bluuebunny/crossref_metadata_2025 huggingface dataset:
Venous Thoracic Outlet Syndrome Diagnosed Using Duplex Ultrasound
Authors: Pacheco Hernan , Yesenko Sandra L. , Gornik Heather L. , Abizer Sakarwala , Bartholomew John R.
Published: March 2018

Venous thoracic outlet syndrome (TOS) is a complex condition involving compression, irritation, or direct injury of the subclavian vein as it courses between the first rib, the clavicle, and the scalene muscle. Compression of the subclavian vein is a potential cause of axillosubclavian vein thrombosis. Duplex examination with color flow Doppler and appropriate abduction maneuvers can be used to identify patients with this syndrome. We describe the case of a 52 year-old female patient with a history of bilateral upper-extremity swelling and pain and a past history of bilateral subclavian deep vein thromboses (DVT). She was referred to our clinic to try and determine the cause of her upper-extremity DVTs. A venous duplex examination with abduction maneuvers was performed. Bilateral subclavian veins were studied in varying degrees of abduction to assess for the presence of venous TOS. The duplex examination revealed normal color flow and a respirophasic pulsed Doppler waveform in the subclavian veins bilaterally with the patient lying supine in the resting position. With abducting the arms, significant changes were noted. Occlusion of the subclavian vein was observed at its proximal segment with absent color flow and pulsed Doppler spectrum. Flow was reestablished after having the patient relax her arm to its resting position. These findings were documented in both the right and left subclavian veins. There was no evidence of residual DVT or venous reflux on either side. These findings suggested that subclavian vein compression at the thoracic outlet may have been responsible for the patient's bilateral deep vein thromboses. Duplex ultrasound examination with abduction maneuvers is an effective method that can be used to diagnose venous TOS. When a patient presents with upper-extremity swelling and/or a history of otherwise unexplained axillosubclavian DVT, the technologist should add abduction maneuvers to the venous duplex examination to help determine the cause.
Incidental Findings during Extracranial Carotid Duplex: Two Cases of Carotid Body Tumors
Authors: Roberts Jason , Shah Rasesh , Strunk Barbara , Garbani Nathalie
Published: March 2018

In Case 1, A 65-year-old man with a family history of carotid body paraganglioma and no other risk factors was referred to the noninvasive vascular laboratory for a carotid duplex with complaints of left eye amaurosis fugax. In Case 2, an 84-year-old woman with a history of hypertension and hyperlipidemia presented to the noninvasive vascular laboratory for carotid duplex under the suspicion of a right hemisphere transient ischemic attack. Duplex sonography of both cases recorded minimal <49% stenosis of both internal carotids. However, in Case 1, a homogenous mass was noted at the left carotid bifurcation, apparently fed by a branch of the external carotid artery, that later was confirmed by angiography to be a branch of the pharyngeal artery.
Oscillating Atherosclerotic Plaque in the Internal Carotid Artery
Authors: Thornton Jenilee B. , Kupinski Ann Marie , Jain Rajinder
Published: March 2018

Duplex ultrasound is used not only to detect atherosclerotic disease but also to define characteristics of the disease. Carotid plaque is often described by its echogenicity and surface characteristics. The following case report depicts the findings of atherosclerotic plaque that appeared to oscillate. An asymptomatic 60 year-old male presented with a right carotid bruit. His medical history is significant for type II diabetes mellitus, hypertension, hyperlipidemia and hypothyroidism. The ultrasound revealed the right internal carotid artery (ICA) peak systolic velocity (PSV) was 125 cm/s with an end diastolic velocity (EDV) of 33 cm/s. Heterogeneous atherosclerotic plaque was present at the origin of the ICA. A portion of the plaque was observed on real-time imaging to be oscillating with the cardiac cycle. The segment was approximately 5 mm in length and swayed from the wall of the vessel into the center stream of flow as normal flow/pressure variations occurred with the cardiac cycle. The right ICA was categorized as having a 50–69% stenosis. Mild atherosclerotic plaque was found in the left ICA with a PSV of 71 cm/s and EDV of 27 cm/s. These findings were categorized as a less than 50% stenosis. Bilaterally, the external carotid arteries demonstrated mild plaque while the common carotid arteries were free of disease. A magnetic resonance angiogram confirmed the presence of a stenosis and the patient underwent a successful right carotid endarterectomy. At surgery the plaque was found to be partially disrupted and described as mobile, correlating with the plaque features observed on ultrasound. This report describes the importance of fully evaluating the plaque characteristics during ultrasound examination. Based on velocities and the percent stenosis, this patient would have likely gone into surveillance and not to surgery. Identification of this potentially hazardous unstable plaque leads to rapid treatment, thus avoiding serious complications.
Customizable Ultrasound Career Ladder: A Preliminary Report
Authors: Jasa Randy P. , Kirkland John S.
Published: March 2018

Purpose

In 2005, Bureau of Labor Statistics growth projections for diagnostic medical sonographers were 27% during the next 5 years and recent surveys by the American Heart Association state that nationwide 42% of hospitals are reporting insufficient numbers of sonographers. Career ladders have been advocated for promoting professional development, stimulate certification, and to ensure employee longevity. We propose a vascular sonographer career ladder (VSCL) with specific objectives to document sonographer competency, reward certification, and stimulate long-term employment.

