bluuebunny/crossref_metadata_2025 huggingface dataset:
Color Duplex of the Renal Arteries: Diagnostic Criteria and Anatomical Windows for Visualization
Authors: Coombs Peter
Published: March 2018

The color duplex examination of the renal arteries continues to create diagnostic uncertainty in the clinical environment, affecting its reputation as a screening test for renovascular hypertension. There are two key reasons for this. The first is continued uncertainty about the diagnostic criteria. This is largely a debate about extrarenal versus intrarenal evaluation. Extrarenal criteria is required if the examination is to be considered optimal; however, the role of the valuable data obtained in the intrarenal assessment requires ongoing consideration. Both methods are described, and an integrated pragmatic approach to implementation is discussed. The second uncertainty arises because of the technical difficulties in visualizing the renal arteries throughout their length. Visualization is important in ensuring the accuracy of the examination. This paper looks at 10 sonographic windows through which the renal arteries can potentially be investigated. This review paper asserts that well-performed renal artery ultrasound is a valuable screening examination for a selected group of hypertensive patients.
Pan-Diastolic Flow Reversal in the Subclavian Artery: An Indicator of Aortic Insufficiency
Authors: Oglesby Beverly , Sorrell Kathryn
Published: March 2018

Introduction

For many labs, Doppler evaluation of the subclavian artery (SCA) is routinely included in the carotid protocol. At our center, we have noted that many patients have a unique SCA waveform present bilaterally, characterized by flow reversal throughout the entire diastolic interval. The purpose of this study was to define the cause and significance of these atypical SCA waveforms.

Methods

During a 6-month period, 21 patients with normal bilateral SCA waveforms, who also had Doppler echocardiography (DEC), were evaluated for the presence of aortic insufficiency (AI). Similarly, 25 patients who had pan-diastolic flow reversal (PDFR) in their SCAs bilaterally were also evaluated for the presence of AI on DEC. Patients with upper extremity deep vein thrombosis (DVT), bypass grafts, compartment syndrome, or dialysis access were excluded from this investigation.

Results

Of the 25 patients with bilateral SCA PDFR, 20 patients had aortic regurgitation present on DEC. Normal triphasic waveforms were present bilaterally in 21 patients. Of these, 20 patients had no evidence of AI by DEC. Statistical analysis resulted in a sensitivity of 80%, specificity of 95%, positive predictive value of 95%, and an overall accuracy of 87% for the detection of AI by SCA Doppler evaluation.

Conclusion

PDFR in the SCA bilaterally is a waveform associated with AI. Although DEC is the preferred technique for the evaluation of suspected aortic valve dysfunction, many patients with this condition have no detectable murmur or other indication of this condition. Consequently, the identification of this unique waveform in both SCAs during carotid duplex may provide useful clinical information and lead to additional cardiac workup.
Role of Intraoperative Completion Duplex Scan for Diagnosis of Iatrogenic Injuries of the Common Femoral Artery (CFA) and External Iliac Artery (EIA) during Endograft Placement
Authors: Marks Natalie A. , Ascher Enrico , Hingorani Anil , Schutzer Richard
Published: March 2018

Objective

To assess whether the femoral artery entry site could cause early endograft limb occlusion complication, we prospectively evaluated the ipsilateral common femoral artery (CFA) with intraoperative duplex scans (IDS).

Methods

Forty-seven patients underwent 41 abdominal aortic and 8 common iliac artery (CIA) aneurysms repair with endografts. All procedures were performed via open exposure of the CFA. All patients underwent IDS of the CFA and distal external iliac artery after repair of the arteriotomies.

Results

Overall, there were 91 arteries assessed with IDS. Overall incidence of significant lesions requiring repair was 11 of 91 (12%). In 10 arteries (11%) we documented intimal flaps causing severe (>80%) stenoses that required repair. One more patient (1%) had no defects at the repair site, but low CFA peak systolic velocity with ratio 2:1 as compared with the contralateral CFA. Intraoperative abdominal duplex scan revealed a severe stenosis in the ipsilateral CIA that was not observed on the completion arteriogram. In addition, 13 (14%) nonsignificant flaps were visualized. No limb thromboses were noted in this group of patients on follow-up examinations.

Conclusions

IDS is helpful in detecting clinically unsuspected technical defects of the CFA. Timely diagnosis and repair of these defects may improve early patency of endograft limbs.
Traumatic Intracranial Arteriovenous Malformation
Authors: Kala Rajinder S. , Lively Stephen A. , McDevitt Daniel T. , Levy Alan M. , Mackay Bruce C. , Elder Terri A. , Marin Ma Lalane A. , Quinteros Diana E.
Published: March 2018

Introduction

This report is the first of a traumatic intracranial arteriovenous malformation (AVM) identified with the use of ultrasound imaging. This case study involves a 49-year-old man with a traumatic intracranial arteriovenous malformation that was identified using transcranial imaging and spectral analysis studies.

Methods

Transcranial ultrasonic imaging with spectral analysis was performed, using a 2.5MHz hand-held probe identified the traumatic AVM. Correlated follow-up testing was conducted using magnetic resonance angiography and computed tomography scan. Results were correlated with ultrasound findings.

