bluuebunny/crossref_metadata_2025 huggingface dataset:
Abdominal Aortic Aneurysm Volume Measurement with Three-Dimensional Ultrasound—A Feasibility Study
Authors: Dajani Khalil F. , Salles-Cunha Sergio , Beebe Hugh G.
Published: March 2018

Introduction

Endoluminal stent grafts are replacing conventional abdominal aortic aneurysm (AAA) surgery in an increasing number of patients in an attempt to minimize morbidity and mortality. Long-term follow-up of endograft-treated AAA demands image-based surveillance to detect endoleak, graft migration, and morphology change in the excluded AAA. AAA diameter is a traditional but simplistic measurement that has inherent flaws and has been shown to be insensitive to changes in AAA sac morphology. Volume measurement, performed by CT data acquisition and computerized postprocessing, has been proposed as the most sensitive index of successful AAA stent graft exclusion. We evaluated two ultrasound (US) volume measuring techniques for AAA volume determination: Virtual Organ Computer-aided AnaLysis (VOCAL) and Multi-Plane Area Summation (MPAS).

Methods

US images of an endograft-treated AAA were obtained with a commercially available three-dimensional (3-D) scanner. A fast rotating motor inside the probe allowed registration of multiple two-dimensional (2-D) images in real time. Data from these images were assembled in a 3-D dataset. With VOCAL, the 3-D AAA boundaries were identified, and volume was calculated. The operator traced AAA boundaries in six virtual planes selected by the software. With MPAS, aneurysm boundaries were traced in 2-D virtual images perpendicular to the longitudinal axis of the aneurysm obtained every 1 mm. AAA area was calculated and multiplied by this 1-mm step to obtain incremental volumes that were summed to obtain the AAA volume. VOCAL and MPAS volumes were calculated 10 times each for one AAA scan.

Results

Average AAA volumes were 86.7 ± 3.7 cm3 with VOCAL and 87.6 ± 3.1 cm3 with MPAS. These averages were not statistically significantly different by t test ( p = 0.54). Standard deviation (SD) to average ratio was 4.3% for VOCAL and 3.5% for MPAS.

Conclusion

Volume of an endograft-treated AAA was successfully measured multiple times with two 3-D US techniques. Volumes obtained were comparable, demonstrating feasible reproducibility.
Upper Extremity Phlegmasia Cerula Dolens: Presentation by Color Duplex Ultrasound
Authors: Tuvell Nancy , Bates Kelly , Sorrell Kathryn
Published: March 2018

Introduction

Phlegmasia cerula dolens (PCD) is an uncommon complication of deep vein thrombosis (DVT), and involvement in the upper extremities is rare. We report a case in which color duplex ultrasound (CDU) was used to diagnose PCD in a patient with extensive upper extremity DVT.

Patient

A 57-year-old woman underwent an open lung biopsy. On the first postoperative day, she had right hand and forearm pain, edema, and cyanosis.

Findings

CDU revealedacute DVT in the right radial, ulnar, and brachial veins and extensive thrombosis of the right cephalic and basilic veins. Arterial signals recorded from the ipsilateral arteries were remarkable for pandiastolic flow reversal (PDFR). In contrast, arterial signals from the contralateral arm had a normal, triphasic pattern. Arteriography revealed patent arteries to the wrist and no flow present in the right hand.

Conclusions

This report demonstrates the sensitivity of CDU to arterial compromise associated with PCD in a case of upper extremity DVT. Vascular technologists should consider including arterial Doppler signals in their venous duplex protocols in cases of extensive deep and superficial vein thrombosis.
Normal Doppler Velocity Values for the Subclavian Arteries
Authors: Rolan Terry , Tice Teresa
Published: March 2018

Physicians interpreting extracranial vascular ultrasound studies are called on to make statements about the normality of subclavian artery Doppler ultrasonography studies. No normative data for the flow velocities in these arteries has been published. We present data that establishes normal Doppler flow velocities for more accurate reporting.
A Case of Congenital Absence of the Right Common Carotid Artery: A Rare Embryologic Anomaly
Authors: Simons Donald , Patetsios Peter , Moglia Robert , Dietz Patrick
Published: March 2018

Congenital anomalies of the aortic arch are rare, with very few cases reported in the literature. Congenital absence of the common carotid artery (CCA), with separate origins of the internal carotid artery (ICA) and external carotid artery (ECA) is a rare anomaly. This case illustrates a congenital anomaly in the development of the right carotid system. By use of duplex sonography, we report of the absence of the right CCA with separate ICA and ECA originating from the innominate artery.
The Hemodynamic Relationships that Exist between Various Parts of the Lower Extremity Arterial Circuit Containing a Bypass Graft: Case Study
Authors: LeBaron Shani D. , Fex Beverly A. , Clay Amber L. , Wakefield Thomas W.
Published: March 2018

Introduction

Circuits containing bypass grafts are made up of four elements: (1) the inflow tract, (2) the graft, (3) the collateral beds, and (4) the outflow tract. The fundamental principles developed by Poiseuille, Ohm, and Bernoulli can facilitate our understanding of the hemodynamics that occur within the arterial circuit containing bypass grafts.

