bluuebunny/crossref_metadata_2025 huggingface dataset:
Carotid Artery Pseudoaneurysm
Authors: Ayoub Kathryn , May Nacion Kristine , Bartholomew John R.
Published: March 2018

Introduction

The development of a carotid artery pseudoaneurysm (PA) after carotid endarterectomy is a rare complication with a reported incidence of 0.25% to 0.74%. It results from suture line failure or disruption, degeneration of the arterial wall, or patch material and/or infection. Patients present with neck swelling and pain that can be complicated by thrombosis, rupture, or infection.

Case Report

We describe a 72-year-old man who underwent bilateral carotid endarterectomies in 1987. He presented with bilateral upper-extremity swelling after a kidney transplant. An upper-extremity venous duplex performed with a Philips iU22 (Bothell, WA) with an 8-4 MHZ linear transducer revealed normal phasic pulsed Doppler waveforms. Compression images of the patient's left side of the neck revealed acute thrombus within the internal jugular vein. An incidental finding of bilateral common carotid PAs at their proximal patch surgical sites was noted. The right carotid PA measured 1.8 × 2.6 cm, whereas the left measured 2 × 1.3 cm.

Discussion

Carotid artery PA has been reported within 2 days or as late as 22 years after surgery. A true carotid aneurysm is usually caused by atherosclerosis or arteritis, whereas a carotid artery PA develops after endarterectomy as the result of infection, suture line disruption, or degeneration of the arterial wall or at the patch angioplasty site. A potential for rupture, embolization, thrombosis, or compression of the cranial nerves requires urgent attention. The conventional treatment approach is excision and repair via a vein graft. However, the risk of complications, especially cranial nerve injury, is high. A reasonable alternative to open surgery is covered carotid artery stenting if infection is excluded as the etiology of the pseudoaneurysm.

Conclusion

Although the diagnosis of carotid artery PA is usually suspected clinically, an imaging procedure is necessary for confirmation. Duplex scanning is the gold standard that can be augmented by arteriography or magnetic resonance imaging.
Incidental Finding on Lower-Extremity Venous Duplex Ultrasound: Vascularized Mass
Authors: Cappuccio Marguerite
Published: March 2018

Nodular fasciitis is an uncommon pathologic finding that mimics the clinical presentation of sarcoma. The similar characteristics of a rapidly invasive growth pattern and abundant cellularity frequently causes nodular fasciitis to be misdiagnosed as sarcoma. Nodular fasciitis has been known to pathologists since the 1940s, yet few discussions have been presented in the literature. Large, high-grade sarcomas have a 79% recurrence rate, with 60% of these patients dying from the disease. Recurrences typically occur within 2 years of the treatment of the original tumor. Because of the aggressive nature of this cancer, early diagnosis and treatment is critical for a favorable prognosis. The ease with which nodular fasciitis can be confused both clinically and histologically with a malignant tumor makes it essential to recognize this distinct entity as benign to avoid unnecessary interventions. More awareness is needed of this entity in assuring more accurate diagnosis and appropriate interventions.
Twins Lead to the Prevention of Atherosclerosis: Preliminary Findings of International Twin Study 2009
Authors: Tarnoki Adam Domonkos , Tarnoki David Laszlo , Stazi Maria Antonietta , Medda Emanuela , Cotichini Rodolfo , Lucatelli Pierleone , Boatta Emanuele , Zini Chiara , Baracchini Claudio , Meneghetti Giorgio , Nisticó Lorenza , Fagnani Corrado , Fanelli Fabrizio , Giannoni Maria Fabrizia , Gazzetti Marianna , Osztovits Janos , Jermendy Gyorgy , Préda István , Kiss Róbert Gábor , Littvay Levente , Metneki Julia , Horvath Tamas , Karlinger Kinga , Pharm Agnes Lannert , Yang Eric Y. , Nambi Vijay , Molnar Andrea Agnes , Berczi Viktor , Garami Zsolt
Published: March 2018

Introduction

Atherosclerosis is an inflammatory process in which the artery wall thickens as a result of plaque deposition, but this process may be preceded by increased arterial stiffness. We sought to evaluate the influence of genetics and shared and unshared environmental components on the onset of atherosclerosis.

Methods

A total of 135 monozygotic (MZ) and 70 dizygotic (DZ) twin pairs (mean age 49 ± 16 years) underwent carotid intima media thickness (IMT; carotid analyzer) and arterial stiffness (augmentation index on brachial artery [ Aixbra], pulse wave velocity on aorta [ PWVao]; TensioMed Arteriograph) measurements.

Results

Age-adjusted intraclass correlations were greater in MZ than in DZ pairs for proximal right common carotid artery (CCA; MZ = 0.19, DZ = 0.06), proximal and distal left CCA (MZ = 0.27, DZ = 0.06; MZ = 0.27, DZ = 0.13, respectively), and proximal left internal carotid artery (ICA; MZ = 0.39, DZ = −0.54), suggesting a moderate genetic effect. Heritability was estimated to be 18% (95% confidence interval [CI] = 3–33) for proximal right CCA, 26% and 27% for proximal and distal left CCA, respectively, and 38% (95% CI = 26–49) for proximal left ICA. Regarding distal right CCA and proximal right ICA, no genetic effects were detected. Age-adjusted intraclass correlation of Aixbra and PWVao were 0.65 (95% CI = 0.55–0.72) and 0.46 (95% CI = 0.33–0.57) in MZ, 0.42 (95% CI = 0.24–0.57) and 0.28 (95% CI = 0.08–0.47) in DZ pairs; heritability 45% (95% CI = 12–71%) and 42% (95% CI = 2–57%) adjusted by age, respectively.

