detection of 70% or greater angiographic stenosis or occlusion of the CA or SMA was calculated.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
The spectral waveforms from the proximal CA and SMA, which are suitable for measurements of peak systolic velocity, were successfully obtained in 80 (98%) of the 82 patients. The causes for the nondiagnostic examinations in two patients included obesity and intestinal meteorism in one patient and shortness of breath in the other. It took less than 20 minutes to complete each Doppler US examination in all patients. All lateral abdominal aortograms were adequate for evaluation of the proximal CA and SMA.

Lateral aortogram findings revealed 12 patients with 70% or greater CA stenosis (n = 7) or occlusion (n = 5). The Doppler US findings were correct in all 12 cases of CA stenosis (Fig 1) or occlusion (Fig 2). No false-negative case (ie, negative Doppler US–based diagnosis in a case of angiographic CA stenosis 70% or greater) was found. Among the 68 patients with less than 70% angiographic stenosis, the Doppler US–based diagnosis was correct in 59; there were nine false-positive cases (ie, positive Doppler US–based diagnosis in cases of angiographic CA stenosis less than 70%) (Fig 3). Thus, Doppler US demonstrated a sensitivity of 100%, specificity of 87%, positive predictive value of 57%, negative predictive value of 100%, and accuracy of 89% for the diagnosis of 70% or greater CA stenosis or occlusion (Table 1).

View larger version (140K): [in this window] [in a new window]   Figure 1a. True-positive Doppler US–based diagnosis of high-grade CA stenosis. (a) The peak systolic velocity of the proximal CA (arrow) on this abdominal Doppler US scan is greater than 400 cm/sec, which resulted in aliasing artifact. AO = abdominal aorta. (b) Lateral abdominal aortogram of the same region shows a tight stenosis (greater than 90%) at the proximal CA (arrowhead).

View larger version (138K): [in this window] [in a new window]   Figure 1b. True-positive Doppler US–based diagnosis of high-grade CA stenosis. (a) The peak systolic velocity of the proximal CA (arrow) on this abdominal Doppler US scan is greater than 400 cm/sec, which resulted in aliasing artifact. AO = abdominal aorta. (b) Lateral abdominal aortogram of the same region shows a tight stenosis (greater than 90%) at the proximal CA (arrowhead).

View larger version (94K): [in this window] [in a new window]   Figure 2a. True-positive Doppler US–based diagnosis of CA and SMA occlusion. (a) Longitudinal color Doppler scan of the abdominal aorta (AO) shows no color signal demonstrated in either the proximal CA or SMA. Note the reversed flow (encoded in blue) in a segment of the SMA (arrow). (b) Longitudinal color Doppler scan of the lower part of the abdominal aorta (AO) in a shows a hypertrophied inferior mesenteric artery (IMA). (c) On the lateral abdominal aortogram of the same region, the CA and SMA are not visible. A tortuous and enlarged inferior mesenteric artery (arrowheads) is demonstrated. (d) On the anteroposterior view of the delayed-phase aortogram of the same region, the SMA (arrows) and hepatic artery (arrowhead) are reconstituted through the enlarged inferior mesenteric artery.

View larger version (118K): [in this window] [in a new window]   Figure 2b. True-positive Doppler US–based diagnosis of CA and SMA occlusion. (a) Longitudinal color Doppler scan of the abdominal aorta (AO) shows no color signal demonstrated in either the proximal CA or SMA. Note the reversed flow (encoded in blue) in a segment of the SMA (arrow). (b) Longitudinal color Doppler scan of the lower part of the abdominal aorta (AO) in a shows a hypertrophied inferior mesenteric artery (IMA). (c) On the lateral abdominal aortogram of the same region, the CA and SMA are not visible. A tortuous and enlarged inferior mesenteric artery (arrowheads) is demonstrated. (d) On the anteroposterior view of the delayed-phase aortogram of the same region, the SMA (arrows) and hepatic artery (arrowhead) are reconstituted through the enlarged inferior mesenteric artery.