Methods

Vascular laboratory leadership and clinical administrators formed a committee to investigate and propose solutions to address staff retention and professional development. On the basis of recommendations from this committee, the Vascular Sonographer Career Ladder checklist was created.

Results

Before 2006, our vascular laboratory had an annual turnover rate of 20–30%. Upon implementation of the VSCL, there has been no vascular sonographer turnover.

Conclusions

Human resources experts state that employees want to feel challenged, engaged, and part of the team. It has established clear and easily modified objectives for defining sonographer competency, acts as a guide for achieving specific department and facility objectives, and has the flexibility to encourage individual initiative.
Patient Position and Phase of Respiration Affect the Doppler Waveform in the Celiac Artery
Authors: Asbeutah Akram M. , Al-Hussaini Abeer J. , Al-Otaibi Jawaher A. , Al-Nagi Mona N. , Al-Obaidi Saud
Published: March 2018

Introduction

Multiple factors might affect the velocity recording in the celiac artery (CA), causing a compression syndrome. Reports that focused on the phase of respiration found that the CA is highly compressed during the phase of expiration. Few reports in the literature have focused on body position during Doppler scanning of the CA. The aim of this study was to evaluate the effect of patient position as well as the phase of respiration on velocity recording in the CA.

Methods

Thirty male subjects were entered prospectively into the study. Peak systolic velocity and vessel diameter at the origin of the CA at different body position and different phases of respiration were recorded by the use of duplex ultrasound while the subject was fasting.

Results

There were 30 healthy men; their average age was 25.5 ± 5.30 (±SD, years), and their average body mass index was 24.8 ± 3.1 (±SD, kg/m2). The average diameter of CA in supine position and expiration was 0.70 ± 0.10 (±SD, cm), and the average peak systolic velocity was 111.2 ± 29.7 (±SD, cm/s). Moreover, the average diameter of CA in standing position in expiration was 0.75 ± 0.10 (±SD, cm), and the average peak systolic velocity was 96.8 ± 25.2 (±SD, cm/s). Paired Student t test for the effect of body position and phase of respiration in the peak systolic velocities and the diameter of the CA was performed and demonstrated statistical significance ( p < 0.05).

Conclusion

The CA peak systolic velocity varies between 2 positions in healthy young men, which may have implications for disease detection and needs further study.
Doppler Ultrasound for the Diagnosis of Intraparotid Hemangioma
Authors: Patil Karthikeya , Guledgud Mahima V. , Srivathsa Srikanth H.
Published: March 2018

Much controversy exists regarding the origin of hemangiomas. Most investigators believe them to be hamartomas. These lesions have been found virtually in all the organs in human body, but the head and neck area appear to be involved more frequently than other regions. Hemangiomas are rarely found in the salivary glands. The identification of salivary gland hemangiomas requires a minimum of ultrasound examination along with color Doppler. One such report of hemangioma of the parotid gland is reported, which was diagnosed with the aid of color Doppler ultrasound examination.
Carotid Artery Mycotic Aneurysm Identified by Duplex Imaging
Authors: Bekker Diana , Hannon Kathleen , Jaff Michael R. , LaMuraglia Glenn
Published: March 2018

Although there have been mycotic aneurysms of the carotid arteries reported in the literature, they are unusual and we wanted to describe our findings of mycotic aneurysm using ultrasound.
A Case Study of Takayasu's Arteritis of Carotid Arteries: A Distinct Role for Sonography in Monitoring Disease Status and Follow-up Care
Authors: Masri Dianne , Puckett John , Selvan Senthamil R.
Published: March 2018

Takayasu's Arteritis (TA) is a rare chronic inflammatory disease characterized as a large-sized vessel vasculitis involving all layers of the arterial wall. In this case report, we describe a 51-year-old Persian woman with a history of TA who had occlusion of the left common carotid artery (CCA) that was successfully treated by left CCA stenting. Carotid duplex ultrasound was performed by the use of B-mode imaging with pulsed Doppler to evaluate the common carotid arteries, internal carotid arteries, external carotid arteries (ECA), and vertebral and subclavian arteries. Ultrasound revealed total occlusion of the left CCA, retrograde blood flow in the left ECA maintaining antegrade flow into the internal carotid artery, and markedly elevated velocities in the right vertebral and subclavian arteries. After stent replacement, ultrasound revealed blood flow in the left CCA, antegrade flow in the left ECA, and decreased velocities in the right vertebral and subclavian arteries. In conclusion, sonography as a noninvasive imaging modality distinctly detects and confirms vascular lesions and progressive changes in the arterial walls. Above all, this method can be used to evaluate and measure luminal wall thickening and narrowing, as well as change in the blood flow velocity to safely implement continuation of follow-up care for patients with Takayasu's Arteritis.
Carotid Plaque Characterization with Contrast-Enhanced Ultrasound Imaging and its Histological Validation
Authors: Molinari Filippo , Liboni William , Giustetto Pierangela , Pavanelli Enrica , Marsico Andrea , Suri Jasjit S.
Published: March 2018

Introduction

Better methods are needed to determine the course of intervention in patients with atherosclerosis; therefore, plaque characterization is increasing in importance. Current guidelines suggest that the degree of stenosis and symptoms are the only criteria for the selection of the surgical intervention. However, there remain some challenges. The characterization of plaque morphology may help determine the best course of therapy. Magnetic resonance imaging and computed tomography are current standard techniques to evaluate plaque morphology, but they are expensive and unsuitable for long term surveillance and monitoring.