Case Report

A 59-year-old man was seen at our diagnostic vascular unit with severe claudication. Invasive and noninvasive vascular studies revealed occlusion of his aorta and bilateral common iliac arteries with reconstitution at bilateral groins by way of visceral vessels. Elective aortobifemoral bypass graft surgery was performed. Postoperatively, duplex ultrasonography (Phillips/ATL 5000, Bothell, WA, 7-MHz linear array transducer) performed on bilateral groins revealed prograde flow distal to the anastomoses and retrograde flow involving the distal external iliac arteries proximal to the anastomoses.

Discussion

Depending on the outflow resistance, flow might be prograde to the leg or retrograde to the pelvis and/or muscle proximal to the anastomosis or a combination of both as demonstrated in this case study. Such retrograde flow is desirable when one needs to perfuse the pelvis or thigh and not desirable if it steals blood from distal circulation.

Conclusions

The preceding fundamental principles refer to flow and pressure as inseparable manifestations of the total energetics of circulation. These principles are applied to the following case study and demonstrate competitive flow and pressure resistance relationships that exist within the arterial circuit containing a bypass graft.
Utility of venous Ultrasound to Diagnose Deep venous Thrombosis when the Primary Indication is Pulmonary Embolus
Authors: Rosenberg David , Waters MaryAnne , Callas Peter , Ricci Michael A.
Published: March 2018

Introduction

With increasing frequency, physicians are requesting a duplex ultrasound (US) to detect lower extremity deep venous thrombosis (DVT) in the face of suspected pulmonary embolus (PE), even when leg symptoms are absent. The objective of this study was to determine the diagnostic accuracy and the prevalence of DVT detected by duplex ultrasonography in patients with suspected PE in the presence or absence of leg symptoms.

Methods

Medical records for the calendar years 2000 and 2001 were examined from inpatients referred for lower extremity venous US. Basic demographic information, comorbidities, and indications for the test were retrieved from the records. Subjects were categorized into groups on the basis of risk factors and/or symptoms of DVT. For positive studies, the location of the DVT was also recorded.

Results

Of the 740 patients, 143 patients were suspected of having PE, whereas the remaining 597 subjects were suspected of having a DVT alone. Among subjects with suspected PE, 2 (2%) of the 110 patients without leg symptoms/risk factors were positive for DVT, whereas 15 (45%) of the 33 patients with symptoms/risk factors were positive for DVT ( p < 0.001). Among patients with questionable DVT, none of 24 asymptomatic patients were positive for DVT, whereas 65 (11%) of the 573 symptomatic patients were positive for DVT ( p = 0.10).

Conclusions

Lower extremity duplex US to diagnose DVT in the absence of leg symptoms when PE is suspected is not an effective strategy. If US is contemplated as the initial examination in patients suspected of having a PE, it should be used in those patients who have suggestive symptoms in the limb or medical contraindications to contrast injection.
The Role of Transcranial Color Duplex Ultrasound in Endovascular Treatment of Cerebral Vasospasm
Authors: Sorrell Kathryn , Harris Shelley , Carpenter Julora , Lugo Alex , Wills Shelly , Tuvell Nancy
Published: March 2018

Introduction

Recent advances in neuroradiology have made it possible to perform superselective catheterization of the intracranial arteries. Intra-arterial papaverine infusion (PI) or percutaneous transluminal balloon angioplasty (PTA) can then be performed to treat vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to determine the correlation between the angiographic result and transcranial color duplex ultrasound (TCDU) and to define a velocity threshold that could be used to predict the success of endovascular treatment for vasospasm.

Methods

Seven patients with SAH and symptomatic cerebral vasospasm underwent endovascular therapy and daily TCDU. PTA and/or PI was performed on a total of 23 arterial segments. Fifteen arterial segments were treated once, and eight segments required a second or third intervention. Preintervention and postintervention TCDU velocities were compared with angiographic results.

Results

Good to excellent relief of spasm was reported in 15 segments on the basis of postintervention angiography. The average preintervention TCDU velocity for these 15 responders was 170 cm/sec. Velocities dropped to an average of 96.5 cm/sec immediately after intervention. For the eight nonresponders, the average velocity pretreatment was 128 cm/sec. Angiography demonstrated modest or no relief of spasm after PTA or PI, and the average velocity after treatment was 130 cm/sec. When a change of >25 cm/sec was used, TCDU correctly predicted angiographic responders with a p value of < 0.01.

Conclusions

Our data demonstrate a strong correlation between the angiographic result and the drop in velocity after endovascular therapy for vasospasm. Postintervention TCDU values can be used as a point of reference from which to monitor further progression or regression of vasospasm. We believe that TCDU has significant value in the management decisions of endovascular interventions for the treatment of cerebral vasospasm.
Sonographic Detection of Renal Artery Dissection Secondary to Stanford Type a Aortic Dissection: Case Report
Authors: LeBaron Shani D. , Brown Sandra L. , Ruttkofsky Heather , Wakefield Thomas W.
Published: March 2018

Introduction

Aortic dissections (AD) are a result of the development of a focal intimal tear, most likely caused by medial degeneration. Medial changes occur as a consequence of hemodynamics and other predisposing factors. This condition most often affects males between 40 and 70 years of age, with the history or presence of hypertension being the most consistent clinical finding. The creation of the intimal tear allows pulsatile blood to enter and propagate through the aortic media, thus forming a false channel and predisposing the patient to possible end-organ complications. Duplex ultrasound demonstrates dissection as an undulating membrane, containing asymmetrical blood flow. Aortic dissections are classified by location and extent of the intimal tear. Stanford type A (DeBakey type I) involves the ascending aorta. These dissections are life-threatening, and patients usually require emergent surgical reconstruction.

