bluuebunny/crossref_metadata_2025 huggingface dataset:
Carotid Artery Pseudoaneurysm after Endovascular Stent Placement: Diagnosis and Follow-up Duplex Ultrasonography
Authors: Zhou Wei , Bush Ruth L. , Lin Peter H. , Hodge Megan D. , Felkai Deborah D. , McCollum Charles H. , Noon George , Lumsden Alan B.
Published: March 2018

Purpose

Carotid artery pseudoaneurysm development after endarterectomy, albeit rare, has been attributed to patch deterioration. We present an unusual case of pseudoaneurysm development 1 year after stent placement for recurrent carotid artery stenosis.

Case Report

A 64-year-old man had transient hemiparesis develop 1 week after carotid artery endarterectomy (CEA) with patch angioplasty for monocular transient ischemic attack. Carotid angiography reviewed an intimal flap at the distal endarterectomy site, which was successfully treated with carotid stent placement. During a duplex scan 1 year later, he was found to have a symptomatic 2.5-cm pseudoaneurysm at the level of stented carotid bifurcation. This was successfully treated with a combined open and endovascular approach, which consisted of stent-graft placement by means of an open carotid exposure. Completion angiogram showed successful stent-graft exclusion of the pseudoaneurysm. A follow-up duplex scan 6 months later demonstrated diminution of pseudoaneurysm size without endoleak.

Conclusion

This report highlights the importance of duplex ultrasound surveillance in patients with CEA or carotid stenting, because it can accurately detect recurrent stenosis or carotid pseudoaneurysm. Moreover, a combined open and endovascular therapy using stent graft successfully treated the carotid pseudoaneurysm in our patient.
Selective use of Duplex Ultrasound after Successful Thrombin Injection of Pseudoaneurysms
Authors: Stone Patrick A. , AbuRahma Ali F. , Hayes J. David , Flaherty Sarah K. , Elmore Michael S. , Lohan James A.
Published: March 2018

Introduction

Duplex-guided thrombin injection (DGTI) has been shown to be a safe and efficacious initial treatment of iatrogenic arterial pseudoaneurysms. Postinjection follow-up duplex ultrasound examination has become the accepted standard of care despite 1) the use of intraprocedural ultrasonography to monitor successful thrombosis, 2) a low post-DGTI recurrence rate, and 3) the relatively high cost of ultrasonography. A retrospective study of DGTI at our institution was conducted to examine the necessity of routine duplex ultrasound after successful DGTI, along with a review of the relevant literature.

Patient Population/Methods

A retrospective review was conducted of 82 patients with iatrogenic arterial pseudoaneurysms (12 complex; 25.6%) treated with DGTI after initial diagnostic duplex ultrasonography. Immediate routine follow-up duplex ultrasound was performed on 71 of 82 cases (86.6%), whereas 11 patients received only clinical follow-up at the surgeon's discretion. Patient demographics, pseudoaneurysm anatomy, procedural details, outcomes, and complications were retrospectively documented and analyzed.

Results

From January 2002 to November 2003, 82 patients (59.8% women) underwent DGTI for pseudoaneurysm, with the majority located in the common femoral artery (48 of 82; 58.5%). Eighty pseudoaneurysms (97.6%) were treated with DGTI, with 78 (95.1%) being initially successful. Four of 78 (5%) follow-up examinations were judged to be of clinical significance: 2 of 78 patients (2.6%) became symptomatic and experienced pseudoaneurysm recurrence, whereas 2 of 78 patients were found to have an additional, previously undocumented, pseudoaneurysm. Three of these four resolved with a second injection, whereas one resolved without additional treatment. No thromboembolic, allergic, or infectious complications related to DGTI occurred.

Conclusions

In concert with the available literature, this cohort confirms that DGTI is a safe and effective treatment of iatrogenic arterial pseudoaneurysms with a low rate of recurrence, complication, and need for conversion to surgical intervention. DGTI should undoubtedly be the initial treatment of choice for pseudoaneurysms; however, follow-up duplex ultrasonography can be reserved for the clinically symptomatic patient.
Femoral Artery Blood Flow in Infants and Children
Authors: Kröger K. , Nettelrodt J. , Müntjes C. , Neudorf U. , Feuersenger A. , Schmaltz A. A.
Published: March 2018

Background

We measured Doppler parameter of common femoral artery (CFA) blood flow in infants and children and investigated how far these parameters change with age, height, weight, body mass index (BMI), and body surface area (BSA).

Material and Methods

CFA was investigated in 97 infants and children (43 females, 54 males, ages ranged from 0.13 to 220 months) on both sides in a supine position after 5 min rest using a 7.5-MHz linear transducer (Type Elegra, Siemens, Germany) 1 cm proximal to the femoral bifurcation. Peak systolic velocity, end-diastolic velocity, blood flow volume, mean average velocity, resistance index, and pulsatility index were measured.