Conclusions

The investigated parameters appeared to be only moderately influenced by genetic factors. Environmental factors of relevance for these measures appeared not to be shared within family but related to individual experience (e.g., smoking habits, diet, and physical activity). Atherosclerosis detection at an early stage is necessary for treatment to prevent serious complications such as stroke and heart attack.
Does Distal Venous Hypertension Affect Lower-Extremity Venous Pulsatility?
Authors: Schroedter William B. , White Jean M. , White Brian D. , Mauriello John D. , Sanchez E. J. , Izzo Edward G.
Published: March 2018

Introduction

Pulsatile flow in the lower-extremity venous system is commonly attributed to various cardiac abnormalities. In patients with significant venous insufficiency and resultant venous hypertension, venous capacitance may be drastically reduced. We have noted multiple patterns of venous pulsatility and theorized that the hemodynamic state of the lower-extremity venous system could in fact play a role in these patterns. If venous reflux is isolated to the superficial system, ablation of these veins could resolve the venous hypertension and potentially influence the pulsatile flow pattern.

Methods

We compared the presence and pattern of lower extremity venous pulsatility in 293 consecutive patients suffering from chronic venous insufficiency (Mean CEAP 3.2). Of these, 242 limbs underwent endovenous thermal ablation (EVTA) of a refluxing truncal vein. Duplex ultrasound was used to evaluate these limbs approximately 3 days post procedure and the results of 101 limbs were available for comparison with the initial exam and provide the basis of this study.

Results

Of the 101 limbs, 47 (46.5%) had evidence of pulsatile flow in the lower extremity venous system preoperatively which was graded into one of three categories. Forty-eight (47.5%) had deep venous insufficiency of either the femoral vein (n = 16) or popliteal vein (n = 32), which was graded as normal, >1 second, or >2 seconds. The remaining had no evidence of deep vein reflux. Paired observations using the Wilcoxon method showed no difference in the venous pulsatility post ablation. Additionally, isolating patients with no evidence of deep venous reflux also revealed no difference in pulsatility following ablation.

Conclusion

Ablation of refluxing truncal veins did not appear to influence the presence or pattern of venous pulsatility in the lower extremities regardless of deep system valve function.
Paradoxical Thromboembolism: A Trip Better Left Untraveled
Authors: Witte Richard G. , Burgess William A. , Vasquez Marla D. , Hanan Tracy L. , Charlton-Ouw Kristofer M.
Published: March 2018

Introduction

Pulmonary embolism is a common sequela of deep vein thrombosis (DVT). Less well documented is the occurrence of DVT and its relationship to stroke via an intracardiac shunt such as a patent foramen ovale (PFO). We report a case of DVT and stroke in conjunction to the presence of intracardiac thrombus and a moderate-sized PFO.

Methods

This is a case study report of a 61-year-old woman with a previous medical history of hyperlipidemia only who traveled to Mexico from the Unites States. The trip included three long bus trips of 12, 13, and 14 hours in duration. This patient presented to a hospital in Mexico with severe headache and right-sided weakness. The patient was diagnosed and treated for left hemispheric stroke and eventually transported to our hospital in Houston, Texas, for further stroke evaluation and management. With the use of a Philips IE33 8 MHz linear array probe and multi-plane TEE probe as well as a Siemens Sequoia 4V phased array probe, we were able to safely and accurately diagnose and manage the patient's condition until intervention could be safely performed.

Results

Multiple diagnostic imaging tests were performed, including a bilateral lower-extremity duplex venous ultrasound, duplex carotid ultrasound, transthoracic and transesophageal echocardiograms, as well as computed tomography scans of the chest and brain. With the patient's current condition and symptoms as well as the collected findings, our test results indicated that a paradoxical thromboembolic event had most likely occurred. There was right lower-extremity DVT, bilateral pulmonary embolisms, and large and highly mobile thrombus within the right-side chambers of the heart that occasionally protruded through a moderate size patent foramen ovale of 0.9 cm. The left distal common carotid artery and internal carotid artery were found to be occluded, and initial computed tomography scan of the brain showed a large left middle cerebral artery distribution infarct.

Conclusion

Venous thromboembolic disease can cause stroke in the presence of an intracardiac shunt such as a PFO. The use of vascular and cardiac ultrasound examinations is critical in determining the etiology of cerebrovascular events. We document a rare case of combined DVT, pulmonary embolism, intracardiac thrombus, PFO, and extracranial carotid arterial occlusion. Although the prevalence of DVT and intracardiac shunts alone is high, it is unclear from the literature which patients would benefit from PFO closure.
Inferior Mesenteric Artery Duplex in the Management of Chronic Mesenteric Ischemia
Authors: Younes Houssam K. , Broadbent Karen , Hodge Megan , Bismuth Jean , Davies Mark G. , Lumsden Alan B.
Published: March 2018

Introduction

Duplex interrogation of the mesenteric arteries is a frequent practice during the workup of chronic mesenteric ischemia (CMI). We report a case in which duplex ultrasound identified a stenosis of the inferior mesenteric artery (IMA) that was not initially detected on either angiogram or computed tomography angiography (CTA).