Results

Bilateral middle cerebral and anterior cerebral arteries were identified revealing normal waveforms and velocities. Left posterior cerebral artery could not be insonated or visualized whereas the right posterior cerebral artery revealed normal waveforms and velocities. A single area of “jet” flow was in the distal internal carotid artery (in the area of carotid cavernous sinus). A peak systolic velocity of 318 cm/sec and an end diastolic velocity of 152 cm/sec were identified in the “jet,” which is consistent with the clinical suspicion of an AVM. The magnetic resonance angiography demonstrated normal right internal carotid, middle cerebral, and anterior cerebral arteries. On the left, there was diffusion of signal in the region of the cavernous sinus. This flow signal extended anteriorly and laterally into the region of the lateral orbit. Also, a second channel of flow appeared extending up into the middle cerebral artery territory, suggesting some retrograde venous flow. Findings reported were consistent with AVM of the carotid artery at the cavernous sinus.

Conclusion

This report represents with the first reported incidence of diagnosis of traumatic AVM of intracranial vessels. Duplex scanning should be considered if concern exists for such an entity as it appears capable of actually identifying this pathology.
Percutaneous Ultrasound-Guided Thrombin Injection for Coagulation of a Post-Traumatic Superficial Temporal Artery Pseudoaneurysm
Authors: Blasingame Nancy , Lewinstein Charles , Winter Jeffrey , Whitney Brooks A. , Zarge Joseph I. , Doubler Peter H. , Villemure Patrice
Published: March 2018

Introduction

Pseudoaneurysm of the superficial temporal artery (STA) is rare and most commonly caused by blunt trauma. The STA is the most frequent site of traumatic aneurysm in the face because of its anatomic location. The diagnosis is easily confirmed by color duplex ultrasound. The usual treatment is surgical ligation and resection. This type of pseudoaneurysm can be successfully treated by ultrasound-guided injection of thrombin, which is easy, quick, and cost-effective.

Case report

A 71-year old man on Coumadin therapy fell out of bed and lacerated his right forehead. A pulsatile mass under the laceration was imaged with color duplex ultrasound, which demonstrated a 1.5- x 1.0-cm pseudoaneurysm off a branch of the STA, 6 mm below the skin line. Under ultrasound guidance, a 21-gauge needle was introduced into the pseudoaneurysm and 300 units of thrombin was injected into the sac with complete thrombosis of the pseudoaneurysm cavity. The STA remained patent after the procedure, and the pseudoaneurysm remained thrombosed after the procedure.

Conclusions

Post-traumatic STA pseudoaneurysm can be safely and successfully treated with ultrasound-guided injection of thrombin. Percutaneous ultrasound-guided injection of thrombin for repair of post-traumatic STA pseudoaneurysm is a fast, safe, and effective alternative to surgical repair resulting in rapid thrombosis of the pseudoaneurysm.
Recurrence of Femoral Pseudoaneurysm after Ultrasound-Guided Thrombin Injection
Authors: Busuttil Steven J. , Schilling Rebecca , Lilly Michael P. , Neschis David G. , Flinn William R.
Published: March 2018

Although pseudoaneurysm is a rare recurrence after ultrasound-guided thrombin injection, it can occur. We report a patient who, despite complete pseudoaneurysm thrombosis, visualized on ultrasound, repeatedly reformed his femoral pseudoaneurysm. For the femoral pseudoaneurysm to recur, continued leakage via the arterial defect was necessary, as the result of an inability to seal the pseudoaneurysm defect. In addition significant thrombolysis of the already-formed thrombus needed to occur. In this patient, the powerful antiplatelet agents and Von Willebrand factor dysfunction could have easily prevented the sealing of the common femoral artery defect. In addition, thrombolysis would likely be enhanced by the increased levels of plasmin that are associated with end-stage renal disease patients on hemodialysis. Ultrasound-guided thrombus injection of iatrogenic femoral pseudoaneurysms is generally safe, effective, and well tolerated. Even with visualization of complete thrombosis, there remains a small group of patients that are at risk for recurrence and that ultimately require surgical repair. This group of patients could easily be missed unless strict adherence to follow-up screening protocols is followed.
Complex Lower-Extremity Venous Disease
Authors: Hannon Kathleen , Iafrati Mark , Mackey William C.
Published: March 2018

Venous insufficiency is a potentially debilitating condition causing symptoms such as tiredness in the legs, chronic pain, and in many instances ulcerations and skin changes. Although the diagnosis of venous insufficiency by duplex ultrasound has been previously described in the literature, there are cases that present to the vascular laboratory with unusual presentations of venous insufficiency. The case described in this study is one such presentation. The use of duplex ultrasound in this case was instrumental in determining the clinical pathway for the treatment of his chronic venous disease.
Superficial Venous Thrombosis Embolizes to Cause Pulmonary Embolus
Authors: Prem Jeffrey , Beck Chris , Lancaster Mark , Miller Jeffrey , Troyer Randy , Williams Rebecca
Published: March 2018

Introduction

Superficial venous thrombosis (SVT) has not received as much attention in research and publications as that of deep venous thrombosis. This case demonstrates the importance of identifying the characteristics of an SVT before releasing the patient and stating the patient was positive for SVT.

Case Study

A 56-year-old man presented to our emergency department complaining of left lower-extremity pain for 2 weeks. The patient described the location of the pain as an area below his left knee. The area was erythematous, cord-like, and the patient denied any history of trauma. A venous duplex was performed on the left lower extremity. Upon examination of the greater saphenous vein (GSV), a free floating SVT was noted. The thrombus moved with patient respirations and was described as a loosely attached, acute SVT.