Results

Theoretically, Doppler parameters could change with age, height, weight, BMI, and BSA. Because age, weight, height, and BSA were highly correlated (Spearman correlation coefficient > 0.90) only one of these variables could be included in a regression model. Only diameter and flow velocity (FV) correlated with age and height. Peak systolic velocity, mean average velocity, pulsatility index, and resistance index did not. Correlation between BMI and age and BMI and height was small. A regression model for the natural logarithm of FV was estimated: ln(FV) = −5.853 + 0.021 height + 0.049 BMI (R2 = 0.73, p < 0.0001 of height, p value of BMI: 0.028; p value of intercept: < 0.0001). The 95% confidence intervals were: −6.470 to −5.237 for the intercept, 0.006 to 0.093 for BMI, and 0.017 to 0.025 for height. Predicted FV and their 95% confidence intervals were calculated. The upper confidence limits were 8–10 times that of the lower ones.

Conclusion

Only FV showed height- and BMI-dependent changes in growing children. Prediction of FV in individual arteries was possible, but with a large range.
Upper-Extremity Venous Duplex Evaluation
Authors: Olmsted Kari A.
Published: March 2018

As many as 80% of upper-extremity venous thrombosis cases develop in response to an easily identified problem, such as central venous catheter. The remaining 20% of obstructions are caused by other central venous obstruction, trauma, or Paget-Schroetter syndrome. Appropriate clinical indications for upper-extremity venous duplex evaluation include (but are not limited to) unilateral upper-extremity swelling in the presence of indwelling central venous catheter, upper-extremity erythema and tenderness, superficial palpable cord, or facial swelling. Physical examination and thorough patient history compliment the duplex findings to arrive at an accurate diagnosis. The most effective way to determine the presence or absence of thrombosis is with vein wall compressions. However, most of the upper-extremity central vein segments are located beneath bony structures, which prevent extrinsic compression with transducer pressure. Therefore, the spectral Doppler waveform analysis component of the duplex exam becomes crucial in determining venous obstruction. Common technical components and pitfalls include appropriate color and spectral Doppler settings to reliably demonstrate presence/absence of flow or accurate accounting for innominate vein and supraclavicular/infraclavicular subclavian vein versus occluded native anatomy and large patent branches. When properly executed, the aforementioned components comprise a thorough duplex evaluation of the upper extremity venous system.
Assessment of Lower Extremity Venous Valvular Insufficiency Examinations
Authors: Needham Terry
Published: March 2018

Usually, venous insufficiency affecting an extremity results from elevated pressure, whereas arterial insufficiency usually is caused by reduced pressure energy. Except when caused by arteriovenous fistulae, elevated venous pressures are caused by obstruction to outflow and/or by incompetence of the venous valves, particularly at popliteal level and in the calf perforator veins. In the lower extremity, such elevated venous pressures can result in chronic changes that cause symptoms and/or signs that range from “tired legs” to ulceration. Although mild venous hypertension may constitute only a relative inconvenience such as varicose veins, more severe cases can lead to debilitating ulceration that may demand a change in lifestyle. Assessing an extremity for venous valvular insufficiency means detecting venous reflux. This work describes the plethysmographic, continuous-wave Doppler, and duplex ultrasound imaging modalities that can be used for detecting venous reflux in the deep, superficial, and perforating veins. Although plethysmographic and continuous-wave Doppler modalities have been supplanted largely by duplex ultrasound imaging, they have been included for completeness because they can continue to fulfill a role in overall functional assessment. Whatever the testing modality used to assess venous reflux, it is essential to verify the patency of the deep veins before any intervention in the superficial venous system.
Preoperative Ultrasound Assessment for Dialysis Access Placement
Authors: Needham M. Ann
Published: March 2018

Vascular access includes any form of cannulation of arteries or veins. For the treatment of chronic renal failure, this term refers to the ability to access both the arterial inflow and the venous outflow for the purpose of replacing the function of the kidney. This work provides a brief review of the history of hemodialysis and presents the method we use currently to map the arterial and venous system prior to placement of an arteriovenous fistula.

The purpose is to present the process we use to determine the status of the arteries and the venous patency, as well as the flow diagram we use to determine the steps taken for each patient referred for preoperative vein mapping, including the worksheet used to collect the information for the surgeon. This work presents the minimum prerequisites that are thought to be necessary to create a viable arteriovenous fistula. A brief discussion of the criteria and protocol is presented that is used to diagnose steal syndrome from the hand. Billing codes are included when this procedure is used.
Neurofibromatosis Resulting in Carotid Aneurysms with Subsequent Rupture: Presentation and Follow-up Management with Duplex Ultrasound
Authors: Tuvell Nancy , Sorrell Kathryn
Published: March 2018

Background

Neurofibromatosis (NF) is a common genetic disorder responsible for the development of neuroectodermal tumors throughout the body. Although vascular involvement with these growths is uncommon, arteriovenous malformations, aneurysms, stenosis, and occlusions have been reported. We report a case of a patient with NF who presented with a ruptured internal carotid artery aneurysm and then developed a common carotid pseudoaneurysm with subsequent hemorrhage during repair. The use of duplex ultrasound (DU) in the initial diagnosis and follow-up management of this patient will be discussed.