Case Report

A 72-year-old Hispanic man with a history of CMI presented with a 1-week history of vague postprandial abdominal pain that became severe and constant during the last 3 days. The patient was admitted and an aortic angiogram was performed, demonstrating a normal celiac axis and IMA, and short segment superior mesenteric artery (SMA) occlusion with reconstitution via a large meandering branch of the IMA. Aortic duplex was also performed that confirmed the occlusion of the SMA and demonstrated significant velocity elevation (>450 mm/sec) with color flow disturbances suggestive of high-grade stenosis at the origin of the IMA. This duplex ultrasound finding prompted further investigation with CTA of the abdomen and pelvis, which demonstrated a high-grade stenosis of the celiac axis, occlusion of the SMA, and an atherosclerotic plaque in the infrarenal aorta near the origin of the IMA without evidence of stenosis. Because of the patient's persistent abdominal symptoms and disparate imaging results, a repeat angiogram with multiple views was able to identify both the celiac and IMA stenoses, each of which was successfully treated with stents. The patient's abdominal symptoms resolved within 4 days. Three months after stenting, the patient remains symptom free, and a follow-up duplex examination showed patency of both the celiac artery and IMA stents.

Conclusion

Multiple imaging modalities are often essential in the work up for patients with CMI. This case demonstrates the sensitivity of duplex ultrasound in the identification of an IMA stenosis in a patient with a known occlusion of the SMA, and not initially identified on the angiogram or CTA.
Plethysmographic Waveform Devices
Authors: Kupinski Ann Marie
Published: March 2018

Plethysmography is a noninvasive technique which measures volume changes. Common instruments include pneumatic or air plethysmographs and photoplethysmographs. These are used in the vascular laboratory to examine both arterial and venous blood flow. The pulse volume recorder (PVR) is a type of pneumatic plethysmograph which provides estimates of arterial blood flow to a limb or digit. The PVR measures pressures changes in a cuff that are the result of volume changes due to arterial blood flow within a segment of a limb or digit enclosed by the cuff. Another type of air plethysmograph is used to measure volume changes within the entire calf after a series of maneuvers. These changes are impacted by status of the venous system and the venous valves. Photoplethysmography measures reflected infrared light in a small sensor applied to a limb or digit. The amount of light reflected is dependent on the volume of blood present. By alternating the display of these changes in the reflected light signals both arterial inflow and venous refilling can be determined. Plethysmography provides qualitative and quantitative data which can be used to estimate global arterial and venous status.
Should Carotid Duplex Velocity Thresholds be Modified for Patients Undergoing Computed Tomographic Angiography?
Authors: Scissons Robert P.
Published: March 2018

Purpose

The use of computed tomographic angiography (CTA) has increased dramatically whereas angiography (ANGIO) has decreased proportionally. The purpose of this study is to evaluate the impact of this trend on internal carotid artery (ICA) ultrasound velocity criteria in the vascular laboratory.

Methods

Carotid duplex quality assurance (QA) databases were queried for similar cohorts of CTA and ANGIO ≥50% and ≥70% stenoses. Optimal velocity thresholds, sensitivity and specificity for ICA peak systolic velocity (PSV), end-diastolic velocity (EDV), peak systolic ICA, and common carotid artery ratio (carotid ratio) were obtained for CTA and ANGIO groups.

Results

A total of 101 vessels were analyzed in each group. Optimal PSV threshold, sensitivity, and specificity for CTA ≥50% stenosis was 152 cm/sec, 92.1% and 94.9% and for ANGIO, 170 cm/sec, 85.9% and 91.9%, respectively. When the optimal PSV threshold for the ANGIO group was applied to the CTA group, sensitivity and specificity were 85.7% and 94.7%, respectively. In the CTA group, PSV threshold was significantly lower when used to diagnose the ANGIO group ≥50% stenosis ( p = 0.0001). Optimal PSV, EDV, and PSV ratio thresholds for CTA ≥70% stenosis were 230 cm/sec, 62 cm/sec, and 2.7 and for ANGIO, 230 cm/sec, 68 cm/sec, and 3.2. Although no PSV differences were noted, when optimal EDV and PSV ratio thresholds for ANGIO ≥70%were applied to CTA ≥70%, EDV sensitivity and specificity were 80.9% and 94.7%, PSV ratio, 78.7% and 92.6%, respectively. CTA EDV and PSV ratio thresholds were statistically lower when used to diagnose ANGIO >70% stenosis ( p = 0.0001).

Conclusions

Optimal PSV threshold for ≥50% and EDV and PSV ratio thresholds for ≥70% ANGIO stenosis were lower, with significant differences in sensitivity and specificity found, when used to diagnose similar CTA stenoses. Modifying angiography-based carotid duplex velocity criteria may be warranted for patients who are evaluated with CTA.
Why the U.S. Preventive Services Task Force Recommendation against Screening for Asymptomatic Carotid Artery Disease Should be Reconsidered
Authors: Lavenson George S.
Published: March 2018

When screening seniors with a quick carotid scan (QCS) with ultrasound, one can discover the silent carotid artery disease (CAD) that is the leading cause of strokes and Medicare expenditures and allow preemptive management and stroke prevention. This is a discussion of the U.S. Preventive Services Task Force (USPSTF) recommendation against screening for CAD. The USPSTF recommended against screening the general population, but CAD and strokes occur predominantly in seniors. An incidence of 1% for 60% to 99% stenosing CAD in seniors was used, but the yield from 22,496 scans reported by the Society for Vascular Ultrasound was 7.5%. A 1% yield requires screening 1500 seniors to prevent 1 stroke, whereas a 7.5% yield requires only 200 scans. This disparity alone invalidates the USPSTF recommendation. Contrary to reports from the NIH, the USPSTF stated that CAD causes few strokes. The QCS was reported as not accurate, but the sensitivity was 93% in our laboratory and 97% at New York University. Risks incurred from screening were given as follow-up with angiography, which is now seldom used, and the risk of surgery, which was overstated. The USPSTF recommendation against screening for CAD, like those for reducing screening for breast and cervical cancer, is ill advised and should be reconsidered.
Venous Waveforms
Authors: Talbot Steven R. , Oliver Mark
Published: March 2018

