Denault TGAUS 2021

Cardiovascular and Thoracic Anesthesiology
E Narrative Review Article
Transgastric Abdominal Ultrasonography in Anesthesia

and Critical Care: Review and Proposed Approach
André Y. Denault, MD, PhD, ABIM-CCM, FRCPC, FASE, FCCS,* Michael Roberts, DO, FASE,†
Theodore Cios, MD, MPH, FASE,† Anita Malhotra, MD,† Sarto C. Paquin, MD,‡ Stéphanie Tan, MD,§
Yiorgos Alexandros Cavayas, MD, MSc, FRCPC,‖ Georges Desjardins, MD, FRCPC, FASE,* and
John Klick, MD, FCCP, FASE, FCCM¶
The use of transesophageal echocardiography (TEE) in the operating room and intensive care
unit can provide invaluable information on cardiac as well as abdominal organ structures and
function. This approach may be particularly useful when the transabdominal ultrasound exami-
nation is not possible during intraoperative procedures or for anatomical reasons. This review
explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine.
We describe several reported applications using 10 views that can be used in the diagnosis of
relevant abdominal conditions associated with organ dysfunction and hemodynamic instability
in the operating room and the intensive care unit. (Anesth Analg 2021;133:630–47)
GLOSSARY
A. = artery; Ao = aorta; AT = acceleration time; CPB = cardiopulmonary bypass; CT = celiac trunk;
ECMO = extracorporeal membrane oxygenation; HV = hepatic vein; ICU = intensive care unit; IVC =
inferior vena cava; LHV = left hepatic vein; LRA = left renal artery; LRV = left renal vein; MHV =
middle hepatic vein; OR = operating room; PFO = patent foramen ovale; PVPI = portal vein pulsatil-
ity index; RHV = right hepatic vein; RPV = right portal vein; RRA = right renal artery; RRI = renal
resistance index; SA = splenic artery; SMA = superior mesenteric artery; SMV = superior mesen-
teric vein; SV = splenic vein; TEE = transesophageal echocardiography; TG = transgastric; TGAUS =
transgastric abdominal ultrasonography
T
he use of transesophageal echocardiography anesthesiologist and intensivist. There is a growing
(TEE) in the operating room (OR) and inten- interest in the use of bedside ultrasound beyond car-
sive care unit (ICU) provides invaluable infor- diac function.1,2 Such an interest also applies to TEE,
mation on cardiac structures and function to the but its potential has not yet been fully appreciated by
clinicians performing TEE from lack of evidence, lim-
ited publication, and training. However, TEE can pro-
From the *Department of Anesthesiology and Critical Care Medicine,
Montreal Heart Institute, Centre Hospitalier de l’Université de Montréal
vide diagnostic and monitoring information of both
(CHUM), Université de Montréal, Montreal, Quebec, Canada; †Department the anatomy and physiology of the abdominal region,
of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic
Anesthesiology, Milton S. Hershey Penn State Medical Center, Penn State
as proposed by Chouinard et al.3
University School of Medicine, Hershey, Pennsylvania; ‡Department of The first description of the use of endoscopic ultra-
Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université
de Montréal (CHUM), §Department of Radiology, Montreal Heart Institute,
sound dates back to 1980.4,5 Numerous applications
Université de Montréal; ǁDepartment of Medicine and Intensive Care Unit, for endoscopic ultrasound are currently being used
Montreal Sacré-Coeur Hospital and Department of Medicine and Intensive
Care Unit, Montreal Heart Institute, Université de Montréal, Montreal,
by gastroenterologist sonographers in the diagnosis
Quebec, Canada; and ¶Department of Anesthesiology, University of and treatment of specific abdominal organ patholo-
Vermont Medical Center, Larner College of Medicine, University of Vermont,
Burlington, Vermont.
gies.6,7 However, application of this knowledge to
Accepted for publication February 9, 2021. TEE remains challenging. In addition, abdominal
Funding: Supported by the Montreal Heart Institute Foundation and the TEE is not included in the guidelines for perform-
Richard Kauffman Endowment Fund in Anesthesia and Critical Care. ing a comprehensive TEE examination published by
Conflicts of Interest: See Disclosures at the end of the article. the American Society of Echocardiography and the
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
Society of Cardiovascular Anesthesiologists.8 Recent
this article on the journal’s website (www.anesthesia-analgesia.org). guidelines on the use of TEE to assist with surgical
Reprints will not be available from the authors. decision-making in the OR suggest a role for abdomi-
Address correspondence to André Denault, MD, PhD, ABIM-CCM, FRCPC, nal TEE in detecting aortic dissection extension
FASE, FCCS, Department of Anesthesiology and Critical Care Medicine,
Montreal Heart Institute, Centre Hospitalier de l’Université de Montréal under the diaphragm and inferior vena cava (IVC)
(CHUM), Université de Montréal, 5000 Belanger St, Montreal, QC H1T 1C8, stenosis in heart transplantation, artificial heart, and
Canada. Address e-mail to [email protected].
Copyright © 2021 International Anesthesia Research Society
extracorporeal membrane oxygenation.9 For these
DOI: 10.1213/ANE.0000000000005537 reasons, significant information on large vessels and
630 www.anesthesia-analgesia.org September 2021 • Volume 133 • Number 3

Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
abdominal organ function, which can impact on the and scanned from left to right and then from top to
care of the critically ill patient, may be obtained with bottom. Color and pulsed-wave Doppler are used
TEE, particularly in an intraoperative setting. While to interrogate vasculature and circulation. The same
not a substitute for the gold standard of transabdomi- principles apply to TGAUS with some exceptions,
nal ultrasound imaging, in contexts such as the OR, described as follows.
abdominal TEE may still provide important informa- First, the acoustic window is more limited with
tion on abdominal organ function and pathology in TGAUS than with transabdominal ultrasound. A dif-
situations where the standard transabdominal ultra- ferent anatomical perspective of the abdominal organs
sound views cannot be obtained. is shown, and only the organs close to the stomach are
The objective of this review is to gather current accessible for TGAUS. Therefore, it is mainly through
knowledge on the relevance of the use of TEE using the stomach wall that the abdominal organs will be
10 transgastric (TG) views in the evaluation of the examined. Identification of the diaphragm allows the
abdominal aorta and related vessels, stomach, liver, clinician to identify the pleural or abdominal origin of
kidney, spleen, and pancreas (Table 1). The term TG any fluid collections.
abdominal ultrasonography, or transgastric abdomi- Second, examination of the stomach, liver, spleen,
nal ultrasonography (TGAUS), will be used instead kidney, and pancreas can often be limited to longitudi-
of TEE, because this type of examination does not nal endoscopic ultrasound examination as performed
pertain to the esophagus or the heart. This review by gastroenterologists.6,7 Regarding examination of
will focus on the potential clinical role and method vessels, transverse views or 0° are often sufficient to
of examination for several reported applications of identify most branches originating from the aorta.
TGAUS in the OR and ICU (Table 2). However, the orientation of the venous vessels will
In the next sections, we will start by describing vary from one organ to the other.
the anatomical regions that can be explored using Third, we will be using the official terminology to
TGAUS, the technique of examination, their relevance describe the manipulation of the TEE probe.8 We will
in the care of patients undergoing cardiac or noncar- also describe the position of the dual rotating knob,
diac surgery, and the validation of TGAUS compared because this will have a major impact on the orientation
to other techniques. We will conclude with the contra- of the image displayed on screen (Supplemental Digital
indications, complications, future applications, and Content 1, Figure 1, Video, http://links.lww.com/AA/
limitations of TGAUS. Expert opinion from other spe- D468). When using TGAUS, it is important to separately
cialties such as gastroenterology and radiology has analyze the displayed image, the orientation of the
been included in our proposed approach to TGAUS ultrasound beam (from 0° to 180°), and the position of
examination. the ultrasound probe. The displayed image follows the
cardiology convention where, in a TG short-axis view
GENERAL PRINCIPLES OF TGAUS EXAMINATION of the left ventricle, the left ventricle is displayed on the
OF THE ABDOMEN right side of the screen and the right ventricle on the
Transabdominal ultrasound typically proceeds by left. In a TG long-axis view, for instance, the right side of
identifying an acoustic window that allows the the screen corresponds to the most cephalad organ (left
examination of a selected organ. Transabdominal atrium) and the left side of the screen will display the
ultrasound is generally performed using surface caudal anatomy (left ventricular apex).
ultrasound probes, which is why TGAUS images of The exact position and orientation of the TEE probe
splanchnic anatomy are in reversed orientation. The must be identified. The TEE probe can be turned from
target organ, with its long and short axes, is identified left to right and posteriorly. To describe the turning
Table 1. TGAUS Views

Dual rotating
TGAUS views N knob position Omniplane (°) Anatomical structure interrogated
Celiac trunk 1 6 o’clock 0–20 Celiac trunk, and hepatic and splenic arteries
SMA-renal confluence 2 6 o’clock 0–20 SMA, SMV, renal arteries, and left renal vein
Gastric 3 12 o’clock 0 and 90 Stomach and peritoneal content
IVC and hepatic veins 4 3 o’clock 0 and 90 IVC, hepatic veins, and peritoneal content
Portal triad 5 3 o’clock 70 ± 20 Portal vein, hepatic artery, and biliary duct
Liver 6 3 o’clock 90a Liver parenchyma and peritoneal content
Spleen 7 9 o’clock 90a Splenic parenchyma and peritoneal content
Kidney 8 9 o’clock 90a Renal parenchyma and adrenal gland
Pancreas 9 6 o’clock 90a Pancreatic parenchyma
Subpancreatic splenic vessels 10 6 o’clock 0–20 Splenic vein and artery
Abbreviations: IVC, inferior vena cava; N, number; SMA, superior mesenteric artery; SMV, superior mesenteric vein; TGAUS, transgastric abdominal ultrasonog-
raphy.
a
Turning the dual rotating knob or axial rotation from left to right to scan the organ.
September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 631