Case Report

A 31 year-old man with a history of NF presented to the emergency department with pharyngitis and right neck swelling. The initial DU revealed a 2.4-cm distal right internal carotid artery (RICA) aneurysm, which was treated with a covered stent. On the first postoperative day, a new wall irregularity in the right common carotid artery measuring 1.6 cm and a high resistant Doppler signal in the RICA suggesting distal occlusion were demonstrated by DU. A transcranial duplex supported the ICA occlusion by demonstrating cross filling from the left to the right through the anterior communicating artery. Because of increased neck swelling, DU was repeated on the third day. At the site of the previously noted CCA irregularity, a 3.4-cm pseudoaneurysm had developed. During attempted repair in the endovascular suite, the patient developed massive hemorrhage. To control bleeding, intravascular coils were used to occlude the right external carotid artery, RICA, and right common carotid artery. An intraoperative DU confirmed the successful occlusion of the carotid vessels.

Conclusion

DU provided an accurate initial and follow-up diagnosis of the carotid aneurysms in a patient with vascular complications from NF.
Clinical Significance of Isolated Retrovalvular Deep Venous Thrombus
Authors: Hard Jonathan M. , Selis James E.
Published: March 2018

Objective

We sought to determine the natural progression of isolated thrombus behind valve leaflets in deep veins that is not associated with any other evidence of deep venous thrombosis (DVT).

Methods

We prospectively evaluated patients that were sent to us for evaluation of DVT. Duplex venous examination protocol established by the American College of Radiology was used. Only those patients who were found to have thrombus behind valve leaflets and did not have any other evidence of DVT were included in this study.

Results

During a period of 5 months, eight patients were found to have retrovalvular thrombus. The patients were further evaluated by follow-up duplex venous examination or telephone interview. The six patients in whom repeat duplex venous examination was performed demonstrated either no progression or complete resolution of thrombus. Two patients who refused to return for repeat duplex examination were reached for telephone interview and revealed no further symptoms that would indicate progression of deep vein thrombosis.

Conclusions

This study provides information on the natural course of isolated retrovalvular thrombus. These thrombi either remain stable or resolve and appear to not require anticoagulation. A large-scale study will be needed to corroborate these findings.
Impact of Postoperative Duplex Surveillance after Radiofrequency Ablation of the Greater Saphenous Vein
Authors: Stone Patrick A. , Armstrong Paul A. , Shames Murray L. , Back Martin R. , Johnson Brad L. , Flaherty Sarah K. , Bandyk Dennis F.
Published: March 2018

Purpose

Radiofrequency ablation (RFA) is an effective therapeutic option for the treatment of greater saphenous vein (GSV) insufficiency; however, recent reports have begun to document an associated incidence of postprocedural deep venous thrombosis (DVT) of up to 16%. We evaluated our incidence of DVT after RFA and the role of venous duplex ultrasonography (VUS) in the assessment and treatment of GSV reflux.

Methods

During a 17-month period, 62 lower extremities with symptomatic GSV reflux were evaluated by VUS in 51 patients (74% women; mean age 51 years, range 25–83 yrs). Clinical history and examination focusing on risk factors for venous insufficiency and DVT were obtained along with a complete preoperative bilateral lower-extremity VUS in all patients. All procedures were completed by performing an intraoperative VUS to confirm patency of the GSV and common femoral veins before and after RFA. All patients received outpatient complete lower-extremity VUS within 5 days of the procedure to assess technical success of the procedure and superficial and deep venous patency.

Results

Fifty (98%) of patients completed RFA, with one patient undergoing high ligation of the GSV because of our inability to pass a guidewire and catheter into the proximal GSV. Duplex ultrasound confirmed successful RFA of the GSV in all limbs treated. Stab phlebectomy was performed in 33 (53%) limbs for associated clusters of large varicose veins. Two postoperative DVTs occurred (2/62,3.2%), both of which were identified as a floating thrombus in the common femoral vein and which subsequently were treated with percutaneous catheter-directed suction thrombectomy without the need for extended anticoagulation therapy.