Case Report

A 33-year-old male with a past medical history significant for hypertension since 15 years of age was transferred from an outside hospital and presented with a greater than 5 cm ascending aortic aneurysm and a Stanford type A aortic dissection. A transesophageal echocardiogram (TEE) was performed and confirmed a type I dissection that showed extension to just below the level of the diaphragm. He was taken for emergent aortic repair. On postoperative day 1, the patient developed acute renal insufficiency. Duplex ultrasound was performed to assess renal artery flow, revealing propagation of dissection into bilateral proximal renal arteries and significant stenosis at the origin of the right renal artery. The patient underwent right renal artery percutaneous transluminal angioplasty and stent placement to restore blood flow to the right kidney.

Conclusions

This case demonstrates and identifies the etiology, pathology, and classifications of aortic dissection as it relates to this case. Duplex ultrasound was a safe, reliable, and sensitive tool for the evaluation of end-organ complications associated with dissection.
Femoral Artery Stenosis in a Marathon Runner
Authors: Greene Kathleen , Lowe Robert
Published: March 2018

The diagnosis of arterial pathology in an athlete is challenging for the clinician. Their symptoms are commonly attributed as being musculoskeletal in origin. Typically, athletes with arterial pathology have normal resting examinations and are not symptomatic unless they are performing extreme physical exertion. This case study describes a marathon runner who, over a 12-month period, complained of severe heaviness and dead sensation in her right lower extremity after running one-half mile that resolved with rest. By customizing usual vascular lab indirect physiological testing and duplex imaging protocols, we were able to identify and quantify the femoral artery narrowing that was ultimately repaired with surgery. This case demonstrates the efficacy of the vascular laboratory in identifying performance limiting atypical arterial pathology in a marathon runner.
Median Arcuate Ligament Syndrome: A Case Report
Authors: Butcher Y. M. , Walker P. J.
Published: March 2018

Introduction

Median arcuate ligament syndrome is a form of nonatherosclerotic visceral ischemia caused by the extrinsic compression of the celiac axis (CA) by the median arcuate ligament. The significance of this finding is controversial, with only 40% of stenoses being symptomatic. This case report describes our findings in a 41-year-old man referred because of an incidental finding of an upper epigastric bruit.

Case Report

An examination of his mesenteric arteries was requested. A duplex ultrasound of his aorta, CA, and branches, superior mesenteric (SMA) and inferior mesenteric arteries (IMA) was performed. A duplex examination of his aorta revealed no plaque, no significant stenosis, and no aneurysmal dilatation. His SMA and IMA were likewise found to be of normal caliber with no significant stenosis identified. On gentle respiration, the CA was found to have a >70% stenosis with peak systolic velocity (PSV) of 308 cm/sec. On deep expiration, the PSV in CA increased to 385 cm/sec; however, on deep inspiration, the PSV in CA dropped to 121 cm/sec indicating a <70% stenosis. It was noted that there was a change in Doppler angle required to remain parallel to the vessel wall in the CA on deep inspiration from 42 degrees to a deep expiration angle of 58 degrees. Also of note was a hyperechoic band at the base of the CA on B-mode imaging. This was believed to represent either the median arcuate ligament itself or the compression of the CA wall by the ligament.

Conclusion

Most researchers agree that specific symptomatic patients may benefit from surgical intervention. As this patient was asymptomatic, it was felt that follow-up without intervention was an appropriate course of action at this time.
Beyond the Categories: A Formula-Driven Prediction of Carotid Stenosis
Authors: Bulger Christopher M. , Gao Weihua , Jacobs Chad , McCarthy Walter J.
Published: March 2018

Purpose

Current methods to predict carotid stenosis from ultrasound duplex criteria involve assigning a category of stenosis on the basis of an individual laboratory-defined combination of peak systolic velocity (PSV), end diastolic velocity (EDV), and ratio of internal carotid artery velocity to common carotid artery velocity. This study will define a formula by use of regression analysis of the duplex ultrasound criteria compared with the angiographic results. This study will then compare the formula predictions of stenosis with the current means of combining categories to determine whether there is an increase in accuracy and correlation with angiographic findings.

Methods

A retrospective review of the duplex scans and NASCET-defined angiogram results from 209 patent carotid arteries in 114 patients over the course of 4 yr at a single institution was performed. Regression analysis comparing each of the PSV, EDV, and internal carotid artery/common carotid artery ratios (RATIO) with angiographic stenosis was performed. Simple and multiple linear regression equations were obtained. The equation was tested for validity. The data were then reanalyzed by use of the formulas, and predicted stenoses from the formulas were obtained. The formula-predicted stenoses (F1 and F2), category-based stenoses (READAS), and angiographic stenoses were compared. A determination was then made of their statistically significant difference by use of the Wilcoxon signed rank test and receiver operator curve (ROC) analysis.