Abdominal Transgastric Ultrasonography
Table 2. Clinical Role of TGAUS Views in the Operating Room and Intensive Care Unit
TGAUS views Clinical role
Celiac trunk view 1 and Vascular monitoring during aortic dissection and vascular stenting3,9–17; detection of compromised
SMA-renal confluence view 2 splanchnic flow with celiac trunk and mesenteric artery monitoring,13 splanchnic vascular stenosis,18
and nutcracker syndrome19
Stomach view 3 Full stomach, upper gastrointestinal bleeding, gastric varices, and free peritoneal fluid14,20,21
Inferior vena cava and Diagnosis of right ventricular systolic and diastolic dysfunction,22–30 pulmonary hypertension,31–33 assess-
hepatic vein view 4 ment for IVC stenosis in liver transplantation, heart transplantation, ECMO, and artificial heart,9,24,34–42
ruling-out abdominal IVC tumor43–57 or thrombus45,48,56,58–62 as a cause of pulmonary embolism and
right-to-left shunting through a PFO in hypoxic patients with right heart dilation,45,48,56,58–61 and abdomi-
nal compartment syndrome24,34,63; intraoperative monitoring during renal cell carcinoma surgery involv-
ing the inferior vena cava43,45,46,49–53,55,64–74
Portal triad view 5 Abdominal compartment syndrome,20,24,63 mesenteric ischemia with portal venous air,13,20 hepatic artery
and portal vein stenosis in liver transplantation,42,62 portal venous Doppler monitoring right ventricular
dysfunction associated with venous congestion,14,75–77 and evaluation of response to medical treat-
ment27,78
Liver view 6 Detection of cirrhosis and ascites,14,44 liver abscess or cysts,14 transjugular portal systemic shunt,79 liver
transplantation, and resection17,62,79,80
Spleen view 7 Free abdominal fluid and splenic rupture in trauma,20,81 splenic venous Doppler monitoring right ven-
tricular dysfunction associated with venous congestion,14,75–77 and evaluation of response to medical
treatment27,78
Kidney view 8 Oligoanuria: renal arterial hypoperfusion or elevate renal resistance index,77,82–90 renal venous conges-
tion,78,83 left hydronephrosis and renal artery air embolization,77 and differentiating acute versus
chronic renal failure14
Pancreatic view 9 and subpancreatic Splenic venous Doppler monitoring right ventricular dysfunction associated with venous congestion14,75–77
splenic vessel view 10 and evaluation of response to medical treatment27,78
Abbreviations: ECMO, extracorporeal membrane oxygenation; IVC, inferior vena cava; PFO, patent foramen ovale; SMA, superior mesenteric artery; TGAUS,
transgastric abdominal ultrasonography.
motion of the probe, we will use the term axial rota- (Figure 1A–D). When the TEE probe is turned posteri-
tion as opposed to the term rotation, which refers to orly at 6 o’clock, for instance (Figure 1C), the left side
the electronic rotation of the ultrasound beam. The of the screen will display left-sided anatomical struc-
position of the ultrasound beam in the stomach can be ture and the right portion of the screen, right-sided
determined at the bedside by looking at the position structures. The 2 basic TG TEE views will be taken as
of the dual rotating knob. When TEE is performed in reference or initiation points to perform TGAUS. By
the OR in a supine patient at the head of the bed, the combining them, the organ can be scanned from left
dual rotating knob position can be described in terms to right and then from top to bottom.
of hours in relation to the main axis. For instance, 9 We propose 10 TGAUS views based on the most
to 10 o’clock or anteriorly is the most common posi- commonly reported applications for this modality
tion for a TG short-axis view of the left ventricle, (Supplemental Digital Content 2, Table 1, http://
because the heart is anterior to and slightly to the left links.lww.com/AA/D469). They are summarized in
of a TEE probe located in the stomach. As abdominal Table 1 and illustrated in Figure 2. Corresponding
organs will be examined through the stomach, their arterial Doppler velocities are summarized in Table 3.
position will not always be anterior to the TEE probe Supplemental Digital Content 3, Figure 1, http://
(Figure 1A–D). Some organs will be on the left side, links.lww.com/AA/D470, illustrates the most
such as the spleen and left kidney. Others will be pos- important upper abdominal organs and the vascular
terior, such as the abdominal aorta and the pancreas, anatomy that can be examined using TGAUS using
while the liver will be viewed on the right side of the simulators and 3D reconstruction. These include the
stomach. As the TEE probe is turned or axially rotated aorta and its branches, stomach, liver, hepatic vein
to the right, to the left, or posteriorly, the orientation and artery, portal vein, spleen, kidneys, and pancreas.
of the images displayed on the screen showing a long-
axis or 90° view will remain unchanged: caudal struc- Abdominal Vasculature
tures will appear on the left portion of the screen. The One of the goals of perioperative TEE is the assess-
right portion of the screen will display the cephalad ment of aortic disease, such as trauma, dissection,
anatomy regardless of the orientation of the ultra- aneurysm, and congenital anomalies. TEE is used
sound beam (Figure 1E–H). The orientation of the to more accurately identify the site of disease in the
images obtained with a transverse or 0° view will be descending thoracic aorta, but it can also identify the
modified as the TEE probe is axially rotated from left abdominal aorta using the celiac artery as an anatomi-
to right. Any axial rotation of the TEE probe will mod- cal marker or a division point between the thoracic
ify the displayed orientation of the transverse images and abdominal aortas.10
632
www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Figure 1. TGAUS probe orientation in a supine patient with the TGAUS probe at the head of the patient. A, The dual rotating knob is positioned
anteriorly at 12 o’clock. The ultrasound beam is at 0°. On a corresponding 2D image, the right side of the screen (red line) corresponds to
the left anterior anatomical structures and the left side of the screen (green line) corresponds to the right anterior anatomical structures. B,
The dual rotating knob is positioned to the right at 3 o’clock. The ultrasound beam is at 0°. On a corresponding 2D image, the right side of
the screen (red line) corresponds to the right anterior anatomical structures and the left side of the screen (green line) corresponds to the
right inferior anatomical structures. C, The dual rotating knob is positioned at the back of the patient, posteriorly at 6 o’clock. The ultrasound
beam is at 0°. On a corresponding 2D image, the right side of the screen (red line) corresponds to the right inferior anatomical structures and
the left side of the screen (green line) corresponds to the left inferior anatomical structures. D, The dual rotating knob is positioned to the left
of the patient at 9 o’clock. The ultrasound beam is at 0°. On a corresponding 2D image, the right side of the screen (red line) corresponds
to the left inferior anatomical structures and the left side of the screen (green line) corresponds to the left superior anatomical structures. E,
The dual rotating knob is positioned anteriorly at 12 o’clock. The ultrasound beam is at 90°. On a corresponding 2D image, the right side of
the screen (red line) corresponds to the anterior cephalad anatomical structures and the left side of the screen (green line) corresponds to
the anterior caudal anatomical structures. F, The dual rotating knob is positioned to the right at 3 o’clock. The ultrasound beam is at 90°. On
a corresponding 2D image, the right side of the screen (red line) corresponds to the right cephalad anatomical structures and the left side
of the screen (green line) corresponds to the right caudal anatomical structures. G, The dual rotating knob is positioned in the back of the
patient, posteriorly at 6 o’clock. The ultrasound beam is at 90°. On a corresponding 2D image, the right side of the screen (red line) corre-
sponds to the inferior cephalad anatomical structures and the left side of the screen (green line) corresponds to the inferior caudal anatomical
structures. H, The dual rotating knob is positioned to the left of the patient at 9 o’clock. The ultrasound beam is at 90°. On a corresponding
2D image, the right side of the screen (red line) corresponds to the left cephalad anatomical structures and the left side of the screen (green
line) corresponds to the left caudal anatomical structures. TGAUS indicates transgastric abdominal ultrasonography. Artwork from Hugo Babin
(Supplemental Digital Content 1, Figure 1, Video, http://links.lww.com/AA/D468).

Figure 2. TGAUS views. Ao indicates aorta; HV, hepatic vein; IVC, inferior vena cava; LHV, left hepatic vein; LRA, left renal artery; LRV, left
renal vein; MHV, middle hepatic vein; RHV, right hepatic vein; RPV, right portal vein; RRA, right renal artery; SA, splenic artery; SMA, superior
mesenteric artery; SMV, superior mesenteric vein; SV, splenic vein; TGAUS, transgastric abdominal ultrasonography.
TGAUS Examination Technique for Celiac Trunk View celiac artery branches into the splenic and hepatic
1 and SMA-Renal Confluence View 2. arteries, while the SMA stays adjacent to the aorta. The
TGAUS Celiac Trunk View 1. To examine the celiac trunk, celiac artery is the first major branch of the descend-
the TGAUS probe is advanced from the thoracic aorta ing aorta (Figure 3; Supplemental Digital Content 4,
beyond the crux of the diaphragm at a transducer Video View 1, http://links.lww.com/AA/D471). To
angle of 0° into a TG short-axis left ventricular view. identify blood velocities, the operator must lower
At this point, the TGAUS probe is gradually rotated the Nyquist limit from the cardiac preset of 55–65 to
so that the TGAUS dual rotating knob is typically ori- 20–30 cm/s. The celiac trunk can easily be visualized
ented downward in a 6 o’clock position. As the probe using color Doppler because of its larger diameter (7.8
is advanced into the stomach, the aorta should be kept ± 0.5 mm) and more cephalad position compared to
in view. As the probe is advanced, the celiac artery the SMA.3,11 The normal velocity of the celiac trunk
will be seen first followed by the superior mesenteric is 113 ± 17.5 cm/s.91,92 The celiac trunk can be imaged
arteries (SMAs) at 1 and 3 o’clock, respectively. The with TGAUS in 81% to 100% of patients.12,82
634
Table 3. Doppler Arterial Velocities of Abdominal Vessels Accessible With TGAUS

Peak systolic Resistance
Artery velocity (cm/s) indexa Comment/references
Celiac trunk 113 ± 17.5 0.6–0.8 Stenosis if >200 cm/s91–94
<200
Hepatic artery 30–40 0.5–0.8 AT <100 ms93,94
Splenic artery 100 0.5–0.7 91,95
Superior mesenteric artery 100–140 >0.8 fasting Low or reversed diastolic velocity in fasting state92,94
Stenosis if >275 cm/s93
Renal artery 52 ± 20 0.56–0.7 AT <57 ms83,91,93,94
<150 Stenosis if >180 cm/s94
Abbreviations: AT, acceleration time; TGAUS, transgastric abdominal ultrasonography.
a
(Systolic velocity-diastolic velocity)/systolic velocity.
TGAUS SMA-Renal Confluence View 2. The second ves- of malperfusion.13 Elevated SMA peak velocities >275
sel after the celiac trunk is the SMA (Supplemental cm/s are highly suggestive of stenosis.18,93 Mesenteric
Digital Contents 5–8, Figures 2 and 3, Video View 2, ischemia after cardiac surgery is a complication with
http://links.lww.com/AA/D472, http://links.lww. high morbidity and mortality.96 Guidelines from the
com/AA/D473, http://links.lww.com/AA/D474, American Society of Echocardiography in 2020 on
http://links.lww.com/AA/D475). It can be identified the use of TEE to assist for surgical decision-mak-
in a similar manner, namely, by advancing the probe ing mentioned that TEE should be used to identify
into the stomach beyond the celiac artery view with the presence of the dissection flap down to the sub-
a Nyquist limit set at 20 to 30 cm/s. The SMA may be diaphragmatic descending aorta.9 Dissection could
distinguished from the celiac trunk by the absence of happen, for instance, during endovascular aortic pro-
its distal bifurcation into the hepatic and splenic arter- cedures and would lead to surgical or angiographic
ies. The SMA is typically located between the superior intervention. Because of the location of the SMA,
mesenteric vein and the left renal vein (Supplemental compression of the left renal vein can occur between
Digital Contents 3, 5, and 7, Figures 1E and 2A, Video the SMA and the abdominal aorta, leading to left
View 2, http://links.lww.com/AA/D470, http:// renal venous congestion, which can also be diagnosed
links.lww.com/AA/D472, http://links.lww.com/ with TGAUS.78,97 This phenomenon is called the “nut-
AA/D474). As the probe is further advanced, the cracker syndrome.” Intraoperative recognition of this
left renal vein will appear between the SMA and the phenomenon could allow surgical or catheter-based
aorta. The right renal artery will appear on the screen intervention.
at 4 o’clock, and the left renal artery will appear at 10
o’clock caudal to the SMA. The SMA normal veloc- Stomach
ity is 145 ± 25.8 cm/s.92 The SMA can be imaged with Cardiac examination is routinely done from the stom-
TGAUS in 95.2% of patients.12 The splenic, hepatic, and ach when performing TEE using a TG short- or long-
renal arteries are discussed in the following sections. axis view (Supplemental Digital Contents 12–15, Figure
5, Video View 3, http://links.lww.com/AA/D479,
Clinical Applications. The ability to precisely locate http://links.lww.com/AA/D480, http://links.lww.
aortic disease and its impact on visceral branches may com/AA/D481, http://links.lww.com/AA/D482).
be of use during aortic repair procedures, especially in
aortic dissections and aneurysms. In addition, TGAUS TGAUS Examination Technique for Stomach View 3.
may help detect any stenosis of major aortic visceral The stomach anatomy can be examined in both short-
branch vessels (Supplemental Digital Contents 9–11, and long-axis views. When advancing the probe
Figure 4, Video View 1, http://links.lww.com/AA/ in short axis, the operator will be able to view the
D476, http://links.lww.com/AA/D477, http://links. fundus followed by the antrum (Supplemental Digital
lww.com/AA/D478).3 Celiac trunk stenosis is present Contents 12–15, Figure 5, Video View 3, http://links.
if peak velocities are >200 cm/s.93 TGAUS was used lww.com/AA/D479, http://links.lww.com/AA/
to identify celiac artery stent thrombosis in critically D480, http://links.lww.com/AA/D481, http://links.
ill patients who are unable to receive contrast due to lww.com/AA/D482). In a long-axis view, a leftward
acute renal failure.10 axial rotation of TGAUS will reveal the spleen behind
SMA blood velocities can be monitored with the fundus (Supplemental Digital Contents 12 and
TGAUS during cardiopulmonary bypass (CPB). In 14, Figure 5C, Video View 3, http://links.lww.com/
aortic dissection, mesenteric ischemia can occur with AA/D479, http://links.lww.com/AA/D481). No
obstruction of the SMA by the aortic false lumen or echo-free space suggestive of fluid in the peritoneal
intimal flap. Narrowing of >50% of the SMA or absence space should be seen anterior to the stomach wall or
of the color Doppler velocity signal can be indicative between the stomach and the spleen.