Conclusion

Research has provided clinicians the percentages of SVT that cause a pulmonary embolism. However, the question is raised: do the superficial venous thromboses that cause a pulmonary embolism become dangerous because they propagate into the deep system or can the SVT itself embolize from the superficial system and travel through the deep system and into the lungs? This case study revealed a loosely attached free-floating SVT within the GSV in the distal thigh. This SVT moved proximally and joined the otherwise-unaffected deep system and moved out of range of ultrasound and embolized to the pulmonary arteries. The patient complained of chest pain and shortness of breath within 2 min. The patient was treated with systemic thrombolytics and anticoagulation and had a favorable outcome.
Arterial Revascularization in Patients with Diabetes: An Overview
Authors: Rollins David L. , Kalakuntla Vikram , Wilson Anne
Published: March 2018

Arterial revascularization in patients with diabetes is challenging. The diabetic state predisposes patients to develop foot lesions, which often require distal arterial revascularization for limb salvage. New interventional techniques have allowed improved early limb salvage with decreased morbidity through the use of minimally invasive procedures. Standard arterial bypass techniques result in more durable limb salvage for most patients. Although long-term results and survival are reduced compared with nondiabetic patients, arterial revascularization is efficacious in healing foot lesions and improving the quality of life.
The Incidence of Popliteal Artery Aneurysms in Patients with Abdominal Aortic Aneurysms
Authors: Grimm Jodi J. , Wise Matthew M. , Meissner Mark H. , Nicholls Stephen C.
Published: March 2018

Purpose

We sought to evaluate the incidence of popliteal artery aneurysms (PAAs) in patients who have a diagnosis of abdominal aortic aneurysm (AAA).

Methods

It has been previously documented that patients with AAA have a greater incidence of PAA. During the past 11 years, 163 patients presented to the Vascular Laboratory at Harborview Medical Center with an AAA. Seventy-one (44%) of these patients had popliteal arteries evaluated using duplex ultrasound (Advanced Technology Laboratory 3000, 5000, 9000). The popliteal artery was measured in the anteroposterior and transverse diameters. A PAA was defined as an artery larger than 1.5 cm and/or an ectatic artery with thrombus present.

Results

Fourteen patients had a PAA; six patients (43%) had PAA bilaterally, for a total of 20 aneurysms. Nineteen (95%) aneurysms had thrombus present. Various interventional treatments were used: five limbs (25%) received an arterial bypass graft, two (10%) underwent amputation, and two (10%) received thrombolytic therapy

Conclusions

There is a high incidence of PAA in patients with AAA (19.7% in this series). Patients with a diagnosis of AAA should be screened for PAA and considered for elective repair to prevent the high rate of complications associated with these lesions.
Prevalence of Carotid Siphon Stenosis in Patients Referred for Cerebrovascular Evaluation
Authors: Hughes Joseph P. , Bowman Gary R. , Dubin Rick , Cochran Terence A. , Porreca Francis J. , Kalisz Denise , Rush Michael P.
Published: March 2018

Introduction

The carotid siphon is second only to the carotid bifurcation in the prevalence of hemodynamically significant atherosclerotic plaque formation, yet few noninvasive vascular laboratories report interrogation of this region during routine noninvasive vascular evaluations. The purpose of this investigation was to determine the prevalence of carotid siphon stenosis in patients referred for noninvasive cerebrovascular evaluation.

Materials and Methods

During a 2-month period, 178 patients (94 male, 84 female, mean age, 71.8 years) were referred to the vascular laboratory for cerebrovascular evaluation, which included interrogation of the extracranial carotid, vertebral, and subclavian arteries as well as the intracranial ophthalmic artery and carotid siphon. All intracranial examinations were performed using a phased array imaging transducer (2–4 MHz).

Results

Ten patients (6%, 10/178) were found to have hemodynamically significant carotid siphon stenosis. There was a statistically significant association between the presence of carotid siphon stenosis and cervical bruit ( p ≤ 0.05), follow-up of known extracranial carotid artery atherosclerosis ( p ≤ 0.001), and a combination of hypertension, hyperlipidemia, and coronary artery disease ( p ≤ 0.01).

Conclusion

Investigation of the carotid siphon is worthwhile when performed in conjunction with extracranial carotid duplex examinations. Siphon lesions detected during the cerebrovascular examination, especially in those with cervical bruits, known extracranial atherosclerotic disease, and combinations of risk factors, may affect medical or interventional therapy and can lead to a reduction in neurovascular events.
Duplex Evaluation of a Carotid Artery Aneurysm
Authors: Ripoll Juan C. , Oglesby Beverly , Sorrell Kathryn , Harris Shelley
Published: March 2018

Introduction

A carotid artery aneurysm is a rare yet significant finding. The purpose of this report is to describe the clinical presentation and sonographic findings of a post-endarterectomy aneurysm.

Case Report

A 65-year-old woman presented to our laboratory with an enlarging mass on the left side of her neck. Her medical history was significant for a left carotid endarterectomy approximately 1o years earlier.

Methods

A standard carotid Duplex evaluation was performed. Gray scale imaging on the left side of the neck revealed multiple irregular dilatations along the distal common carotid (CCA) and internal carotid arteries (ICA).