The role of waveforms in the diagnosis of venous thrombosis and venous insufficiency has changed dramatically during the past few decades. Historically, venous physiologic devices and Doppler waveform analysis attempted to replace venography. Although these indirect testing methods fell short of this goal, direct venous imaging did not. There is still, however, valuable information that can be obtained from Doppler waveform analysis and, in some instances, this information is the most accurate way to answer a particular clinical question.
A Systematic Literature Review of Ultrasonography for Morphology and Characterization of Vulnerable Carotid Artery Plaques
Authors: Kingstone Lysa Legault , Torres Carlos , Currie Geoff
Published: March 2018

Background and Purpose

Although ultrasound (US) evaluation of the carotid artery for stenosis is the accepted method for identifying risk factors for cerebrovascular (CV) events, patients with specific plaque morphology may be at increased risk. Plaque characterization via US is a potentially useful adjunct to stenotic grading for identifying vulnerable carotid disease. The aim of this study was to systematically review published clinical trials via the use of US to identify vulnerable plaques among both symptomatic and asymptomatic plaques.

Methods

We used a systematic search using Medline, Embase, and the Cochrane library databases to find relevant studies published between 2001 and 2011. We reviewed randomized, controlled human clinical trials that validated the applicability, diagnostic accuracy, and diagnostic impact of US carotid plaque characterization. For studies reporting qualitative findings, we abstracted information about the study design and technique and the quality of the methodology and analyzed the data using a modified Jadad scale.

Results

In this review, we identified 12 studies related to the evaluation of carotid plaque using US. The studies used a wide range of methodologies to quantify and image the plaque morphology. Published literature on this subject is lacking; however, this deficit may be because current studies are ongoing. Specific plaque characteristics identified as vulnerable included particular echo texture, the presence of echolucency and/or ulceration, surface alterations, and volume assessment using 3-dimensional US (3D US). In a minority of studies investigators used histopathology as the reference standard, and in most they used subsequent clinical observations. All studies demonstrated that US has good accuracy and specificity in identifying possible imaging characteristics related to vulnerable plaques.

Conclusion

The collected evidence shows that US is effectively able to detect specific carotid plaque characteristics related to high-risk plaques vulnerable for CV events. We anticipate that additional well-designed prospective studies will provide more definitive evidence and distinguish specific distinctive findings that may serve as indicators of vulnerable plaques. Our findings must be extended to demonstrate the accuracy and validity in everyday clinical imaging findings.
Diastolic Ankle-Brachial Indices as a Complementary Measure to Screen for Peripheral Arterial Disease in Diabetic Patients
Authors: Salles-Cunha Sergio X. , Braga Filipe A. , Caiafa Jackson S. , Melo Larissa H. A. , Castro Aldemar A. , Pitta Guilherme B.B.
Published: March 2018

Introduction

Ankle-brachial systolic pressure ratio or Index (ABI or ABI-S) has influenced cardiovascular screening for decades. Total or partial rigidity (i.e. calcification) of tibial arteries has hampered Doppler ABI-S measurements in patients with diabetes. Diastolic pressures are measurable with the oscillometric technique. The authors of a previous study demonstrated that ABI-D (ankle-brachial index based on diastolic pressure ratio) was less sensitive than ABI-S, but partial or total incompressibility of tibial arteries was suspected if ABI-D < ABI-S. This study examined whether ABI-D added information to screen for peripheral arterial disease (PAD) in patients with diabetes.

Methods

An “eye-to-foot” screening/educational program was performed at the city of Arapiraca, state of Alagoas, northeast of Brazil. A vascular surgeon, an expert on the diabetic foot, selected subjects with decreased pulse and/or older age. Bilateral arm and ankle pressures were performed in 71 diabetic patients: 47 (66%) women and 24 (34%) men, 68 ± 10 years (range, 46–86). ABI-S and ABI-D were calculated on the basis of bilateral brachial and ankle oscillometric pressures. Screening for PAD was compared on the basis of the prevalence of ABI < 0.90.

Results

ABI-S, ABI-D, or either ABI < 0.90 were detected in 36 (51%), 48 (68%), and 55 (77%) diabetics, respectively. ABI-S and ABI-D, only ABI-S, or only ABI-D were <0.90 in 53% (n = 29), 13% (n = 7), and 35% (n = 19) of the 55 diabetics with ABI < 0.90. The increase in frequency of ABI < 0.90 was significant if ABI-D complemented ABI-S ( p < 0.001 by chi-square). ABI-D and ABI-S were 0.83 ± 0.06 (0.68–0.895) versus 1.01 ± 0.10 (0.92–1.30) in the only ABI-D < 0.90 group.

Conclusions

Diastolic ankle pressures were estimated successfully by use of the oscillometric technique. Diastolic ABI correlated with expert physician assessment and contributed to quantitative screening for PAD in diabetic patients with apparently falsely elevated systolic ABI caused by partial incompressibility of tibial arteries.
Venous Insufficiency Anatomical Variations and Nomenclature: A Review
Authors: Fowler Brian , Ramirez Hugo , Kolluri Raghu
Published: March 2018

Venous disease is more common than arterial and lymphatic disease, resulting in significant patient morbidity and mortality. The primary diagnostic tool used to diagnose venous disease is duplex ultrasound. Venous duplex has virtually eliminated the use of venograms to diagnose deep venous thrombosis. Venous duplex is an indispensable diagnostic tool in the diagnosis of venous insufficiency, planning ablative and surgical procedures, performing those procedures, and postprocedure surveillance. As such, it is extremely important for vascular sonographers to understand the anatomical variations as well as the appropriate nomenclature of the lower extremity venous system. This allows the sonographer to accurately represent the extent of venous insufficiency to the reading physician. In this article we present a review of the most current guidelines for anatomical variations and for venous insufficiency.
Bilateral Deep Femoral Vein Thrombosis
Authors: Ratanaprasatporn Linda , Gonsalves Gail , Garcia-Toca Manuel , Slaiby Jeffrey M. , Marcaccio Edward J. , Chong Tec
Published: March 2018

Introduction

Deep vein thrombosis (DVT) is a major national health problem, especially among the critically ill and elderly. Most clinically significant DVTs involve the proximal veins of the lower limb, particularly the iliac, common femoral, femoral, and popliteal veins.

