Pediatr Radiol (2004) 34: 772786 DOI 10.

1007/s00247-004-1227-3

REVIEW

Brian D. Coley

Pediatric applications of abdominal vascular Doppler: Part II

Received: 13 March 2004 Revised: 19 April 2004 Accepted: 3 May 2004 Published online: 5 August 2004 Springer-Verlag 2004

B. D. Coley Department of Radiology, Columbus Childrens Hospital, 700 Childrens Dr, Columbus, OH 43205, USA E-mail: bcoley@chi.osu.edu Tel.: +1-614-7222359 Fax: +1-614-7222332

Abstract Ultrasound is a remarkably powerful and versatile modality for pediatric imaging, without requiring exposure to radiation or sedatives. By providing information on blood ow, Doppler sonography can reveal details about normal physiology and disease processes not discernable from gray-scale anatomic images alone. In part I, the basics of hemodynamics and eects on the Doppler waveform were discussed, along with clinical applica-

tions in hepatic disease. In part II, the application of Doppler in renal disease and in conditions aecting the deep abdominal vessels are discussed. The role of ultrasound contrast agents in pediatric Doppler imaging is briey reviewed.

Keywords Doppler Ultrasound Renal Abdominal vascular Children

Introduction
The utility of US in pediatric diagnosis is well recognized. Unfortunately, with most attention in the literature focusing on advances in CT and MRI, US is sometimes viewed as a less useful modality. While CT and MRI may in some cases provide superior anatomic information, the utility of color and pulsed Doppler US in the evaluation and quantitation of blood ow is difcult to match. In part I, the basics of hemodynamics, the measurements used to describe them, the causes of blood ow alterations, and the clinical applications of Doppler US in the pediatric liver were reviewed. In part II, Doppler examination of the kidney and deep abdominal vessels are discussed, as well as current and potential applications of US contrast agents.

Kidney
Normal vasculature The main renal arteries arise from the lateral aspect of the abdominal aorta at approximately the level of the

rst or second lumbar vertebral body. Most people have a single artery to each kidney, although accessory renal arteries may be present in up to 30% of patients [1]. Renal veins are usually single, although one-third of patients have multiple renal veins, usually on the left [2]. The left renal vein typically receives drainage from the left adrenal, lumbar, and gonadal veins, whereas the right renal vein usually only drains the right kidney. Interrogation of the renal vasculature in children is generally easier than in adults due to more favorable body habitus. The renal arterial resistive index (RI) is a useful tool in the evaluation of a wide variety of renal abnormalities. While it is often sucient to consider alterations in RI as due only to alterations in renal vascular resistance, many physiologic factors contribute to the renal RI including vascular resistance, vessel compliance, heart rate, downstream cross-sectional vascular area, hydration status, and age [39]. The renal arterial RI varies markedly over the 1st year of life, and can be aected by cardiac disease, aortic coarctation, and a patent ductus arteriosus [10, 11]. Preterm infants can normally have RI values up to 0.9, with neonates and infants having RI values from 0.6 to 0.8, and older infants and children having values similar to adults of