Clinical Applications. If free peritoneal bleeding at a transducer angle of 0° (Supplemental Digital

is present in hemodynamically unstable patients, Contents 23–25, Figure 7, Video View 4, http://links.
it may be identified by TGAUS between the lww.com/AA/D490, http://links.lww.com/AA/
stomach, the left lobe of the liver, and the heart D491, http://links.lww.com/AA/D492) or using
(Supplemental Digital Contents 12 and 15, Figure a midesophageal bicaval view at 90°. In the latter
5E, Video View 3, http://links.lww.com/AA/ case, only 1 hepatic vein will be identified at a time.
D479, http://links.lww.com/AA/D482).14 Studies Sequential identification of the hepatic veins can be
have shown that transabdominal ultrasound can be done and facilitated using color Doppler at a Nyquist
used to estimate stomach volume and consequently limit of 30 to 40 cm/s when rotating the TEE probe
the risk of aspiration.98 In emergency settings, from left to right.8,101,102 To identify the hepatic vein
TGAUS examination can detect an empty stomach confluence with the IVC, Blinn et al43 proposed the use
(Supplemental Digital Contents 16 and 17, Figure of an ultrasound orientation of 40° to 70°, 50° to 90°,
6A, Video View 3, http://links.lww.com/AA/D483, and 80° to 130° for the right, middle, and left hepatic
http://links.lww.com/AA/D484) and, sometimes veins, respectively. A normal hepatic vein diameter is
as an incidental finding, a full stomach with clear 7.3 ± 1.3 mm,103 with triphasic mean systolic, diastolic,
liquid (Supplemental Digital Contents 16 and 18, and atrial reversal velocities of 21.3 ± 13.9, 15 ± 9.5,
Figure 6B, Video View 3, http://links.lww.com/ and 7.5 ± 5.2 cm/s, respectively.104 The right, middle,
AA/D483, http://links.lww.com/AA/D485), and left hepatic vein Doppler tracings can be obtained
blood or blood clot (Supplemental Digital Contents with TGAUS in 100%, 97%, and 18% of patients,
16 and 19, Figure 6C, Video View 3, http://links. respectively.102
lww.com/AA/D483, http://links.lww.com/AA/
D486), solid food (Supplemental Digital Contents TGAUS Portal Triad View 5. The portal vein can be
16 and 20, Figure 6D, Video View 3, http://links. evaluated by TGAUS by rotating the probe toward
lww.com/AA/D483, http://links.lww.com/AA/ the patient’s right side with the dual rotating knob
D487), gastric varices using color or power Doppler at 3 o’clock, and a longitudinal view of the IVC can
(Supplemental Digital Contents 16 and 21, Figure be obtained at 90° with further insertion of the probe
6E, Video View 3, http://links.lww.com/AA/ into the stomach. A multiplane angle of 50° to 70°
D483, http://links.lww.com/AA/D488), and severe will align the right portal vein. Using a Nyquist
gastric and bowel edema often associated with right limit of 20 cm/s, color and pulsed-wave Doppler
heart failure99 (Supplemental Digital Contents 16 can be applied to interrogate the portal vein and
and 22, Figure 6F, Video View 3, http://links.lww. hepatic artery (Supplemental Digital Contents
com/AA/D483, http://links.lww.com/AA/D489). 26–28, Figure 8A, Video View 5, http://links.lww.
However, contrary to the transabdominal approach, com/AA/D493, http://links.lww.com/AA/D494,
an accurate estimation of the amount of gastric fluid http://links.lww.com/AA/D495). The portal vein
using TGAUS has not yet been validated.98,100 (diameter of 10.5 ± 1.7 mm),103 which is downstream
from the splenic and the superior mesenteric vein
Liver (Supplemental Digital Content 26, Figure 8C,
The liver and its vessels, which include the hepatic http://links.lww.com/AA/D493), can be identified
vein, portal vein, and hepatic artery, are easily exam- by its echodense sheath, and a typical laminar
ined by TGAUS. The intrahepatic bile ducts can occa- or monophasic velocity between 16 and 31 cm/s
sionally be seen in patients after cholecystectomy, (Supplemental Digital Contents 26 and 27, Figure
without elevated serum bilirubin. 8B, Video View 5, http://links.lww.com/AA/D493,
http://links.lww.com/AA/D494).93 The hepatic
TGAUS Examination Technique for IVC and Hepatic artery can be seen in proximity to the portal vein
Veins View 4, Portal Triad View 5, and Liver View 6. or identified also as the right-sided bifurcation of
TGAUS examination of the liver starts with the the celiac trunk (common hepatic artery) (Figure 3;
identification of the IVC. As mentioned by Hahn et Supplemental Digital Content 4, Video View 1,
al,8 the IVC is located in the retroperitoneal space, to http://links.lww.com/AA/D471), as described
the right of the vertebral body and abdominal aorta. previously. The portal vein Doppler tracing can be
obtained with TGAUS in 94% of patients.75
TGAUS IVC and Hepatic Vein View 4. From a TG
short-axis view of the left ventricle, the probe is TGAUS Liver View 6. To examine the whole liver
rotated to the patient’s right, where the dual rotating from a longitudinal view, the TEE probe has to be
knob will be at 3 o’clock. The IVC and the hepatic rotated to the patient’s right with the dual rotating
veins should be identified. The IVC and the 3 hepatic knob at 3 o’clock and advanced at the origin of the
veins (left, middle, and right) can be examined IVC (Supplemental Digital Contents 29–32, Figure
636
Figure 3. A, Transgastric abdominal ultrasonography view at 0° with color Doppler (Nyquist 16–22 cm/s) shows the CT in relation to the
Ao and its division into the hepatic and splenic artery. B and C, Anatomical representation using the Vimedix simulator and (D) correspond-
ing computed tomographic scanning. A. indicates artery; Ao, aorta; CT, celiac trunk. Courtesy of CAE Healthcare, Canada, for subparts B
(Supplemental Digital Content 4, Video View 1, http://links.lww.com/AA/D471).
9, Video View 6, http://links.lww.com/AA/D496, Clinical Applications. Examination of the IVC can be

http://links.lww.com/AA/D497, http://links.lww. used in determining the etiology of hemodynamic
com/AA/D498, http://links.lww.com/AA/D499). instability and hypoxemia. For instance, TGAUS can
By scanning from the left lobe to the right lobe of the detect IVC thrombus (Supplemental Digital Contents
liver, it is possible to evaluate the liver texture. The 29 and 30, Figure 9B, Video View 6, http://links.lww.
texture of a normal liver should be homogeneous, com/AA/D496, http://links.lww.com/AA/D497),
with no echo-free space between the liver, diaphragm, which is particularly common after extracorporeal
and stomach. Apart from the position of the left, membrane oxygenation weaning.105 Such thrombus
middle, and right hepatic veins, there are no precise can lead to pulmonary emboli, right ventricular
ultrasound landmarks to identify the transition point failure, and, in some patients, paradoxical emboli
from the left to the right lobe of the liver. Although through a patent foramen ovale.106 Spontaneous
evaluation of the whole liver is beyond the scope of contrast in the IVC can be observed in patients with
TGAUS evaluation, by performing an axial rotation of right ventricular dysfunction and cardiac tamponade
the probe beginning at the median side of the left lobe (Supplemental Digital Contents 29 and 31, Figure 9C,
of the liver toward the right, it is possible to analyze D, Video View 6, http://links.lww.com/AA/D496,
part of the parenchyma, mainly the left lobe, with only http://links.lww.com/AA/D498). Hemoperitoneum
a section of the right lobe.44 can be diagnosed when free fluid is present at the