Case Study

We report a 53-year-old man sent to our vascular laboratory for ultrasound examination of the lower extremities to investigate the cause of nonpitting edema in both lower extremities. The ultrasound examination revealed isolated bilateral thrombosis in the deep femoral veins.

Conclusion

This is the first reported case of bilateral isolated deep femoral vein thrombosis.
Alterations in Venous Flow Patterns in a Pediatric Patient: Impact of Mechanical Ventilation
Authors: Kampmann Meghan , Medeiros Heather
Published: March 2018

Lower extremity venous waveforms are normally phasic with respiration and not pulsatile. The following case study describes abnormal venous spectral Doppler waveforms encountered during a pediatric ultrasound examination. A four-year-old female patient presented to the hospital with acute respiratory distress. The patient was immediately intubated and placed on an oscillating ventilator. A lower extremity venous duplex was ordered to rule out a deep venous thrombosis (DVT) due to the presence of lower extremity swelling and a fever. Thrombus was observed in the left common femoral vein surrounding a central venous catheter. The thrombus extended into the external iliac vein. This thrombus appeared hypoechoic and spongy in nature and was interpreted to be acute. Additionally, pulsatile waveforms were noted bilaterally through both lower extremities. There was no history of congestive heart failure or pulmonary hypertension. Subsequently, the patient was found to have Factor V Leiden. A repeat venous ultrasound was ordered 10 days later at which time the patient was no longer intubated. The venous waveforms in the left leg were now continuous while the right leg displayed normal, phasic waveforms. No venous pulsatility was present in either extremity. Continuous venous Doppler signals are expected in the presence of non-occlusive DVT. This case illustrates the unusual occurrence of pulsatile lower extremity venous Doppler signals. These were the result of respiratory pressure changes due to the oscillating ventilator. It is important to consider the effects of mechanical ventilation on venous blood flow patterns.
Comparison of Duplex Ultrasound and Computed Tomography Surveillance after Endovascular Aneurysm Repair in Determining Proximal Endograft Location
Authors: Almaroof Babatunde H. , Ahanchi Sadaf S. , Chen Brian L. , Day Jarrod D. , Nelms Courtney R. , Panneton Jean M.
Published: March 2018

Introduction

—Color Duplex ultrasound (CDU) is the primary modality for endovascular abdominal aneurysm repair (EVAR) surveillance in our institution. Computed tomography (CT) scan (also known as CT scan or as CTA meaning CT Angiography) is, however, the gold standard to evaluate for endograft migration. We compared duplex ultrasound with CT scan for determination of proximal endograft location.

Methods

—A retrospective review was performed with the AneuRx® endograft of EVAR patients who had paired CDU and CTA imaging studies within a 3-month interval from January 2009 to June 2010. Patient demographics and distance measurements from the superior mesenteric artery (SMA) to the proximal graft on both CDU and CTA images were obtained. CTA measurements were done by measuring the distance between the SMA and the endograft using digital calipers. CTA patients did not fast. Duplex measurements were obtained in fasted patients by measuring the distance between the SMA and the hyperechoic proximal graft in the sagittal plane on B-mode and color-flow images. Correlation statistics was performed.

Results

—Twenty-two patients with 26 paired CTA and CDU studies were identified with a mean age of 73.3 years. There were 13 males (59.1%) and 9 females (40.9%). Mean interval between studies was 39.6 days (range, 0–84 days). Mean duplex SMA-endograft measurements were 21.8 ± 6.3 mm and mean CTA measurements were 17.3 ± 7.8 mm. Spearman's correlation coefficient (ρ) between both measurements was 0.44 ( p = 0.012). A subset of patients who had studies within a 1-month interval was also analyzed, with 11 paired studies identified. Mean CTA and duplex measurements were 20.2 ± 9.7 mm and 22.1 ± 7.2 mm respectively (ρ = 0.58; p = 0.031).

Conclusion

—There is a moderate correlation between CDU and CTA measurements of proximal endograft position after EVAR. Our data suggest that duplex ultrasound is valuable in assessing proximal Aneurx® endograft position and may be so reliable and accurate that it may eventually surpass CTA methodology typically used for assessing endograft migration to become the gold standard.
Differences in Saphenous Vein Reflux Detection According to Patient Positioning
Authors: Houle Marresa , Neuhardt Diana L. , Straight Nicole T. , Salles-Cunha Sergio X.
Published: March 2018

Objective

—To demonstrate differences in saphenous reflux detection performed with the use of a simplified protocol with the patient in the supine or reverse Trendelenburg positions (nonstanding) compared with an extensive protocol with the patient standing.