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0.50.7 [3, 4, 7]. RI values generally approach normal adult values by the age of 1 year [3, 4], although some reports suggest that this may not occur until later childhood [7, 12]. The normal renal veins show constant ow away from the kidney; mild pulsations due to cardiac and respiratory activity are usually present but variable, and there is normally a reduction in ow at end diastole [13]. Renal artery hypertension Hypertension in children and infants has a wide variety of causes, including renovascular disease, renal parenchymal abnormalities, renal obstruction, tumors, medications, and endocrine dysfunction [14]. Essential hypertension in an infant is rare, and secondary causes are due to renovascular disease in about 70% of cases [15, 16]. In neonates, this is usually related to renal arterial embolization or thrombosis following umbilical artery catheterization [14, 17]. In older children and adolescents, hypertension is more likely to be essential or due to medical disease. Of those with a denable etiology, as many as 10% are due to renovascular disease [15, 18]. Fibromuscular dysplasia is the most common cause, and may involve the main renal artery or only intrarenal branches. Other causes include those associated with syndromes (neurobromatosis, Williams), the arteritides, mid-aortic and thoracic aortic coarctation, extrinsic vessel or renal compression, and renal vein thrombosis [14]. Gray-scale renal sonography in hypertension is valuable in looking for the eects of renovascular disease (renal size, scarring) and for excluding masses, obstruction, and parenchymal abnormalities. The utility of duplex Doppler sonography in diagnosing renal arterial hypertension is debated, with opinions ranging from enthusiastic to pessimistic. In adults, sensitivities and specicities range from 60 to 100%, which probably reects dierences in Doppler criteria used, angle of the Doppler beam with the renal artery interrogated, patient populations, and the experience and skill of the examiner [19]. However, there are characteristic features that when found provide a high degree of sensitivity and specicity for signicant stenosis (generally regarded as >60% vessel diameter narrowing) [20, 21]. A renal artery-to-aorta peak systolic velocity (PSV) ratio of greater than 3.5 has been reported to have an accuracy of as high as 96% in diagnosing signicant stenoses [20, 21]. Other indicators include an acceleration time (AT) of greater than 0.07 s and attening of the systolic peak. With severe stenoses, the tardusparvus pattern develops with markedly slow systolic acceleration, decreased PSV, and often an associated elevation of diastolic ow (due to the stenosis as well as downstream vasodilatation) and decreased renal artery RI [22, 23] (Fig. 1).

Fig. 1 Renal artery stenosis in a teenager with hypertension. Main right renal artery Doppler (a) distal to a stenosis shows a tardus parvus waveform; the other kidney was normal. Selective right renal arteriogram (b) shows a web-like stenosis (arrow) from bromuscular dysplasia with a high pressure gradient. After angioplasty, the gradient was completely eliminated

While direct examination of the main renal arteries is desirable in assessing stenosis, if properly performed visual analysis of the early systolic peak of intrarenal vessels was shown to have a positive predictive value of 92% and a negative predictive value of 98% in an adult series [24]. The sensitivity of Doppler in diagnosing children with renal arterial hypertension is unclear. Certainly, Doppler is reliable in evaluating complications of umbilical arterial catheterization and overt arterial thrombosis. However, as stated above, the most common cause of renal arterial disease in older children is bromuscular dysplasia, which may only aect smaller intrarenal arteries, and thus a signicant stenosis may be missed due to sampling error. The incidence of intrarenal stenosis without main renal artery involvement is not precisely known, but certainly does occur [15, 18, 19, 25]. Additionally, an accessory renal artery may be involved, which may escape detection altogether [18], although the

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treating bromuscular dysplasia [28]. In the child with a normal Doppler examination but refractory hypertension, the decision to proceed with angiography is more dicult although may be warranted depending upon the individual clinical details. The continued renement of MRI and CT angiography may soon provide a less invasive alternative. Renal vein thrombosis Dehydration, nephrotic syndrome, shock, sepsis, maternal diabetes, glomerulonephritis, and malignancy may cause renal vein thrombosis in the neonate and child [17, 29], and thrombosis may even occur prenatally [30, 31]. Thrombus rst forms in the arcuate and interlobular veins, with variable extension into the main renal vein and inferior vena cava (IVC) [17, 32, 33]. Clinically, there may be gross hematuria, unilateral or bilateral renal enlargement, and perhaps hypertension [17, 34]. Adrenal hemorrhage may coexist, particularly if the left renal vein is involved [35]. Acute gray-scale ndings include a large swollen kidney with decreased cortical echogenicity and corticomedullary dierentiation. Echogenic streaks with an interlobular distribution are thought to be due to thrombosed vessels, and are felt to be pathognomonic for renal vein thrombosis [33] (Fig. 3). Direct visualization of the thrombosed renal vein is dicult in the adult [36], but is commonly seen in children [35] although hypoechoic clot may be dicult to recognize [17]. Doppler interrogation of the renal vein showing absent ow is a reliable nding for thrombosis [37, 38]. Recanalization or recruitment of collateral venous