Conclusion

Duplex venous scanning is an important component in the diagnosis and treatment of GSV insufficiency. VUS not only is necessary to direct the success of these catheter-based ablative procedures but is mandatory to confirm the absence of extended DVT after the procedure is completed. Our series has recorded a relatively low incidence of DVT and demonstrates that early recognition and aggressive treatment of nonocclusive common femoral DVT after RFA can obviate the need for long-term anticoagulation and potentially the sequelae of deep venous thrombosis.
Lower Extremity venous Cross-Sectional Area Changes associated with Pregnancy
Authors: Pemble Lucia
Published: March 2018

Objective

This study aimed to assess the effect of posture on lower-extremity vein areas in primigravida women during pregnancy and postpartum.

Methods

Real-time duplex ultrasound was used to study 39 primigravida women (with no evidence of varicose veins or peripheral vascular disease) during pregnancy and postpartum to determine the areas of the superficial and deep leg veins. Vein areas where measured with the subjects in both supine and erect positions. These areas were than compared statistically for any differences between the right and left leg and for the significance of changes that occurred as the result of advancing pregnancy. The reversibility of pregnancy-induced changes was determined by comparison of postpartum results.

Results

No statistically significant differences were found between the veins of the right and left leg. Veins areas increased as pregnancy advanced and decreased postpartum. All vein areas measured with the subject in the erect position were larger than those obtained in the supine position. Vein area increases associated with advancing pregnancy were significant when measured in the supine position. Although vein areas measured in the erect position showed a similar trend, they did not show statistically significant changes.

Conclusion

Vein areas increased early in pregnancy and with advancing pregnancy continued to enlarge significantly when the subject was in the supine position. With the subject in the erect position, venous compliance reached a plateau by midpregnancy. With the veins then fully distended, the pregnancy induced changes, which continued with advancing pregnancy (blood volume expansion, hormonally induced decreased smooth muscle tone, pelvic vascular compression) coupled with increased hydrostatic pressure in the erect position must result in increased lower extremity venous pressure. The pregnancy induced vein changes were reversible postpartum.
Noninvasive Vascular Testing with the Surgeon Present in Planning and Maintenance of Arteriovenous Hemodialysis Access
Authors: Kiseleva Yelena A. , Caylor Kathy L. , Royer Ronson M. , Scoggins Eva A. , Davidson Ingemar J. , Clagett G. Patrick
Published: March 2018

Background

The goal of the study was to determine the incidence of upper extremity noninvasive vascular findings in guiding anatomic site and management strategies in the creation and maintenance of arteriovenous (AV) access for hemodialysis. All studies were performed with the surgeon present.

Methods

An ICAVL-accredited vascular laboratory database of upper extremity noninvasive vascular studies performed during a 12-month period was reviewed. The study group consisted of 152 end stage renal disease patients who received Doppler ultrasound and/or noninvasive physiologic testing for the purpose of assisting in planning or maintenance of hemodialysis access. The study group yielded a total of 252 exams as follows: (1) preoperative evaluation to determine site and suitability for use in AV access creation (n = 133); (2) existing AV access (AV fistula or graft) with clinical symptoms indicating malfunction and need for identifying the location and/or nature of the problem (n = 98); (3) finger arterial pressures and wave forms (with and without access compression) in patients with clinical symptoms of steal syndrome (n = 21).

Results

Of the 133 preoperative evaluations, 67 (51%) resulted in creation of an AV graft and 66 (49%) in an AV fistula. AV graft was chosen over fistula because of duplex findings of inadequate (<2 mm in diameter) or deep (>7 mm below skin level) veins. In all cases, the site and arm were determined by duplex findings and were marked preoperatively by the surgeon. In 72 (73.5%) of the 98 malfunctioning AV accesses, the etiology and site were identified by duplex ultrasound. These included thrombosing/failing access (n = 18, 25%), outflow venous stenosis (n = 16, 22.2%), inflow arterial stenosis (n = 15, 20.8%), anastomotic stenosis (n = 9, 12.5%), and miscellaneous causes (n = 14, 19.5%). Again, sites were marked by the access surgeon to guide intraoperative management. Steal was confirmed to be present in 11 (52%) of 21 patients and the surgeon determined the degree of arterial banding based on intraoperative changes in digital pressures.

Conclusions

Preoperative duplex scanning of upper extremity vasculature with the access surgeon present allows for accurate and precise planning in the creation of AV access. This has the potential to improve compliance with K/DOQI guidelines. Success in rescuing failing angioaccess is also enhanced by non-invasive testing in the presence of the operating surgeon.
Hemodynamically Significant Carotid Disease in Duplex Ultrasound Patients with Carotid Artery Tortuosity
Authors: Hoskins Megan S. , Scissons Robert P.
Published: March 2018

Purpose

—Tortuous vessels are known to hinder the accuracy of extracranial carotid duplex ultrasound evaluations, yet the prevalence and location of hemodynamically significant lesions in these patients is relatively unknown. We evaluated the frequency and location of significant carotid occlusive disease in duplex ultrasound patients with carotid artery tortuosity.