Methods

—Reflux detection in the standing and nonstanding positions were compared for measurements at the great saphenous vein (GSV-thigh, GSV-calf), small saphenous vein (SSV), and common femoral vein/saphenofemoral junction (CFV/SFJ). Reflux longer than 1 sec was considered a positive finding. A total of 171 measurement comparisons were made in 40 extremities of 20 women, ages 54 ± 13 years (range 34–82), all evaluated for varicose veins. False-negative (FN) results were calculated for standing and nonstanding positions compared with positive results obtained in the other position.

Results

—FN results in the nonstanding position were 49% (16/33), 38% (12/32), 27% (12/45), and 26% (9/35) for GSV-calf, GSV-thigh, SSV, and CFV/SFJ, respectively. FN results for the standing position were 6% (1/18) and 7% (2/28) for GSV-calf and CFV/SFJ, respectively. Technologists perceptions were that coaptable veins in the nonstanding position and detection of low-velocity reflux in the standing position influenced the results.

Conclusions

—The data collected favored evaluation of saphenous vein reflux in women with varicose veins in the standing position.
The Importance of Routine Graft Duplex in the Presence of Normal Ankle Brachial Indexes
Authors: Nichols Stephanie J.
Published: March 2018

Recent changes to our Medicare broker state that either a graft duplex or segmental pressures must be performed for routine follow-up for arterial bypass grafts. We have had several cases in which the ankle brachial index (ABI) has been within normal limits, 0.9, and the graft duplex has revealed an abnormality with the graft. The Intersocietal Accreditation Commission standard says that if a graft duplex is performed, the ABI must be included; the ABI must be done within 2 weeks at the same facility with no change in the patient's symptoms. When we obtained the patient histories, each patient noted no specific vascular claudicating symptom, but more general symptoms of weakness or pain in a specific area of the leg. It is important for laboratories to perform both tests. The ABI is a good indicator of disease in the normal population, but in older patients and those with diabetes, it can yield false-positive results.
A Cross-Sectional Analysis of Femoral Artery Intima-Media Thickness
Authors: Wang Grace J. , Layne Andrew J. , Mohler Emile R. , Davis Julia T. , Sonnad Seema S. , Fairman Ronald M.
Published: March 2018

Introduction.

—Arterial intima thickness (IMT) of the carotid artery has been established as a surrogate marker of atherosclerosis. The role of femoral IMT remains incompletely defined. This study was undertaken to define the potential relationship between patient demographics, comorbidities, and femoral IMT and to establish it as a potential marker for future peripheral arterial disease.

Methods.

—A total of 160 patients (89 male, 71 female) between the ages of 18 and 50 years were enrolled and demographic data were obtained by chart review. Images of the common femoral artery were obtained with B-mode ultrasonography gated to the R-wave of the electrocardiograph. Automated edge detection software (Carotid Analyzer for Research) was used to measure femoral IMT and vessel diameter, and these measurements were used to derive the IMT cross-sectional area (CSA). Triplicate measurements of each femoral artery were made and averaged. T-tests and multivariate analysis were performed and significance was indicated by a p < 0.05.

Results.

—The mean femoral IMT measurements for men and women were 0.514 ± 0.011 mm and 0.465 ± 0.005 mm, respectively. Univariate analysis found significant differences in IMT for sex, age, and presence of diabetes, hypercholesterolemia, and hypertension. Univariate analysis found significant differences in CSA for sex, age, race, body mass index (BMI), and presence of chronic renal insufficiency and hypercholesterolemia. When significant variables were included in a multivariate regression, age and sex ( p < 0.001) remained significant predictors of IMT and age, sex, and BMI ( p < 0.001) remained significant predictors of CSA.

Conclusions.

—In this subset of patients, multivariate analysis revealed a thicker IMT in males and in patients ≥35 years of age. Greater IMT CSA was associated with male sex, age ≥ 35 and BMI ≥ 30. These findings have ramifications for the future study of femoral IMT as it relates to atherosclerosis and vessel remodeling.
Hepatic Artery Aneurysm: A Case Study
Authors: Khurana Yashvika
Published: March 2018

Hepatic artery aneurysms are very uncommon, with an estimated incidence of less than 0.25%. Most patients are asymptomatic and because of the tendency to rupture with potential catastrophic hemorrhage and liver ischemia, early diagnosis is important. Hepatic artery aneurysms are the second most common visceral aneurysms, representing 20% of visceral aneurysms.
Ultrasound Guidance in Radiofrequency Ablation of Multiple Incompetent Vessels Using Single-Site Access
Authors: Healey Christopher D. , Massop Douglas W.
Published: March 2018

Varicose veins are common in the adult population, occurring in approximately one third of men and women. Several endovenous treatment options are now available, including radiofrequency, laser thermal, and foam ablation. These minimally invasive procedures rely on the use of ultrasound for safe and efficacious treatment. Ultrasound has become standard for diagnosis of venous pathology, and its increasing use has lead to a more thorough description of the variability in lower-extremity venous anatomy. The presented patient case exemplified variations in venous anatomy that may be encountered during endovenous ablative procedures and how these variables can be managed under ultrasound guidance. The patient was a 58-year-old woman who was experiencing leg pain from her calf varicose veins despite conservative therapy. Her superficial reflux was greater than 0.5 seconds, and radiofrequency ablation was recommended. At time of the procedure a large, incompetent anterior accessory saphenous vein (AASV) with a corresponding segment of hypoplastic great saphenous vein (GSV) at the proximal thigh was noted. Her AASV was transmitting venous reflux to the lower, more medial, true GSV through a large collateral. With the use of ultrasound, the GSV was accessed distally at the upper calf and a guidewire passed through the collateral vein to the AASV. This allowed the radiofrequency catheter to pass from the lower GSV to the saphenofemoral junction and treat both segments of incompetent vein from a single access site. To the authors' knowledge, this selective cannulation of the AASV from the true GSV during radiofrequency ablation has not been previously reported in the literature. Alternative treatment would have required separate sheath access of each vein, leading to greater patient discomfort, extended procedure time, and a less-effective therapy. This case highlights the integral role of skilled ultrasonography during radiofrequency venous ablation in a certified laboratory, especially when dealing with variations in venous anatomy of the lower extremity.
Anatomic Distribution of the Carotid Bulb as Determined by Duplex Ultrasound
Authors: Thornton Jenilee B. , Kupinski Ann Marie , Paty Philip S. K. , Darling R. Clement
Published: March 2018