Fig. 2 Hypertension and aortic coarctation in an asymptomatic teenage girl. Doppler waveforms from the renal arteries (a) showed a tardus parvus pattern with a markedly prolonged acceleration time (AT). However, the aortic waveform (b) was very similar, suggesting a proximal aortic coarctation, conrmed at MRI (arrow) (c)

practical signicance of this has recently been questioned [26]. The aorta must be interrogated, as alterations in ow from abdominal or thoracic coarctations may produce signicant alterations in renal arterial ow, leading to a misdiagnosis of bilateral renal artery disease [27] (Fig. 2). Angiography with selective renal arteriography and renal vein renin sampling remains the gold standard for evaluation of any child with a positive Doppler examination for whom interventional therapy would be considered. Even very young children may safely undergo angioplasty, which is highly successful in

Fig. 3 Renal vein thrombosis in an infant with hematuria. Longitudinal image of the right kidney shows echogenic streaks (arrows) probably indicating thrombosed vessels

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Fig. 5 Renal vein thrombosis. Longitudinal duplex Doppler image shows marked reversal of renal arterial ow in diastole reecting the increased arterial impedance due to renal vein thrombosis Fig. 4 Renal vein thrombosis in a neonate with hematuria. Transverse duplex Doppler image shows low-velocity monophasic renal vein ow

Medical renal disease A variety of renal diseases causing parenchymal changes produce increased vascular impedance that de-

channels, however, may occur rapidly, producing detectable renal venous ow and obscuring the diagnosis. The nding of monophasic renal vein ow without the normal reection of cardiac activity is suggestive of renal vein thrombosis [35] (Fig. 4). With complete venous thrombosis, there is increased renal interstitial pressure leading to increased vascular impedance and decreased or reversed arterial diastolic ow (Fig. 5). These ndings may be subtle, with the RI of the aected kidney increased only relative to the uninvolved side [17, 35, 36, 39]. After renal vein thrombosis, the kidney usually atrophies to a variable degree, although this is not a universal occurrence and renal function may be preserved [40, 41]. Calcied thrombi within intrarenal veins and the IVC are common [34, 40, 41] (Fig. 6). Chronically damaged kidneys may continue to have abnormally elevated renal arterial RI values, and hypertension is a possible long-term complication [41].

Fig. 6 Remote renal vein thrombosis in a child with a history of prematurity and central venous catheterization. Longitudinal grayscale image shows linear echogenicities indicative of calcied thrombus within intrarenal vessels. Calcied thrombus was also present within the IVC

