bluuebunny/crossref_metadata_2025 huggingface dataset:
Duplex Waveform Analysis of the Subclavian Artery in a Case with Internal Mammary Steal Syndrome
Authors: Ginzburg Victor , Margulis Giora , Greenberg George , Mayzler Olga , Wolak Talya , Zlotnik Moshe , Avrahami Elizabeth , Bat-Sheva Jonatan , Szendro Gabriel
Published: March 2018

In patients undergoing chronic hemodialysis through an arteriovenous fistula (AVF), coronary insufficiency may occur if the patient undergoes coronary artery bypass grafting (CABG) using the ipsilateral internal mammary artery (left internal mammary artery [LIMA] or right internal mammary artery [RIMA]). Creation of a new AVF after CABG should therefore avoid using the arm ipsilateral to the side where the internal mammary artery was used. In cases where coronary syndrome appears when this advice was not followed, treatment should be offered aiming to overcome the hemodynamic interference between the diminished coronary supply through the LIMA/RIMA and the excessive flow through the AVF. By using subclavian artery (SCA) waveform analysis on a duplex scan, a noninvasive evaluation of the flow through the SCA ipsilateral to the side of the mammary artery and the fistula can be performed both with the patent (functioning) and closed fistula. Waveform analysis can enlighten the phenomena of steal syndrome through the internal mammary artery and is highly recommended in this small and unusual group of patients.
Fibromuscular Dysplasia of the Carotid Artery: Diagnosis with Duplex Ultrasonography
Authors: Zhou Wei , Bush Ruth L. , Lin Peter H. , Hodge Megan D. , Felkai Deborah D. , McCollum Charles H. , Noon George , Lumsden Alan B.
Published: March 2018

Purpose

The diagnosis of carotid artery fibromuscular dysplasia is usually made with conventional angiography performed to evaluate a suspected carotid stenosis. The ultrasound findings with fibromuscular dysplasia have not been well described. This study was performed to assess the characteristics of carotid artery fibromuscular dysplasia with duplex ultrasonography.

Methods

The hospital records for all patients who had carotid duplex ultrasonography were reviewed from January 2000 to October 2003. Patients with findings suspicious for fibromuscular dysplasia formed the basis of this study. The patient demographics, their presenting symptoms, and ultrasound findings were analyzed.

Results

Carotid duplex studies were performed on 9157 patients during the study period. The presumptive diagnosis of fibromuscular dysplasia was made in 13 female patients (1.2%), with a mean age of 67 ± 10 years (range, 52-79 years). Patients were referred for asymptomatic carotid bruits ( n = 10, 77%) or transient ischemic attack ( n = 3, 23%). Both mid and distal internal carotid artery involvement were seen in five patients (38%), whereas eight patients (62%) had disease isolated to the distal internal carotid artery. Bilateral carotid artery involvement occurred in eight patients (62%). A consistent finding in all patients was multiple areas of alternating focal thickening with thin, dilated arterial walls. Other sonographic findings included velocity increases (mean, 181 cm/sec; range, 135-318 cm/sec), color flow disturbance, and scarcity of plaque in the suspected arterial segment. Magnetic resonance angiography or carotid angiography was performed on seven (54%) patients, confirming the ultrasound diagnoses. One symptomatic patient was successfully treated with open graduated endoluminal dilatation. One patient with asymptomatic carotid bruit underwent carotid stent placement for rapid progression of the disease. No disease progression was seen on follow-up duplex examination in the remaining group, and no patient became symptomatic.

Conclusions

Fibromuscular dysplasia should be suspected in female patients with high-grade mid to distal carotid artery stenosis without significant atherosclerotic disease. This study demonstrates the usefulness of duplex ultrasound as both a screening test and diagnostic examination for carotid artery fibromuscular dysplasia. Follow-up is warranted in these patients.
Traumatic Renal Transplant Subcapsular Hematoma: Diagnosis by Duplex Ultrasound
Authors: Tuvell Nancy , Sorrell Kathryn
Published: March 2018

Introduction

Subcapsular renal hematomas result from a hemorrhage within the kidney that is contained by its fibrous capsule. In some cases, enlarging or acute hematomas may compress the renal parenchyma and result in ischemia or impaired renal function. In the renal transplant recipient or a patient with a solitary kidney, this situation requires immediate identification and aggressive intervention to preserve renal function.

Patient

A 54-year-old renal transplant recipient was seen in our vascular laboratory with complaints of severe pain over his transplanted kidney, hematuria, and an elevated creatinine level. His recent history was significant for a minor automobile accident in which his seatbelt engaged over the site of his transplant in the right iliac fossa.

Findings

Gray-scale imaging revealed a reniform collection surrounding the lateral surface of the kidney, displacing and compressing the renal parenchyma. Resistive indices were elevated at 1.0 throughout the transplant. At the hilum of the kidney, color Doppler documented a high-velocity flow jet in the main renal vein with a continuous Doppler flow pattern. On the basis of these findings, the patient was taken to the operating room for emergent evacuation of the hematoma. A follow-up duplex ultrasonography on the first postoperative day revealed a significant decrease in the size of the hematoma. The resistive indices and the renal vein flow returned to normal.