Objective

In this research, an ultrasound-based methodology for the characterization of carotid plaques is shown. This technique requires the injection of a small volume (approximately 1.5 mL) of contrast agent and the acquisition of postcontrast images. The rationale of this technique is that poorly perfused tissues (such as lipids) show a lower contrast enhancement with respect to highly perfused tissues (such as fibrous and muscular tissue).

Methods

The technique consists of two steps. First, the plaque region is automatically segmented by a completely user-independent algorithm. Then, the portion of the wall corresponding to the plaque is analyzed and color-coded intensity is assigned to a specific tissue. Performance evaluation was performed against histology. Twenty plaque specimens were sent to pathology for reporting. Correlation of the histology report and of the contrast-enhanced ultrasound analysis was performed.

Results

Plaque components that could be effectively identified were thrombi, lipids, fibrous/muscular tissue, and calcium. Overall the errors on 20 plaques between automated classification and histology were: 3.1 ± 1.1% for thrombus, 4.2 ± 1.5% for lipids, 5 ± 3.4% for fibrous/muscular tissue, and 3.2 ± 1.0% for calcium.

Conclusion

Despite the need for further investigation and a quantitative evaluation of the results, this methodology showed encouraging results. This analysis architecture is undergoing validation in a neurology division and is aimed at being used for the follow-up of patients and quantification of drug therapy effects.
Pre- and Postprocedure Duplex Evaluation of Distal Revascularization-Interval Ligation Procedure: A Case Study
Authors: Scarola Lisa , Eliassi Lois , Rodriguez-Wong Angela , Porreca Francis J.
Published: March 2018

Introduction

Duplex ultrasound is a valuable modality for the assessment of hemodialysis access function. A potential complication of hemodialysis access is arterial steal, which occurs when venous outflow exceeds the capacity of the inflow artery, and flow in this distal artery becomes retrograde, stealing blood flow from the hand to the fistula site. A potential condition resulting from arterial steal is hand or digit ischemia. Distal revascularization-interval ligation (DRIL) procedures can be used to “bypass” the fistula or graft site and deliver blood to the hypoperfused hand. Presented is a case of an arterial steal with severe hand ischemia that was alleviated by a DRIL procedure.

Case Study

A 69-year-old woman presented to the vascular laboratory with an ischemic right hand and digital ulcer distal to a brachial-axillary arteriovenous graft (AVG). Duplex ultrasound was performed of the right upper-extremity inflow arteries, AVG, and outflow veins. Ipsilateral brachial, radial, and ulnar artery waveform analysis for direction of flow was performed with and without AVG compression. The evaluation revealed significant arterial ischemia that returned to normal after manual compression of the AVG. The patient underwent a DRIL procedure after the pre-op duplex evaluation. Postprocedural duplex evaluation revealed patent inflow and outflow vessels, patent graft, and bypass (DRIL) with antegrade flow in the brachial and radial arteries and no change of flow with manual graft compression; clinically, the patient had a healing ulceration of the digit.

Conclusion

Duplex ultrasound for hemodialysis access should not only be used to evaluate for patency of the fistula or graft but should include assessment for ischemia and/or steal. This case demonstrates the importance of the assessment of the distal arterial segments including digital waveforms, and the use of manual compression to complete the hemodialysis access evaluation. DRIL procedures can potentially correct arterial steal while preserving access function.
Schwannoma of the Posterior Tibial Nerve: An Unusual Finding during Arterial Ultrasound Examination of the Lower Extremities
Authors: Maia Miguel , Riobom Filipe , Ferreira Joana , Braga Sandrina , Vasconcelos João , Brandão Pedro , Vaz Guedes
Published: March 2018

Introduction

Ultrasound examination of the lower extremity, regardless of the motive, can yield a considerable amount of data essential to the diagnosis of various diseases.

Case Report

We reported a clinical case of a woman, 50 years of age, who was sent to our vascular laboratory for arterial ultrasound examination of the lower extremities. She complained of coldness of the left foot associated with paresthesia and hypersensitivity of the middle third of the left lower leg for the past 3 years. During physical examination, there was a diminished, but palpable, posterior tibial artery pulse. The ultrasound performed revealed a tumor of the posterior tibial nerve, with 4 cm in longitudinal dimension and 2.7 cm of maximum diameter, typical of a neurofibroma or a schwannoma, with anterior deviation of the vascular structures. She was referred to a plastic surgeon and submitted to surgical resection of the nerve sheath tumor, with preservation of artery and venous flow. Histological analysis revealed a capsulated mass with fusiform cells, without atypical cells, compatible with a schwannoma. Patient completed 1 year of follow-up, maintaining a slight, nondisabling, local hypersensitivity.