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creases diastolic ow and produces increased RI. These changes are nonspecic and are not generally useful in specifying the precise disease involved [9, 39, 42]. However, in the hemolyticuremic syndrome, Doppler waveform analysis can predict disease severity and recovery. This disease is characterized by an intrarenal vasculitis leading to increased vascular impedance and reduced or even reversed ow during diastole. Patriquin et al. [43] showed that the RI was most abnormal during the oliguric or anuric phase of the disease with normalization of the arterial waveforms coming 24 48 h prior to recovery of renal function. Similarly, an elevated RI in patients with lupus nephritis and normal baseline renal function has been reported to be predictive of a poor outcome [44]. Renal dysfunction in the setting of hepatic disease has been detected by elevated renal artery RI in both children and adults [45, 46], even with normal renal laboratory values, and has been shown to predict renal dysfunction after liver transplantation [46]. Thus, while renal arterial Doppler and the renal RI might not be specic for a particular disease, it has demonstrated predictive capabilities in the clinical course of some diseases, potentially adding value in patient management [9]. Renal transplantation Positioned within the lower abdomen, the renal allograft is well suited for US evaluation, and renal transplant dysfunction is often rst evaluated with Doppler US. High-resolution transducers may be used, and obscuration by bowel gas is seldom problematic. Transplant dysfunction may be due to parenchymal causes (rejection, acute tubular necrosis, cyclosporine toxicity) or vascular complications (renal arterial or venous stenosis, or occlusion). Renal vascular thrombosis occurs in 510% of pediatric transplants [47]. Thrombosis typically occurs immediately postoperatively due to surgical damage, vessel kinking, or hyperacute rejection, and usually leads to graft loss [17, 48]. In main renal artery occlusion, Doppler reveals absent ow within the vessel. With hyperacute rejection, only the intrarenal vessels may be initially involved, and Doppler will show high impedance ow within the main renal artery with diastolic reversal [48]. Transplant renal vein thrombosis usually occurs within the 1st week of surgery [48], and presents like native renal vein thrombosis with pain and decreased renal function. While dehydration, thrombophilia, and cyclosporine may contribute to renal vein thrombosis, anastomotic complications play a large role [17]. Doppler ndings are the same as previously described, with echogenic clot in the renal vein, absent venous ow, and an abnormally elevated RI within the renal artery.

Transplant renal artery stenosis occurs in up to 10% of patients, usually at the site of anastomosis [17, 48]. Patients present with hypertension or decreased renal function. Doppler changes are the same as those previously discussed, with accelerated PSVs and turbulence at the stenosis, and delayed systolic upstrokes and diminished ow downstream. Because it often has a tortuous course, bends or kinks may produce similar ndings [17]. While Doppler US has a sensitivity of 95% for detecting transplant renal artery stenosis [49, 50], arteriography or crosssectional angiography is still sometimes necessary [17]. Intrarenal branch stenosis may be dicult to detect with a pulsed Doppler survey of the vasculature [48]. Color or power Doppler scanning to assess for areas of decreased or absent perfusion may help localize abnormalities for subsequent focused pulsed Doppler examination [51]. There was once great hope that US and Doppler would provide the ability to dierentiate among the various parenchymal causes of graft dysfunction. Unfortunately, acute tubular necrosis, acute and chronic rejection, and cyclosporine toxicity all create increases in arterial impedance (albeit by dierent mechanisms), decreasing diastolic arterial ow and increasing the RI. While an elevated RI is a reasonable indicator of graft dysfunction, it is neither sensitive nor specic as to any precise cause, and biopsy is often needed for denitive diagnosis [5255] Renal arteriovenous stula While they may be congenital, renal arteriovenous stulae (AVF) are most commonly the result of renal biopsy, with an incidence of up to 12% [48, 5658]. Patients are usually asymptomatic, but may present with pain, hematuria, and diminished renal function. Most stulae will close spontaneously, but those that do not require interventional radiologic embolization [5760]. Color Doppler is very useful in the diagnosis of AVF [48, 5759]. In renal color Doppler, the tendency is to make the scale as sensitive to low ow as possible in order to obtain a perfusion image of the kidney. By lling the screen with intrarenal ow, the AVF may actually be obscured. By reducing color ow sensitivity so that normal intrarenal vessels are no longer seen, the abnormal high-velocity ow within the stula becomes readily apparent, and the diagnosis can then be conrmed by the characteristic waveforms [48] (Fig. 7). Since there is an abnormal communication between artery and vein with loss of the intervening capillary bed, the impedance to local arterial ow is essentially nonexistent. This produces high-velocity arterial ow, elevation of diastolic ow, and marked turbulence with spectral broadening and disorganization. In the veins, there may be markedly increased ow with turbulence and arterialization, with visible systolic peaks [48, 60].