Conclusion

Duplex ultrasonography provided an accurate diagnosis of the subcapsular hematoma and its hemodynamic impact on the transplanted kidney.
The American Vascular Association Screening Program: Rationale, Method, Guidelines, and Progress
Authors: Lavenson George S.
Published: March 2018

Introduction

The Society of Vascular Surgery, in partnership with the Society for Vascular Ultrasound (SVU), established a National Vascular Screening Program thru the American Vascular Association (AVA). The program screens for the immediate causes of stroke, abdominal aortic aneurysms (AAA), and peripheral vascular disease. Detection of these conditions while the patient still is asymptomatic allows for early management and avoidance of the devastating events they can cause.

Methods

A quick carotid scan is used for detection of carotid artery disease, an EKG rhythm strip for atrial fibrillation, blood pressure determination for hypertension, a quick abdominal scan for AAA, and ankle/brachial indices for peripheral vascular disease. The SVU position on screening, recommending credentialed technologists and accredited laboratories, is used in the AVA screening program, and reporting only the presence or absence of disease has been recommended.

Results

The AVA program, and three other programs reported, screened 6,073 seniors. It is estimated that the carotid screenings alone prevented 30 strokes and saved $12,061,400,000 in stroke costs.

Conclusion

The AVA screening program, with quality ensured by the SVU guidelines, has the potential to prevent a major number of strokes and deaths. Recommendation is for extension of the screening program and for efforts to obtain Medicare funding for the screening.
Examining the Brachial Artery Reactivity Curve Measured by B-Mode Ultrasound in the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Pilot Study
Authors: Joseph Parveen Nedra , Dorn Joan , Violanti John M. , Andrew Michael E. , Riley Ward A.
Published: March 2018

Brachial artery reactivity was assessed in the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Pilot Study using B-mode ultrasound. Carotid artery intima-media thickness (CIMT), a known subclinical predictor of cardiovascular disease, also was examined in relation to brachial artery reactivity. A continuous scan was performed on the artery for 8 min (1 min of baseline, 4 min of cuff inflation at 40 mmHg greater than systolic pressure, 3 min after cuff release).

The sample for analysis (n = 78; 43 men, 35 women) consisted of active-duty police officers from a larger sample in the BCOPS pilot study. Means and standard deviations (SDs) stratified by gender were calculated, along with Pearson's correlations between brachial variables, and with CIMT. Arterial diameters (baseline, pre-cuff release, peak) were significantly different ( p < 0.001) between men and women. Peak arterial dilation occurred at 50.77 ± 21.97 sec (49.67 ± 20.22 cardiac cycles) after cuff deflation in men, and 44.66 ± 24.07 sec (44.57 ± 20.36 cardiac cycles) after cuff deflation in women. Mean common carotid artery IMT and mean maximum IMT of all carotid sites were significantly correlated ( p < 0.01) in men (r = 0.691) and women (r = 0.450). Brachial reactivity measures were inversely correlated with CIMT in women, and in contrast, positively correlated in men.
Renal Vein and Inferior Vena Cava Tumor Thrombus: Presentation and Mapping of Venous Extension with Color Duplex Ultrasound
Authors: Sorrell Kathryn , Harris Shelley , Hanna Judy , Oglesby Beverly
Published: March 2018

Introduction

Renal cell carcinoma (RCC) has a unique tendency toward intravascular growth into the renal vein (RV), inferior vena cava (IVC), or even into the heart. To determine the operative approach and degree of surgical resection required, an accurate preoperative assessment of the extent of the tumor thrombus (TT) is mandatory. The purpose of this report is to describe the presentation of TT with color duplex ultrasound (CDU) and to report our initial experience in mapping the extent of vascular invasion in five patients.

Methods

Between January and November 2004, 5 patients with suspected RCC underwent a renal CDU examination. The presence and extent of TT by CDU was correlated with contrast enhanced computerized tomography (CT), magnetic resonance imaging (MRI) or surgical findings.

Results

Three men and two women were found to have a unilateral renal mass. The arterial supply to each tumor was conspicuous and consisted of prominent feeding arteries by color or power Doppler that circumscribed and penetrated the mass. TT was localized to the RV in one case and involved the RV and IVC in four. For two patients, the growth of TT into the IVC was limited and nonocclusive whereas in two others it was extensive and occlusive. In one case, TT invaded the IVC and the contralateral RV. By gray-scale imaging, TT appeared as an echogenic, heterogeneous mass that caused focal dilatation of the vein followed by rapid tapering. Interestingly, in three patients, low-resistance pulsatile flow could be recorded within the TT tissue itself. When compared with computed tomography, magnetic resonance imaging, or the operative findings, CDU agreed with the location and extent of TT in all 5 cases.

Conclusion

CDU appears to be an accurate technique for mapping the extent of TT in patients with RCC. Although this series is small, the unique gray scale and spectral Doppler characteristics of TT noted on CDU may be beneficial in distinguishing bland thrombus from TT.
The Role of Pre and Postprocedural Color Duplex Ultrasound for the Treatment of Lower Limb Ischemia by Subintimal Angioplasty
Authors: Kidd Jenifer , Bourke Bernard M. , Dunwoodie John , Lyons John
Published: March 2018

Introduction

Subintimal angioplasty (SIA) is the endovascular recanalization of vessels in the subintimal plane and most often is used to treat long-segment occlusions involving the femoropopliteal segment. This study demonstrates the value of pre- and postprocedural color duplex ultrasound (CDU) imaging.

Methods

Forty-three subintimal angioplasty procedures were performed to treat lower-extremity arterial occlusions. CDU was used as the definitive imaging modality in all cases. There were 26 women and 17 men, with a mean age of 76 years. Sixteen patients had anklebrachial index < 0.45. Most patients had significant medical comorbidities, placing them at high risk for arterial bypass procedures.