View larger version (172K): [in this window] [in a new window]   Figure 2c. True-positive Doppler US–based diagnosis of CA and SMA occlusion. (a) Longitudinal color Doppler scan of the abdominal aorta (AO) shows no color signal demonstrated in either the proximal CA or SMA. Note the reversed flow (encoded in blue) in a segment of the SMA (arrow). (b) Longitudinal color Doppler scan of the lower part of the abdominal aorta (AO) in a shows a hypertrophied inferior mesenteric artery (IMA). (c) On the lateral abdominal aortogram of the same region, the CA and SMA are not visible. A tortuous and enlarged inferior mesenteric artery (arrowheads) is demonstrated. (d) On the anteroposterior view of the delayed-phase aortogram of the same region, the SMA (arrows) and hepatic artery (arrowhead) are reconstituted through the enlarged inferior mesenteric artery.

View larger version (188K): [in this window] [in a new window]   Figure 2d. True-positive Doppler US–based diagnosis of CA and SMA occlusion. (a) Longitudinal color Doppler scan of the abdominal aorta (AO) shows no color signal demonstrated in either the proximal CA or SMA. Note the reversed flow (encoded in blue) in a segment of the SMA (arrow). (b) Longitudinal color Doppler scan of the lower part of the abdominal aorta (AO) in a shows a hypertrophied inferior mesenteric artery (IMA). (c) On the lateral abdominal aortogram of the same region, the CA and SMA are not visible. A tortuous and enlarged inferior mesenteric artery (arrowheads) is demonstrated. (d) On the anteroposterior view of the delayed-phase aortogram of the same region, the SMA (arrows) and hepatic artery (arrowhead) are reconstituted through the enlarged inferior mesenteric artery.

View larger version (134K): [in this window] [in a new window]   Figure 3a. False-positive Doppler US–based diagnosis of CA stenosis. (a) The peak systolic velocity of the proximal CA (arrow) on this abdominal Doppler US scan measured 247 cm/sec, which was considered to be abnormal on the basis of our Doppler US criteria. AO = abdominal aorta. (b) On the lateral abdominal aortogram of the same region, the CA (arrows) and SMA (arrowheads) show no evidence of high-grade stenosis. In this patient, the tortuous course of the CA may have contributed to the recording of high peak systolic velocities in an otherwise normal CA.

View larger version (167K): [in this window] [in a new window]   Figure 3b. False-positive Doppler US–based diagnosis of CA stenosis. (a) The peak systolic velocity of the proximal CA (arrow) on this abdominal Doppler US scan measured 247 cm/sec, which was considered to be abnormal on the basis of our Doppler US criteria. AO = abdominal aorta. (b) On the lateral abdominal aortogram of the same region, the CA (arrows) and SMA (arrowheads) show no evidence of high-grade stenosis. In this patient, the tortuous course of the CA may have contributed to the recording of high peak systolic velocities in an otherwise normal CA.

View larger version (146K): [in this window] [in a new window]   Figure 4a. True-positive Doppler US–based diagnosis of SMA stenosis. (a) The peak systolic velocity of the proximal SMA (arrow) on this abdominal Doppler US scan was 302 cm/sec. AO = abdominal aorta. (b) Lateral abdominal aortogram of the same region shows a tight stenosis (greater than 90%) of the proximal SMA (arrowhead).

View larger version (128K): [in this window] [in a new window]   Figure 4b. True-positive Doppler US–based diagnosis of SMA stenosis. (a) The peak systolic velocity of the proximal SMA (arrow) on this abdominal Doppler US scan was 302 cm/sec. AO = abdominal aorta. (b) Lateral abdominal aortogram of the same region shows a tight stenosis (greater than 90%) of the proximal SMA (arrowhead).

View larger version (118K): [in this window] [in a new window]   Figure 5a. False-positive Doppler US–based diagnosis of SMA stenosis. (a) The peak systolic velocity measured at the proximal SMA (arrow) on this abdominal Doppler US scan was 408 cm/sec. AO = abdominal aorta. (b) On the lateral abdominal aortogram of the same region, the CA (arrows) and SMA (arrowheads) show no evidence of high-grade stenosis. The proximal SMA has an acute angulation, which most likely led to an erroneous interrogation of the Doppler sample volume.