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gray-scale sonography is unreliable at distinguishing obstructive from nonobstructive hydronephrosis. Based upon research showing that vascoconstriction follows ureteral obstruction [9], it was hoped that the renal artery RI would prove to be useful in diagnosing renal collecting system obstruction. Many criteria have been proposed (RI>0.7, RI dierence of >0.1 between kidneys, RI indices, etc.), but the data over the last 15 years have been mixed [9, 6165]. While results have generally been more favorable for complete obstruction, relative or partial obstruction is less reliably distinguished. Several studies have reported improved results by evaluating changes in RI after diuretic administration [61, 66, 67]. These techniques have not been widely employed, however, and their utility in daily practice remains unclear. A recent report [13] suggests that, alterations of renal venous waveforms may be a more sensitive indicator of obstructive uropathy than arterial changes. In older children, compression of the ureteropelvic junction by a crossing vessel is a common cause of obstructive hydronephrosis [68]. Color Doppler has been shown to have reasonable sensitivity in detecting these vessels, which may have relevance in directing appropriate patient management [69]. Nutcracker syndrome Nutcracker syndrome derives its name from the compression of the left renal vein as it passes between the SMA and aorta. If the angle or space between these two arteries is small, the left renal vein will become narrowed and resistance to ow increased. The current imaging gold standard is venography, with a pressure gradient of more than 3 mmHg across the venous stenosis indicating venous hypertension [70, 71]. Renal venous hypertension has been implicated in hematuria, orthostatic proteinuria, and left varicocele formation [7174]. Grayscale US shows dilatation of the left renal vein [70, 72, 75], although some degree of left renal venous enlargement can be normal [76]. Acceleration of venous velocities through the area of stenosis has been reported [70, 72], although this can be variable depending upon the chronicity of the condition and the development of decompressive collateral vessels [70]. The detection of collateral vessels greatly improves the sensitivity of Doppler diagnosis [70], but may be dicult due to bowel gas and body habitus. CT with reconstructed images has been shown to be useful in detection of renal venous compression [77] (Fig. 8). Pyelonephritis Evaluation of hydronephrosis is one of the most commonly performed pediatric US studies. While highly sensitive for the detection of collecting system dilatation, Renal US is an important part of the imaging evaluation of children with urinary tract infection.

Fig. 7 Renal AVF in a child with hematuria after renal biopsy. Longitudinal color Doppler image with maximal ow sensitivity shows no perfusion abnormalities. a Reducing color Doppler sensitivity so that only higher velocities are displayed allows recognition of an area of abnormal high-velocity ow within the lower pole at the site of biopsy (arrow, b). Doppler waveform of this vessel (c) shows low-impedance arterial waveform with high diastolic ow and spectral broadening indicating turbulence as well as elevated venous ow

Hydronephrosis

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Fig. 8 Nutcracker syndrome in a teenager with asymptomatic gross hematuria. Transverse sonogram (a) of the left kidney (K) shows dilatation of the left renal vein (RV). Sagittal reformatted CT angiogram (b) shows the left renal vein (arrow) being constricted through the narrow angle between the aorta and SMA. Paraspinal collateral channels are also present (arrowheads)

Gray-scale ndings of upper tract infection include focal or diuse renal swelling, abnormal echogenicity, and loss of corticomedullary dierentiation, but unfortunately are normal in at least half of cases [78 84]. Renal cortical scintigraphy detecting focal areas of diminished perfusion remains the gold standard, although gadolinium-enhanced MRI is proving to be equivalent [85, 86]. With advances in color and power Doppler technology, many have demonstrated perfusion defects in the setting of pyelonephritis (Fig. 9) after rst described by Eggli and Eggli [79] in 1992. Sensitivity of power Doppler has ranged from 63 to 89% for detecting pyelonephritis [78, 79, 87, 88], and while a promising technique, it has not replaced scintigraphy for denitive evaluation.