Results

In all patients, the extent of the occlusion was accurately diagnosed with CDU before intervention. SIA was technically successful in 42 of 43 patients (98%). The postprocedure CDU follow-up (1–2 months) demonstrated 10 patients had reoccluded (24%). Our primary patency rate was 42% at 30 months.

Conclusion

SIA can be an effective method of treatment in aged, high-risk patients with lower-extremity ischemia and threatened limb loss. CDU accurately locates the site of and measures the length of arterial occlusions in such patients, allowing the interventionalist to plan the site of arterial puncture and to prognosticate the likely success. CDU obviates the need for diagnostic angiography and remains the modality of choice for surveillance after SIA intervention.
Continuous Ultrasound Contrast Infusion as an Adjunct to Color Duplex Ultrasound in the Assessment of Aortic Endografts
Authors: Hodge Megan , Parker Daniel , Collado Esther , Broadbent Karen , Lumsden Alan B. , McCollum Charles H. , Noon George P. , Bush Ruth L.
Published: March 2018

Objective

—We sought to evaluate continuous ultrasound contrast infusion Optison® as an adjunct to color duplex ultrasound (CDU) in endoleak detection.

Methods

—Endoleak surveillance, including CDU, Optison®, and computed tomography (CTA), was performed during 18 examinations. One (3 ml) vial of Optison® was diluted in a 57-ml syringe of normal saline (total 60 ml) and administered by infusion pump at 4 ml/hr. Transverse and sagittal views were performed of the aortic aneurysm sac, endograft, and arteries outside the aneurysm sac. Primary endpoints were endograft patency, the presence or absence of endoleak, and limb dysfunction.

Results

—There were no adverse events related to the contrast agent. Contrast appearance through the endograft occurred after an average of 1 min using a mean of 46.8 ml of contrast infusion per patient. There were 10 enodleaks clearly identified by CDU and Optison®, i.e., 2 type I, 4 type II, and 2 type III endoleaks with an additional study suspicious for endoleak. Using CDU and CTA, we found 9 studies without endoleaks whereas with Optison®, we found 8 studies normal. Comparatively, when using CTA, we identified only 2 definitive endoleaks. Of the 9 endoleaks identified by using CDU and Optison®, 2 of the endoleaks were type I and not observed on conventional CTA and were later confirmed by arteriogram. One study was deemed negative by CDU and Optison® whereas CTA results were suspicious. Body habitus was prohibitive for definitive CDU findings in one patient.

Conclusions

—Using continuous ultrasound contrast infusion as an adjunct to CDU allowed for longer imaging time and more extensive evaluation of the endograft, the aneurysm sac, and the perianeurysmal arteries in these patients. Our early results demonstrate that the use of ultrasound contrast for endoleak detection is reliable and may be considered a primary surveillance modality after endovascular aortic aneurysm repair.
Duplex Ultrasound Surveillance after Axillofemoral Bypass
Authors: Stone Patrick A. , Armstrong Paul A. , Flaherty Sarah K. , Brumberg Robert , Back Martin R. , Weir Sheryl A. , Flasher Jacqueline T. , Kendrick Mary , Bandyk Dennis F.
Published: March 2018

Objective

—There are limited data available in the literature on duplex imaging after axillofemoral bypass grafting. We sought to explore this topic and identify duplex findings predictive of graft failure.

Methods

—All patients who underwent axillo-femoral or bifemoral prosthetic bypass procedures during an 9-year period and returned for follow-up duplex ultrasound scans (U/S) were included. Protocol based testing included ankle brachial indices, toe pressures, and duplex velocities at proximal anastomosis, mid-axillary graft, and femoral anastomosis sites.

Results

—Forty-seven patients underwent axillo-femoral bypass prosthetic procedures and returned for follow-up U/S. Mean follow-up was 61 ± 180 months (range, 1–1232) with a mean number of postoperative U/S of 4.5 per person ± 3.6 (range, 1–16). Eight bypass grafts (17%) occluded, i.e., 4 ax-bifemoral segments and 4 femoral-femoral segments. Two of eight occluded patients had not returned for postoperative U/S until occlusion occurred. Of the other 6 patients who underwent postoperative U/S before occlusion, all but one had midgraft peak systolic velocities of <85 cm/sec. Considering all patients evaluated with at least one postoperative examination, midgraft axillary femoral bypass velocities were predictive of future graft failure ( p = 0.0001) with occlusion occurring in 66% (5 of 8) of those with velocities <85 cm/sec, and 1 patient (1/37) with velocities >85 cm/sec. Two patients had velocities <85 cm/sec and remained patent. Six patients had abnormal studies (peak systolic velocities >250 cm/sec) but that did not progress to failure at follow-up. One patient had a para-anasatamotic aneurysm that was identified during follow-up that was treated by endovascular grafting.

Conclusion

—Midgraft axillary femoral bypass velocities are predictive of future graft failure.
What are the Duplex Ultrasound signs that Characterize an “Unstable Abdominal Aortic Aneurysm Sac” after Endograft Implantation?
Authors: Busch Kathryn , Kidd Jenifer , White Geoffrey , Harris John , Kelly Alison
Published: March 2018

Introduction

Classification of endoleak is determined by the mechanism by which the endograft fails to exclude the aneurysm. In some instances, the endoleak may be very subtle or not visible; yet, the aneurysm continues to expand. This report presents our experience in identifying unstable abdominal aortic aneurysm sacs associated with endoleaks or endotension in early and late monitoring using color duplex ultrasound (CDU) in a series of more than 1000 endograft patients.