level of the left hepatic lobe, between the stomach and spectral profile (Supplemental Digital Content 29,
the heart (Supplemental Digital Contents 12 and 15, Figure 9D, http://links.lww.com/AA/D496). This
Figure 5E, Video View 3, http://links.lww.com/AA/ pattern and even flow reversal can also be observed
D479, http://links.lww.com/AA/D482). Several in cirrhosis and portal hypertension.109 Portal vein
authors have also reported on the role of TGAUS in pulsatility index (PVPI) can be calculated as the ratio
managing patients with renal tumor extending to the of maximal and minimal velocity ([Vmax − Vmin]/
IVC,43,45–49,58–61,64 which is discussed in the following Vmax). An association has been observed between
section. The hepatic venous velocity patterns can give PVPI >0.5 and high right atrial pressure, moderate or
insight into hepatic perfusion as well as right heart greater tricuspid regurgitation, and right ventricular
dynamics.22,23,44 Monitoring of hepatic venous velocities dysfunction.75,110 More recently, PVPI has been linked
in humans,101 as well as in experimental animal to cardiorenal syndrome and acute kidney injury
models107 undergoing laparoscopic cholecystectomy, after cardiac surgery.111,112 Eljaiek et al75 previously
has shown that positive end-expiratory pressure reported that an intraoperative PVPI ≥0.5 measured
and elevated intraabdominal pressure have adverse with TGAUS was the most important predictor of
effects on overall splanchnic velocities.101,107 Blunting postoperative complications after cardiac surgery in
or reversal of the systolic forward flow velocities 115 cardiac surgical patients; it was also determined
through the hepatic venous system may be a marker as superior to any hemodynamic, 2D, and Doppler
of either right ventricular diastolic dysfunction or cardiac measurement. An international multicenter
severe tricuspid regurgitation,44,102,104 and absence study (NCT03656263) is currently exploring the clin-
of a biphasic hepatic signal or blunted velocities ical significance of portal hypertension after cardiac
may indicate IVC stenosis24 or resistance to venous surgery. Finally, air resulting from intestinal isch-
return.34 This can occur in any procedure in which the emia can be present in the portal vein of hemody-
IVC is surgically manipulated or anastomosed, as in namically unstable patients (Supplemental Digital
a Fontan procedure (Supplemental Digital Contents Contents 36 and 37, Figure 12, Video View 5, http://
33 and 34, Figure 10, Video View 6, http://links. links.lww.com/AA/D503, http://links.lww.com/
lww.com/AA/D500, http://links.lww.com/AA/ AA/D504).13,20 The absence of a portal velocity signal
D501),108 orthotopic heart transplantation,24 or liver in a patient in shock has been reported in abdominal
transplantation.24,35 The abnormal aspect of the hepatic compartment syndrome.24
venous velocity is similar to pulmonic vein stenosis Hepatic artery Doppler velocities can be used to
in lung transplantation with loss of systolic and assess hepatic perfusion and anastomosis after liver
diastolic flow.9 This can lead to venous hypertension, transplantation.113 Changes in hepatic artery Doppler
as well as liver and renal failure.36 Hemodynamically velocities and resistance indices are influenced by
compromised anastomotic stricture and extrinsic the severity of cirrhosis and portal hypertension.109
compression of the IVC have been detected by In cardiac surgery, Gårdebäck et al22 were able to
TGAUS, allowing for rapid intervention.37,62 Hepatic demonstrate a 50% reduction in hepatic blood veloc-
vein evaluation may also be of use during noncardiac ities during hypothermic CPB using TGAUS as the
surgical procedures such as transjugular intrahepatic primary method of monitoring. No reduction was
portosystemic shunt placement.44 In these observed in normothermic CPB. Careful examination
patients, their shunts can be examined by TGAUS of the liver may also give rise to new and important
(Supplemental Digital Content 35, Figure 11, http:// diagnoses. Heterogeneous appearance of the liver
links.lww.com/AA/D502). Maximum velocities parenchyma is suggestive of cirrhosis or chronic
through the shunt >190 or <90 cm/s may indicate liver disease, whereas the detection of focal lesions
shunt occlusion, which may place the patient at risk may cause suspicion of neoplasm or liver abscess.44
for variceal bleeding and hepatic dysfunction—both In unstable patients, free fluid between the liver and
significant concerns in the perioperative setting.44,79 the diaphragm can indicate the presence of a hemo-
Careful examination of portal venous velocity peritoneum or be suggestive of ascites. They should
with color and pulsed-wave Doppler may also assist be followed by paracentesis if suspicion of sponta-
in the assessment of right heart function, which can neous bacterial peritonitis is raised (Supplemental
lead to hepatic venous congestion.75,76 This can be Digital Contents 29 and 30, Figure 9, Video View 6,
done by interrogation of the portal vein or splenic http://links.lww.com/AA/D496, http://links.lww.
vein just caudal to the pancreas (see the following). com/AA/D497).
Normal portal venous velocity is typically laminar.
However, elevated right atrial pressure may trans- Spleen
mit retrograde through the IVC and portal venous The spleen is located on the left side of the stomach.
system, which will decrease forward systolic flow The upper pole sits under the diaphragm, while the
velocity and cause a pulsatile pulsed-wave Doppler lower pole sits at the splenic flexure of the colon.
638
TGAUS Examination Technique for Splenic View 7. Finally, changes in the resistance index of the splenic
Using a 2-chamber TG TEE view, a leftward axial artery have been validated as a method to evaluate
rotation of the TEE probe with dual rotating knob fluid responsiveness95,109 similar to the renal resistance
at 9 o’clock will enable identification of the spleen index (RRI).115 A <4% reduction in the splenic
(Supplemental Digital Contents 38–43, Figure 13, Doppler resistance index generally excludes fluid
Video View 7, http://links.lww.com/AA/D505, responsiveness in mechanically ventilated patients,
http://links.lww.com/AA/D506, http://links.lww. while >9% splenic Doppler resistance index reduction
com/AA/D507, http://links.lww.com/AA/D508, indicates fluid responsiveness.95
http://links.lww.com/AA/D509, http://links.
lww.com/AA/D510). A leftward axial rotation of Kidneys
the ultrasound probe will then display the complete The left kidney lies posterior and inferior to the spleen
homogenous anatomical structure. TGAUS imaging and can be visualized during TGAUS. Doppler exam-
of the splenic artery and vein can be obtained from ination of renal artery blood flow velocity confirms
a TG view by rotating to the left and changing the the presence of renal flow, which may be a concern
omniplane angle to 90°.34 The splenic vein and artery during aortic surgery, as well as allows for the calcu-
can be evaluated with color Doppler using a Nyquist lation of RRI. In one-third of kidneys, >1 renal artery
limit of 30 cm/s for the interrogation of the splenic might be present.91
hilum. The normal maximal splenic vein velocity is 27
± 4 cm/s and is typically monophasic.114 The splenic TGAUS Examination Technique for Kidney View 8.
vein position under the pancreas is described in the Chouinard et al3 first described TEE examination
following. The splenic artery can also be identified as of the kidneys in 1991, and then Yang et al83 and
a branch of the celiac artery as described previously Bandyopadhyay et al84 described their examination
(Figure 3; Supplemental Digital Content 4, Video View protocol by using color Doppler to visualize renal
1, http://links.lww.com/AA/D471). The maximal perfusion and the renal parenchyma. The examination
arterial Doppler velocity is 100 cm/s.91,95 Pulsed- should start with a TG left ventricular long-axis view
wave Doppler is placed 1 cm into the artery from with left-sided axial rotation of the dual rotating knob
the hilum, and the splenic arterial Doppler resistive up to 9 o’clock. In our experience, as the kidney is just
index can be calculated as (splenic resistance index = behind the spleen, further axial rotation of the TGAUS
[peak systolic velocity − end-diastolic velocity]/peak probe at an imaging plane of 90° is often enough
systolic velocity). to image the left kidney. Contrary to the spleen,
the kidney has an outer cortex and inner medulla
Clinical Applications. Splenomegaly should be surrounded by the hyperechogenic Gerota fascia
suspected when the spleen is noted to extend beyond (Supplemental Digital Contents 44 and 45, Figure
the left kidney, with normal dimensions: longitudinal: 14A, Video View 8, http://links.lww.com/AA/
12 to 14 cm, lateral: <5 cm, and anteroposterior: <7 cm. D511, http://links.lww.com/AA/D512). To calculate
The longitudinal measurement of the spleen is limited the maximal longitudinal diameter, it is possible to
by the maximal width of the TGAUS beam, with the advance multiplane angle rotation to 120° to 140°. The
probe being close to the organ. Free peritoneal fluid normal renal size is 10 to 12 cm on its long axis. Then,
(Supplemental Digital Contents 38, 42, and 43, Figure as with other organs, a rightward to leftward axial
13D, E, Video View 7, http://links.lww.com/AA/ rotation allows for a more complete examination of
D505, http://links.lww.com/AA/D509, http://links. the left kidney. The use of TGAUS to image the right
lww.com/AA/D510) and splenic rupture may be kidney using a TG short-axis view has been reported
detectable using TGAUS in the setting of a traumatic in adults and in children.85,86 In our experience, it is
injury or surgical complication (Supplemental Digital difficult to identify the right kidney given its location
Content 38, Figure 13F, http://links.lww.com/AA/ further from the stomach. Once the 2D examination
D505).14,81 Splenic vein interrogation at the hilum is complete, interrogation of the arterial and venous
will provide similar information to the portal vein in circulation can be done using Doppler at a Nyquist
terms of right ventricular dysfunction. Splenic arterial limit of 10 cm/s. This low-velocity limit is important
Doppler will also be influenced by any stenosis to identify the venous velocities.78 On certain
beyond its origin, identified by abnormal aliasing systems, low-velocity filters have to be removed
on color Doppler or elevated velocities on spectral before interrogation. The short-axis view at the
Doppler (Supplemental Digital Content 9, Figure level of the aorta is also useful in the identification
4C, http://links.lww.com/AA/D476). The presence of the 2 renal arteries, renal vein, SMA, splenic vein,
of right heart failure will lead to an increase in the and artery (Supplemental Digital Contents 5–8,
splenic vein pulsatility index ([peak systolic velocity Figures 2 and 3, Video View 2, http://links.lww.
− end-diastolic velocity]/peak systolic velocity).103 com/AA/D472, http://links.lww.com/AA/D473,

http://links.lww.com/AA/D474, http://links.lww. In addition, TGAUS can also assist in the diag-