Methods

—Data from consecutive patients for a 7-month period were prospectively entered into a database. Only initial studies were included in this study. Follow-up examinations, endarterectomy or stent vessels, and internal carotid artery (ICA) occlusions were excluded from analysis. Tortuosity was classified according to the angle of vessel curvature, i.e., between 60° and 90° (C1); 30° and 60° (C2); less than 30° (C3), and the location of the area of maximum stenosis in relationship to the area of tortuosity, i.e., pre- (S1), intra- (S2), or post- (S3) tortuosity. Lesions causing ≥50% diameter reduction (>125 cm/sec) were considered hemodynamically significant (HSIG).

Results

—A total of 200 patients and 370 vessels were analyzed. ICA tortuosity was found in 22% (82/370) of all vessels analyzed. Classification of the angle of vessel curvature for vessels with tortuosity was C1-50% (41/82), C2-40% (33/82), and C3-10% (8/82). HSIG disease was found in 17% (48/288) of nontortuous and 10% (8/82) of tortuous ICA vessels ( p = 0.172). The level of maximum stenosis preceded the area of tortuosity (S1) in all tortuous ICA vessels with HSIG disease.

Conclusions

—In this study, vessel tortuosity affected nearly a quarter of all vessels analyzed. The frequency of significant carotid disease was similar for patients with tortuous and nontortuous vessels. The location of maximum stenosis occurred before the area of curvature in all tortuous vessels with hemodynamically significant internal carotid artery disease, suggesting that this area should be the primary region of interest when evaluating duplex ultrasound patients with carotid artery tortuosity.
The Perioperative Role of Duplex Venous Scanning in Endovenous Laser Therapy
Authors: Evans Julie , Mong Renee , Satiani Bhagwan
Published: March 2018

Varicose veins that emerge as a result of the venous valvular incompetence of the great saphenous vein (GSV) are a common chronic condition affecting millions of people. When invasive treatment is necessary, surgical removal of the GSV and varicosities has been the standard procedure to relieve symptoms. Recent advances in laser technology have resulted in endovenous laser therapy as an alternative to open surgery by ablating the GSV. Duplex venous ultrasound is a critical part of preoperative planning, intraoperative safe execution of the procedure and postoperative care. It is necessary that the vascular surgeon and the sonographer work in tandem and have experience in intraoperative duplex venous scanning to achieve an optimal outcome.
Case Study: Cystic Adventitial Disease of the Popliteal Artery
Authors: Shaw Meagan , Del Pizzo David J. , Pevec William C. , Holcroft James W. , Dawson David L.
Published: March 2018

Introduction

—Adventitial cystic disease is an unusual cause of lower-extremity ischemia. It affects large arteries, typically where the artery is near a joint space, and the popliteal artery is most commonly involved.

Methods

—A 60-year-old man with venous insufficiency and prior deep vein thrombosis was referred for a lower-extremity venous evaluation. He had chronic degenerative joint disease, with bilateral knee osteoarthritis, but a history of exertional right calf pain was elicited. His right femoral and popliteal pulses were normal, but the posterior tibial pulse was diminished and the dorsal pedal artery pulse was absent. A lower-extremity duplex ultrasound examination was performed, including conventional and panoramic B-mode imaging, color Doppler and power Doppler imaging, and pulsed flow assessment.

Results

—Chronic deep and superficial venous thrombosis was identified in the right lower extremity. During the examination, the right popliteal artery was noted to be abnormal. Imaging showed the flow lumen in the popliteal artery to be visibly narrowed by more than 50%. Peak systolic velocities (PSV) in the proximal popliteal artery were 82 cm/sec, with a normal triphasic waveform, but the PSV increased to 221 cm/sec through the stenotic segment. The luminal narrowing was limited to an approximately 3 cm segment of the popliteal artery. There was no visible plaque or evidence of vascular calcification. The lumen appeared compressed by hypoechoic, septated cystic material. There was no flow within the well-visualized cystic structure. The findings were subsequently correlated with arteriography. Adventitial cystic disease of the popliteal artery was diagnosed. The patient underwent successful right popliteal artery cystectomy. Intra-operative and post-operative duplex evaluations demonstrated normal findings.