View larger version (118K): [in this window] [in a new window]   Figure 5b. False-positive Doppler US–based diagnosis of SMA stenosis. (a) The peak systolic velocity measured at the proximal SMA (arrow) on this abdominal Doppler US scan was 408 cm/sec. AO = abdominal aorta. (b) On the lateral abdominal aortogram of the same region, the CA (arrows) and SMA (arrowheads) show no evidence of high-grade stenosis. The proximal SMA has an acute angulation, which most likely led to an erroneous interrogation of the Doppler sample volume.

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

In a retrospective study with 34 patients, Moneta et al (6) suggested that a fasting peak systolic velocity of 275 cm/sec or greater or no flow signal in the SMA, or 200 cm/sec or greater or no flow signal in the CA enabled the prediction of 70%–100% stenosis or occlusion with high accuracy (6). In a blind prospective study (7) with 100 patients, they found that these criteria were highly accurate (96% for the detection of 70% or greater SMA stenosis and 82% for the detection of 70% or greater CA stenosis). Bowersox et al (5) suggested that an end diastolic velocity of greater than 45 cm/sec was the best indicator of 50% or greater SMA stenosis (sensitivity 100%, specificity 92%). They noted that a peak systolic velocity of greater than 300 cm/sec in the SMA was highly specific (100%) but less sensitive (63%) for the detection of 50% or greater SMA stenosis. No criteria for CA stenosis detection were proposed.

Before this prospective study, we used various Doppler US parameters to determine which would be the most effective indicator of splanchnic arterial stenosis or occlusion and noted that the fasting peak systolic velocity measurement was more reliable than was the end diastolic velocity. To our knowledge, among several studies, the one by Moneta et al (7) had the only blinded prospective validation of specific duplex Doppler US criteria for the diagnosis of CA or SMA stenosis or occlusion with a large patient population. Thereafter, we have performed all Doppler US examinations of the splanchnic arteries with the criteria proposed by Moneta et al (6,7).

In our series, Doppler US demonstrated a sensitivity of 100%, specificity of 87%, and accuracy of 89% for the diagnosis of 70% or greater CA stenosis or occlusion, and 100%, 98%, and 99%, respectively, for the diagnosis of 70% or greater SMA stenosis or occlusion. Our results are comparable to those of Moneta et al (87%, 80%, 82%, respectively, for CA stenosis or occlusion detection and 92%, 96%, 96%, respectively, for SMA stenosis or occlusion detection). We had nine false-positive diagnoses of CA stenosis or occlusion and one false-positive diagnosis of SMA stenosis or occlusion with Doppler US; there were no false-negative cases of either CA or SMA stenosis or occlusion. In the study by Moneta et al (7), there were 12 false-positive cases and three false-negative cases in the detection of CA stenosis or occlusion and three false-positive cases and one false-negative case in the detection of SMA stenosis or occlusion.

The orifices of the CA and SMA are usually deep in the abdomen, and the proximal CA frequently has a tortuous course compared with the SMA. These factors may prevent precise interrogation of the Doppler sample volume at the stenotic segment and be responsible for the false-positive diagnoses of CA stenosis. Unprecise placement of the Doppler sample volume with an improper Doppler angle is the most common cause of erroneous spectral waveforms, which result in wrong measurements of velocity. We started the Doppler US studies in the color mode in all patients to quickly check the presence or absence of flow signal in the proximal CA, SMA, and orifices of both arteries. We thought that color Doppler US guidance might be helpful in the proper placement of the Doppler sample volume in the proximal splanchnic arteries, even when the arteries had a tortuous course. However, we found no difference in the proportion of false-positive cases between the study of Moneta et al (7) and our study. Moneta et al did not use color Doppler guidance in the prospective study (7). We think that the usefulness of color Doppler guidance for adequately placing the Doppler sample volume needs to be studied.

On the basis of the review of 82 aortograms in our study, compared with the CA, the SMA was less tortuous in its entire course after it originated from the aorta, which may explain the rarity of false-positive diagnoses of SMA stenosis or occlusion. We had one false-positive diagnosis of SMA stenosis, in which aortography demonstrated an acutely angulated proximal segment of the SMA with no evidence of stenosis. In this case, erroneous interrogation of the Doppler sample volume in an acutely angulated proximal SMA was the most likely cause of the false-positive examination result (Fig 5).