com/AA/D475). The renal artery and vein diameters nosis and surgical management of renal cell car-
are 4.0 ± 0.9 and 8.1 ± 2.90 mm, respectively.83 The renal cinoma (Supplemental Digital Contents 44 and
artery Doppler velocities are typically 52 ± 20 cm/s 47, Figure 14E, F, Video View 8, http://links.lww.
with a rapid upstroke.83,91,93 Pulsed-wave Doppler can com/AA/D511, http://links.lww.com/AA/D514),
be applied to an interlobar artery to examine peak from which IVC involvement can occur in 4% to
systolic and end-diastolic velocities, which can be 10% of cases.65 Traditionally, these tumors may
used to calculate RRI (RRI = [peak systolic velocity require complicated resections involving sternot-
− end-diastolic velocity]/peak systolic velocity).3,84,85 omy, CPB, and even deep hypothermic circulatory
Normal renal venous Doppler velocities obtained with arrest with significant morbidity and mortality
TGAUS83 are typically laminar, continuous, and <20 rates.46,65,122 TGAUS can be used to monitor the bur-
cm/s.116 Right renal artery velocities are obtainable in den of thrombus and possible propagation/migra-
approximately 56% to 88% of patients12,82,86 and left tion to the right atrium during surgery with IVC
renal artery in 15% to 67% of patients.12,82,83 thrombectomy and reconstruction. Some authors
have suggested that TGAUS can provide real-time
Clinical Applications. Because fibrous tissue (eg, assessment of the mobility, fragility, and degree of
glomerulosclerosis and interstitial fibrosis) increases IVC invasion by the tumor or risk of embolization
echogenicity, chronic kidney disease is typically into the right atrium using the Neves and Zincke
associated with increased echogenicity and reduction classification of renal cell carcinoma.43,45,50,51,66,123,124
in size. The contrast between the cortex and medulla Tumors can evolve between the time of preoperative
disappears. TGAUS can diagnose hydronephrosis or testing and the day of surgery; TGAUS is, therefore,
renal cysts (Supplemental Digital Contents 44 and considered an important tool to accurately locate
46, Figure 14D, Video View 8, http://links.lww.com/ the tumor intraoperatively, which will improve sur-
AA/D511, http://links.lww.com/AA/D513). The gical planning,50,52,67,68 as well as guide and direct69
RRI may be of particular interest in patients at risk catheter-guided49 or robot-assisted thrombectomy.70
of renal dysfunction, as elevated values (>0.7) have Tumor resection may require clamping of the IVC,
been shown to be associated with an increased risk of which dramatically affects preload. TGAUS is also
acute kidney injury in cardiac surgical patients,117–119 a useful tool to differentiate hypotension due to
although it can be falsely elevated in patients with changes in preload versus tumor embolization with
aortic insufficiency.87 Aspects of the arterial renal resulting right ventricular failure and obstructive
Doppler profile can also be diagnostic of certain shock.51,67 Once the resection is complete, TGAUS
pathological conditions. For instance, a tardus parvus can also be used to carefully examine the IVC for
spectral profile can be seen with renal artery stenosis any residual tumor.67 The intraoperative guidance
or aortic stenosis (Supplemental Digital Content 48, afforded by TGAUS may allow for a less invasive
Figure 15A, http://links.lww.com/AA/D515). In catheter-based cavoatrial thrombectomy, thus spar-
addition, renal venous congestion can be diagnosed ing the patient from sternotomy, CPB, and its associ-
using Doppler interrogation at the corticomedullary ated complications.50,71,72
junction. Three patterns have been described: normal
continuous, biphasic, and monophasic patterns Pancreas
(Supplemental Digital Contents 48, 51, and 52, The pancreas sits behind the stomach. The pancre-
Figures 15B and 16, Video View 8, http://links.lww. atic body lies anterior to the aorta and the pancre-
com/AA/D515, http://links.lww.com/AA/D518, atic head is located to the right of the portal vein.
http://links.lww.com/AA/D519).112,116,120 The renal The pancreatic body and tail are located to the left
venous Doppler profiles change in parallel with the of the portal vein, with the body approximately
increase in right atrial pressure and the severity of between the portal vein and left kidney and the
right ventricular dysfunction.78,112,116,120 The biphasic tail approximately between the left kidney and the
and monophasic patterns have been associated spleen. A lesion in the head versus body-tail can
with increased mortality in heart failure116,121 and greatly impact management (eg, Whipple surgery
postoperative renal failure in cardiac surgery.78,112 versus distal body-tail pancreatectomy). However,
Finally, during cardiac surgery, air emboli can be the exact distinction between pancreatic body and
detected in the renal vessels that could contribute tail does not significantly impact management.
to postoperative renal dysfunction (Supplemental Recognition of the splenic artery and vein helps
Digital Contents 48–50, Figure 15C, D, Video locate the pancreatic body, because these vessels
View 8, http://links.lww.com/AA/D515, http:// travel along its length. Normal pancreatic texture is
links.lww.com/AA/D516, http://links.lww.com/ isoechoic with dimensions of head (3 cm), body (2–3
AA/D517). cm), and tail (1–2 cm).14
640
TGAUS Examination Technique for Pancreatic View 9 7.5-MHz probe, the spatial resolution will be higher
(Pancreas) and Subpancreatic Splenic Vessels View 10. with a 0.2-mm wavelength than a transabdominal
TGAUS Pancreatic View 9. The examination of the pan- ultrasound using a 3.75-MHz probe with a 2.4-mm
creas is similar to the other abdominal structures. The wavelength. This resolution provides more precise
TGAUS probe is turned to the patient’s back with the information for structures near the probe, similar to
dual-rotating knob at 6 o’clock, using a longitudinal the comparison between TEE and TTE imaging for
plane and scanning from the spleen hilum to the head the diagnosis of endocarditis.125 The proximity to
of the pancreas (Supplemental Digital Contents 53 abdominal organs and major vessels, along with the
and 55, Figure 17A, B, Video View 9, http://links.lww. absence of gastrointestinal air artifacts, is the advan-
com/AA/D520, http://links.lww.com/AA/D522). tage of TGAUS. However, a larger number of abdomi-
The pancreas sits between the TGAUS probe and the nal organs can be interrogated using transabdominal
splenic vein. Using color Doppler at a Nyquist limit of ultrasound compared to TGAUS.
20 cm/s, both the splenic vein and splenic artery can In regard to Doppler studies comparing TGAUS
be visualized in a short-axis view. and transabdominal ultrasound, hepatic vein exami-
nation with TGAUS was first described by Pinto et
TGAUS Subpancreatic Splenic Vessels View 10. The al,104 who showed it to be superior to a transabdominal
splenic vessels can be more easily visualized and approach.102,104 The success rate of TGAUS was 100%
interrogated using a short-axis view. By turning the compared to 48% with a transabdominal approach.
dual rotating knob at 6 o’clock, the aorta and celiac Examinations were not done simultaneously, but flow
trunk can be identified (Figure 3; Supplemental pattern and velocities were similar.104 Similar findings
Digital Content 4, Video View 1, http://links.lww. were recorded by another group, with the exception
com/AA/D471). A slight axial rotation of the dual that Doppler tracings of the left hepatic vein could only
rotating probe toward the celiac bifurcation will allow be acquired in 18% of patients with TGAUS compared
the identification of the splenic artery. Color Doppler to 47% with transabdominal ultrasound. Hulin et al24
is then turned on using a Nyquist limit of 20 cm/s. reported blunted hepatic venous flow in a patient after
Slowly advancing the probe shows the splenic vein, heart transplantation using both modalities simul-
which is optimally oriented for Doppler interroga- taneously. RRI was measured with both TGAUS and
tion (Supplemental Digital Contents 53 and 56, Figure transabdominal ultrasound in 2 studies of postopera-
17C, Video View 10, http://links.lww.com/AA/ tive cardiac surgical patients.88,89 In the first study by
D520, http://links.lww.com/AA/D523). The success Kararmaz et al,88 there was a statistically significant
rate of obtaining TGAUS views 9 and 10 is >90% of correlation between RRI done with TGAUS and RRI
the time, similar to the portal vein.75,76 obtained using transabdominal ultrasound (r = 0.86, P
< .0001). In the second study by Regolisti et al,89 both
Clinical Applications. The splenic artery can easily be techniques were done sequentially and not compared.
monitored intraoperatively from a pancreatic view or However, as observed in the first study, Regolisti et al89
just after the bifurcation of the celiac trunk (Figure 3; observed that an elevated RRI was associated with an
Supplemental Digital Content 4, Video View 1, increased risk of postoperative renal failure but with
http://links.lww.com/AA/D471), and its role has a limited predictive ability. In terms of TGAUS of the
been described before in TGAUS View 8. Splenic stomach, gastric volume estimated with ultrasound
artery air emboli can be monitored and detected from was originally validated and compared to upper endo-
this position (Supplemental Digital Contents 9 and 11, scopic examination findings. No comparison between
Figure 4D, Video View 1, http://links.lww.com/AA/ TGAUS and surface ultrasound has been reported to
D476, http://links.lww.com/AA/D478). The splenic this day. Doppler signals of the celiac artery, SMA,
vein reaches the portal vein (Supplemental Digital hepatic artery, splenic artery, and portal and splenic
Content 26, Figure 8C, http://links.lww.com/AA/ veins using both TGAUS and transabdominal ultra-
D493) and, therefore, yields similar information in sound acquired simultaneously have also not been
terms of right ventricular dysfunction and splanchnic reported. However, portal pulsatility diagnosed with
venous congestion (Supplemental Digital Contents either method correlates with echocardiographic and
57–59, Figure 18, Video View 10, http://links.lww. hemodynamic parameters of right ventricular func-
com/AA/D524, http://links.lww.com/AA/D525, tion75 and is associated with similar prolonged post-
http://links.lww.com/AA/D526).14,76 operative length of ICU stay.75,111,112 In addition, splenic
venous Doppler signals have been correlated with the
VALIDATION OF TGAUS parameters of right ventricular function using TGAUS
Information about 2D anatomy and Doppler veloc- (Supplemental Digital Content 54, Figure 17, Video
ity of specific abdominal organs can be provided View 10, http://links.lww.com/AA/D521), similar to
using TGAUS. Because TGAUS uses a high-resolution those reported using transabdominal ultrasound.103

Few studies have compared TGAUS with com- from the use of both TEE and TGAUS. Oropharyngeal,
puted tomography or magnetic resonance. The spatial esophageal, stomach, and splenic lacerations can be
resolution of TGAUS remains higher than computed associated with the use of TEE and TGAUS.129–133 The
tomography.126 However, computed tomography pro- invasive nature of the modality also precludes imag-
vides more complete information on several organs ing in patients with known esophageal or gastric
inaccessible to TGAUS. Several studies have reported pathologies. In a survey that included 100,604 TGAUS
findings using both techniques. Moreover, TGAUS procedures performed in 67 centers in Germany, the
enables direct intraabdominal access views dur- complication rate was 0.34%, and almost all com-
ing the simultaneous performance of TEE and may plications were duodenal and esophageal perfora-
uncover unrelated yet significant findings. TGAUS tions, with only 1 case of stomach perforation.134 The
may provide a significant advantage over computed reduced risk of stomach perforation could be related
tomography or magnetic resonance imaging when a to the increased flexibility of the stomach compared
patient is critically ill, hemodynamically unstable, or to the esophagus and the duodenum.135 As TGAUS
already undergoing a surgical procedure.13 does not allow imaging at the level of the duodenum,
In one study, TGAUS and computed tomography the risk is most likely similar to that associated with
of the descending aorta were performed to identify TEE. The risk of major complications mentioned to
the position of the celiac artery.11 There was no signifi- patients by gastroenterologists is <1 of 1000, a rate
cant difference between both methods. Another study similar to that reported for TEE by Piercy et al.136
described detecting an aortic dissection at the level of Comprehensive training and competency in the use
the mesenteric artery with visualization of the true of TEE remain essential elements to prevent such
and false lumens and the celiac trunk using TGAUS complications.8
and computed tomography.13 The corresponding The role of TGAUS in the imaging of other abdomi-
computed tomography examinations of TGAUS nal structures will likely continue to evolve. The rel-
views 1, 4, and 8 are shown in Figure 3 (Supplemental evance of TGAUS in exploring the anatomy of the
Digital Content 4, Video View 1, http://links.lww. small and large bowels and adrenal gland has been
com/AA/D471) and Supplemental Digital Contents reported137–139 and should be studied with TGAUS in
23 and 44, Figures 7D and 14C, http://links.lww. the perioperative setting and in the ICU. For periop-
com/AA/D490, http://links.lww.com/AA/D511. In erative applications, TGAUS is relegated to patients
a systematic review, the use of endoscopic ultrasound whose clinical conditions limit appropriate transab-
of the stomach for cancer staging was compared with dominal ultrasound imaging. Common examples
computed tomography.127 In studies comparing them in the OR and ICU include patients presenting with
directly, endoscopic ultrasound performed better. morbid obesity, subcutaneous emphysema, anasarca,
Some trials have reported the diagnosis of renal cell surgical dressings, and open chests or abdomens. In
tumor extension in the IVC diagnosed by TGAUS, the OR, TEE and TGAUS provide the anesthesiologist
computed tomography, and magnetic resonance with the ability to perform clinically useful noncar-
imaging.50,52,53 In another study, computed tomog- diac imaging that the surgical field and drapes would
raphy and TGAUS have been used in a patient with normally preclude. TGAUS is most useful when there
liver angioma undergoing liver resection,80 as well as is a cardiac indication for TEE probe placement, and
in the diagnosis of portal air embolism (Supplemental an abdominal organ assessment is complementary.
Digital Contents 36 and 37, Figure 12, Video View 5, As the resolution of ultrasound equipment such
http://links.lww.com/AA/D503, http://links.lww. as 3D TGAUS will continue to evolve, the TEE and
com/AA/D504),20 in splenic hematoma,81 and in TGAUS probes of the future may allow improved
renal cell carcinoma (Supplemental Digital Content imaging of structures outside of traditional cardiac
44, Figure 14F, http://links.lww.com/AA/D511). applications. However, the anatomical location of
Dynamic Doppler changes during a medical78 or the esophagus and stomach in relation to other struc-
surgical intervention such as cavoatrial thrombec- tures will always be a major limiting factor. Finally,
tomy46,49,69,72 are radiation-free and easier to monitor this review is based on the currently limited litera-
with TGAUS than with computed tomography. ture (Supplemental Digital Content 2, Table, http://
links.lww.com/AA/D469), which only counts a few
CONTRAINDICATIONS, COMPLICATIONS, FUTURE prospective and clinical trials, and on the authors’
DEVELOPMENTS, AND LIMITATIONS OF TGAUS bias and experience on the use of TGAUS. The pro-
The contraindications for TGAUS are similar to those posed 10 views need to be systematically studied,
for TEE128 and include absolute contraindications, compared, and validated with other modalities to
such as esophageal stricture or tumor, and those that determine their feasibility and usefulness. Outcome
are relative, such as esophageal varices or a previous from a systematic use of TGAUS remains to be docu-
gastrointestinal surgery.128 Complications can arise mented. E
642
DISCLOSURES that questions related to the accuracy or integrity of any part of