Results

An r2 value of 0.7231, 0.6341, and 0.7262 was obtained, respectively, for the equations comparing PSV, EDV, and ICA/CCA ratio with angiographic stenosis. Limiting the data to stenosis >30% resulted in correlation coefficients between the regression formula predicted data and the angiographic data of 0.71. A statistically significant difference was demonstrated between the category results and angiography ( p < 0.0001). No statistically significant difference was demonstrated between the formula-predicted data and the angiographic data. ROC analysis and Area (AZ) test demonstrated a statistically significant difference and better prediction of a >60% stenosis by the regression equation than by the current category method ( p < 0.05).

Conclusion

Regression analysis of duplex data versus NASCET-defined angiographic findings allows formation of a model to predict carotid stenosis. This can be done with greater accuracy than the commonly accepted means of categorizing the duplex results.
Ultrasound Assessment of Takayasu's Arteritis
Authors: Butcher Y. M. , Hetherington R. L. , Gibbs H. H.
Published: March 2018

Introduction

Atherosclerosis is the most common abnormality seen in the vascular laboratory. Rarely, other arterial diseases, such as large vessel vasculitis, are seen. We describe our experience of Takayasu's arteritis (TA).

Methods

The clinical and duplex ultrasound findings of six patients with TA were analyzed. Common sites of involvement and the ultrasound appearances of TA were compared with typical findings of atherosclerosis.

Results

The mean age of the patients was 53 yr, and all were female. TA had been present for 11.8 yr (range, 1–27 yr). All six patients underwent upper extremity duplex scanning. In all cases, abnormalities were present in the proximal and mid common carotid arteries; however, the carotid bifurcation was normal in five of six cases. The proximal subclavian artery was abnormal in five of six cases. In addition, four patients had a severe stenosis in the distal axillary/proximal brachial artery. All of these abnormalities were situated distal to the origin of the subscapular artery. All patients underwent duplex scanning of the abdominal aorta. Severe stenotic disease was present in two patients, with one of these having had a previous aortic grafting procedure. Three additional patients had aortic wall thickening without stenosis. B-mode ultrasonography demonstrated homogenous, concentric, long arterial wall thickening in all areas of abnormality in all cases.

Conclusions

TA is an uncommon disease affecting the large branches of the aorta. The proximal and mid common carotid and the distal axillary arteries are commonly involved, and these sites are unusual in atherosclerosis. The detection of abnormalities on duplex scanning at these sites raises the diagnostic possibility of TA.
Atypical Color Doppler Findings Related to Remote Lower-Extremity Traumatic Injury
Authors: Diaz Suzanne W. , Roper Laura D. , Back Martin R.
Published: March 2018

Introduction

Ultrasound artifacts can be misleading. This case demonstrates an unusual color Doppler artifact encountered while performing a lower-extremity venous evaluation. This color Doppler artifact was so unique that initially it was thought to be an incidental vascular finding.

Case Study

A 46-yr-old military veteran was seen in our noninvasive vascular laboratory for a lower-extremity venous evaluation because of left lower-extremity edema. He gave a history of chronic left lower-extremity pain from a war injury to his anterior left calf. An abscess developed 1.5 yr ago after he received whirlpool therapy. When the transducer was placed on the injury site, a large portion of the abscess filled with mosaic color that appeared to originate from the anterior portion. This color occurred without transducer movement. The appearance was similar to an arteriovenous fistula, which was suspected because of varicosities in the vicinity. However, pulsed Doppler revealed artifactual noise.

Conclusion

It was suspected that this was an impressive, atypical color Doppler reverberation artifact. The patient's tibiofibula radiographs showed pieces of shrapnel throughout the abscess. We hypothesize that the artifact was created by acceleration of the sound waves through the fluid in the large abscess with resonation between fragments of shrapnel. This is an example of a color Doppler artifact making it appear that there is flow in a location where there is none.
Appropriate Resource Utilization in Portable Noninvasive Vascular Studies: The Role of Disruptive Technology
Authors: Patel Darshan , Satiani Bhagwan , Mong Renee , Baetz Laureen , Spiezio Kim
Published: March 2018

Purpose

Common reasons for avoiding portable noninvasive vascular laboratory (VL) studies include degraded study quality, repetitive stress injuries, the wear and tear of equipment, and inefficiency. We examined the efficiency of portable VL studies in the context of productivity and potential loss of revenue.

Methods

From January 2005 to March 2005, sonographers in the VL recorded the time required to conduct “in-lab” and portable studies with conventional full-size scanners. A blended average based on frequency of portable studies within different areas of the hospital was used to determine the additional time required to conduct a portable study. The sonographer also made a qualitative assessment on the necessity of the portable study in each case.

Results

The VL performed an average of 31 portable studies (18% of total studies) per week. On average, portable testing increased overall study time by 17.7 min per test and 1.8 h per day, resulting in 9.1 h of additional study time lost per week. The potential increase in study volume could result in incremental annual gross revenue of $41,204 to $77,258 for the VL. The sonographers estimated that 24% to 45% of portable procedures could have been conducted in the lab.