Ultrasound reports describe carotid plaque as being located within the bulb or bifurcation. These terms are used interchangeably; however they refer to two distinct regions. The purpose of this study was to determine the presence of a bulbous region within the common (CCA), internal (ICA) or external (ECA) carotid arteries by using ultrasound. Ultrasound images were examined from 100 carotid systems from 53 males and 47females ranging in age from 17–88 years (mean age 65 ± 15 years). An outward dilation, consistent with the expected appearance of a carotid bulb, was observed in the ICA in 49 patients. Nineteen patients had a bulb in both the ECA and ICA. In 10 patients, a bulb was present within both the ICA and CCA. In 5 patients, the CCA, ICA and ECA all contained bulbous regions. A bulb was present only within the CCA in five patients and only within the ECA in three patients. No bulb was present in nine patients. These data reveal that a bulbous region occurs in multiple segments. Defining plaque as being present within the carotid bulb is ambiguous since this applies to more than one vessel. Based on these findings, it is more appropriate to define plaque by using terms such as proximal, mid or distal. Carotid bifurcation refers to a specific anatomic region and would be acceptable as defining the location of disease. However, given carotid bulb variability, the term “carotid bulb” should be removed from common use within carotid duplex interpretations.
Patterns and Distribution of Deep Vein Thrombus in the Lower Extremity
Authors: Sapp Brian , Craddock Garnet , Sapp James
Published: March 2018

Introduction

Practices vary widely among sonography laboratories in the imaging and evaluation of calf thrombus, contributing to diagnostic and treatment uncertainty. Our goal was to isolate and determine patterns of deep vein thrombus to question the level of sonography required for best diagnosis.

Materials and Methods

We retrospectively evaluated all patients that had a positive venous duplex exam from 2004 to 2013. Our lab performed 11,503 venous studies during the 8-year period, with 382 showing, via symptom review and reporting, acute first-time thrombus.

Results

Mean age 62 years 8 months old, 209 females (54.71%), 171 male (44.76%), 221 left sided (57.85%), 161 right sided (42.15%). Percentages for the following segments: above the knee (139, 36.39%), calf (375, 98.17%), superficial (54, 14.14%), IVC (14, 3.66%), iliac (36, 9.42%), CFV (67, 17.54%), PFV (7, 1.83%), FV (114, 29.84%), popliteal AK (123, 32.20%), popliteal fossa (142, 37.17%), popliteal BK (148, 38.74%), gastrocnemius veins (141, 36.91%), peroneal (243, 63.61%), posterior tibial vein (191, 50.00%), soleal (109, 28.53%), anterior tibial veins (3, 0.79%), great saphenous vein (38, 10%), small saphenous vein (18, 5%), and varicosities (8, 2%).

Conclusion

Calf vein thrombus is found with above the knee thrombus (98.17%). Peroneal (63.61%), posterior tibial (50%), gastrocnemius (36.91%), and soleal (28.53%) veins should be routinely imaged. Binomial logistic regression was conducted with eleven-predictor variables significantly predicted proximal thrombus (above the knee). A test with all eleven-predictor variables, compared with the null model, was significant ( x2 [14] = 288.511, p < 0.001), showing that these variables predict above-the-knee thrombus better than without them (or by chance). We have developed a tool that shows the potential trajectories or tracks of a given patient's DVT (with associated probabilities), based on aggregated patient data.
Initial Evaluation of Virtual Histology Ultrasonographic Techniques Applied to a Case of Renal Transplant
Authors: Engelhorn Ana Luiza D. Valiente , Engelhorn Carlos A. , Salles-Cunha Sergio X.
Published: March 2018

Ultrasound virtual histology (USVH) techniques have been applied to B-mode images of coronary, carotid, and peripheral arteries and to deep venous thrombosis. We expanded USVH to evaluate the kidney. This case reports USVH applied to a renal transplant. A 29-year-old male with chronic renal insufficiency received his sister's kidney. B-mode images were recorded during (a) routine 1-day posttransplant US examination; and (b) a second follow-up US performed 6 days later once the patient became symptomatic. B-mode brightness of each pixel was classified into 14 ranges. USVH demonstrated high echogenicity of the kidney on day 1; gray scale median, GSM = 60, was elevated when compared with average GSM = 37 for normal, young kidneys. Muscle-like plus fiber-like echoes, 46 + 10 = 56%, were higher than expected for a normal young kidney, 34 + 3 = 37% ( p = 0.0071). GSM increased to 88 on day 7. Normal resistivity indices (RI) on day 1 increased from 0.66–0.70 to 0.81–0.90. Biopsy confirmed kidney rejection. These findings confirmed the concepts that tissue changed before hemodynamics were altered and signs and symptoms developed. Ultrasonographic tissue characterization, particularly of transplanted kidneys, deserves extensive investigation focused on early changes that precede present-day detectable abnormalities.
Ultrasonographic Tissue Characterization of Kidneys in Patients with Unilateral Renal Artery Stenosis
Authors: Engelhorn Ana Luiza D. Valiente , Engelhorn Carlos A. , Salles-Cunha Sergio X. , Andruska Gabriele , Batisti Karolini
Published: March 2018