Name: André Y. Denault, MD, PhD, ABIM-CCM, FRCPC, the work are appropriately investigated and resolved.
FASE, FCCS. Conflicts of Interest: None.
Contribution: This author helped with the conception and Name: John Klick, MD, FCCP, FASE, FCCM.
design; the acquisition, analysis, and interpretation of data; and Contribution: This author helped with the conception and
critical revision for key intellectual content, gave final approval design; the acquisition, analysis, and interpretation of data; and
of the version to be published, and agreed to be accountable for critical revision for key intellectual content, gave final approval
all aspects of the work in ensuring that questions related to the of the version to be published, and agreed to be accountable for
accuracy or integrity of any part of the work are appropriately all aspects of the work in ensuring that questions related to the
investigated and resolved. accuracy or integrity of any part of the work are appropriately
Conflicts of Interest: A. Y. Denault is on the Speakers Bureau investigated and resolved.
for CAE Healthcare (2011), Masimo (2017), and Edwards (2019). Conflicts of Interest: None.
He received a research grant from Edwards (2019). This manuscript was handled by: Nikolaos J. Skubas, MD,
Name: Michael Roberts, DO, FASE. DSc, FACC, FASE.
Contribution: This author helped acquire, analyze, and inter-
pret the data and critically revise the key intellectual content; REFERENCES
gave final approval of the version to be published; and agreed 1. Bryson GL, Grocott HP. Point-of-care ultrasound: a pro-
to be accountable for all aspects of the work in ensuring that tean opportunity for perioperative care. Can J Anaesth.
questions related to the accuracy or integrity of any part of the 2018;65:341–344.
work are appropriately investigated and resolved. 2. Ramsingh D, Bronshteyn YS, Haskins S, Zimmerman J.
Conflicts of Interest: None. Perioperative point-of-care ultrasound: from concept to
Name: Theodore Cios, MD, MPH, FASE. application. Anesthesiology. 2020;132:908–916.
Contribution: This author helped acquire, analyze, and inter- 3. Chouinard MD, Pinheiro L, Nanda NC, Sanyal RS.
pret the data and critically revise the key intellectual content; Transgastric ultrasonography: a new approach for imag-
gave final approval of the version to be published; and agreed ing the abdominal structures and vessels. Echocardiography.
to be accountable for all aspects of the work in ensuring that 1991;8:397–403.
questions related to the accuracy or integrity of any part of the 4. Strohm WD, Phillip J, Hagenmüller F, Classen M. Ultrasonic
work are appropriately investigated and resolved. tomography by means of an ultrasonic fiberendoscope.
Conflicts of Interest: None. Endoscopy. 1980;12:241–244.
Name: Anita Malhotra, MD. 5. DiMagno EP, Buxton JL, Regan PT, et al. Ultrasonic endo-
Contribution: This author helped acquire, analyze, and inter- scope. Lancet. 1980;1:629–631.
pret the data and critically revise the key intellectual content; 6. Bhutani MS, Deutsch JC. Digital Human Anatomy and
gave final approval of the version to be published; and agreed Endoscopic Ultrasonography. B C Decker; 2005.
to be accountable for all aspects of the work in ensuring that 7. Hawes RH, Fockens P, Varadarajulu S. Endosonography.
questions related to the accuracy or integrity of any part of the Saunders/Elsevier; 2015.
work are appropriately investigated and resolved. 8. Hahn RT, Abraham T, Adams MS, et al; American
Conflicts of Interest: None. Society of Echocardiography; Society of Cardiovascular
Name: Sarto C. Paquin, MD. Anesthesiologists. Guidelines for performing a compre-
Contribution: This author helped acquire, analyze, and inter- hensive transesophageal echocardiographic examina-
pret the data and critically revise the key intellectual content; tion: recommendations from the American Society of
gave final approval of the version to be published; and agreed Echocardiography and the Society of Cardiovascular
to be accountable for all aspects of the work in ensuring that Anesthesiologists. Anesth Analg. 2014;118:21–68.
questions related to the accuracy or integrity of any part of the 9. Nicoara A, Skubas N, Ad N, et al. Guidelines for the use
work are appropriately investigated and resolved. of transesophageal echocardiography to assist with surgi-
Conflicts of Interest: None. cal decision-making in the operating room: a surgery-based
Name: Stéphanie Tan, MD. approach: from the American Society of Echocardiography
Contribution: This author helped acquire, analyze, and inter- in collaboration with the Society of Cardiovascular
pret the data and critically revise the key intellectual content; Anesthesiologists and the Society of Thoracic Surgeons. J
gave final approval of the version to be published; and agreed Am Soc Echocardiogr. 2020;33:692–734.
to be accountable for all aspects of the work in ensuring that 10. Zhou L, Jariwala N, Frazin L. Should the celiac artery be
questions related to the accuracy or integrity of any part of the used as an anatomical marker for the descending tho-
work are appropriately investigated and resolved. racic aorta during transesophageal echocardiography?
Conflicts of Interest: None. Echocardiography. 2016;33:66–68.
Name: Yiorgos Alexandros Cavayas, MD, MSc, FRCPC. 11. Vasaiwala S, Vidovich MI, Connolly J, Frazin L.
Contribution: This author helped acquire, analyze, and inter- Transesophageal echocardiography of the descending tho-
pret the data and critically revise the key intellectual content; racic aorta: establishing an accurate anatomic marker using
gave final approval of the version to be published; and agreed the celiac artery. Echocardiography. 2010;27:1093–1097.
to be accountable for all aspects of the work in ensuring that 12. Orihashi K, Matsuura Y, Sueda T, et al. Abdominal aorta
questions related to the accuracy or integrity of any part of the and visceral arteries visualized by transgastric echocar-
work are appropriately investigated and resolved. diography: technical considerations. Hiroshima J Med Sci.
Conflicts of Interest: None. 1997;46:151–157.
Name: Georges Desjardins, MD, FRCPC, FASE. 13. Orihashi K, Sueda T, Okada K, Imai K. Perioperative diag-
Contribution: This author helped with the conception and nosis of mesenteric ischemia in acute aortic dissection by
design; the acquisition, analysis, and interpretation of data for transesophageal echocardiography. Eur J Cardiothorac Surg.
the work; and revising it critically for important intellectual 2005;28:871–876.
content, gave final approval of the version to be published, and 14. Denault A, Liberman M, Paquin S. Extra-Cardiac
agreed to be accountable for all aspects of the work in ensuring Transesophageal Ultrasonography Basic Transesophageal and