Discussion

This clinical case shows an interesting imaging finding, with major repercussions in the treatment of this patient.
Nerve Sheath Tumor found in a Patient with Horner's Syndrome
Authors: Thompson Yolanda A. , Back Thomas L.
Published: March 2018

A patient with Horner's syndrome, as evidenced by a droopy eyelid, was referred to the vascular lab for a carotid duplex ultrasound exam to rule-out carotid dissection. Instead of a carotid abnormality, the duplex exam showed a mass at the carotid bifurcation, consistent with a carotid body tumor or soft tissue mass. The mass was confirmed by computed tomography (CT) and magnetic resonance imaging (MRI). Pathology, following surgical excision of the mass, determined that this was a nerve sheath tumor—a less common finding at the carotid bifurcation than is a carotid body tumor.
A Case of Mistaken Identity: When a Deep Vein Thrombosis is not a Thrombosis
Authors: Hamilton Debbie , Omari Abdullah
Published: March 2018

Introduction

Although rare, nonthrombotic causes of venous obstruction do occur. Their ultrasound findings can mimic deep vein thrombosis (DVT). We sought to examine the ultrasound appearance of these tumors to determine whether their differentiation from DVT was possible.

Case Report

Two patients, in whom a DVT was initially suspected, were subsequently diagnosed with intravascular tumors: a leiomyosarcoma and a hemangioma. The first patient presented with thigh pain, and an initial diagnosis of long saphenous vein (LSV) and common femoral vein thrombosis was made. The apparent thrombus remained unchanged despite anticoagulation. Proliferation of the lesion outside of the LSV developed, resulting in a review of the diagnosis, and surgical resection was performed. A histological diagnosis of leiomyosarcoma was made. The second patient presented with leg swelling and an initial diagnosis of External Iliac vein thrombosis was made. Further ultrasound assessments demonstrated arterialized flow within the lesion and surgical resection was performed, with a histological diagnosis of intravascular epithelioid hemangioma.

Results

The B-mode appearance was similar for both. The presence of arterialized flow within the lesions is helpful but may not be diagnostic because of recent reports that neovascularization may develop within thrombus.

Conclusion

Suspicion needs to be raised in a patient presenting with an unprovoked DVT or when conventional treatment does not result in improvement of symptoms; as well as when prolonged arterialization is identified within the thrombus. These signs can alert the clinician to a possible non-thrombotic mechanism of venous obstruction.
Evaluation of Carotid Wall Thickness by using Computed Tomography and Semiautomated Ultrasonographic Software
Authors: Saba Luca , Sanfilippo Roberto , Tallapally Niranjan , Molinari Filippo , Montisci Roberto , Mallarini Giorgio , Suri Jasjit S.
Published: March 2018

Purpose

The increased thickness of the carotid artery is associated with the development of coronary and cerebrovascular events. In this study our purpose was to evaluate the carotid artery wall thickness (CAWT) by using multidetector-row computed tomography angiography (MDCTA) and the intima media thickness (IMT) by using semiautomated ultrasonography (SA-US) to evaluate the agreement between the two methods.

Methods

This is a retrospective study, and the institutional review board approval was obtained. Twenty-one patients (age range, 59–81 years) were analyzed with the use of a 16-detector row CT and a sonographic scanner. In total, 14 subjects had shown cerebral ischemic symptoms. The IMT was quantified by the use of specific semiautomated software (ImgTracer™, Global Biomedical Technologies, Roseville, CA) by four expert observers, and the CAWT was measured by use of the MDCTA. Data were compared with the Wilcoxon test for paired samples. Bland–Altman statistics was used to measure the agreement between MDCTA and SA-US. A p value < 0.05 was considered significant.

Results

Forty-two carotids were analyzed, and the CAWT ranged from 0.64 to 2.99 mm, with a mean value of 1.438 mm. By analyzing the Bland–Altman plots, we observed a good agreement between SA-US and correlation coefficient r were 0.9250 (95% confidence interval [CI] 0.864–0.959; p < 0.0001), 0.9265 (95% CI 0.866–0.961; p < 0.0001), 0.9466 (95% CI 0.902–0.971; p < 0.0001), and 0.8621 (95% CI: 0.756–0.924; p < 0.0001) for observer 1, observer 2, observer 3 and observer 4 respectively.

Conclusions

Data of this preliminary study by using SA-US and MDCTA demonstrated a good agreement between in the measurement of CAWT and IMT.
Carotid Sinus Hypersensitivity-Induced Syncope: A Phenomenon Unmasked during Carotid Sonography
Authors: Allen Christopher , Kuo Bruce T. , Morales Gustavo X. , Elayi Claude S.
Published: March 2018

We present a case in which carotid duplex was ordered to evaluate a patient with recurrent syncope. The patient experienced syncope during the carotid examination; however, the vascular technologist did not notice this.
Controversies in the Interpretation of Doppler Waveform
Authors: Scissons Robert
Published: March 2018

Waveform analysis is inherent to nearly every procedure performed in the vascular laboratory, yet waveform terminology and definitions have not been standardized. A review of waveform literature notes that three terms have been used to classify Doppler waveforms in the peripheral arterial circulation—triphasic, biphasic, and monophasic. These terms, however, are briefly detailed, often contradictory, are substituted by alternative terminology and also used for classifying waveforms generated by plethysmographic devices. Because sonographers are the primary party in waveform classification, failing to address this issue will be most keenly felt in the future. In the advent of vascular ultrasound sonographers received an average of three years on-the-job training; today career option is no longer available and formal ultrasound education is mandatory. Furthermore, physicians and ancillary medical personnel are integrating ultrasound into their practices. A lack of waveform standards has the potential to stimulate inappropriate testing and is hindering the advancement of the vascular ultrasound profession.
Is Preoperative Vein Mapping Beneficial for the Creation of Dialysis Arteriovenous Fistulas?
Authors: Croft Renee , Brooks Sara , Nicolaou Angela , Kakkos Stavros , Kennedy Nicole , Haddad Georges , Lin Judith
Published: March 2018

Introduction

The use of preoperative vein mapping for arteriovenous fistula creation has shown promise in multiple studies over the years. However, a definitive scanning technique has not been well described. Our center has developed a standard method of preoperative vein mapping performed by a select group of trained technologists. Together with a single surgeon, we believe that this technique is equivalent to if not better than previously described methods.