Aims

We sought to (1) describe ultrasound features of atypical endoleaks and endoleaks from unusual sources and (2) characterize other CDU features that may be associated with endotension.

Methods

Philips HDI 5000 and IU22 machines were used during routine post-endograft surveillance scans of the abdominal aorta. Color, spectral, and power Doppler analysis were also performed to identify evidence of perigraft flow, graft stenosis, thrombus, kink, or migration. Secondary diagnostic maneuvers were conducted in the presence of perigraft flow to characterize the type of endoleak. Particular attention was also paid to the abdominal aortic aneurysm sac contents, size, and pulsatility. Correlation was made to angiography and computed tomography imaging in a series of 22 patients who underwent secondary endograft procedures or open conversion.

Results

Technically satisfactory studies were achieved in approximately 90% of patients. We detected type II endoleaks in 10% of patients assessed and graft migration in 12 cases. Endotension was characterized by sac enlargement and/or shape change without identifiable perigraft flow and correlated highly with device migration. Suggestive features of graft/sac instability included increased sac pulsatility, prominent areas of echolucency within the sac, and occasional low-amplitude atypical color signals within the sac thrombus close to the graft wall.

Conclusion

Reliable CDU assessment for late endograft follow-up requires careful scrutiny of the aneurysm sac contents and wall, as well as the graft device. Endoleak may not always be obvious yet CDU features can assist in identifying the source of endoleak or the presence of endotension. There are suspicious ultrasound features that may alert one to graft/sac instability and potentially dangerous outcome.
Fishing for BASS: Surveying Primary Physicians in the Barriers to Aortic Screening Study
Authors: Dueck Andrew D. , Wooster Elizabeth M. , Wooster Douglas L.
Published: March 2018

Introduction

In response to published guidelines for abdominal aortic aneurysm (AAA) screening, primary care physicians were surveyed to determine attitudes and identify barriers to screening.

Methods

Six hundred standardized, structured surveys were distributed to all primary care practitioners in a defined geographic area. Participation was voluntary, and results were anonymous.

Results

A total of 10.7% of surveys were returned. All questions were answered by >93% of respondents. A total of 71.9% of respondents were general practitioners; 94.4% worked in a community setting. 60.9% saw >11 male patients per week who were older than 65 years of age. Responses indicated support for identifying asymptomatic AAAs; only 4.7% thought their patients were too sick to undergo repair, 0% felt their patients would be unwilling to undergo repair, and 0% felt the risk of rupture was too small to justify repair. Access to vascular surgical services was available to more than 75% in the hospital closest to them, and to 100% in the city in which they practice. A total of 42.2% were aware of recommendations regarding AAA screening, and 65.6% of physicians routinely screened eligible patients for AAAs. Screening for other diseases was more frequent. Respondents routinely screened their patients for breast cancer (79.1%), prostate cancer (80.5%), colon cancer (80.9%), and hypertension (83.7%); 42.9% routinely screened for peripheral artery disease.

Conclusion

Screening for AAAs lags significantly behind other major screening programs. Although primary practitioners are routinely exposed to the target population, a minority of patients are screened. Neither access to a vascular surgeon nor knowledge about the importance of AAAs appears to be limiting factors. Despite recent publicity, almost 60% of primary care physicians remain unaware of screening guidelines for AAAs. Of those who were aware of guidelines, only one third follow them. Further research and education is required to increase the efficacy of screening.
Common Carotid Intimal-medial Thickness is associated with Coronary In-Stent Restenosis
Authors: Jones Gregory T. , van Rij A. M. , Hill G. B. , Wilkins G. T. , Williams M. J. A.
Published: March 2018

Introduction

Coronary artery in-stent restenosis (ISR) consists of a rapid vascular smooth muscle cell proliferation after stent placement. This study tested the hypothesis that carotid artery intimal thickening may be associated with susceptibility to coronary ISR.

Methods

Coronary stent treated patients with (ISR, n = 81) and without (ISR-free, n = 163) ISR were examined along with age- and gender-matched vascular disease-free controls (n = 200). All participants underwent bilateral carotid duplex ultrasound assessment and cardiovascular risk factor evaluation. Multiple logistic regressions were used to determine the independence of any risk associations with either coronary artery disease or ISR.

Results

Maximal carotid intimal medial thickness was independently associated with symptomatic coronary ISR, with an adjusted odds ratio of 3.4 (95% confidence interval, 1.5–7.7, p < 0.005 for carotid intimal medial thickness >1 mm). Atherosclerosis within the carotid bifurcation and internal carotid artery, as measured by carotid stenosis scores, was significantly greater in both coronary artery patient groups compared with vascular disease-free controls but was not associated with ISR.

Conclusions

Intimal thickening within the common carotid artery may represent a distinct pathological process from that which occurs within the carotid bifurcation and internal carotid arteries. Changes in common carotid IMT appears to represent an independent risk indicator for symptomatic coronary ISR.
Age, Race, and Gender Influence Internal Carotid Artery Doppler Velocities in Children
Authors: McCoy Connie E. , Urbina Elaine M. , Khoury Philip R. , Kimball Thomas R.
Published: March 2018

Introduction

Few data are available describing internal carotid artery pulsed-wave Doppler velocities in children. Therefore, mean values were obtained in healthy children and correlates of peak systolic (PSV) and end diastolic (EDV) velocities were determinants.