Results

The maximum diameter of the distal CCA measured 2.3cm compared with 0.8cm proximally. Areas of mixed echogenicity suggesting thrombus formation were observed in the CCA where the diameter of the artery was at its greatest. Color and spectral Doppler demonstrated highly turbulent flow in the aneurysmal area, along with an unremarkable velocity profile proximal and distal to this segment. The unusual irregularity of these dilatations along with no obvious neck characteristic of a pseudoaneurysm made it difficult to distinguish whether this lesion represented a false or true aneurysm. A computed tomography angiogram (CTA) demonstrated aneurysmal dilatation of the carotid artery with possible pseudoaneurysm formation at the level of the bifurcation. Angiography and subsequent surgical exploration revealed that the lesion was a true aneurysm. Repair was accomplished by insertion of a 6mm polytetrafluoroethylene interposition graft.

Conclusion

Color Duplex ultrasound was an accurate technique for identification of an uncommon carotid artery aneurysm.
Carotid Aneurysm: A Case Study
Authors: Pazienza Kathryn J. , Duke Rhonda I. , Whitehouse W. M. , Higginbotham Candace
Published: March 2018

Introduction

A 73-year-old woman presented to the vascular laboratory for evaluation of a right-sided neck mass. This case study details the course of her evaluation and the need for using carotid duplex in a complete work-up. The patient had noted a mass over several months, but it was asymptomatic.

Case Report

The patient had a computed tomography scan at an outside institution, which showed an intensely enhancing lesion within the right carotid bifurcation, measuring 2.9 cm × 2.1 cm. The study was interpreted as a carotid body tumor and was referred for surgical consultation. A carotid duplex exam was ordered for further definition of the lesion. The carotid duplex exam revealed a 2.7-cm × 2.5-cm mass within the carotid bifurcation, which appeared to be a carotid aneurysm. A cerebral angiogram was obtained, which confirmed the diagnosis of carotid aneurysm.

Conclusion

Aneurysms of the extracranial carotid arteries are uncommon arterial lesions. Many different modalities may be used when evaluating a carotid mass, but this case demonstrates the importance of carotid duplex scanning.
Practical Approaches to Billing, Reporting, and Staffing Issues in the Vascular Laboratory
Authors: Garbani Nathalie I.
Published: March 2018

The following recommendations are intended to offer a practical approach to the understanding of non-technical issues arising in a vascular laboratory. While as sonographers we would all probably prefer to focus on the technical aspect of the profession, we are also living in a society shaped with policies, rules and regulations. It is therefore imperative that we also understand the non-technical aspects of the profession, to maneuver safely in clinical setting and offer safety and quality to our patients.
Changes in Perforating Vein Reflux after Saphenous Vein Ablation
Authors: Parks Tara , Lamka Christine , Nordestgaard Aksel G.
Published: March 2018

Introduction

This prospective duplex study evaluates what percentage of perforators remains incompetent after saphenous vein ablation by endovenous laser ablation (EVLT).

Methods

Patients with venous disease, incompetent perforating veins (IPVs), and saphenous vein reflux identified on initial duplex ultrasound exam were included. Perforators were re-evaluated 3 days postoperatively for size and competency.

Results

One hundred patients with a mean age of 53 years with incompetent saphenous veins and a total of 169 IPVs were included. Of the 169 initially incompetent perforators, 92 (54.4%) became competent, 21 (12.5%) occluded, and only 56 (33.1%) remained incompetent after the EVLT procedure. When grouped by diameter, 25 (89.29%) of small-diameter perforators (<3 mm), 49 (62.03%) of medium-diameter perforators (3–4 mm), and 18 (29.03%) of large-diameter perforators (>4 mm) became competent after the EVLT procedure. Only 3 of the 28 (10.7%) small-, 23 of the 79 (29.1%) medium-, and 30 of the 62 (48.4%) large-diameter perforators remained incompetent after the EVLT procedure. Preoperative perforator diameter was a determining factor in reversal of reflux ( p < 0.0002).

Conclusion

Only 33% of all initial incompetent perforators remained incompetent after the EVLT procedure. Reversal of incompetence was size dependent.
Ultrasound-guided Thrombin Injection for Gluteal Pseudoaneurysm Resulting from Trans-sacral Drain Removal
Authors: Harthun Nancy L. , Ripplinger DeeAnn
Published: March 2018

Introduction

Thrombin injection for the treatment of arterial pseudoaneurysms has been performed safely and effectively for many years. These pseudoaneurysms typically develop after a performance of a percutaneous procedure that uses the common femoral artery for access. This technique has also been applied effectively for pseudoaneurysms arising from other arteries. This report presents the first use of thrombin injection technique with ultrasound guidance for ablation of a gluteal pseudoaneurysm.

Case Report

A 44-year-old man presented with complicated diverticulitis and was treated with two operations. Afterward, he had an infected pelvic fluid collection that was drained with computed tomography-guided, trans-gluteal approach. After drain removal, pain developed in the right buttock, and a gluteal pseudoaneurysm was diagnosed, which was successfully treated with an ultrasound-guided, thrombin injection.

Conclusions

Complications resulting from trans-gluteal drainage are unusual. Pain and hemorrhagic complications have been documented and are more common when a transpiriformis muscle approach is mandated by location of the fluid collection. Thrombin injection provided a rapid, safe, and effective treatment for this complication. This approach required no significant anesthesia and recovery was less than 2 days. Ultrasound demonstrated clearly that the gluteal fluid collection was a pseudoaneurysm and that it demonstrated characteristics favorable for thrombin injection.
Alterations of Flow-Mediated Dilation of the Brachial Artery in Women after Menopause
Authors: Montenegro Carlos Antonio B. , Mathias Marcia L. , Leite Sandra P. , Garrido Karla U. , Salles–Cunha Sergio X.
Published: March 2018

Introduction

Risk of cardiovascular diseases increases after menopause. Decrease in estrogen alters endothelium function, the first event in the atherosclerotic process. Endothelium function can be assessed by flow-mediated dilatation (FMD) during reactive hyperemia. We compared differences in brachial artery FMD in women before and after menopause.