Methods

In a retrospective study of 88 patients, all patients underwent preoperative scanning according to our dialysis mapping protocol with subsequent operative intervention.

Results

Eighty-three of the 88 patients mapped correctly matched the surgeon's findings. Seventy-five patients had successful fistula creation. Sixty-one patients (82%) who had fistulas placed were accurately predicted by their preoperative mapping. Of the 83 patients, 94% presented for a 2-week follow-up appointment. At this point, 81% of fistulas showed evidence of a good thrill and were developing at a sufficient rate. In addition, 89% of these patients presented for a long-term follow-up appointment at 60 days postoperatively. Approximately 6.7% of these patients required additional intervention to progress fistula maturation at this point.

Conclusion

Further prospective studies with additional centers to use as control groups would be helpful in evaluating this technique. However, this scanning protocol shows promise as a method of obtaining favorable results in a consistent fashion.
Isolated Superficial Femoral Artery Aneurysm: A Case Study
Authors: Wise Matthew , Klein Daren , Gibson Kathleen D.
Published: March 2018

Introduction

Isolated aneurysms of the superficial femoral artery (SFA) are rare, and their etiology is not yet fully understood. Although not as common as abdominal aortic or popliteal artery aneurysms, they pose a serious threat of rupture and/or thrombosis. Because of their atypical presentation, they can be easily misdiagnosed.

Methods

A 58-year-old man presented with a painful lump over his left medial thigh, first noted 6 months previously. The patient was asymptomatic in regards to claudication. The findings of magnetic resonance imaging suggested a vascular mass versus pseudoaneurysm of the SFA. The patient was referred to the vascular laboratory and underwent duplex evaluation. This revealed an 8.3–cm long SFA aneurysm with a maximum diameter of 5.9 cm with extensive mural thrombus present. Angiography confirmed a true aneurysm, with an estimated length of 5 cm and luminal diameter of 2.5 cm.

Result

The patient underwent open aneurysmorrhaphy with a femoral to popliteal reverse saphenous vein bypass graft. Upon direct visualization, the aneurysm was estimated to measure 8 cm length and 6 cm in diameter. The patient recovered without incident and has normal ankle brachial indices.

Conclusion

True isolated aneurysms in the SFA are rare, and the exact cause is not yet known. Proper diagnosis and identification are crucial to patient outcome. In our case, duplex ultrasound yielded a more accurate measurement of the true aneurysm size when compared with the angiogram. This is attributable to the angiogram measuring the flow channel of the residual lumen while not visualizing the thrombus filled sac. Endovascular stent grafts or open repair with bypass grafts (vein or prosthetic) are the accepted methods of treatment with good patient outcome. Allowed to progress untreated, these aneurysms often rupture or thrombose, which can ultimately lead to limb loss. Because of the increased incidence of aneurysmal disease elsewhere in the body, these patients should undergo additional screening.
Incidental Findings of Tumors in a Routine Venous Duplex
Authors: Young Laurie
Published: March 2018

Introduction

Deep venous thrombosis (DVT) is a condition routinely evaluated for in a vascular laboratory on a daily basis. Patients usually present with symptoms of peripheral pain, swelling, shortness of breath, or chest pain. Pain and swelling are not symptoms unique to DVT, however, and an ultrasound test could potentially serve as a basis for incidental findings that would serve as an underlying reason for the patient's symptoms. It is important to recognize the role in evaluating flow characteristics and using appropriate methods for identifying deep veins to exclude, or include, DVT as a cause for symptoms.

Case Reports

Two case studies are presented here in light of excluding DVT and identifying tumors. The first patient presented to the emergency department with left upper extremity swelling and pain. A left upper-extremity venous ultrasound was performed to discover all veins were fully compressible. No intraluminal thrombus was noted, yet all veins demonstrated abnormal, continuous flow. A significant proximal venous obstruction was indicated at the level of the left clavicle by ultrasound based on the observed abnormal flow. A chest X-ray and computed tomography was ordered, and the presence of a large Pancoast tumor was discovered. It extended superiorly from the left lung towards the clavicle, extrinsically compressing the proximal left subclavian vein. The patient subsequently had concurrent chemotherapy and radiation therapy treatment and rehabilitation. The second patient presented with a mild fever and tachycardia and was status postcervical tumor surgery. The ultrasound revealed multiple segments of homogenously echogenic, Doppler-silent, incompressible structures visualized adjacent to the deep vasculature system throughout bilateral lower extremities. These structures could easily be mistaken for DVT as they appeared similar in B-mode character. Clear identification of venous flow demonstrated around these structures differentiated the veins, and the contiguous visualization of the vein lumen, from these structures. These structures were diagnosed as Schwannoma, tumors consisting only of Schwann cells, that run along the nerves, which in turn run along the deep vasculature.
Characterization of Blood Flow Patterns in the Hepatoportal, Mesenteric, and Renal Vessels by Analysis of Doppler Spectral Waveforms
Authors: Neumyer Marsha M.
Published: March 2018