Deep abdominal vessels

Aorta and iliac arteries The aortic waveform exhibits predictable changes from the aortic root to the bifurcation of the iliac arteries. In the ascending aorta, ow is markedly pulsatile. Due to the elasticity of the aorta and the Windkessel phenomenon [94, 95], when one interrogates the proximal abdominal aorta, the pulsatility has decreased and there is forward ow throughout diastole. Beyond the origin of the visceral arteries, the aortic waveform is dominated by the high-impedance muscular arterioles of the lower extremities, and reversal of ow in diastole is the norm (Fig. 10). In neonates, aortic and iliac thrombus complicates umbilical arterial catheter placement in up to 26% of patients [96, 97]. While these thromboses may be clinically silent [97], most children will have clinical signs such as catheter dysfunction, diminished lower extremity perfusion, or hematuria and hypertension if the renal arteries are involved [38, 9699]. Color and pulsed Doppler readily conrms thrombotic occlusion or narrowing, and is useful in monitoring progression or regression of thrombus over time and with thrombolytic intervention [98101]. Thrombus usually appears as an echogenic mass variably lling the aortic lumen or adherent to the vessel wall. However, it may appear more thin, linear, and free oating within the lumen (Fig. 11), and dierentiation of clot from intimal dissection may be dicult [96, 98, 102, 103]. Even with aortic thrombosis, iliac and common femoral arterial ow may be reconstituted by collateral vessels. Unlike the usual peripheral arterial waveforms with sharp systolic upstrokes and triphasic high-resistance ow,

Tumors As with liver tumors, renal tumors are not histologically distinguishable based on their internal Doppler waveforms. Malignant lesions more often show high Doppler spectral shifts than benign lesions. However, specicity is poor, the ndings are inconstant, and can also be seen with inammatory processes [8992]. Doppler US is valuable in assessing renal venous and IVC invasion by tumors, which is important for surgical planning. Renal vein extension occurs in 5 10% of cases, and can extend into the IVC and even reach the right atrium [17]. Gray-scale US shows variably echogenic tumor thrombus with an enlarged vessel [93] and color Doppler will show absent or disturbed ow depending on the amount of tumor present. Arterial vascularity within the thrombus itself conrms neoplasia, rather than thrombus.

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Fig. 10 Normal aorta. Doppler waveforms at three levels of a neonatal aorta show the eects of aortic compliance in diminishing the pulsatility from the ascending to the proximal abdominal aorta. The distal aorta shows reversal of diastolic ow from normal high impedance in the lower extremities

will show vessel dilatation and detect the presence of mural thrombus. Color Doppler conrms the vascular origin of hypoechoic masses, and pulsed Doppler can demonstrate characteristic to-and-fro ow within the neck of pseudoaneurysms. Celiac and superior mesenteric arteries
Fig. 9 Pyelonephritis in a child with fever and ank pain. Longitudinal gray-scale image of the right kidney (a) shows an area of increased echogenicity in the upper pole (arrow). Power Doppler image (b) of the same area shows diminished perfusion (arrow) consistent with pyelonephritis

collateral vessels often produce waveforms characterized by low velocity with delayed upstroke and constant forward ow during diastole secondary to downstream arteriolar vasodilatation. Long-term complications of aortic thrombosis include lower extremity growth disturbances and hypertension [101]. The aorta itself may be narrowed in a variety of conditions (neurobromatosis, Takayasus arteritis, mid-aortic syndrome, and others) [103, 104] and produce elevated velocities at the site of stenosis (Fig. 12) and dampened ow velocities distally. Renal arterial stenosis may coexist with these conditions. Neonatal aortic aneurysms are usually mycotic, secondary to umbilical arterial catheterization and bacteremia [103, 105109]. In older children, aortic aneurysms are often secondary to connective tissue disorders [103] or arteritis [110]. US