Methods

As part of an ongoing longitudinal study of cardiovascular risk factors in children, bilateral PSV and EDV were obtained in 115 subjects (age 17.0 ± 3.8 years; 37% Caucasian, 63% African American; 43% male, 57% female). Standard carotid duplex imaging was performed with a GE Vivid 7, 7–12 MHz linear array transducer. Velocities were acquired in the proximal 2 cm of each artery, placing the angle of insonation parallel to vessel wall resulting in angles of ≥50 degrees and ≤60 degrees. All velocities were measured in triplicate. Means and standard deviations of all significant variables were calculated and differences tested with t-testing. Pearson correlation coefficients between PSV, EDV, and covariates (age < or ≥ 18 years, height (HT), weight (WT), gender, systolic blood pressure) were determined. General linear models were constructed to elucidate significant determinants of velocities.

Results

Mean values for PSV and EDV differed significantly by age and race. PSV values differed by gender (all p < 0.02). Age and race correlated with PSV and EDV, whereas gender correlated only with PSV measures. In general linear models, when stratified by age groups, age and race were significant determinates of both velocities and HT only a determinate for PSV. Younger subjects had greater velocities. When stratified by race, results were similar, with Caucasians having increased velocities. When stratified by gender, no models were significant.

Conclusion

Normal PSV and EDV values are greater in children than adults and in Caucasians versus African-Americans. These may be influenced by age and race differences in HT. Proximal internal carotid pulsed Doppler velocities in children should be interpreted based by age and race.
Case Study: Large Hepatic Artery Aneurysm and a Review of the Literature
Authors: Rezac Jennifer
Published: March 2018

Introduction

Hepatic artery aneurysm is a rare and life-threatening lesion. Patients with hepatic artery aneurysm are often asymptomatic, which makes diagnosis difficult. Early diagnosis is essential because of the high risk of rupture. The following case describes an incidental finding of a large hepatic artery aneurysm.

Methods

A 74-year-old woman presented to the vascular lab for a renal artery evaluation. The patient had hypertension and chronic renal failure with elevated blood urea nitrogen and creatinine. Evaluation of the abdominal aorta was also requested because of a palpable, pulsatile abdominal mass and abdominal bruit. The patient additionally stated epigastric and right upper quadrant pain for the previous 6 months.

Results

The renal arteries displayed normal flow velocities without evidence of stenosis. Bilateral kidneys did exhibit parenchymal disease. Examination of the abdominal aorta demonstrated an infrarenal abdominal aortic aneurysm measuring 6.4 cm. In the proximal abdomen, at the level of the patient's pain, a large 11-cm aneurysm was identified. because of the large size of the aneurysm causing displacement of the vasculature, the artery of origin was not positively identified. To further delineate this lesion, the patient underwent computed tomography and angiography; however, these were also unsuccessful. The patient was eventually brought to the operating room for surgical repair of this aneurysm as well as her infrarenal AAA. Intraoperatively, the aneurysm was found to be originating from the hepatic artery.

Conclusion

Although a rare finding, hepatic artery aneurysm can be identified and evaluated with ultrasound. Additional testing with computed tomography and angiography helps to define the arterial source and location of the aneurysm, as well as collateral flow to the liver if the hepatic artery is compromised. Once identified, these lesions need to be surgically or interventionally treated due to their high mortality rate.
Duplex-Guided Angioplasty of Failing or Nonmaturing Arteriovenous Access
Authors: Marks Natalie , Hingorani Anil , Ascher Enrico
Published: March 2018

Objective

Patients not yet on dialysis with nonmaturing arterio-venous (AV) accesses present a therapeutic problem. Because the standard treatment with balloon angioplasty requires nephrotoxic contrast use for diagnosis and treatment, we have sought an alternative therapy.

Methods

Five consecutive patients with chronic renal insufficiency and failing arteriovenous (AV) access underwent duplex-guided balloon angioplasties at our institution. These were 3 women and 2 men with age ranging from 70 to 85 years (mean 77 ± 7 years). All patients were hypertensive, 4 (80%) were diabetics, and 3 (60%) had coronary artery disease. Three patients (60%) had target AV access used for dialysis. Preoperative volume flows (VF) measured by duplex ranged from 200 mL/min to 1160 mL/min (mean 755 ± 358 mL/min). Peal systolic velocity obtained at the most significant stenosis preoperatively ranged from 428 cm/sec to 656 cm/sec (mean 555 ± 87 cm/sec).

Technique

All procedures were performed via short sheath inserted under duplex guidance. Wire and balloon passage and inflation were performed under duplex surveillance as well.

Results

None of these procedures required use of fluoroscopy or contrast material. One patient had a stent placed for recoiling lesion. Postoperative VF ranged from 520 mL/min to 1750 mL/min (mean 1272 ± 486 mL/min). Peal systolic velocity obtained at the most significant stenosis postoperatively ranged from 142 cm/sec to 321 cm/sec (mean 233 ± 64 cm/sec).