Conclusions

In addition to suboptimal imaging and sonographer/equipment wear and tear, the current practice of unrestricted portable tests performed with existing bulky equipment is economically inefficient. New “disruptive” technology, leading to high-quality bedside scanning and limiting portable studies to patients who genuinely need it, will allow for greater productivity, decrease wait time for elective outpatients, and generate incremental revenue for the VL.
Management of Varicose Veins by High Ligation, Sclerotherapy and Duplex Scanning
Authors: Chang John B. , Stein Theodore A.
Published: March 2018

Background

Venous duplex scanning helps in the management of patients after high ligation of the greater saphenous vein and spares it for future vascular reconstructions.

Methods

Duplex scanning was used to locate incompetent veins in these patients. The clinical, etiologic, anatomic, and pathophysiologic (i.e., CEAP) criteria classified the clinical severity of disease. High ligations of the greater saphenous vein at the saphenofemoral junction were performed in 1,021 limbs of 608 patients who only had chronic superficial venous insufficiency. Unless contraindicated, the use of 30–40 mmHg compression hose was prescribed. The progression of venous disease was determined by examination, history, and duplex scanning at 1- to 3-month and 6- to 12-month intervals. Ulceration, ankle edema, night cramps, stasis changes, cellulitis, varicose veins, and reflux were recorded. If there was a nonhealing ulcer, no significant improvement, or a recurrence of symptoms, then residual varicose veins were injected with a sodium tetradecyl sulfate solution to sclerose incompetent veins. At follow-up times, limbs were classified as improved, stable, or worse.

Results

After the high ligation, symptoms were improved in 449 limbs (44%), stable in 398 limbs (39%), and worse in 174 limbs (17%). After sclerotherapy of 572 limbs, 517 limbs (90%) improved. Ulcers occurred in 14 limbs. Edema occurred in 33 limbs, cellulitis developed in 15 limbs, and night cramps occurred in 12 limbs. If varicose veins persisted, they were managed by sclerotherapy, and 60% of the sclerotherapy-treated limbs were free of symptoms or varicosities at 8 years.

Conclusion

High ligation at the saphenofemoral junction is a valuable procedure in select patients to preserve the greater saphenous vein. Periodic venous duplex scanning is needed to properly manage these patients.
Upper Extremity Deep Vein Occlusion Attributable to Metastatic Renal Cell Carcinoma
Authors: Caswell Rebecca M. , Gerhard-Herman Marie D. , Binkert Christoph , Alessi-Chinetti Jean M. , Gornik Heather L.
Published: March 2018

Venous occlusion typically is caused by thrombosis, as is demonstrated by non-compressibility of the suspected vessel on duplex ultrasound. We report an unusual case of extensive bilateral upper-extremity and jugular venous obstruction caused by tumor thrombus. A 59-year-old man with a history of metastatic renal cell carcinoma presented to the vascular laboratory with right upper-extremity swelling. Our study revealed atypical masses of mixed echogenicity within the right and left internal jugular veins. At one location, the mass appeared to enter the left internal jugular vein from the surrounding tissue. Spectral Doppler within the mass demonstrated arterial vascularity. There also was Doppler evidence of occlusion of the right subclavian vein. The unusual appearance of the mass, in conjunction with the clinical history, prompted further investigation. Magnetic resonance venography confirmed the finding of extensive thrombosis of bilateral internal jugular veins, bilateral innominate veins, and the right subclavian vein. The patient underwent venography, transvenous biopsy, and stenting of the left innominate vein. Biopsy of the left innominate vein thrombus revealed renal cell carcinoma, which was consistent with the patient's known malignancy. We report an unusual cause of upper-extremity deep vein obstruction caused by metastatic cancer. Although renal cell carcinoma is associated with inferior vena cava extension and lower-extremity deep vein thrombosis, this is the first known case of bilateral upper-extremity deep vein thrombosis caused by this malignancy.
Duplex Scanning for Detection and Follow-Up of Iliac Artery Aneurysms and Pseudoaneurysm Amenable to Endovascular Therapy
Authors: Beals Holly , Del Pizzo David J. , Pevec William C. , Dawson David L.
Published: March 2018

Duplex ultrasound can be a valuable tool in detecting potentially life-threatening iliac artery aneurysms and pseudoaneurysms amenable to endovascular therapy. Four patients were found to have aneurysms other than abdominal aortic aneurysms, which were treated successfully with endovascular exclusion techniques. These included a 5.4 x 5.1-cm pseudoaneurysm arising from the distal anastomotic site of a previous aortic aneurysmorrhaphy; a 7.8 x 6.4-cm right common iliac artery aneurysm with an associated arteriovenous fistula that caused high-output heart failure, and a 4.1 x 5.0-cm aneurysm of the left internal and common iliac artery in a patient who had previous surgical repair of an aortic aneurysm with a bifurcated graft. A patient with a 7.5-cm aneurysm of the internal iliac artery also was treated, but the initial ultrasound diagnosis was made by a referring hospital. Treatment methods included placement of bifurcated endografts (two cases), use of a covered stent (one case), and use of a single iliac component from an aortic endograft (one case). Three internal iliac arteries were embolized with coils. In one patient, subsequent duplex surveillance identified a stenosis within a covered stent. This was treated with placement of a balloon-expandable stent.
Extracranial Carotid and Vertebral Artery Ultrasonography: Resistive Indices for Diagnosing Cerebral Brain Death
Authors: Barreto Jaqueline L.W. , Scissons Robert P. , Salles-Cunha Sergio
Published: March 2018