Conclusion

—Cystic adventitial disease is a rare disorder that can compromise arterial perfusion to the leg and it is one nonatherosclerotic cause of intermittent claudication. In some cases, the popliteal artery may occlude. Incidental arterial disease may be encountered frequently with lower extremity venous duplex scanning. With a careful examination by a thorough technologist, rare and interesting pathology, such as cystic adventitial disease, is possible.
The Use of Transcranial Doppler during Tilt Table Testing in Children Presenting with Syncope
Authors: Nicoletto Heather A. , Ellis Mark W. , Laskowitz Daniel T. , Kanter Ronald J. , Perry April E. , Burkman Marilyn
Published: March 2018

Childhood syncope is common, and there are three categories of causes of syncope: noncardiovascular pseudosyncope, cardiovascular syncope, and neurally mediated syncope. Tilt table testing has become a valuable tool in the evaluation for the cause of syncope in children. Adding transcranial Doppler (TCD) to the tilt table test to monitor the middle cerebral arteries (MCA) adds valuable information about the cerebral blood flow during a syncopal episode and can help the physician differentiate between the various causes of syncope. Three children with frequent syncopal episodes were evaluated using tilt table testing with multimodal monitoring, including TCD. One child, during her syncopal episode, had an increase in blood pressure, heart rate, and MCA flow velocities. This finding was consistent with noncardiovascular pseudosyncope, and she was sent for psychiatric treatment. The other two patients had hypotension, bradycardia, a significant decrease in MCA flow velocities, and an increase in pulsatility indices. Additionally, one of them experienced a 6-sec period of asystole. Both were diagnosed with neurally mediated syncope and were placed on fludrocortisone and a water and salt regimen.
Iatrogenic Pseudoaneurysms: Optimal Management and Treatment Options
Authors: Hill Gerry , Albayati Sinan , Thomson Ian , Macfarlane Josie , Dutton Samantha , van Rij André M.
Published: March 2018

Background

Iatrogenic trauma is the most common cause of pseudoaneurysm. Several treatment methods are now available, including surgical repair, direct compression with the assistance of ultrasound, and ultrasound-guided thrombin injection. Each of these treatments has its own risks and advantages.

Objective

We sought to retrospectively assess the causes of pseudoaneurysm and the evolution of treatments and outcomes.

Results

Ninety-three pseudoaneurysms were diagnosed at Dunedin Public Hospital between September 1994 and December 2005, the majority resulting from cardiac catheterization. Fifteen patients were treated with ultrasound-guided compression, with a success rate of 66%. Sixty-three patients were treated with ultrasound-guided thrombin injection, with a success rate of 95%. No major or lasting complications were observed with either compression or thrombin injection; however, delayed diagnosis and treatment may have serious consequences requiring surgical salvage.

Conclusions

Ultrasound-guided thrombin injection is safe, effective, quick, and well tolerated by patients. It has become preferable to compression treatment and it is less invasive than surgical repair. Treatment should be given promptly upon diagnosis of the pseudoaneurysm rather than delaying with watchful expectation.
The Influence of Routine Duplex Scanning Surveillance on Outcome after Percutaneous Iliac Angioplasty and Stenting
Authors: Westerband Alex , Berman Scott S. , Brown Amy , Quick Rhonda C. , Mendoza Bernardo
Published: March 2018

Purpose

We sought to determine the utility of noninvasive color-flow duplex imaging (CDI) in the detection of iliac artery stenoses or occlusions and correlate the findings of long-term color flow duplex surveillance (CFDS) to clinical outcome after percutaneous iliac interventions.

Methods

All patients undergoing percutaneous iliac angioplasty and stenting are prospectively entered in a surveillance protocol with CFDS and ankle-brachial indices (ABIs) performed within 6 weeks, 6 months, 12 months, and every year thereafter. Preprocedural ABI and peak systolic velocity (PSV) values were compared with postprocedural values with the Student t-test. Kaplan-Meier life-table analysis was used to estimate the patency rates.

Results

During the last 4 years, 80 patients with 112 treated iliac systems fulfilled the study criteria. A total of 68 patients (84%) had claudication, 8 (10%) had pain at rest, and 5 (6%) had a nonhealing ulcer or gangrene. The procedural success rate was 96.4%. Comparison of ABIs and PSV values before and after iliac intervention was statistically significant ( p < 0.0001). Duplex scan allowed the detection and/or monitoring of abnormal velocities in 14 treated iliac arteries. Four cases (3.5%) required reintervention on previously treated iliac arteries for symptomatic restenosis and/or disease progression. Late stent occlusions were correctly identified in two cases. Primary patency, assisted primary patency, and secondary patency rates were 77%, 94%, and 96% at 4 years, respectively.