Conclusions

Angioplasty of failing AV access can be performed under duplex guidance alone. Duplex guidance offers advantages of hemodynamic evaluation for recoiling lesions and need for stenting.
Duplex-Derived Maximum Venous Outflow Velocity (MVOV) of the Common Femoral Veins is Asymmetric in Normal Women
Authors: Lebow Michael , Edmondson James , Nagarsheth Khanjan , Cassada David , Currie Kate , Goldman Mitchell
Published: March 2018

Background

It is generally accepted that a significant portion of our population harbors asymptomatic compression of the left iliac vein by the right iliac artery. This was demonstrated originally in autopsy studies by McMurrich in 1908 (33% of 107 cadavers) and more recently by the analysis of Contrast CT scans 1 (66% of 50 patients). Authors have found that Venography may lack the sensitivity to be considered a true “gold standard” (66% sensitive) while IVUS is over 90% sensitive 2. No studies have addressed the physiologic difference in flow hemodynamics between the left and right lower extremities in normal individuals. We use Doppler ultrasound to demonstrate asymmetric flow in the lower extremities of normal individuals.

Methods

Maximum venous outflow velocity (MVOV) in the Common femoral veins were recorded using Doppler ultrasound on 30 volunteers. Inclusion criteria included age 18–30, BMI <30, female sex and no history of venous disease or leg swelling. All studies were preformed by the same experienced vascular technologist. Volunteers were instructed to lay supine while a blood pressure cuff was inflated to 100 mmhg around the mid-thigh. Presence of arterial flow was confirmed with color duplex after cuff inflation. Prior to rapid cuff release at 1 minute patients were instructed to exhale and hold their breath to augment venous outflow. Flow velocities in the left and right common femoral veins were recorded.

Results

The average age was 20.9 years (range 19–28 years) and the average BMI was 21.9 (range, 18–25). MVOV was slower on the left side in 22, slower on the right in 7 and equal in one volunteer. The mean right MVOV was 117.23 cm/sec, SD 46.95 and the mean left MVOV was 95.44 cm/sec, SD 32.94 ( P = 0.0095). There was no correlation between left and right MVOV with respect to age, BMI or height.

Conclusions

Significant differences in lower extremity venous flow are present in normal individuals at rest. This finding correlates with anatomic studies demonstrating a predilection towards narrowing of the left iliac vein in normal subjects. This simple, non-invasive method of quantifying venous hemodynamics may aid in selecting patients for further diagnostic testing or intervention.
Suspicious Extracranial Duplex Examination: A Predictor of Intracranial Disease?
Authors: Collado Esther , Hodge Megan , McCollum Charles , Noon George , Bush Ruth L. , Garami Zsolt , Lumsden Alan B.
Published: March 2018

Introduction

Moyamoya disease is a rare and progressive condition with poor long-term prognosis. A meticulous evaluation during an extracranial carotid duplex exam, with attention to subtle changes in anatomy and Doppler signals, can alert the sonographer to pathology in the intracranial circulation, which may suggest this diagnosis.

Case Report

A 45-year-old woman presented to our vascular lab with an episode of slurred speech, right arm weakness, right-sided numbness, and generalized weakness that lasted 15 – 20 min, with total resolution of symptoms. A carotid duplex examination was ordered and demonstrated no evidence of extracranial carotid disease; however, bilaterally the external carotid artery was larger in size than the internal carotid artery, multiple prominent external carotid artery branches were noted, the internal carotid artery and vertebral artery Doppler signals demonstrated low-resistance waveforms with high diastolic flow velocity, and the left vertebral artery was enlarged. Magnetic resonance imaging with angiography demonstrated multiple intracranial abnormalities, and conventional angiography was compatible with Moyamoya disease. A superficial temporal artery-to-middle cerebral artery bypass was performed with an uneventful postoperative course and no recurrence of symptoms.

Conclusions

Subtle changes in anatomy and Doppler signals observed during an extracranial carotid duplex examination can be important indicators of pathology in a location that is not under direct visualization and interrogation. It is important for the sonographer to note these changes and report them to the physician for further evaluation by more direct methods of testing. This case provides an example of the use of such indirect sonographic evidence.
Horseshoes Are Not Always Lucky: A Rare Cause of Varicose Veins
Authors: Busch Kathryn , Doyle Judith , Forbes Martin , White Geoffrey , Harris John , Stephen Michael
Published: March 2018

Introduction

Color duplex ultrasound (CDU) assessment for patients with varicose veins has increased in prevalence as new techniques for treatment continue to emerge. Occasionally, patients present with atypical varicosities that warrant the typical study to be extended to unveil the true underlying cause of the condition.

Clinical Details

A 41 year old man presented to our laboratory for assessment of bilateral varicose veins. He had recently developed venous eczema. Examination of the patient revealed large varicose veins associated with the long saphenous system, especially prominent on the left side.

Methods

Using a standard venous incompetence study protocol, CDU was performed with a Philips IU22 machine. The lower-extremity deep and superficial venous systems were assessed for patency and competency. Measurements of incompetent venous junctions and noteworthy vessel diameters were included. The examination was extended to include the pelvic and abdominal veins on the basis of unusual findings during the CDU imaging of the legs.

Results

Superficial venous insufficiency was detected involving the saphenofemoral junctions (SFJs), long saphenous veins (LSVs), and tributaries bilaterally. Bilateral incompetent calf perforators were identified. On the left, two large SFJs were identified and the LSV measured up to 2.1 cm in diameter. On both sides, an incompetent superficial pelvic vein arising from the SFJ was identified tracking proximally. Examination of the iliac veins revealed normal right iliac veins. On the left, the common iliac vein was extrinsically compressed as was the inferior vena cava. Further examination revealed a horseshoe kidney. The confluence of the lower poles of the kidneys were anterior to the aorta, inferior vena cava, and left common iliac vein, compressing the venous vasculature, accounting for the venous hypertension and left sided prominence. Further management included confirmatory radiological imaging and intervention.