Introduction

—Transcranial Doppler (TCD) has been used to document blood flow indicative of patients who are clinically brain dead. Limitations of TCD include signal loss in the absence of an adequate acoustic window, or extensive craniotomies that interfere with TCD insonation. Additionally, when compared with duplex ultrasonography of extracranial carotid and vertebral arteries, TCD is more technically difficult to master, with limited availability in many institutions.

Objective

—We sought to evaluate the use of carotid and vertebral artery ultrasound resistive indices in patients with clinically diagnosed brain death.

Methods

—Standard carotid and vertebral duplex ultrasound protocol was used to evaluate extracranial arteries in 2 groups: I: 8 control subjects, mean age of 49 years, without evidence of carotid or vertebral atherosclerosis, and II: 8 patients, mean age of 48 years, diagnosed with brain death confirmed by electroencephalography. All patients had insignificant (< 50% stenosis) carotid and vertebral atherosclerosis. T-test was used to compare common carotid, internal carotid (ICA), external carotid, and vertebral (VERT) artery resistive indices between Groups I and II.

Results

—Common carotid (0.74 ± 0.04 vs. 0.88 ± 0.08), ICA (0.60 ± 0.06 vs. 1.00 ± 0.00), and VERT (0.61 ± 0.05 vs. 1.00 ± 0.00) artery resistive indices were significantly lower in normal subjects than in brain death patients ( p < 0.05). Both ICA and VERT waveforms in brain death patients demonstrated the oscillatory, “to-and-fro,” pattern already established with TCD.

Conclusion

—Extracranial ICA and VERT waveforms in patients diagnosed with clinical brain death have the same resistive indices and waveform patterns that have been used to identify brain death intracranially with TCD. Because standard duplex ultrasonography is the most commonly used noninvasive modality for cerebrovascular evaluation, we believe this method may be easier to understand and more readily available for the initial diagnosis of cerebral brain death.
Incidental Finding during Venous Duplex Examination: Solitary Fibrous Tumor or Arteriovenous Malformation in the Left Lower Extremity
Authors: Hodge Megan , Hund Twyla , Bush Ruth , Lumsden Alan B. , McCollum Charles H. , Noon George P.
Published: March 2018

Purpose

—Superficial varicosities surrounding a palpable mass in the posterior aspect of the left thigh were investigated during a venous duplex examination. A well-defined mass with arterial and venous feeding branches strongly suggested the presence of an arteriovenous malformation. We present an unusual case of a soft-tissue thigh mass that appeared to be an arteriovenous malformation by ultrasound and arteriography but after surgical resection was confirmed to be a benign soft tissue tumor.

Case Report

—A 32-year old woman presented with superficial varicosities surrounding a painful mass on the posterior aspect of her left thigh. Venous duplex exam demonstrated normal findings of the deep veins, but further investigation of the superficial varicosities revealed a 3.5-cm x 6.0-cm soft-homogenous mass with a large complex network of arterial and venous feeding branches. Arteriography confirmed a well-defined thigh mass with an arterial network feeding the mass. Surgical resection of this well-circumscribed mass was performed. Histological tissue exam revealed a benign low-grade spindle cell neoplasm with blood vessels.

Conclusion

—This report highlights the importance of evaluating all abnormal superficial varicosities and palpable soft-tissue masses as part of a lower extremity vascular duplex evaluation because incidental findings not diagnosed through clinical examination may be detected.
High-Resolution Duplex Ultrasound Imaging Proves a High Incidence of an Arterial Neovascularization Phenomenon Associated with venous Thrombosis
Authors: Busch Kathryn , White Geoffrey , Burnett Alison , Harris John
Published: March 2018

Introduction

We have recently observed an interesting phenomenon of prominent arterial neovascularization (ANV) within the thrombus and vein wall of patients with major venous thrombosis, sometimes intense enough to mimic small arteriovenous fistula. A prospective study was therefore conducted in 50 patients to further characterize this process.

Aims

We sought to determine the incidence of ANV; to characterize the process in more detail; and to determine whether there was an eventual recanalization of the thrombosed vein and favorable clinical outcome

Methods

All patients presenting with lower-extremity venous thrombus were prospectively imaged with Philips HDI 5000 and IU22 ultrasound systems using a standard protocol, including spectral and color Doppler analysis. Blood flow patterns in and around the thrombus were closely observed and recorded. In each patient, the phenomenon was assigned a grading from 0 to III according to prominence and penetration of the neovascularization process into the thrombosed vein.

Results

A total of 50 consecutive patients (age range; 35–80 years) were included in the study. 32 patients had DVT and 18 patients had superficial venous thrombus (SVT). ANV was observed as small vessels demonstrating a low-resistive arterial signature appearing predominantly on the vein wall and/or within the thrombus. The typical vessel diameter was 0.3–3.0 mm. ANV was present in 80% of patients examined and in 97% of cases with thrombus aged less than a year old. It was more common with SVT (100%). The process was most prominent at the 2–4 month interval after venous thrombosis.