Introduction

Ultrasound tissue characterization (USTC) has been applied to B-mode images of normal, young and transplanted kidneys, carotid, and peripheral atherosclerosis and venous thrombosis. We analyzed USTC from both kidneys of patients with severe unilateral renal artery stenosis. Seven women and 11 men, 79 ± 9 standard deviation (range = 57–96) years of age, were included. Severe, unilateral, renal artery stenosis was based on renal artery peak-systolic velocity (PSV) > 200 cm/sec and/or renal-aortic PSV ratio > 3.5. This sample population, selected sequentially by date of ultrasonographic examinations requested, was heterogeneous: kidney lengths and resistivity indices varied from 6.7 to 13.4 cm and 0.45 to 0.85.

Methods

USTC was applied to images selected for kidney length measurements. Pixel brightness in the 0–255 range was rescaled to zero for black and 200 for fascia brightness. Gray-scale medians (GSM) of entire kidneys were estimated for statistical comparisons between: (a) kidneys ipsilateral to stenosis (KIS), (b) kidneys contralateral to stenosis (KCS), and (c) normal, young kidneys (KN), previously published GSM = 37 ± 6 (27–48).

Results

Two distinct KCS subgroups were identified: (1) near-normal GSM < 54 (KCSN, n = 10, 56%); and (2) elevated GSM > 60 (KCSH, n = 8, 44%). Subgroup increasing GSM order was (1) KN, (2) KCSN (47 ± 7, > KN, p < 0.002), (3) KIS-CN (59 ± 20, >KCSN, p < 0.003), (4) KIS-CH (73 ± 20, > KCSN, p < 0.007), and (5) KCSH (78 ± 17, >KIS-CN, p < 0.05). GSM was independent of kidney length or resistivity index, with Pearson correlation coefficients < 0.5 for either KIS or KCS, respectively.

Conclusions

Tissue echogenicity, represented by GSM, was an independent variable characterizing effects of unilateral renal artery stenosis on the ipsilateral or on both kidneys.
Duplex Ultrasound Detection of a Chronic Contained Rupture of an Abdominal Aortic Aneurysm
Authors: Warren Melissa N. , Roberts Jason
Published: March 2018

Introduction

Chronic containment of a ruptured abdominal aortic aneurysm (AAA) is a rare clinical phenomenon that is often accompanied by abstract symptomatology, delayed diagnosis, and treatment. We describe a case of chronic contained rupture (CCR) in a hemodynamically stable and asymptomatic patient detected by duplex ultrasound (DU).

Patient Description

A 71-year-old white male presented to our medical facility to establish cardiac care for newly diagnosed pleural effusion and bilateral lower extremity edema. Physical examination revealed prominent abdominal aortic pulsations. An abdominal DU was ordered to evaluate for an AAA.

Methods

An abdominal DU examination was performed utilizing a Philips iU22 xMATRIX Ultrasound System equipped with a C5–1 MHz PureWave transducer. The aorta, common iliac and external iliac arteries were evaluated with gray scale, color, and spectral Doppler applications.

Imaging Results

The DU confirmed the presence of a 5.6 cm × 5.7 cm infrarenal AAA. The lumen was noted to have irregularities and multiple avascular hypoechoic lesions that were reproducible in multiple imaging planes. Computed tomography (CT) confirmed the presence of the 4.8-cm aneurysm accompanied by a 5.6 cm × 4.0 cm multi-lobular fluid collection extending into the mesentery. Active extravasations were not visualized during contrast administration; nevertheless, the appearance of the irregularity was suspicious of aneurysm leak resulting in evolving hematoma. The CCR was treated with a bifurcated intraluminal stent graft.

Conclusion

This case describes an extremely rare rupture complication that may be present during routine evaluation of the abdominal aorta. Because of its rarity in case presentation, standardized protocol for detection and sonographic presentation remain undocumented.
Congenital Absence of the Left Common Carotid Artery in a Patient with a Right-Sided Aortic Arch: A Case Study
Authors: Masri Dianne
Published: March 2018

Absence of a common carotid artery (CCA) is an extremely rare congenital anomaly. The first documented case was in 1787 during a postmortem examination. The incidence of agenesis of the CCA is unknown with fewer than 25 cases reported in literature. Agenesis of the CCA is commonly associated with separate origins of the internal carotid artery (ICA) and external carotid artery (ECA) and is usually an incidental finding on imaging studies and can pass unnoticed or misdiagnosed. Such an anomaly is typically asymptomatic unless associated with an accompanying arterial lesion that results in a work-up for symptomatic intracerebral pathology, a focal neurological deficit, or during autopsy. Although absence of the CCA is usually asymptomatic, transient ischemic attacks, hemiplegia, and intracranial hemorrhage may occur.
Ultrasound Detection of Absent Inferior Vena Cava
Authors: Smith Matthew G. , Kane Katherine
Published: March 2018

The congenital absence of the inferior vena cava (AIVC) is a rare condition affecting any portion of the infrahepatic IVC. Most confirmed patients are male, with unilateral or bilateral deep vein thrombosis (DVT) involving the iliac and femoral veins. AIVC is typically diagnosed by computed tomography (CT) or magnetic resonance imaging after an abnormal lower extremity venous ultrasound study. The following case report involves a 30-year-old man who developed a unilateral iliofemoral DVT without known risk factors. CT scan confirmed the presence of DVT but failed to identify AIVC. Repeat ultrasound imaging identified the absence of the IVC and common iliac veins, which was confirmed by venogram.