Critical Care Ultrasound. Taylor and Francis, CRC Press, 32. Sun DD, Hou CJ, Yuan LJ, Duan YY, Hou Y, Zhou FP.
2018:41–61. Hemodynamic changes of the middle hepatic vein in
15. Orihashi K, Matsuura Y, Sueda T, et al. Abdominal aorta patients with pulmonary hypertension using echocardiog-
and visceral arteries visualized with transesophageal raphy. PLoS One. 2015;10:e0121408.
echocardiography during operations on the aorta. J Thorac 33. Hekimsoy İ, Kibar Öztürk B, Soner Kemal H, et al. Hepatic
Cardiovasc Surg. 1998;115:945–947. and splenic sonographic and sonoelastographic find-
16. Orihashi K, Matsuura Y, Sueda T, Watari M, Okada K. ings in pulmonary arterial hypertension. Ultrasonography.
Reversible visceral ischemia detected by transesophageal 2021;40:281–288.
echocardiography and near-infrared spectroscopy. J Thorac 34. Vegas A, Denault A, Royse C. A bedside clinical and
Cardiovasc Surg. 2000;119:384–386. ultrasound-based approach to hemodynamic instabil-
17. Denault AY, Couture P, Vegas A, Buithieu J, Tardif JC. ity—part II: bedside ultrasound in hemodynamic shock:
Transesophageal Echocardiography Multimedia Manual: A continuing professional development. Can J Anaesth.
Perioperative Transdisciplinary Approach. 2nd ed. Informa 2014;61:1008–1027.
Healthcare; 2011. 35. Beaubien-Souligny W, Pépin MN, Legault L, et al. Acute
18. Biri S, Biri İ, Gultekin Y, Yurdakul M, Ozdemir M, Tola M. kidney injury due to inferior vena cava stenosis after liver
Doppler ultrasonography criteria of superior mesenteric transplantation: a case report about the importance of
artery stenosis. J Clin Ultrasound. 2019;47:267–271. hepatic vein Doppler ultrasound and clinical assessment.
19. Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ II, Can J Kidney Health Dis. 2018;5:2054358118801012.
Gloviczki P. Left renal vein transposition for nutcracker 36. Jacobsohn E, Avidan MS, Hantler CB, Rosemeier F, De Wet
syndrome. J Vasc Surg. 2009;49:386–393. CJ. Case report: inferior vena-cava right atrial anastomotic
20. Denault A, Shaaban Ali M, Couture EJ, et al. A practical stenosis after bicaval orthotopic heart transplantation. Can J
approach to cerebro-somatic near-infrared spectroscopy Anaesth. 2006;53:1039–1043.
and whole-body ultrasound. J Cardiothorac Vasc Anesth. 37. Bjerke RJ, Mieles LA, Borsky BJ, Todo S. The use of trans-
2019;33(suppl 1):S11–S37. esophageal ultrasonography for the diagnosis of inferior
21. Denault A, Deschamps A, Murkin JM. A proposed algorithm vena caval outflow obstruction during liver transplanta-
for the intraoperative use of cerebral near-infrared spectros- tion. Transplantation. 1992;54:939–941.
copy. Semin Cardiothorac Vasc Anesth. 2007;11:274–281. 38. Ko EY, Kim TK, Kim PN, Kim AY, Ha HK, Lee MG. Hepatic
22. Gårdebäck M, Settergren G, Brodin LA. Hepatic blood vein stenosis after living donor liver transplantation: evalu-
flow and right ventricular function during cardiac sur- ation with Doppler US. Radiology. 2003;229:806–810.
gery assessed by transesophageal echocardiography. J 39. Almeida J, Garcia R, Monteiro V, Pinho P. Pseudo-pericardial
Cardiothorac Vasc Anesth. 1996;10:318–322. tamponade after cardiac surgery. J Am Soc Echocardiogr.
23. Raymond M, Grønlykke L, Couture EJ, et al. Perioperative 2009;22:211.e5–211.e6.
right ventricular pressure monitoring in cardiac surgery. J 40. Mizuguchi KA, Padera RF Jr, Kowalczyk A, Doran MN,
Cardiothorac Vasc Anesth. 2019;33:1090–1104. Couper GS, Fox AA. Transesophageal echocardiogra-
24. Hulin J, Aslanian P, Desjardins G, Belaïdi M, Denault phy imaging of the total artificial heart. Anesth Analg.
A. The critical importance of hepatic venous blood flow 2013;117:780–784.
Doppler assessment for patients in shock. A A Case Rep. 41. Rehfeldt KH, Wittwer ED, Mauermann WJ. Inferior vena
2016;6:114–120. cava obstruction after total artificial heart implantation.
25. Nomura T, Lebowitz L, Koide Y, Keehn L, Oka Y. Evaluation Anesth Analg. 2014;119:26–29.
of hepatic venous flow using transesophageal echocardiog- 42. Essandoh M, Whitson BA. Caval stenosis after bicaval
raphy in coronary artery bypass surgery: an index of right orthotopic heart transplantation: routine transesophageal
ventricular function. J Cardiothorac Vasc Anesth. 1995;9:9–17. echocardiography assessment of the caval anastomoses
26. Denault AY, Couture P, Buithieu J, et al. Left and right may avert this complication. J Cardiothorac Vasc Anesth.
ventricular diastolic dysfunction as predictors of difficult 2020;34:568–569.
separation from cardiopulmonary bypass. Can J Anaesth. 43. Blinn JA, Margulis V, Joshi RV. Transesophageal echocar-
2006;53:1020–1029. diography imaging of the inferior vena cava and hepatic
27. Couture P, Denault AY, Pellerin M, Tardif JC. Milrinone vein masses. A A Pract. 2019;12:295–297.
enhances systolic, but not diastolic function during 44. Huang J, Zhou J, Settles D, Maher T. Evaluation of
coronary artery bypass grafting surgery. Can J Anaesth. hepatic structures by transesophageal echocardiography. J
2007;54:509–522. Cardiothorac Vasc Anesth. 2014;28:1328–1330.
28. Couture P, Denault AY, Shi Y, et al. Effects of anesthetic 45. Schallner N, Wittau N, Kehm V, Humburger F, Schmidt
induction in patients with diastolic dysfunction. Can J R, Steinmann D. Intraoperative pulmonary tumor embo-
Anaesth. 2009;56:357–365. lism from renal cell carcinoma and a patent foramen
29. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the ovale detected by transesophageal echocardiography. J
echocardiographic assessment of the right heart in adults: Cardiothorac Vasc Anesth. 2011;25:145–147.
a report from the American Society of Echocardiography 46. Sobczyński R, Golabek T, Mazur P, Chłosta P.
endorsed by the European Association of Echocardiography, Transoesophageal echocardiography reduces invasiveness
a registered branch of the European Society of Cardiology, of cavoatrial tumour thrombectomy. Wideochir Inne Tech
and the Canadian Society of Echocardiography. J Am Soc Maloinwazyjne. 2014;9:479–483.
Echocardiogr. 2010;23:685–713. 47. Burbano NH, Vlah C, Argalious M. Residual inferior vena
30. Denault AY, Beaulieu Y, Couture P, et al. Acute intraopera- cava thrombus detected by transesophageal echocardiogra-
tive effect of intravenous amiodarone on right ventricular phy after resection of a malignant adrenal mass. A A Case
function in patients undergoing valvular surgery. Eur Heart Rep. 2015;5:143–145.
J Acute Cardiovasc Care. 2015;4:316–325. 48. El-Sayed Ahmed MM, Al-Najjar RM, Aftab M, Anton JM,
31. Fadel BM, Husain A, Alassoussi N, Dahdouh Z, Mohty D. Colen JS, Reul RM. Early detection of a cavopulmonary
Spectral Doppler of the hepatic veins in pulmonary hyper- tumor embolus with the use of transesophageal echocar-
tension. Echocardiography. 2015;32:170–173. diography. Tex Heart Inst J. 2015;42:66–69.
644
49. Seiler A, Gnadinger P, Glotzbach J, Silverton NA. 66. George J, Grebenik K, Patel N, Cranston D, Westaby S. The
Transesophageal echocardiography-guided tumor/throm- importance of intraoperative transoesophageal monitor-
bus debulking using the angiovac transcatheter aspiration ing when operating on renal cancers that involve the right
device. J Cardiothorac Vasc Anesth. 2020;34:1005–1009. atrium. Ann R Coll Surg Engl. 2014;96:e18–e19.
50. Oikawa T, Shimazui T, Johraku A, et al. Intraoperative trans- 67. Thangaswamy CR, Manikandan R, Bathala Vedagiri
esophageal echocardiography for inferior vena caval tumor SC. Role of transoesophageal echocardiography in
thrombus in renal cell carcinoma. Int J Urol. 2004;11:189–192. renal cell carcinoma: a brief review. BMJ Case Reports.
51. Komanapalli CB, Tripathy U, Sokoloff M, Daneshmand 2017;2017:bcr2017221532.
S, Das A, Slater MS. Intraoperative renal cell carcinoma 68. Calderone CE, Tuck BC, Gray SH, Porter KK, Rais-Bahrami
tumor embolization to the right atrium: incidental diag- S. The role of transesophageal echocardiography in the
nosis by transesophageal echocardiography. Anesth Analg. management of renal cell carcinoma with venous tumor
2006;102:378–379. thrombus. Echocardiography. 2018;35:2047–2055.
52. Treiger BF, Humphrey LS, Peterson CV Jr, et al. 69. Souki FG, Demos M, Fermin L, Ciancio G. Transesophageal
Transesophageal echocardiography in renal cell carcinoma: echocardiography-guided thrombectomy of intracardiac
an accurate diagnostic technique for intracaval neoplastic renal cell carcinoma without cardiopulmonary bypass. Ann
extension. J Urol. 1991;145:1138–1140. Card Anaesth. 2016;19:740–743.
53. Sigman DB, Hasnain JU, Del Pizzo JJ, Sklar GN. Real-time 70. Essandoh M, Tang J, Essandoh G, et al. Transesophageal
transesophageal echocardiography for intraoperative sur- echocardiography guidance for robot-assisted level
veillance of patients with renal cell carcinoma and vena III inferior vena cava tumor thrombectomy: a novel
caval extension undergoing radical nephrectomy. J Urol. approach to intraoperative care. J Cardiothorac Vasc Anesth.
1999;161:36–38. 2018;32:2623–2627.
54. Allen G, Klingman R, Ferraris VA, Fisher H, Harte F, Singh 71. Kostibas MP, Arora V, Gorin MA, et al. Defining the
A. Transesophageal echocardiography in the surgical man- role of intraoperative transesophageal echocardiogra-
agement of renal cell carcinoma with intracardiac exten- phy during radical nephrectomy with inferior vena cava
sion. J Cardiovasc Surg (Torino). 1991;32:833–836. tumor thrombectomy for renal cell carcinoma. Urology.
55. Singh I, Jacobs LE, Kotler MN, Ioli A. The utility of trans- 2017;107:161–165.
esophageal echocardiography in the management of 72. Zlatanovic P, Koncar I, Jakovljevic N, Markovic D, Mitrovic
renal cell carcinoma with intracardiac extension. J Am Soc A, Davidovic L. Transesophageal echocardiography-
Echocardiogr. 1995;8:245–250. guided thrombectomy of level IV renal cell carcinoma
56. Chen H, Ng V, Kane CJ, Russell IA. The role of transesopha- without cardiopulmonary bypass. Braz J Cardiovasc Surg.
geal echocardiography in rapid diagnosis and treatment of 2019;34:229–232.
migratory tumor embolus. Anesth Analg. 2004;99:357–359. 73. Martinelli SM, Mitchell JD, McCann RL, Podgoreanu MV,
57. Hou JZ, Zeng ZC, Wang BL, Yang P, Zhang JY, Mo HF. High Mathew JP, Swaminathan M. Intraoperative transesopha-
dose radiotherapy with image-guided hypo-IMRT for hepa- geal echocardiography diagnosis of residual tumor frag-
tocellular carcinoma with portal vein and/or inferior vena ment after surgical removal of renal cell carcinoma. Anesth
cava tumor thrombi is more feasible and efficacious than Analg. 2008;106:1633–1635.
conventional 3D-CRT. Jpn J Clin Oncol. 2016;46:357–362. 74. Sharma V, Cusimano RJ, McNama P, Wasowicz M, Ko R,
58. Berman AT, Parmet JL, Harding SP, et al. Emboli observed Meineri M. Intraoperative migration of an inferior vena
with use of transesophageal echocardiography immedi- cava tumour detected by transesophageal echocardiogra-
ately after tourniquet release during total knee arthroplasty phy. Can J Anaesth. 2011;58:468–470.
with cement. J Bone Joint Surg Am. 1998;80:389–396. 75. Eljaiek R, Cavayas YA, Rodrigue E, et al. High postop-
59. Hudcova J, Schumann R. Fatal right ventricular failure with erative portal venous flow pulsatility indicates right ven-
intracardiac thrombus formation during liver transplan- tricular dysfunction and predicts complications in cardiac
tation not apparent on postmortem examination. Anesth surgery patients. Br J Anaesth. 2019;122:206–214.
Analg. 2006;103:506. 76. Denault AY, Beaubien-Souligny W, Elmi-Sarabi M, et al.
60. Tashjian JA, Fraint H, DiNardo J, Rouine-Rapp K. Inferior Clinical significance of portal hypertension diagnosed with
vena cava thrombus in a postpartum patient with Fontan bedside ultrasound after cardiac surgery. Anesth Analg.
physiology: a case report. A A Case Rep. 2017;9:136–139. 2017;124:1109–1115.
61. Nanji JA, Ansari JR, Yurashevich M, et al. Transesophageal 77. Beaubien-Souligny W, Denault A, Robillard P, Desjardins G.
echocardiographic observation of caval thrombus followed The role of point-of-care ultrasound monitoring in cardiac
by intraoperative placement of inferior vena cava filter for pre- surgical patients with acute kidney injury. J Cardiothorac
sumed pulmonary embolism during cesarean hysterectomy Vasc Anesth. 2019;33:2781–2796.
for placenta percreta: a case report. A A Pract. 2019;12:37–40. 78. Beaubien-Souligny W, Denault AY. Real-time assessment of
62. Vetrugno L, Barbariol F, Baccarani U, Forfori F, Volpicelli renal venous flow by transesophageal echography during
G, Della Rocca G. Transesophageal echocardiography in cardiac surgery. A A Pract. 2019;12:30–32.
orthotopic liver transplantation: a comprehensive intraop- 79. Vannucci A, Johnston J, Earl TM, Doyle M, Kangrga IM.
erative monitoring tool. Crit Ultrasound J. 2017;9:15. Intraoperative transesophageal echocardiography guides
63. Diebel LN, Wilson RF, Dulchavsky SA, Saxe J. Effect of liver transplant surgery in a patient with thrombosed tran-
increased intra-abdominal pressure on hepatic arterial, sjugular intrahepatic portosystemic shunt. Anesthesiology.
portal venous, and hepatic microcirculatory blood flow. J 2011;115:1389–1391.
Trauma. 1992;33:279–282. 80. Vetrugno L, Pompei L, Zearo E, Della Rocca G. Could trans-
64. Casanova GA, Zingg EJ. Inferior vena caval tumor exten- esophageal echocardiography be useful in selected cases
sion in renal cell carcinoma. Urol Int. 1991;47:216–218. during liver surgery resection? J Ultrasound. 2016;19:47–52.
65. Skinner DG, Pritchett TR, Lieskovsky G, Boyd SD, Stiles 81. Poularas J, Saranteas T, Karakitsos D, Karabinis A.
QR. Vena caval involvement by renal cell carcinoma. Transoesophageal ultrasound monitoring of subcapsu-
Surgical resection provides meaningful long-term survival. lar splenic haematoma in the intensive care unit. Anaesth
Ann Surg. 1989;210:387–392. Intensive Care. 2009;37:862–863.