Methods

Average ages of control (n = 35) and postmenopausal (n = 38) women were 34 ± 8 (SD) and 57 ± 7 years respectively. No subjects were on estrogen therapy or had known risk factors for cardiovascular disease. Brachial artery FMD was measured 5 cm above the cubital crease, using a 14 MHz transducer. B-mode images were selected during diastole using the flow waveform. Diameter measurements were performed before brachial artery occlusion and 60 seconds after release of a 5-min occlusion accomplished with pneumatic cuff inflation. FMD expressed the percentage change in diameter during reactive hyperemia versus baseline.

Results

Average FMD was 19 ± 6% (11 – 30%) for controls, decreasing significantly to 14 ± 6% (3–26%) post-menopause ( p < 0.001 by t-test). FMD was abnormally lower than 10% in 9 post-menopausal women, 7 older than 60 years, and 8 with menopause ≥10 years.

Conclusions

FMD decreased significantly post menopause and were abnormally low in older women with longer menopause. Changes in FMD with age, duration of menopause and relation of low FMD to risk development deserves further investigation to determine if FMD can be used as an independent risk factor.
Prevalence and Patterns of Small Saphenous Vein Reflux
Authors: Neuhardt Diana L. , Salles–Cunha Sergio X. , Morrison Nick
Published: March 2018

Objective

The small saphenous vein (SSV) often is a forgotten source of venous valvular insufficiency signs and symptoms or is a “victim” of unwillingness to treat. Either way, ultrasound (US) frequently focuses on the great saphenous vein without an equivalent thorough evaluation of the SSV. We investigated the prevalence and patterns of SSV reflux during a voluntary service to the community of Santiago de Guayaquil in Ecuador.

Methods

Patients were screened for SSV reflux while standing. A portable laptop scanner was used to examine the SSV at the proximal, mid, and distal calf (positions A, B, and C) in 410 legs of 205 subjects. Although all patients were C1 – C6 according to the clinical CEAP (i.e., clinical severity, etiology or cause, anatomy, and pathophysiology) classification, 14% of the legs were C0. Forward and reverse flows were noted after a variety of manual compressions. Only severe reflux lasting longer than 4 seconds is reported herein.

Results

The prevalence of SSV abnormalities was 17% (69/410). Reflux was noted in 54 (13%) of the extremities whereas in 15 (4%), the SSV did not have reflux but was intertwined with the pathways of varicose veins. The diameters of the refluxing veins were related to the location and extent of reflux. The most common pattern was reflux in the A, B, and C positions (n = 17) of SSV averaging 4.6 (A) to 4.4 mm (C) in diameter. Reflux was noted in the AB, A, and B positions in 10, 11, and 12 SSV, respectively; diameters of these veins averaged 4.1 (A) to 3.7 mm (B), 4.1 mm (A), and 3.4 mm (B). SSV reflux in the B and C and C only positions were least common (n = 4), noted in veins averaging 2.5 mm in diameter. Varicose veins interconnected with short SSV segments were noted in all three positions (A, B, and C) in seven legs whereas in eight legs the varicosities were segmental, most commonly in the B position (n = 6).

Conclusions

The prevalence of SSV abnormalities was significant. SSV reflux or connection to varicose veins was noted in close to one of five legs. The SSV should be evaluated at least at the proximal and mid calf to avoid missing significant reflux.
Ultrasound and Computed Tomography-Guided Thrombin Injection of a Type 2 Endoleak
Authors: Wilson Stephanie R. , Atnip Robert G. , Singh Harjit , Wilson Ryan H. , Zang William A.
Published: March 2018

Introduction

Type II endoleaks are a well-documented complication of endovascular aortic aneurysm repair. This case demonstrates the successful combined use of duplex ultrasound to assist in the percutaneous treatment of type II endoleaks.

Case report

A 75 year-old man who had previously undergone endovascular aortic aneurysm repair was found to have a type II endoleak. As the result of failure of the transfemoral endovascular coil embolization to repair the leak, the patient underwent computed tomography-and ultrasound-guided thrombin injection of the aneurysm sac via a trans-lumbar approach. Duplex ultrasound proved useful in guiding the placement of the translumbar needle, in confirming the thrombosis of the endoleak, and in demonstrating continued patency of the endograft.

Conclusion

The two imaging modalities worked in a complementary fashion to guide needle placement and to enable real-time imaging of color-enhanced flow within the aneurysm sac.
A Rare Axillary Artery Aneurysm with Limb-Threatening Ischemia
Authors: Grimm Jodi J. , Tran Nam
Published: March 2018

Introduction

Isolated subclavian or axillary artery aneurysms are extremely rare, accounting for less than 3% of peripheral aneurysms. These aneurysms can be caused by a secondary infection such as syphilis, trauma, Ehler – Danlos syndrome, poststenotic dilation from thoracic outlet obstruction, arthrosclerosis, or congenital reasons. They are at risk for rupture, distal embolism, and thrombosis. These complications can cause limb loss and or death.