The celiac artery typically has a low-resistance waveform and demonstrates some increase in PSV after eating [111]. The SMA has a variable waveform. During fasting, the velocity prole is triphasic, with a small reversal of ow in early diastole. After eating, SMA peak systole velocity may increase as much as 190%, and end diastolic velocity may increase by 350% [111]. Postprandial SMA blood ow has constant forward ow throughout diastole with a lowered RI, reecting vasodilatation of the downstream mesenteric arterial bed. Stenoses of the celiac and SMA may occur along with conditions aecting the aorta. An uncommon condition aecting the celiac trunk (and sometimes the SMA) is the median arcuate ligament syndrome. This condition typically aects young females, and is caused by constriction of the mesenteric vessels by anomalous bers from the median arcuate ligament of the diaphragmatic crura. Symptoms include weight loss, abdominal pain, nausea, and vomiting [111], thought to be due to intermittent intestinal ischemia or irritation of the celiac ganglia [111113]. Doppler interrogation of the celiac artery shows elevation of ow velocities during

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transverse sonograms of the upper abdomen. The SMA is typically surrounded by an echogenic collar of fat, but Doppler interrogation can eliminate any doubt as to which is artery and vein. While inversion of the normal position of the SMA and SMV can occur with malrotation, false-positive and false-negative cases exist, making it insuciently sensitive to replace uoroscopy [120, 121]. Color Doppler demonstration of a whirlpool sign with the SMV wrapping around the SMA has high specicity for midgut volvulus (Fig. 14), but is not detectable in all cases [122]. Inferior vena cava The IVC waveform varies with location. Proximally, ow in the IVC is inuenced by the activity of the right atrium with a triphasic pattern identical to that seen in the hepatic veins. Distally, cardiac activity has a lesser eect on ow velocities, and variations in thoracic or abdominal pressure dominate the variability seen in forward ow. An exception to this is in a patient with congestive heart failure or with tricuspid regurgitation, in whom cardiac pulsations may be seen even in the distal IVC. In the neonate, positive pressure ventilation may produce marked variability in forward ow due to changes in thoracic pressure, whereas extracorporeal membrane oxygenation produces a more monophasic ow pattern reecting the bypass circuit. IVC occlusion may be caused from extrinsic compression or from luminal thrombosis, which can be differentiated with US [93]. A variety of neoplasms can extend into the IVC [103], the most common being Wilms tumor (Fig. 15). Non-neoplastic thrombosis can occur in the setting of dehydration, sepsis, nephritic syndrome, and thrombophilic disorders [102, 103]. Indwelling central venous catheters pose a high risk, with up to 14.5% of infants developing complete IVC occlusion [123]. While these thromboses may be asymptomatic [123, 124], they may be complicated by embolism, renal or hepatic vein thrombosis, and longterm post-thrombotic syndrome [123]. Color Doppler is useful in demonstrating caval patency, as thrombi may be hypoechoic acutely and dicult to visualize [38, 111]. The dampening of normal pulsed Doppler waveforms can indicate partial obstruction [125] or drainage via collateral vessels. Ultrasound contrast agents Still unavailable for general use in the United States, the rest of the world has discovered the utility of US contrast agents in pediatric US. There are various ways to image contrast agents and dierent mechanisms of interaction with the US beam that are beyond the scope

Fig. 11 Aortic clot in a neonate after umbilical arterial catheter removal. Longitudinal gray-scale image (a) of the aorta (A) shows a linear echogenic thrombus (arrows) within the aortic lumen extending into the SMA (arrowheads). Color Doppler image (b) shows ow within the SMA and distal aorta, indicating nonocclusive thrombus. The patient had no signs of vascular compromise

expiration (as the ligament constricts the vessels) with decreased ow velocities during inspiration (when the ligament is nonconstricting) [111, 113, 114] (Fig. 13). Lateral aortography is the traditional conrmatory imaging, although CT angiography and MRI provides a less invasive alternative [112, 115]. Celiac arterial narrowing at MRI performed at end-expiration has been reported in asymptomatic adults, making the signicance of this nding unclear; however, no correlation with Doppler ow velocities was made [112]. Blood ow within the superior mesenteric artery (SMA) increases not only after ingestion of food, but also with inammatory processes such as gastroenteritis [111], celiac disease [116], and necrotizing enterocolitis [117, 118]. In the neonate, compromised SMA ow may occur with aortic thrombus and with the presence of an umbilical arterial catheter even without coexistent clot [119]. The SMA normally lies to the left and slightly posterior to the superior mesenteric vein (SMV) on