82. Royse CF, Bird H, Royse AG. Routine assessment of coeliac 100. Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge
axis and renal artery flow is not feasible with transoesopha- A. Ultrasound assessment of gastric content and volume.
geal echocardiography. Anaesthesia. 2009;64:103–104. Anesthesiology. 2009;111:82–89.
83. Yang PL, Wong DT, Dai SB, et al. The feasibility of measur- 101. Sato K, Kawamura T, Wakusawa R. Hepatic blood flow
ing renal blood flow using transesophageal echocardiogra- and function in elderly patients undergoing laparoscopic
phy in patients undergoing cardiac surgery. Anesth Analg. cholecystectomy. Anesth Analg. 2000;90:1198–1202.
2009;108:1418–1424. 102. Meierhenric R, Gauss A, Georgieff M, Schütz W. Use of
84. Bandyopadhyay S, Kumar Das R, Paul A, Sundar Bhunia multi-plane transoesophageal echocardiography in visu-
K, Roy D. A transesophageal echocardiography technique alization of the main hepatic veins and acquisition of
to locate the kidney and monitor renal perfusion. Anesth Doppler sonography curves. Comparison with the trans-
Analg. 2013;116:549–554. abdominal approach. Br J Anaesth. 2001;87:711–717.
85. Garwood S, Davis E, Harris SN. Intraoperative transesoph- 103. Bolognesi M, Quaglio C, Bombonato G, et al. Splenic
ageal ultrasonography can measure renal blood flow. J Doppler impedance indices estimate splenic congestion
Cardiothorac Vasc Anesth. 2001;15:65–71. in patients with right-sided or congestive heart failure.
86. Zabala L, Ullah S, Pierce CD, et al. Transesophageal Ultrasound Med Biol. 2012;38:21–27.
Doppler measurement of renal arterial blood flow veloci- 104. Pinto FJ, Wranne B, St Goar FG, Schnittger I, Popp RL.
ties and indices in children. Anesth Analg. 2012;114: Hepatic venous flow assessed by transesophageal echo-
1277–1284. cardiography. J Am Coll Cardiol. 1991;17:1493–1498.
87. Andrew BY, Cherry AD, Hauck JN, et al. The association of 105. Menaker J, Tabatabai A, Rector R, et al. Incidence of
aortic valve pathology with renal resistive index as a kidney cannula-associated deep vein thrombosis after veno-
injury biomarker. Ann Thorac Surg. 2018;106:107–114. venous extracorporeal membrane oxygenation. ASAIO J.
88. Kararmaz A, Kemal Arslantas M, Cinel I. Renal resistive 2017;63:588–591.
index measurement by transesophageal echocardiogra- 106. Chartier L, Béra J, Delomez M, et al. Free-floating thrombi
phy: comparison with translumbar ultrasonography and in the right heart: diagnosis, management, and prog-
relation to acute kidney injury. J Cardiothorac Vasc Anesth. nostic indexes in 38 consecutive patients. Circulation.
2015;29:875–880. 1999;99:2779–2783.
89. Regolisti G, Maggiore U, Cademartiri C, et al. Renal resis- 107. Schütz W, Meierhenrich R, Träger K, Gauss A, Radermacher
tive index by transesophageal and transparietal echo- P, Georgieff M. Is it feasible to monitor total hepatic blood
Doppler imaging for the prediction of acute kidney injury flow by use of transesophageal echography? An experi-
in patients undergoing major heart surgery. J Nephrol. mental study in pigs. Intensive Care Med. 2001;27:580–585.
2017;30:243–253. 108. Denault A, Vegas A, Lamarche Y, Tardif J, Couture P. Basic
90. Andrew BY, Andrew EY, Cherry AD, et al. Intraoperative Transesophageal and Critical Care Ultrasound. Taylor and
renal resistive index as an acute kidney injury biomarker: Francis, CRC Press; 2018.
development and validation of an automated analysis algo- 109. Kok T, van der Jagt EJ, Haagsma EB, Bijleveld CM, Jansen
rithm. J Cardiothorac Vasc Anesth. 2018;32:2203–2209. PL, Boeve WJ. The value of Doppler ultrasound in cirrho-
91. Pellerito J, Polak J. Introduction to Vascular Ultrasonography. sis and portal hypertension. Scand J Gastroenterol Suppl.
6th ed. Elsevier Health Sciences; 2012. 1999;230:82–88.
92. Asbeutah AM, Buredha B, Mahmood M, Al-Mohana A. 110. Styczynski G, Milewska A, Marczewska M, et al.
Doppler waveform characteristics in the celiac and supe- Echocardiographic correlates of abnormal liver tests in
rior mesenteric arteries in normal children and adults patients with exacerbation of chronic heart failure. J Am
with the use of duplex ultrasound. J Vasc Ultrasound. Soc Echocardiogr. 2016;29:132–139.
2018;32:133–136. 111. Beaubien-Souligny W, Eljaiek R, Fortier A, et al. The asso-
93. Wood MM, Romine LE, Lee YK, et al. Spectral Doppler sig- ciation between pulsatile portal flow and acute kidney
nature waveforms in ultrasonography: a review of normal injury after cardiac surgery: a retrospective cohort study.
and abnormal waveforms. Ultrasound Q. 2010;26:83–99. J Cardiothorac Vasc Anesth. 2018;32:1780–1787.
94. Myers KA, Clough A. Making Sense of Vascular Ultrasound: A 112. Beaubien-Souligny W, Benkreira A, Robillard P, et al.
Hands-on Guide. Arnold; 2004. Alterations in portal vein flow and intrarenal venous flow
95. Brusasco C, Tavazzi G, Robba C, et al. Splenic Doppler are associated with acute kidney injury after cardiac sur-
resistive index variation mirrors cardiac responsiveness gery: a prospective observational cohort study. J Am Heart
and systemic hemodynamics upon fluid challenge resus- Assoc. 2018;7:e009961.
citation in postoperative mechanically ventilated patients. 113. García-Criado A, Gilabert R, Salmerón JM, et al. Significance
Biomed Res Int. 2018;2018:1978968. of and contributing factors for a high resistive index on
96. Sakamoto T, Fujiogi M, Matsui H, Fushimi K, Yasunaga H. Doppler sonography of the hepatic artery immediately
Clinical features and outcomes of nonocclusive mesenteric after surgery: prognostic implications for liver transplant
ischemia after cardiac surgery: a retrospective cohort study. recipients. AJR Am J Roentgenol. 2003;181:831–838.
Heart Vessels. 2020;35:630–636. 114. Stankovic Z, Csatari Z, Deibert P, et al. Normal and altered
97. Siddiqui WJ, Bakar A, Aslam M, et al. Left renal vein com- three-dimensional portal venous hemodynamics in
pression syndrome: cracking the nut of clinical dilem- patients with liver cirrhosis. Radiology. 2012;262:862–873.
mas—three cases and review of literature. Am J Case Rep. 115. Beaubien-Souligny W, Huard G, Bouchard J, Lamarche Y,
2017;18:754–759. Denault A, Albert M. Doppler renal resistance index for
98. Perlas A, Mitsakakis N, Liu L, et al. Validation of a the prediction of response to passive leg-raising following
mathematical model for ultrasound assessment of gas- cardiac surgery. J Clin Ultrasound. 2018;46:455–460.
tric volume by gastroscopic examination. Anesth Analg. 116. Iida N, Seo Y, Sai S, et al. Clinical implications of intrarenal
2013;116:357–363. hemodynamic evaluation by Doppler ultrasonography in
99. Ikeda Y, Ishii S, Yazaki M, et al. Portal congestion and intes- heart failure. JACC Heart Fail. 2016;4:674–682.
tinal edema in hospitalized patients with heart failure. 117. Bossard G, Bourgoin P, Corbeau JJ, Huntzinger J, Beydon
Heart Vessels. 2018;33:740–751. L. Early detection of postoperative acute kidney injury by
646
Doppler renal resistive index in cardiac surgery with car- 129. Chow MS, Taylor MA, Hanson CW III. Splenic lacera-
diopulmonary bypass. Br J Anaesth. 2011;107:891–898. tion associated with transesophageal echocardiography. J
118. Guinot PG, Bernard E, Abou Arab O, et al. Doppler-based Cardiothorac Vasc Anesth. 1998;12:314–316.
renal resistive index can assess progression of acute kid- 130. Olenchock SA Jr, Lukaszczyk JJ, Reed J III, Theman TE.
ney injury in patients undergoing cardiac surgery. J Splenic injury after intraoperative transesophageal echo-
Cardiothorac Vasc Anesth. 2013;27:890–896. cardiography. Ann Thorac Surg. 2001;72:2141–2143.
119. Hertzberg D, Ceder SL, Sartipy U, Lund K, Holzmann MJ. 131. Côté G, Denault A. Transesophageal echocardiography-
Preoperative renal resistive index predicts risk of acute related complications. Can J Anaesth. 2008;55:622–647.
kidney injury in patients undergoing cardiac surgery. J 132. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra
Cardiothorac Vasc Anesth. 2017;31:847–852. MN, Eltzschig HK. Safety of transesophageal echocardiog-
120. Husain-Syed F, Birk HW, Ronco C, et al. Doppler-derived raphy. J Am Soc Echocardiogr. 2010;23:1115–1127.
renal venous stasis index in the prognosis of right heart 133. Ramalingam G, Choi SW, Agarwal S, et al; Association
failure. J Am Heart Assoc. 2019;8:e013584. of Cardiothoracic Anaesthesia and Critical Care.
121. Puzzovivo A, Monitillo F, Guida P, et al. Renal venous pat- Complications related to peri-operative transoesophageal
tern: a new parameter for predicting prognosis in heart echocardiography—a one-year prospective national audit
failure outpatients. J Cardiovasc Dev Dis. 2018;5:52. by the Association of Cardiothoracic Anaesthesia and
122. Hatcher PA, Anderson EE, Paulson DF, Carson CC, Critical Care. Anaesthesia. 2020;75:21–26.
Robertson JE. Surgical management and prognosis of 134. Jenssen C, Faiss S, Nürnberg D. [Complications of endo-
renal cell carcinoma invading the vena cava. J Urol. scopic ultrasound and endoscopic ultrasound-guided
1991;145:20–23. interventions—results of a survey among German cen-
123. Neves RJ, Zincke H. Surgical treatment of renal cancer ters]. Z Gastroenterol. 2008;46:1177–1184.
with vena cava extension. Br J Urol. 1987;59:390–395. 135. Jenssen C, Alvarez-Sánchez MV, Napoléon B, Faiss
124. Clarke R, Wells J, Finn C. Morphology identification S. Diagnostic endoscopic ultrasonography: assess-
using transesophageal echocardiography in migratory ment of safety and prevention of complications. World J
renal cell carcinoma surgery. J Cardiothorac Vasc Anesth. Gastroenterol. 2012;18:4659–4676.
2011;25:153–155. 136. Piercy M, McNicol L, Dinh DT, Story DA, Smith JA. Major
125. Birmingham GD, Rahko PS, Ballantyne F III. Improved complications related to the use of transesophageal echo-
detection of infective endocarditis with transesophageal cardiography in cardiac surgery. J Cardiothorac Vasc Anesth.
echocardiography. Am Heart J. 1992;123:774–781. 2009;23:62–65.
126. Kim IC, Chang S, Hong GR, et al. Comparison of cardiac 137. Sandek A, Bauditz J, Swidsinski A, et al. Altered intestinal
computed tomography with transesophageal echocar- function in patients with chronic heart failure. J Am Coll
diography for identifying vegetation and intracardiac Cardiol. 2007;50:1561–1569.
complications in patients with infective endocarditis in 138. Maturen KE, Wasnik AP, Kamaya A, et al. Ultrasound
the era of 3-dimensional images. Circ Cardiovasc Imaging. imaging of bowel pathology: technique and keys to
2018;11:e006986. diagnosis in the acute abdomen. AJR Am J Roentgenol.
127. Kelly S, Harris KM, Berry E, et al. A systematic review of 2011;197:W1067–W1075.
the staging performance of endoscopic ultrasound in gas- 139. Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D,
tro-oesophageal carcinoma. Gut. 2001;49:534–539. Takhar S, Seethala RR. Utilization of ultrasound for the
128. Mayo PH, Narasimhan M, Koenig S. Critical care trans- evaluation of small bowel obstruction: a systematic review
esophageal echocardiography. Chest. 2015;148:1323–1332. and meta-analysis. Am J Emerg Med. 2018;36:234–242.


Denault TGAUS 2021

Uploaded by

Copyright:

Available Formats

Denault TGAUS 2021

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Denault TGAUS 2021

Uploaded by

Copyright:

Available Formats

Cardiovascular and Thoracic Anesthesiology

E Narrative Review Article

Transgastric Abdominal Ultrasonography in Anesthesia

630 www.anesthesia-analgesia.org September 2021 • Volume 133 • Number 3

Table 1. TGAUS Views

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 631

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 633

Table 3. Doppler Arterial Velocities of Abdominal Vessels Accessible With TGAUS

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 635

Clinical Applications. If free peritoneal bleeding at a transducer angle of 0° (Supplemental Digital

9, Video View 6, http://links.lww.com/AA/D496, Clinical Applications. Examination of the IVC can be

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 637

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 639

http://links.lww.com/AA/D474, http://links.lww. In addition, TGAUS can also assist in the diag-

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 641

DISCLOSURES that questions related to the accuracy or integrity of any part of

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 643

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 645

September 2021 • Volume 133 • Number 3 www.anesthesia-analgesia.org 647

You might also like