Conclusion

CFDS allows the detection of iliac artery stenoses and is a useful tool to identify restenosis after intervention. Because of the overall excellent patency rates observed with iliac angioplasty and stenting, CFDS surveillance in the absence of symptoms may not always be necessary and its long-term use should be individualized.
The Limitations of Ankle Brachial Index when used Alone for the Detection/Screening of Peripheral Arterial Disease in a Population with an Increased Prevalence of Diabetes
Authors: Hembling Brian P. , Hubler Kelley C. , Richard Peter M. , O'Keefe William A. , Husfloen Chelsey , Wicks Rebecca , Dressor Heather
Published: March 2018

A retrospective analysis was performed comparing the effectiveness of ankle brachial index (ABI) to Doppler waveform analysis for the detection of peripheral arterial disease (PAD) in a group of patients with an estimated 31% prevalence of diabetes. A total of 21,199 ankle pressures and corresponding Doppler waveforms were correlated; 8,628, or 41%, of the ankle pressures were within normal limits; 8,335, or 40%, of the ankle pressures were below normal limits; and 4,042, or 19%, of the ankle pressures were noncompressible. Using ABI alone for screening in a population with a high incidence of diabetes is significantly limited because of noncompressible ankle pressures caused by arterial calcification. A total of 19% of the segments evaluated in this population yielded noncompressible vessels. The prevalence of PAD, detected by Doppler waveform analysis in the segments with non-compressible ankle pressures, was 69%. Additional modalities such as Doppler waveform analysis would further increase the accuracy of screening for PAD in this population. Alternately, using the ABI alone for the detection of PAD can be improved by interpreting ABIs greater than 1.2 as positive results because of the high prevalence of PAD in this group.
The Relationship between Velocity and Cerebral Resistance during Vasomotor Reactivity Testing: Should We Report a Different Measurement?
Authors: Byrd-Raynor Sheila , Alastruey Jordi , Hughes Alun , Thom Simon , Parker Kim H.
Published: March 2018

Introduction and Objective

Changes in arterial resistance are an important aspect in the regulation of cerebral blood flow. Vasomotor reactivity testing with transcranial Doppler (TCD) is used commonly to report findings in terms of mean flow velocity changes. Yet, the pertinent clinical question is about resistance changes. How effectively do the cerebral resistance vessels dilate and constrict, or what is their vasomotor capacity? In this study, we examine the relationship between cerebral flow velocity and resistance and propose a new measurement for vasomotor reactivity studies.

Methods

We recruited 35 healthy subjects and measured TCD mean flow velocities in the middle cerebral artery during vasoreactivity testing using 6% CO2 inhalation (hypercapnia) to produce cerebral vasodilatation, and controlled hyperventilation (hypocapnia) to produce vasoconstriction. Brachial blood pressure was also recorded. Mean Resistance (mean blood pressure/mean flow velocity) was calculated at baseline, hypercapnia, and hypocapnia. We compared the % change from baseline in both mean flow velocity (cm/s) and Mean Resistance (mmHg s/cm), in relation to gender and age.

Results

For the group overall, hypercapnia produced a 39.3 ± 19.9% increase in mean flow velocity; however, this resulted in only a 21.9 ± 9.9% decrease in Mean Resistance. Whereas during hypocapnia, a 32.4 ± 9.3% decrease in velocity produced a much larger increase in Mean Resistance (48.9 ± 22.2%). Young women had the greatest capacity to vasodilate, showing a 26.1 ± 9.2% decrease in Mean Resistance (46.0 ± 14.6% increase in velocity). However, young men showed the largest change during vasoconstriction; a 59.5 ± 31.6% increase in Mean Resistance (35.3 ± 9.5% decrease in velocity).

Conclusions

Large velocity increases during hypercapnia do not represent large changes in resistance. Whereas small velocity decreases during hypocapnia actually represent much larger changes in resistance, the calculation of Mean Resistance is a more clinically relevant measurement to report than velocity alone, and should be incorporated into TCD studies in the future.
Correlation between Renal Resistive Index and Estimated Glomerular Filtration Rate in Patients with Hypertension
Authors: Gaurav Kumar , Yalavarthy Umesh , Chamberlain Nathan , Pugh Sandra , Panda Mukta
Published: March 2018

Introduction

Renal resistive index (RRI) is a marker of flow resistance in renal parenchymal vessels. Kidneys may appear normal when imaged by ultrasound in early stages of chronic kidney disease (CKD). Several studies have shown that cortical echogenicity is not an objective way to assess CKD. Thus, if RRI correlates with estimated glomerular filtration rate (eGFR), it could serve as an additional predictor and objective measure of CKD. Currently to our knowledge studies assessing correlation between eGFR and RRI are lacking.

Objective

We sought to assess the correlation between RRI and eGFR.

Methods

In the 1-year study period, 874 abdominal Doppler examinations were performed in an accredited vascular laboratory by a single technologist. Analysis was performed for 310 Doppler results that met inclusion criteria. Serum creatinine was obtained from the electronic chart, and eGFR was calculated with the use of the abbreviated Modification of Diet in Renal Disease Study Group GFR equation.

Results

Statistical analysis using Pearson's correlation coefficient demonstrated a significant negative correlation between RRI and eGFR (r = −0.285, p < 0.01).