Another limitation of duplex Doppler US of the splanchnic arteries is that there could be interobserver variability in performing Doppler US examinations. This issue was well addressed in the study of Zoli et al (9), in which the peak systolic velocity of the SMA was substantially different between operators. Therefore, they recommended cooperative training to reduce the interobserver variability and bring the results to an acceptable level of reproducibility. In our study, we had no chance to observe operator variability because only one skilled radiologist performed all the examinations.

Detection of the collateral pathways has been suggested as a useful adjunct in the diagnosis of severe CA or SMA stenosis or occlusion (10). The inferior mesenteric artery is an important collateral pathway when both the CA and SMA are occluded. Denys et al (11) reported that the inferior mesenteric artery was visible ultrasonographically in 92% of 100 consecutive fasting adults with no evidence of vascular disease. We also found that the inferior mesenteric artery was frequently identified with color Doppler US by its characteristic origin on the left anterior aspect of the aorta and its course descending along the left side of the aorta. According to our experience, the normal inferior mesenteric artery is usually less than 2 mm in diameter and is always much smaller than the SMA. In our series, four of five patients with occlusion of both the CA and SMA and two of nine patients with severe stenosis of the SMA demonstrated a hypertrophied inferior mesenteric artery that was larger than the visualized SMA segment (Fig 2).

It has been suggested that a postprandial study is helpful in the diagnosis of SMA stenosis or occlusion that is not detected during the fasting examination with the systolic velocity criteria (4,6). Failure of the SMA peak systolic velocities to increase 20–30 minutes after a test meal may indicate hemodynamically significant SMA stenosis. This observation, however, remains unsupported and should be studied with a large population.

It is interesting that not all patients with high-grade mesenteric arterial stenosis or occlusion have symptoms that suggest chronic intestinal ischemia. In our series, three of five patients with occlusion of the CA and SMA had no abdominal symptoms. Moreover, symptom-free patients with angiographically proved high-grade stenosis or occlusion of the CA or SMA are well recognized. The discrepancy between the symptoms and pathologic findings of the splanchnic arteries remains unclear. Therefore, duplex Doppler US detection of high-grade splanchnic arterial stenosis or occlusion does not necessarily indicate that the patient has chronic intestinal ischemia and cannot be used as a confirmatory examination for the clinical entity of this disease. However, the use of Doppler US for evaluation of the CA and SMA may be useful in guiding further examinations of patients with postprandial abdominal pain, because most patients with chronic intestinal ischemia have high-grade lesions of the splanchnic arteries.

We believe that Doppler US examination, owing to its high diagnostic accuracy, may be helpful in determining the need for conventional angiography in patients with symptoms that suggest chronic intestinal ischemia. Our data indicate that Doppler US criteria with the fasting peak systolic velocity measurement enable an accurate prediction of high-grade splanchnic arterial stenosis, and Doppler US can be a useful noninvasive examination for the detection of high-grade splanchnic arterial stenosis or occlusion when the examination is performed by an experienced examiner.

	Footnotes

 
Abbreviations: CA = celiac artery SMA = superior mesenteric artery

Author contributions: Guarantor of integrity of entire study, H.K.L.; study concepts, H.K.L.; study design, H.K.L., Y.S.D., W.J.L.; definition of intellectual content, H.K.L.; literature research, H.K.L., S.H.K., S.J.L., S.H.C.; clinical studies, H.K.L., Y.S.D., H.S.P., S.W.C., I.W.C.; data acquisition, H.K.L., Y.S.D., H.S.P.; data analysis, H.K.L., Y.S.D., W.J.L., S.H.K.; statistical analysis, W.J.L., S.H.K.; manuscript preparation, H.K.L.; manuscript editing, H.S.P.; manuscript review, H.K.L., H.S.P., Y.S.D.

	References

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 

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This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lim, H. K. Articles by Choo, I. W. Search for Related Content PubMed PubMed Citation Articles by Lim, H. K. Articles by Choo, I. W.