Exploration of the abdominal arteries and veins may be technically challenging but it also reveals valuable information about the blood flow patterns present in normal vessels and those with pathology. While B-mode imaging demonstrates the morphology of vessel walls and lumens, spectral, color and power Doppler imaging detail the presence, location and severity of disease. Evaluation of the hepato-portal system provides information on blood flow patterns through the arteries, veins and collateral network that supply and drain the liver in the normal patient and those with hepato-portal dysfunction. Interrogation of the mesenteric system in the pre and post-prandial patient reveals the fascinating changes in Doppler spectral patterns that occur with alterations in flow demand in response to the metabolic demands associated with digestion. Renal duplex studies provide an opportunity to experience changes in blood flow patterns that occur not only with stenosis and occlusion of the renal artery and its branches but also with changes in vascular resistance of the end –organ. As with the circulatory systems in other areas of the body, B-Mode imaging of the abdominal vessels complemented with analysis of the Doppler spectral waveforms yields valuable clues to the detection and classification of vascular disorders.
Lower-Extremity Arterial Air Plethysmography Evaluation
Authors: McPharlin Michalene
Published: March 2018

Plethysmography is a noninvasive technique based on detecting small volume changes in the limb secondary to the cardiac cycle. These changes provide a methodology for qualitative assessment of arterial waveforms and are obtained in conjunction with the measurement of systolic blood pressures. The quality of the waveform is directly related to technical components of the study as well as physical components of the patient. Interpretation of the waveform includes the utilization of qualitative waveform descriptor categories, comparison of waveforms to adjacent ipsilateral levels, as well as contralateral waveforms at the same level. Examples of normal findings and various levels of arterial occlusive disease states will demonstrate the practical application of this testing technique. However, plethysmography does have a number of potential sources of error that must be recognized to ensure the study is of diagnostic quality. These potential pitfalls are described as well as some important considerations to provide the most accurate information. Although other studies may provide greater detail about the presence and location of arterial occlusive disease, plethysmography does provide an efficient and cost-effective method to assist in the diagnosis and management of the disease process.
Arterial Duplex Imaging of Lower-Extremity Arteries and Interventions
Authors: Hodgkiss-Harlow Kelley D. , Bandyk Dennis F.
Published: March 2018

The application of duplex ultrasound for the evaluation of patients with lower-limb arterial occlusive disease provides the clinician with detailed information on its location, extent, and severity. Duplex scanning from the visceral aortic segment to the tibial arteries allows the detection of aneurysms and occlusive disease with a classification of its severity, including the presence of critical limb ischemia. Testing should be performed in conjunction with limb pressure measurements to accurately categorize arterial hemodynamics and functional impairment. Interpretation of duplex-acquired velocity spectra recordings is fundamental to successful clinical evaluation, including the characteristic features of normal versus and abnormal lower-limb arterial flow and hemodynamic changes associated with stenosis both at the occlusive lesions and its impact on distal limb perfusion. Duplex testing is accurate both before and after intervention for the diagnosis of occlusion and stenosis severity allowing decisions regarding treatment (medical, open surgical repair, endovascular therapy) to be made. Scanning can provide an arterial map of occlusive or aneurysm lesions analogous to magnetic resonance or computed-tomography angiography. An important duplex ultrasound application is for the surveillance of lower-limb bypass grafts and peripheral angioplasty for the development of stenosis that is their common mode of failure. The detection of high-grade stenosis in an arterial repair allows for pre-emptive treatment before thrombosis and improves long-term patency.
Ultrasound-Guided Transcatheter Ethanol Injection and Sclerotherapy of an Arteriovenous Malformation of the Foot
Authors: Seckora Makenzie M. , Pizzo Del David J. , Link Daniel P.
Published: March 2018

Introduction

Arteriovenous malformations (AVMs) are abnormal, direct connections between the arteries and veins. AVMs are most commonly associated with the brain and spinal cord; however, they can occur in any part of the body. Duplex ultrasound can play a pivotal role in both the diagnosis and treatment of AVMs.

Methods

A high-resolution duplex ultrasound machine along with a high-frequency 15–7 MHz probe was used in transcatheter techniques to treat an AVM. Ultrasound was used to guide arterial and venous access, target specific vessels for treatment, and ultimately reduce radiation exposure.

Case Report

A 6-year-old female patient was diagnosed with a left foot AVM and hemihypertrophy (Parkes Weber). Despite previous treatments with coil embolization, the patient developed discoloration and swelling of the left second toe and a nonhealing ulceration on the plantar aspect of the left foot. Duplex ultrasound was used to confirm the diagnosis and to aid in the treatment of the AVM. Under ultrasound guidance, catheter access was achieved via the dorsalis pedis artery and advanced distally into a large digital artery directly associated with the AVM. Anhydrous ethanol alcohol was injected through the catheter to treat the arterial inflow of the AVM. Ultrasound was then used to identify cavernous veins on the plantar aspect of the foot and to guide direct ethanol injections into the affected veins. Two weeks after the procedure, ultrasound confirmed 90% reduction in the AVM. The patient's toe discoloration resolved, and the ulceration healed.