Conclusion

There is a process of neovascularization that commonly occurs in association with venous thrombus. This was detected in 97% of patients with thrombus less than a year old. ANV appears to be a normal component of the recanalization process and may result from an inflammatory reaction. Further studies will be required to determine if the grade of this process can be correlated with favorable long-term outcome.
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 47 females 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.
Determination of a Safe Target Zone for the Use of Endovenous Laser Therapy of the Small Saphenous Vein
Authors: Wang Xiu-Jie , Impeduglia Theresa , Elias Steve
Published: March 2018

Background and Purpose

This study was designed to determine a safe target distance (TD) from the saphenopopliteal junction (SPJ) to initiate endovenous laser therapy (EVLT).

Methods

A retrospective chart review was performed. Thirty-six limbs in 33 patients were treated with EVLT for small saphenous vein (SSV) incompetence. An 810-nm diode laser at 12W in the continuous mode was used. Clinical assessment was performed 1 week postoperatively and duplex scanning within 30 days.

Results

Mean vein diameter was 7.1 mm (max, 11 mm). The distance between the EVLT starting point and the SPJ ranged from 1.5 to 3.5 cm (mean, 2.19cm). Closure of the SSV was confirmed by completion ultrasonography in all cases. Twenty of 33 patients had 1 month follow-up scanning. None had SSV recanalization, deep venous thrombosis, adverse reactions to the laser, or clinical signs of nerve injury. Closure was noted 0.5–1 cm proximal to the initial target distance fiber location at the onset of EVLT ranging from 1 to 1.5 cm from the SPJ.

Conclusion

We propose a minimal 2 cm distance from the SPJ and a 2 cm radius of tumescent solution to counteract the perivenous effects of the laser energy. Anatomic morphology and these calculated distances determined by intraoperative ultrasound guidance are critical to the safe outcome of EVLT of the SSV.
New Transcranial Doppler (TCD) Waveform Shape Parameters: A Repeatability/Reproducibility Study
Authors: Byrd-Raynor S. , Parker K.
Published: March 2018

Introduction and Objective

Doppler ultrasound is used in nearly every medical discipline for the evaluation of blood flow. The cerebral circulation is of particular interest, but is difficult to interpret because of the complex hemodynamics of the brain's blood flow. However, advances in the field of transcranial Doppler (TCD) could have important clinical and cost-saving benefits. We describe the testing of a novel method for acquiring and analyzing TCD flow velocity waveforms, in conjunction with other physiologic data. We also evaluate the repeatability and reproducibility of the technique.

Methods

We used custom-designed waveform analysis software to calculate 16 new waveform shape parameters and indices. We present the repeatability and reproducibility results for the new waveform shape parameters, as well as traditional TCD measurements, during repeated vasomotor reactivity studies on five healthy subjects. A ranked score ( mean value of test 1 and 2/coefficient of repeatability) is used to evaluate each parameter. The scores are presented by category: Traditional TCD Measurements, Velocity Minima, Velocity Maxima, Acceleration/Deceleration, Miscellaneous measures (e.g. blood pressure, heart rate), Time Measurements, and Shape Indices. Higher scores indicate better reproducibility.

Results

The mean scores of all parameters for each testing segment were Baseline 4.60, Hypercapnia 4.34, and Hypocapnia 4.00; showing that Baseline measurements are more easily reproduced than measurements during an intervention, particularly Hypocapnia. Individual parameters with the best reproducibility over all three testing segments are: RI (Resistance Index) 19.02; Mean Resistance ( mean blood pressure/mean velocity) 10.64; Umin (end-diastolic velocity) 9.84; Umaxdias (velocity rise immediately after aortic valve closure) 9.83; and DuDtmax (systolic acceleration) 8.54. We discuss why some parameters are more reliable than others in TCD studies and how the cyclical variations in the cerebral circulation can affect reproducibility.

Conclusions

This new methodology allows for discrete measurements of Doppler waveforms and would have the ability to track subtle changes during physiological or pharmacological interventions. These advances may aid the interpretation of complex cerebral hemodynamics, and increase the utility of this non-invasive, low-cost technique.
Unusual Representation of a Common Iliac Artery Double Aneurysm
Authors: Oliveri Janine
Published: March 2018