Conclusion

Atypical varicose veins may be a result of a plethora of causes. It is crucial to the patient's outcome to reveal the true nature of the underlying cause. Abdominal sources of venous incompetence need appropriately tailored intervention to prevent recurrence and potential worsening of symptoms.
Expected Diameter and Velocity Parameters for Internal Mammary Artery Mapping Procedures
Authors: Mady Ehab N. , Whitelaw Susan , Gornik Heather L.
Published: March 2018

Background

The internal mammary artery (IMA) is the preferred conduit for coronary artery bypass grafting because of its improved long-term patency. Duplex IMA mapping may be requested as a component of preoperative assessment. We reviewed our institutional experience with IMA mapping procedures and determined expected values for IMA size and Doppler parameters.

Methods

Query was sent to the Cleveland Clinic Non-Invasive Vascular Laboratory database for all bilateral IMA mapping procedures performed from January 1, 2005 to June 30, 2007. Examinations were performed by the use of high-resolution B-mode and Doppler ultrasound. Mean values for IMA dimensions and Doppler parameters were determined along with reference ranges (mean ± 2 standard deviations).

Results

A total of 949 patients were identified. Mean age was 69.6 years, and 64.7% were men. Patients with significant subclavian stenosis were excluded from the primary analysis. Mean values and reference ranges for right and left IMA size and Doppler parameters are presented in tabular format. Bilateral IMAs were larger in men compared with women ( p < 0.0001). The mean right IMA diameter was larger than left ( p < 0.001). The presence of subclavian artery stenosis was associated with smaller vessel diameter and increased peak systolic velocity.

Conclusion

We report a range of expected values for preoperative IMA mapping procedures. These data may be used for development of laboratory diagnostic criteria or incorporated into future research on IMA duplex ultrasound for postoperative surveillance.
A Comparison of Transcranial Doppler and Transesophageal Echocardiography (with Conscious Sedation) in the Detection of Right-to-Left Cardiac Shunts
Authors: Alexander Thomas H. , Collins Lester B.
Published: March 2018

Background and Purpose

Transesophageal echocardiography (TEE) is used and accepted as a method for detecting right-to-left cardiac shunts, most commonly caused by patent foramen ovale (PFO). Transcranial Doppler (TCD) is an accepted alternative test involving the injection of agitated saline with a timed and gauged Valsalva maneuver. Controversy exists about the exact role of PFO in patients with cryptogenic stroke and the resultant therapeutic alternatives; however, there is no controversy about the need to accurately detect the PFO.

Methods

We reviewed the records of 264 consecutive patients referred for TCD with the diagnosis of cryptogenic stroke or transient ischemic attack.

Results

A total of 89 (33.7%) patients had a positive TCD test for PFO; 39 went on to have TEE studies. A total of 19 of the TEE results failed to confirm the PFO (48.7%). TEE in the East Texas Region is routinely performed by the use of conscious sedation, which requires the supervising cardiologist to compress the abdomen to simulate Valsalva.

Conclusion

In the East Texas region, transcranial Doppler is superior to transesophageal echocardiography for the detection of right-to-left shunt in stroke patients, presumably because of the Valsalva limiting effect of intravenous sedation routinely given during the latter procedure.
Bilateral Superficial Temporal Artery Aneurysms
Authors: Wise Matthew , Gibson Kathleen D.
Published: March 2018

Aneurysms of the superficial temporal artery are rare and most often traumatic in origin. In this case study we present an extremely rare occurrence of bilateral nontraumatic superficial temporal artery aneurysms. Spontaneous bilateral superficial temporal artery aneurysms have not been previously reported. The patient was a 49-year-old woman who presented to our outpatient vascular lab with pulsating masses noted over bilateral temporal regions. Duplex ultrasound revealed a 2.3 mm right and 4.5 mm left temporal artery aneurysm. The aneurysms were subsequently resected and the patient recovered without incident. Non-invasive duplex ultrasound is an effective method in identifying these rare aneurysms. A literature search revealed few published cases of non-traumatic STAs and of these cases none involved bilateral vessels.
Occurrence of Digital Photoplethysmography Waveforms in Patients with Lower-Extremity Critical-Limb Ischemia
Authors: Scissons Robert P. , Jones Linda , Altenburg Laura , Mason Julie , Musatkina Svetlana , Snyder Todd , Tiell Todd , Wilson Amy
Published: March 2018

Purpose

Digital photoplethysmography (PPG) has been proposed as an alternative to Doppler technology for measuring ankle pressures and ankle-brachial indices (ABIs). However, in patients with critical-limb ischemia (CLI), digital waveforms may not be detectable, which would negate digital pressure measurement and ABI calculation. In this study we evaluated the presence of digital PPG waveforms in patients with lower-extremity CLI (ABI < 0.40).

Methods

From January through December 2007, vascular laboratory patients who had a lower-extremity physiological study, including an ankle waveform, PPG waveform analysis of their great toe, and an ABI of =0.40, were prospectively entered into a database. ABIs and waveforms were obtained in the standard fashion. Patients with incomplete waveform data and CLI follow-up examinations were excluded from the analysis. Subjects were separated into 2 groups: those with digital PPG waveforms (group 1) and those with flatline digital waveforms (group 2). Each group was evaluated for audible posterior tibial (PT) and dorsalis pedis (DP) Doppler signals.