Conclusion

Undiagnosed or poorly managed AVMs of the extremities can result in multiple surgical resections and skin deterioration. Ultrasound imaging of arteriovenous malformations with B-mode, color, and Doppler is essential for the evaluation (staging), treatment, and follow-up of vascular malformations. Ultrasound-guided transcatheter and direct techniques can be used in the treatment and prolonged management of AVMs. The application of ultrasound during these treatments will reduce radiation exposure in these patients.
The Postexercise Common Femoral Artery Doppler Waveform: A Powerful Noninvasive Vascular Laboratory Test to Exclude Aortoiliac Disease
Authors: Kalish Jeffrey , Nguyen Tony , Hamburg Naomi , Eberhardt Robert , Farber Alik
Published: March 2018

Objective

The detection of aortoiliac occlusive disease (AIOD) has important clinical implications for patients with peripheral arterial disease. The clinical utility of the common femoral artery (CFA) Doppler waveform (DW) at rest and after exercise in the detection of AIOD was investigated.

Methods

A retrospective review was performed of 203 consecutive exercise treadmill tests at Boston Medical Center from January 2006 to July 2009 that included both resting and postexercise CFA DW. The study population consisted of 62 patients (124 limbs) who had additional anatomical imaging studies, including computed tomography, magnetic resonance, or conventional angiography. Two blinded observers reviewed the CFA DW and imaging studies. Triphasic or biphasic CFA DW were considered normal. Monophasic CFA DW was considered abnormal. To determine test characteristics, resting and postexercise CFA DW were compared with the imaging findings. Similar analysis was performed for the ankle brachial index (ABI) for comparison.

Results

Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (with 95% confidence interval) of the resting CFA DW in detecting a >50% aortoiliac stenosis were 29% (21–37%), 92% (87–97%), 31% (23–39%), 91% (86–96%), and 85% (79–91%), respectively. The results for the postexercise CFA DW in detecting a >50% aortoiliac stenosis were 93% (89–97%), 59% (50–68%), 22% (15–29%), 99% (97–100%), and 63% (55–71%), respectively. Resting CFA DW detected only 4 of 14 limbs with AIOD. Postexercise CFA DW markedly increased the detection of AIOD: 9 limbs with normal resting CFA DW were correctly diagnosed on the basis of postexercise CFA DW for a total of 13 of 14 limbs with AIOD. In addition, postexercise change in ABI was analyzed and only detected 9 of the 14 limbs with AIOD.

Conclusions

These findings support the use of postexercise CFA DW to enhance the evaluation of clinically important AIOD. The sensitivity of the test to detect AIOD was improved compared with resting CFA DW or postexercise drop in ABI. Normal postexercise CFA DW has high predictive value in excluding significant inflow disease.
Duplex Ultrasound Findings in Intravenous Drug Users with Femoral Vein Injection
Authors: Smith Watson B. , Campbell Kari A. , Zierler R. Eugene
Published: March 2018

Introduction

—Intravenous drug users (IVDUs) who access their common femoral vein (CFV) repetitively are at risk for a variety of vascular complications. Duplex ultrasound is often the initial imaging modality used when these patients present for medical care. The purpose of this study was to document the duplex ultrasound findings and associated clinical outcomes in IVDU with CFV injection.

Methods

—This was an institutional review board-approved retrospective review of all lower-extremity duplex ultrasound examinations performed on IVDU in our laboratory from January 1, 2007 through December 31, 2009. Vascular laboratory reports and images were reviewed along with clinic and hospital records.

Results

—The study cohort included 29 patients, 52 lower limbs, and 102 duplex ultrasound examinations. There were 16 males and 13 females with an age range of 19 to 53 years (mean, 33 years). Follow-up intervals ranged from 0 to 24 months (mean, 11 months). The most common indication for duplex ultrasound was a swollen painful leg. Abnormalities were present on duplex ultrasound in 92% of the limbs. A CFV stricture was identified in 63% of the limbs and 44% had cystic masses associated with the proximal femoral vessels. Progression to DVT was observed in 45% of the CFV strictures. Arterial lesions were found in 21% of the limbs. One retained needle was identified. Venous or arterial interventions were required in 9 limbs.

Conclusion

—Femoral injection in IVDU results in a high prevalence of abnormal vascular findings on duplex ultrasound. Although venous lesions were more common, arterial and venous interventions were approximately equal in frequency. The IVDU patients also had a high prevalence of lower-limb DVT. The vascular laboratory can play an important role in the evaluation of IVDU with CFV injection. This review suggests that duplex ultrasound in these patients should include both a complete lower extremity venous examination and assessment of the iliac and femoral arteries.
Impact of Routine Use of a Tourniquet during Preoperative Vein Mapping on the Diameter of Arm Veins and Creation of Functional Arteriovenous Fistulas
Authors: Jayaraj Arjun , Crawford Courtney , Logar Christine , Hatsukami Thomas , Allen Brenda , Tran Nam
Published: March 2018

Purpose

—To examine the impact of tourniquet usage during preoperative vein mapping on diameter of arm veins and functionality of autogenous arteriovenous fistulas (AVF) thus created.