Case Report

An 80-year-old woman presented to the emergency room with a cold left upper extremity. The patient had a history of atrial fibrillation, congestive heart failure, and hypertension. A presumptive diagnosis of peripheral emboli was made because of the patient's atrial fibrillation and recent myocardial infarction. She was taken to the operating room for a thrombectomy of the left brachial, radial, and ulnar arteries. At that time, a pulsatile mass was noted on the patient's shoulder, and an ultrasound was ordered. The ultrasound revealed a left axillary artery aneurysm measuring 3.62 cm anteroposteriorly x 3.72 cm transverse. There was nonocclusive thrombus within the lumen of the aneurysm. There was diminished, monophasic flow in the axillary and brachial arteries. Postoperatively the patient was placed on intravenous heparin. She was taken back to the operating room where a 7-mm Dacron graft was placed between the left axillary and brachial artery with exclusion of the axillary artery aneurysm. On postoperative duplex the bypass graft was patent. The patient did not suffer any long-term complications as the result of ischemia.

Conclusion

Although upper-extremity aneurysms are rare, and little is known about the natural history, there are multiple documented limb-threatening and or life-threatening complications. It is essential that they be treated in a timely manner as to avoid limb-threatening complications. An ultrasound can provide a noninvasive method of detecting a subclavian-axillary aneurysm. It can be used to screen patients when there is a suspicion of an aneurysm and determine the presence of concomitant thoracic or abdominal aneurysm.
Venous Popliteal Aneurysm
Authors: Mahr Christina S.
Published: March 2018

Venous aneurysms are an uncommon finding yet important to understand because they can have very serious ramifications. They are associated with pulmonary emboli, venous thrombosis, and, in some cases, death. Although no clear consensus has been reached regarding the cause of venous aneurysms or their treatment, their presence is of concern. In the case presented, a man in his eighties was admitted to our institution for an intracranial bleed. During his hospitalization, a computed tomography angiography was obtained because of shortness of breath. The test was positive for pulmonary emboli. A venous Doppler was subsequently performed and that demonstrated an occlusive thrombus in a popliteal venous aneurysm.
Pseudoaneurysm of the Deep Femoral Artery: Case Report and Literature Review
Authors: Nemcova Simona , Simone Samuel T. , Lally Michael E.
Published: March 2018

Deep femoral artery pseudoaneurysms are infrequent. The case of a patient who developed a pseudoaneurysm of the deep femoral artery after bacterial endocarditis is described. We discuss pathogenesis of mycotic pseudoaneurysms and briefly review literature on the subject.
Incidental Finding of Asymptomatic Aortic Dissection
Authors: Goh Elaine Y. L. , Ng Shirley C. K. , Chao Victor T. T. , Ding Zee P.
Published: March 2018

Introduction

Aortic dissection limited to the abdominal aorta is not common. This case report describes the role of duplex ultrasound in the diagnosis of asymptomatic dissection of the abdominal aorta.

Case Report

A 59-year-old man with hypertension and mild renal impairment was referred to the vascular laboratory for color ultrasound examination of the renal arteries to rule out renal arterial stenosis. The ultrasound examination revealed a nonsignificant (<60%) stenosis in the right renal artery and two thickened but patent left renal arteries; however, there was an incidental finding of dissection of the abdominal aorta arising from the level of the celiac trunk down into the iliac arteries. Magnetic resonance imaging of the thoracic and abdominal aorta was requested; contrast was not used in view of the patient's deteriorating renal function. The finding revealed no features to indicate dissection in the thoracic or abdominal aorta. In view of the discrepancy in findings, computed tomography aortogram was performed. Dissection of the abdominal aorta just distal to the origins of the renal arteries was seen. This case study details the high sensitivity of color ultrasound imaging in identifying abdominal aorta dissection.

Conclusion

Color duplex ultrasound may be operator dependent but it is a highly sensitive and cost effective modality for identifying abdominal aortic dissection.
Ultrasound-Guided Nonsurgical Closure of Postangiographic Femoral Pseudoaneurysm
Authors: Khera Pushpinder S. , Asbeutah Akram M. , Ramadan Abdullah
Published: March 2018

Iatrogenic femoral arterial injuries are a common occurrence because of the large number of angiographic studies that are performed nowadays. Color Doppler is a sensitive technique for the diagnosis of femoral pseudoaneurysms and arteriovenous fistulas. Importantly, it can also be used to guide external compression in an attempt to obliterate pseudoaneurysm and arteriovenous fistula, with good results.
Duplex Ultrasound Mapping Protocol for Placement of Cardiopulmonary Bypass Cannulae for Robotic Mitral Valve Surgery
Authors: Grattan Alia G. , Digiannantonio Alexa , Mihaljevic Tomislav , Gillinov A. Marc , Gornik Heather L.
Published: March 2018

Background

Duplex ultrasound is a noninvasive, low-cost modality for evaluation of lower-extremity arteries and veins. We developed a protocol to evaluate the lower-extremity vasculature for patients who may undergo robotic mitral valve repair that requires placement of cardiopulmonary bypass cannulae in the common femoral artery and vein. We report our early experience with this mapping protocol.

Method

The protocol includes imaging of bilateral distal external iliac, common femoral, and femoral arteries and veins. Documentation includes minimal vessel diameter at each segment, the presence of stenotic or calcified plaque, and lumen diameter in the presence of protruding atheroma. Bilateral ankle-brachial indices are recorded.