This case discusses an unusual representation of a 3.1-cm double aneurysm of the right common iliac artery with an ectatic distal abdominal aorta. The patient was a 64-year-old asymptomatic male who participated in a routine ultrasound screening at his church. On the basis of the findings, a full ultrasound study was ordered and conducted at the request of his primary physician. The patient's history included smoking cessation in 1975. He currently had hypertension and hyperlipidemia. He was physically active and ran 40 miles per week until developing right Achilles tendonitis. Because of this injury, the patient biked daily. The patient's medications included atenolol and daily vitamins. The ultrasound findings revealed two aneurysms of the right common iliac artery. Both areas were fusiform and measured 3.1 and 2.9 cm, respectively. The dilation extended to the right internal iliac artery. The left common iliac was mildly dilated and kinked to the left. There was mild enlargement of the distal abdominal aorta measuring 3.4 cm by ultrasound and 3.1 cm by computed tomography angiogram. There is no evidence of internal thrombus. Usually asymptomatic, iliac artery aneurysms can be lethal if large (above 3.0 cm) and undetected. With appropriate, timely intervention the aneurysm can be safely repaired before rupture. Various aneurysm treatment options include conventional open abdominal surgery or endovascular stent graft placement with coil embolization. This patient discussed options with the vascular surgeon and was scheduled to have a cardiac catheterization with right internal iliac coil embolization. Staging of the endovascular graft was planned to follow. This case presents the uncommon finding of a large iliac artery aneurysm. This patient's disease was made more unusual by the presence of two distinct aneurysms present within the same vessel. It further reinforces the common practice of fully examining patients with aneurismal disease bilaterally and over multiple levels as a significant portion of patients have multilevel disease.
A Retrospective Analysis of the Clinical Effects to Ultrasound Screening for Abdominal Aortic Aneurysms: The RACE to SAAAVE Study
Authors: Santin Brian J. , Bahner David , Satiani Bhagwan
Published: March 2018

The Screening for Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act authorizes Medicare to pay for an ultrasound screening for select patients. We hypothesized that the potential increase in screening would affect the ability of a high-volume medical center to respond to this need. Selection criteria included age >65 years and evidence of or risk factors for cardiovascular and/or atherosclerotic disease. We queried the medical center's information warehouse to define a patient population which, in a retrospective fashion, would have met the aforementioned criteria. We sought to quantify the potential increase in the number of abdominal aortic aneurysm (AAA) ultrasound screenings. There were 29,875 patients who met the inclusion criteria. Upon admission, 476 patients (1.5%) were diagnosed with AAA, and 35 were diagnosed with ruptured AAAs. There were 742 AAA diagnosed at time of discharge, equivalent to a 55.9% increase in prevalence of aneurysms compared with admission diagnoses. Of these, 48 were diagnosed upon discharge after rupture, which was greater than a 37% increase compared with the number diagnosed upon admission. During the study period, the medical center imaging laboratories performed an average of 1700 to 2100 ultrasound scans per full-time equivalent sonographer. Our results suggest that the additional patient volume would be approximately 10,000 patients per year. The SAAAVE Act of 2005 will have a profound impact on health care institutions nationwide.
Perforator and Axial Venous Insufficiency in Sickle Cell Disease Patients with and without Leg Ulceration
Authors: Braverman Albert S. , Nehra Anupama , Olowokure Olugbenga , Raftery Thomas , Gillette Peter , Weedon Jeremy , Olivier Tracy , Belyayeva Irina , Deitch Jonathan
Published: March 2018

Chronic or recurrent leg ulceration occurs in at least 25% of patients with sickle cell disease (SSD). Conflicting data exist concerning the association between SSD leg ulcers and axial venous insufficiency. To determine whether the incidence of perforator vein insufficiency (PVI) is greater in the ulcerated legs of SSD patients than in those without ulcers, the legs of 46 SSD patients, 25 of whom had chronic ulceration and of 19 normal young adult volunteers, were investigated with color-flow venous duplex Doppler sonography. PVI was found in 25 of 37 ulcerated legs and in 14 of 55 nonulcerated legs of SSD patients. The difference was significant (odds ratio 6.2). PVI may contribute to leg ulceration in SSD disease.
Work Flow Analysis: Evaluation of Conventional Mobile versus Portable Ultrasound Scanners in the Noninvasive Vascular Laboratory
Authors: Pawaskar Manjiri , Balkrishnan Rajesh , Kiser Dennis , Gray Marisa , Satiani Bhagwan
Published: March 2018

Purpose

We sought to compare workflow and efficiency of mobile and portable scanners in ultrasound assessment at the bedside.

Method

A prospective observational study was conducted using traditional mobile (GE LOGIQ 9) and lightweight portable (Z.one) scanners to measure the time taken for unilateral venous examination at the bedside. Total examination time was measured, including patient preparation, procedure, documentation, cleanup, travel, and rebooting time. Descriptive statistics and two sample t test was performed to compare work flow of mobile and portable scanners.

Results

A total of 100 lower extremities of patients were evaluated with mobile (n = 43) and portable (n = 57) scanners. Mean total time required for an imaging procedure by portable (40.18 ± 9.06 min, mean ± SD) and mobile scanner (36.64 ± 8.84 min) was not significantly different. Mean procedure time (20.84 ± 4.08 min) needed by portable scanner was significantly greater than mobile scanner (16.94 ± 4.38 min; p < 0.05). However, mean rebooting time taken by a portable scanner (0.58 ± 0.55 min) was significantly less than a mobile scanner (2 ± 0.57 min; p < 0.05).

Conclusion

The total examination time for both portable and mobile scanners was similar. The rebooting time was shorter for portable scanners whereas the actual procedure time was shorter for the mobile equipment. Travel time to and from the bedside is a significant component of total examination time. Further strategies to improve workflow may include refining the indications for portable testing and centralized stationing of equipment closer to high volume areas.