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Fig. 12 Mid-aortic syndrome in a 5-year-old child with hypertension. Longitudinal duplex Doppler image (a) of the aorta shows narrowing of the aorta (arrows) with aliasing of color ow. Pulse Doppler of this region showed acceleration of ow to 5 m s. Corresponding abdominal aortogram (b) demonstrates severe narrowing of the mid-aorta (arrow) as well as bilateral renal artery stenoses (arrowheads). Large mesenteric collaterals from the SMA to inferior mesenteric artery were also present on later images

of this paper, but they all serve to increase US signal [126, 127]. The evaluation of organ perfusion and tumor vascularity has been widely reported in experimental models and adults. While pediatric experience is still accumulating, contrast-enhanced power Doppler examination of deep abdominal vessels and organs poorly visualized with conventional sonography has already been shown to improve sensitivity and accuracy of US examinations, although young children and supercial structures may benet less from US contrast agents [128]. The potential applications for US contrast are broad. Clinical and experimental studies have been performed for assessment of brain perfusion, detection

and characterization of focal hepatic lesions as well as parotid masses and lymphadenopathy, visceral and extremity arterial disease, tumor angiogenesis, inammatory bowel disease, and testicular torsion [126, 129 138]. Assessment of organ perfusion becomes more feasible after the administration of intravenous US contrast agents. Studies already performed in the detection of pyelonephritis, renal scarring, and focal perfusion defects show favorable results compared with traditional imaging approaches [139144]. Other applications include improving Doppler signal conspicuity in examining for renal artery stenosis, the characterization of indeterminate masses, and depiction of traumatic injuries [139, 145]. While not a vascular

Fig. 13 Median arcuate ligament syndrome in a teenage girl with postprandial abdominal pain and weight loss. Angle-corrected waveforms of the celiac trunk show the PSV at expiration (a) is nearly double the value during inspiration (b)

Fig. 14 Midgut volvulus in a child with bilious vomiting. Transverse color Doppler image shows the SMV (arrows) wrapping around the superior mesenteric artery (SMA), the whirlpool sign

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The use of US contrast agents and methods of imaging have been shown to have the potential to produce adverse bioeects [152154]. While these thus far appear clinically insignicant, as agents and imaging techniques evolve, continued evaluation of bioeects is necessary to ensure that US retains its reputation as a safe and eective modality. The precise role and utility of US contrast agents for pediatric US versus other imaging modalities remains to be seen, but these agents will no doubt play a role in problematic examinations in the future.

Conclusion
The hemodynamics of owing blood are complex, but by understanding a few main concepts and how blood ow can be altered as discussed in part I, a useful working knowledge can be obtained. Applying this knowledge to the clinical arena can greatly improve ones appreciation for the power Doppler US, can improve ones understanding of patient physiology, and can hopefully lead to better diagnostic capability. US is a powerful modality that avoids patient radiation exposure, does not require sedation, and can be performed portably in even the most critically ill patients. In an era of cost-consciousness and radiation awareness, maximizing the use of US in pediatrics is especially desirable.

Fig. 15 IVC thrombosis in a child with Wilms tumor. Longitudinal sonogram of the IVC shows echogenic tumor thrombus (arrows) lling and expanding the IVC lumen and extending into the right atrium (RA)

application, the use of contrast-enhanced cystosonography has shown great promise in the diagnosis of vesicoureteral reux (even in diagnosing intrarenal reux [146]), and is the recommended imaging modality by some authors [147151].

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