Results

During the period October 9, 2009 to February 4, 2010, we performed 100 mapping protocol studies. Mean patient age was 57.2 years (range, 20–84 years), and 65% were men. The presence of vascular calcification was noted in 34% of patients. No patient had hemodynamically significant arterial stenosis or deep-vein thrombosis. Mean lower-limb ankle-brachial indices were 1.13 (range, 0.90–1.34). Intraoperative common femoral artery and/or common femoral vein diameter measurements were available for 15 patients who underwent robotic surgery. Among this sample, there was no statistically significant difference between ultrasound mapping measurements and intraoperative diameter measurements (common femoral artery: 0.99 cm ultrasound versus 1.03 cm intraoperatively, p = 0.29; common femoral vein: 1.06 cm ultrasound versus 1.09 cm intraoperatively, p = 0.82).

Conclusion

Our surgical colleagues have found these mapping procedures to be useful in selecting candidates for robotic surgery and in planning the procedure. Duplex ultrasound is a useful and accurate tool for evaluating patients for robotic cardiac surgery requiring femoral cannulation for cardiopulmonary bypass.
Vascular Diagnosis by Analysis of Waveforms
Authors: Beach Kirk W.
Published: March 2018

Analysis of waveforms has, historically, served as the basis for noninvasive diagnosis of vascular disease. In attempting to understand the blood flow patterns associated with vascular disorders, investigators have assessed the morphology of waveforms recorded directly or indirectly from tissues and blood vessels by a variety of instruments. Phonoangiography, plethysmography, analogue recordings of continuous wave Doppler signals, and analysis of spectral waveforms recorded with pulsed Doppler have all been used for diagnosis of vascular disease. Decades of research with these instruments have revealed much about the nature of normal and abnormal blood flow patterns. Even so, clinicians in modern vascular laboratories are often confounded by alterations in waveform morphology and the characterization of waveforms remains controversial. In this and following articles, Dr. Beach and other experts in the field of noninvasive vascular diagnosis take us on a journey from where it all began to the present day, allowing us to take a look at what we now know and, most importantly, the questions that still remain.
Characteristics of Pressure and Flow in Arteries and Veins: The Application to Noninvasive Peripheral Vascular Testing
Authors: Needham Terry , Needham Ann
Published: March 2018

Knowledge of vascular hemodynamics is essential for understanding how noninvasive testing is applied to the accurate detection of disease in the peripheral vasculature and it is particularly necessary for the correct interpretation of nonimaging studies. It is important to know how blood flow characteristics can be affected by changes in peripheral resistance, vessel dilations, bifurcations, and by tortuosity and how these can affect the study results from normal arteries. The characteristics of venous blood flow are affected similarly to these changes in vessel geometry, additional to which the presence of venous valves in the lower extremity also needs to be considered. It is essential to learn the foregoing before attempting to distinguish between normal and abnormal conditions in blood flow because comprehension of these conditions is fundamental to the meticulous interpretation of all non-invasive peripheral vascular studies.
Clinical Significance of Standing versus Reversed Trendelenburg Position for the Diagnosis of Lower-Extremity Venous Reflux in the Great Saphenous Vein
Authors: DeMuth R. Patrick , Caylor Kathy , Walton Tina , Leondar LuAnne , Rosero Eric , Chung Jayer , Arko Frank , Clagett G. Patrick , Valentine R. James
Published: March 2018

Introduction

Sonographic detection of incompetence in the deep and superficial veins requires proper patient positioning. Although these tests have been traditionally performed in the reversed Trendelenburg (RT) position, recent mandates from The Intersocietal Commission for the Accreditation of Vascular Laboratories and some insurance providers require that patients be evaluated for reflux in the standing position (SP). The purpose of this study was to determine whether performing venous duplex in the SP versus RT position adds information that affects patient treatment.

Methods

Twenty-eight subjects (25 women; mean age of 52 years) with signs and symptoms of venous insufficiency were evaluated prospectively with the use of ultrasound imaging and Doppler in the 5- to 8-MHz ranges. The great saphenous vein (GSV) was evaluated for each limb from below the knee to the saphenofemoral junction. Patients were initially evaluated at 15–25 degrees of RT position. Reflux was defined by reversal of flow for >0.5 seconds via use of the Valsalva and/or manual compression maneuvers. The GSV was measured in A-P diameter at the saphenofemoral junction and at the knee level. The subjects were then elevated to SP and measurements were repeated while the limb was in a nonweight-bearing position.

Results

A total of 52 limbs were evaluated for venous reflux in 28 study subjects. The mean lower-extremity CEAP score was 3 SD ± 3. Twenty-six (50%) GSVs were positive for venous reflux in the RT position. Of these GSVs, three were negative for reflux in SP. Twenty-seven (53%) GSVs were positive for venous reflux in SP; however, four of these GSVs were negative for reflux in RT. The median difference in reflux time from RT to SP was 0.15 seconds (interquartile range 0–3.8 seconds and 0–2.7seconds, respectively, p = 0.02). The mean difference in GSV diameter from RT to SP was 0.7 mm (±0.96 mm SD, p < 0.0001). These results changed the clinical course for one subject who did not have reflux in RT but did in SP (3.5%, p = 0.085).