Methods

—A total of 160 patients in need of hemodialysis access underwent segmental upper-extremity duplex ultrasonography. Vein measurements were performed with and without application of an upper arm tourniquet. Criteria for AVF creation included superficial veins with diameter ≥3.0 mm and continuity with proximal superficial veins. Group I had patients with veins with diameter ≥3.0 mm attained without use of a tourniquet whereas Group II had patients with vein diameters ≥3.0 mm achieved with a tourniquet. Clinical outcomes were compared between the two groups.

Results

—Of the 160 patients, 114 underwent placement of an upper extremity AVF, whereas the remaining underwent placement of an AV graft or peritoneal dialysis catheter. Of these, 87 patients were in Group I and 27 in group II. The primary outcome was defined as a functional AVF within 6 months of surgery. In Group I, almost two of every three fistulas created were successful, resulting in a failure rate of 37.5%. In contrast, only one out of every six AVFs in Group II was successful resulting in a failure rate of 86%.

Conclusion

—The use of tourniquet results in a greater number of patients qualifying for AVF creation. However, AVFs created using vein diameter obtained from the application of a tourniquet have much greater rates of failure compared with AVFs created by using a vein of similar diameter but without a tourniquet.
Importance of Multi-Planar Imaging for the Evaluation of Arterial Stents
Authors: Goodwin Joseph D. , Amador Fernando , Lipsitz Evan C. , Berdejo George L.
Published: March 2018

Endovascular intervention has emerged as a first-line therapy for peripheral arterial occlusive disease. Duplex ultrasound has been used for surveillance after vascular interventions and is an integral component for evaluating patients after endovascular procedures. Technical protocols vary; however, most include color flow imaging and pulsed Doppler with an emphasis on single plane long-axis imaging. Exclusion of short-axis imaging, however, may miss pathologies involving the medial or lateral vessel wall. This report will describe the importance of imaging in multiple planes for evaluation of the peripheral arteries in patients after endovascular interventions.
Comparison of Automated Oscillometric Measurement of Ankle Brachial Index with Standard Doppler Measurement as a Screening Tool for Peripheral Artery Disease
Authors: Jayaraj Arjun , Blomberg Jane , Kohler Ted
Published: March 2018

Objective

—The use of continuous-wave Doppler ultrasound to determine ankle brachial index (ABI) is the gold standard for diagnosing asymptomatic peripheral artery disease. This method is labor intensive, requires training, and has considerable interobserver variability. Automated oscillometric measurement (AOM) of blood pressure is fast, simple, and generally available in clinics, but there are few studies of its usefulness for determination of the ABI. We compared these two methods to determine the usefulness of AOM as a screening tool. We also assessed the agreement between two different AOM devices.

Methods

—Seventy-four patients, including 33 diabetics, who presented to our vascular clinic to have their ABI measured were enrolled. A vascular nurse certified in ABI measurements (J.B.) performed blood pressure measurements in all four extremities by using the traditional Doppler method and two different automated oscillometric devices. The order of the three measurements was randomized. To avoid the effect of interrelated measures within each subject, we analyzed left and right legs separately (74 for each group). Measurements were grouped as abnormal (ABI = 0.90), normal (ABI 0.91–1.30), or elevated (ABI > 1.30). Agreement between Doppler measurements and oscillometric measurements was investigated by use of Pearson's χ2 analysis. In addition, correlation coefficients, including Spearman and Gamma statistic, were computed, as was the Kappa statistic, a measure of interrater agreement.

Results

—The correlation coefficients for comparison of Doppler with the two AOM devices were 0.70 and 0.73 ( p < 0.01). For the diabetics, correlation coefficients were 0.64 and 0.70 ( p < 0.01). The intermachine correlation ranged from 0.65 to 0.69 ( p < 0.01). As a screening tool oscillometric measurement had a sensitivity of 44%, specificity of 96%, positive predictive value of 87%, negative predictive value of 68%, and am accuracy of 73%. Kappa statistic was 0.41.

Conclusions

—Oscillometric measurement of ABI had good correlation with Doppler ultrasound measurements, and there was little difference between the two different machines tested. AOM has value as a rapid, initial screening examination in primary care clinics. When positive, the examination is a reliable indicator of atherosclerosis to identify patients who need intense risk factor modification. When negative, it is only moderately predictive of the absence of disease. Patients suspected of high risk for atherosclerosis who have negative examinations require further testing.
Digital Metronomes and Metric Devices for Venous Ablation Procedures
Authors: Mueller Richard L. , Mueller Bridget , Mueller Jacqueline
Published: March 2018

Ultrasound-guided endovenous ablation procedures have revolutionized the care of patients with venous reflux disease for more than a decade. Precise application of energy forms and substances that occlude superficial truncal veins is pivotal for technical success. Exact spatial and temporal delivery of ablative vectors to the vein is operator dependent, readily measurable, and hinges on precise timing of pullback of the various catheters and fibers that effect vein ablation. Several physical and online electronic pullback timing aids, including metronomes and other metric devices, are available to ensure precise ablation, although operators are often left to discover them. Although these are not ultrasound devices per se, they are essential adjuncts for the effective delivery of a key ultrasound-guided intervention and are used in direct proximity to ultrasound. To the authors’ knowledge, there are no publications regarding this key ablation step, which is typically dependent on operator resourcefulness.