Results

A total of 160 extremities (140 patients) with CLI were identified during the study period; 45 patients and 53 extremities were excluded. There were 41% (44/107) group 1 and 59% (63/107) group 2 extremities. In group 2 extremities, 67% (42/63) had flatline ankle waveforms, 40% (25/63) had absent PT and DP Doppler signals, and 60% (38/63) had one or more audible PT or DP signals.

Conclusions

Less than one half of the extremities with CLI had digital PPG waveforms. However, 60% of those limbs with flatline digital waveforms had one or more audible pedal Doppler signal, requiring a more detailed noninvasive evaluation with a Doppler ABI endpoint. Automated digital PPG devices may be inadequate for ABI evaluation of patients with CLI.
Greedy Technique and Its Validation for Fusion of Two Segmentation Paradigms Leads to an Accurate Intima–Media Thickness Measure in Plaque Carotid Arterial Ultrasound
Authors: Molinari Filippo , Zeng Guang , Suri Jasjit S.
Published: March 2018

The intima–media thickness (IMT) of carotid arteries is a reliable indicator of cardiovascular risk. IMT is usually manually measured on longitudinal B-mode ultrasound images. Many computer-based techniques for IMT measurement have been proposed to overcome the limits of manual segmentation. Most of these, however, require a certain degree of user interaction. We recently developed two automated techniques for segmentation of carotid arteries in ultrasound images and its intima–media thickness (IMT) measurement. The first technique was determined on the basis of local statistics and signal analysis (we named it CULEXsa, ie, Completely User-independent Layer EXtraction based on signal analysis). The second technique was determined on the basis of an integrated approach consisting of feature extraction, line fitting, and classification (or CALEXia, Completely Automated Layers EXtraction based on integrated approach). Both the techniques automatically traced the lumen—intima (LI) and the media—adventitia (MA) boundaries of the carotid wall. IMT was measured as the distance between LI and MA. We observed that CULEXsa offers better performance in the LI segmentation and CALEXia offers better performance in MA segmentation. The goal of this research was to estimate the IMT measurement by using a greedy approach by fusing CULEXsa and CALEXia segmentations, given the ground truth (manually traced by experts). Starting from the technique with the lower system error (CULEXsa for LI and CALEXia for MA), we iteratively swapped the vertices of the profiles until we minimized its overall distance with respect to manual boundary. The fusion boundary, consisting of points of CULEXsa and points of CALEXia, was the Greedy boundary. We used the polyline distance as a metric for both performance evaluation and error minimization. We ran the segmentation protocol over the database of 200 carotid longitudinal B-mode ultrasound images and compared the performance of all the three techniques. The mean error of the greedy technique yielded 0.42 ± 0.89 pixel (26.3 ± 55.6 μm) for the LI boundary (a 12.5 ± 5.6% improvement over CULEXsa) and 0.26 ± 0.56 pixel (16.2 ± 31.3 μm) for MA boundary (a 16.1 ± 6.7% improvement over CALEXia). IMT measurement error is 1.33 ± 0.99 pixel (83.1 ± 61.8 μm), a 3.6 ± 1.4% improvement over CULEXsa.
Acquired Arteriovenous Fistula of the Temporal Artery and Vein: A Rare Finding
Authors: Porter Joanne , Brener Bruce , Vea Yolanda , El-Halabi Waseem
Published: March 2018

An arteriovenous fistula is an abnormal communication that exists between an artery and a vein. There have been few cases of arteriovenous fistulae involving the superficial temporal artery reported and even fewer deemed to be nontraumatic in origin. This report describes a case of arteriovenous fistula of the superficial temporal artery that was diagnosed by duplex ultrasound complemented with color Doppler and confirmed by pathology. In addition to relating the details of the sonographic examination, the case study will examine the etiology, clinical manifestations, and treatment options for arteriovenous fistulae of the superficial temporal artery.
Effect of Harmonic and Compound Imaging on Estimates of Carotid Artery Intima-Media Thickness
Authors: Alessi-Chinetti Jean , Tran Hong , Harrington Anita , Wanke Christine , Polak Joseph F.
Published: March 2018

Background

Carotid artery intima-media thickness (IMT) is a marker of atherosclerosis linked to cardiovascular outcomes. These outcome studies were made before advanced imaging techniques such as harmonic imaging (HI) and compound (CrossBeam) were available. We study the effects of these new imaging approaches on estimates of carotid artery IMT.

Materials and Methods

A total of 26 subjects (44 common carotid arteries) with an average age of 49.3 years were imaged with fundamental imaging (FI) presets, HI, and compound imaging (CrossBeam; XB). Images were the evaluated with a commercially available edge detector. Comparisons of group means were made with analysis of variance and the Tukey-Kramer test. Associations with age were studied with linear regression analysis.

Results

Mean values of carotid artery IMT of the common carotid far wall were different ( p < 0.04) between groups (FI: 0.63 ± 0.09 mm; HI: 0.66 ± 0.16 mm; crossbeam imaging: 0.59 ± 0.13 mm). XB gave significantly lower IMT values than HI. XB IMT was not significantly associated with age whereas FI and HI IMT were.

Conclusion

We conclude that advanced imaging approaches need to be evaluated against traditional imaging approaches to insure concordance with published IMT values. Failure to do so may result in significant differences with published normative IMT values.