Conclusion

The results from evaluating subjects in SP were not independently associated with a change in clinical outcome. However, 15% of GSVs negative for reflux in RT were positive for reflux in the SP. As a result, 3.5% of subjects in our study had a change in clinical course as the result of evaluation of the GSV in SP. This finding suggests that failure to identify GSV reflux in RT in patients with signs and symptoms of venous insufficiency may be an indication to evaluate the GSV in SP.
Upper-Extremity Arterial Evaluations
Authors: Dargon Phong T. , Moneta Gregory L.
Published: March 2018

Upper-extremity ischemia is much less common than lower-extremity ischemia. There are diverse etiologies for upper-extremity ischemia, making the diagnosis challenging. A thorough history and physical examination coupled with noninvasive vascular laboratory studies are important in the diagnosis and treatment of these patients. Noninvasive examinations include duplex ultrasound, segmental arm pressures, digital pressures, arterial waveforms using photoplethysmography, and cold challenge testing. These are the tools that can help evaluate arterial stenosis, occlusion, aneurysm, hemodialysis access, Raynaud's syndrome, and arterial thoracic outlet syndrome.
Extra- and Intracranial Waveform Analysis Algorithm, Descriptions, Classifications, and Differential Diagnosis
Authors: Alexandrov Andrei V.
Published: March 2018

Waveform recognition is an essential step in the interpretation of vascular ultrasound studies. Waveforms can vary widely as the result of systemic and focal hemodynamic changes in the precerebral and particularly intracranial vessels. Waveform pattern recognition can aid or refine the application of strict velocity criteria, and this review will focus on typical normal and abnormal waveforms. Algorithms for waveform analysis and interpretation of extra- and intracranial waveforms are discussed along with correlative imaging and clinical findings. Waveform descriptions and classifications based on prediction of vessel patency, systemic versus local circulatory conditions, and resistance to flow are provided for specific clinical conditions. Interpretation of waveforms rests on our ability to integrate systemic and cerebral hemodynamics across a wide spectrum of conditions. Intracranial vasculature poses unique challenges yet may yield new knowledge if our technologies are able to quantify blood flow beyond just velocities in the future.
Internal Carotid Occlusion in a Newborn
Authors: Blackburn Donna R.
Published: March 2018

The vascular laboratory was called to the neonatal intensive care unit to perform a carotid duplex examination on a 2-day-old infant. This term female newborn was delivered via caesarian because of labor that failed to progress. There were no significant maternal risk factors. On day 2, the infant was noted to have seizures. Magnetic resonance imaging of the brain demonstrated a large left hemispheric infarct with a midline shift. The findings of an echocardiogram were normal. The carotid system was evaluated by the use of a “hockey stick” 15–7 MHz linear array transducer. The common, external, and internal carotid arteries were well visualized bilaterally, as well as the vertebral and subclavian arteries. The right side was normal. The left common carotid artery signal was high resistance and a drumbeat, high resistance signal was noted at the origin of the internal carotid artery. The internal carotid artery appeared to be filled with soft echoes, and no signal was detected within the internal carotid artery beyond the origin. The infant was then transferred to Children's hospital for further evaluation and possible tissue plasminogen activator treatment.

Neonatal cerebral infarction has been reported to be present in 1 in 4,000 full-term infants. Neonatal cerebral infarct was found in 12% of infants who developed neonatal seizures. Newborns with arterial ischemic stroke usually present with seizures. Primary risk factors for arterial ischemic stroke include cardiac disease, perinatal complications, and other acute illnesses, including dehydration and prothrombotic disorders. Mortality rates after arterial ischemic stroke in newborns are less than 10%. In many cases, the outcome is normal. Duplex imaging of the carotid vessels is feasible in neonates and can provide the treating physician with valuable diagnostic information.
Duplex Ultrasound Diagnosis of an Arteriovenous Fistula between the Left Subclavian Artery and the Left Internal Jugular Vein after Attempted Central Venous Catheter Placement
Authors: Venitelli Zeah , Holtman Chelsea , Mack Aisha , Gahtan Vivian , Costanza Michael J.
Published: March 2018

Introduction

—An arteriovenous fistula between the subclavian artery and the internal jugular vein represents a rare iatrogenic injury that has almost exclusively been described on the right side. We describe the case of an arteriovenous fistula between the left subclavian artery and the left internal jugular vein after attempted central venous cannulation. The initial duplex ultrasound exam established the definitive diagnosis.

Patient Description

—A 72-year-old man had a central venous catheter inadvertently placed in the arterial system during attempted cannulation of the left internal jugular vein. After the catheter was removed, a duplex ultrasound exam of the left common carotid artery was requested to evaluate for injury.

Methods

—A carotid duplex ultrasound exam was performed using an Acuson Antares Ultrasound System with a VFX 9–4 MHz probe. The left common, internal, and external carotid arteries were evaluated with grayscale imaging; color Doppler, and spectral flow analysis. The left vertebral artery and subclavian arteries were also evaluated sonographically.

Results

—The duplex ultrasound did not detect an injury to the left common carotid artery; however, a color flow bruit was noted in the surrounding tissue. Further investigation clearly demonstrated a high-flow vascular communication between the left subclavian artery and the left internal jugular vein consistent with an arteriovenous fistula. The arteriovenous fistula was treated with an endovascular intervention that involved placing a stent graft in the left subclavian artery to cover the arterial origin of the arteriovenous fistula. The completion arteriogram and follow-up duplex ultrasound showed that the stent graft completely excluded the arteriovenous fistula.

Conclusion

—This case describes an extremely rare iatrogenic arteriovenous fistula between the left subclavian artery and the left internal jugular vein. The images obtained with duplex sonography were detailed enough to definitively diagnose the injury and plan for treatment.