Conclusion

Our study serves as a pilot assessing correlation between eGFR and RRI. This correlation could serve as an early objective indicator of renal impairment as kidneys may appear normal by ultrasound in early stages of CKD.
Spontaneous Regression of a Type I Endoleak Documented with Duplex Ultrasound
Authors: Iida Jenavi , Vyniski Virginia , Holmes Raymond J. , Sales Clifford M.
Published: March 2018

Endovascular repair for abdominal aortic aneurysms (EVAR) has evolved as a common treatment for this disease entity. Although it provides outstanding early and mid-term results, the use of EVAR requires vigilant follow-up to insure that delayed complications—such as endoleaks–do not complicate an initially successful procedure. The optimal modality for detection of this entity remains undetermined. We present the case of a 77-year-old woman with a type I proximal endoleak identified on duplex ultrasound examination 1 month postoperatively. It was confirmed with computed tomography scanning and contrast aortography. The diameter of the aneurysm sac had increased from 5.8 cm (preoperatively) to 6.0 cm, prompting consideration of an intervention to address the endoleak. Repeat duplex examination, performed immediately before the planned repair, failed to demonstrate the endoleak, and the aneurysm sac measured 5.6 cm. This case report demonstrates the ability of duplex ultrasound to identify endoleaks and its importance in the close follow-up of patients who have undergone EVAR.
Doppler Waveform Characteristics in the Celiac and Superior Mesenteric Arteries in Normal Children and Adults with the Use of Duplex Ultrasound
Authors: Asbeutah Akram M. , Buredha Bader , Mahmood Mustafa , Al-Mohana AbdulAziz
Published: March 2018

Purpose

To compare and contrast the flow patterns in celiac artery (CA) and superior mesenteric artery (SMA) in normal children to those in normal adults with the use of duplex ultrasound techniques.

Methods

Thirty male subjects were entered prospectively to the study. Peak systolic velocities and diameter at the origin of CA and SMA were recorded while the subject was fasting for at least 4–6 hr. The Human Ethics Committee at the Faculty of Allied Health Sciences-Kuwait University approved the study. Informed consent form was obtained from all subjects.

Results

There were 15 healthy male adults. Their average age (yr ± SD) was 22.7 ± 4.7 and their average body mass index (kg/m2 ± SD) was 23.5 ± 2.1. There were 15 healthy male children. Their average age (yr ± SD) was 7.2 ± 2.92, and their average body mass index (kg/m2 ± SD) was 18.5 ± 4.8. The average diameters (cm ± SD) of CA and SMA in adults were 0.73 ± 0.8 and 0.76 ± 0.11, and the average peak systolic velocities (cm/s ± SD) were 113 ± 17.5 and 145 ± 25.8, respectively. However, the average diameter (cm ± SD) of CA and SMA in children was 0.52 ± 0.06 and 0.53 ± 0.06, and the average peak systolic velocities (±SD, cm/s) of CA and SMA were 179.5 ± 39.5 and 175 ± 31.7. respectively. Paired student's t-test showed no statistical significance between the two groups. Coefficient of variation for diameter calculation and velocity measurement was <10%.

Conclusion

The peak systolic velocities in normal children at the superior mesenteric artery and celiac artery are slightly greater than in normal adults but it did not exceed 200 cm/sec in CA and 275 cm/sec in SMA. The Doppler waveforms are still within normal range in both groups despite the caliber of the vessels being smaller in children. Most probably greater velocities in children are caused by the high pressure of the transducer in superficially located vessel inducing flow disturbances.
Large Pseudoaneurysm Associated with Compressive Symptoms after Cardiac Catheterization
Authors: Trapp Lia , Fleser Paul S.
Published: March 2018

This case study follows a patient who presented with a right burning thigh pain and diffuse swelling 6 months after cardiac catheterization. The patient had a medical history of coronary artery disease, hypertension, and at the time was also on warfarin therapy for atrial fibrillation. This persistent discomfort and pain was limiting her ambulation and prompted a trip to the emergency room; she was then sent to our lab for further evaluation for a pseudoaneurysm. In the course of evaluating this patient with duplex ultrasound and Doppler waveforms, a very large common femoral artery pseudoaneurysm (PSA) with a short <2-mm neck and obvious significant compression of the common femoral artery and common femoral vein was identified. Because of the short neck of the PSA, an open surgical repair was performed. Surgical notes observed significant compression of the common femoral nerve as well as the common femoral artery and vein. Postoperatively, there were no complications, and the patient has had some improvement in her neurological symptoms as well as completes resolution of the swelling of her right leg. Although postcardiac catheterization complications are minimal (0.5%), the use of ultrasound imaging is a simple and cost-effective means of addressing persistent patient discomfort and pain after cardiac catheterization.
Findings of Brain Death with the Use of Carotid Duplex Ultrasonography
Authors: Yesenko Sandra L. , Gornik Heather L. , Henion Dale , Bartholomew John R.
Published: March 2018

Introduction

Brain death is the complete and irreversible loss of cerebral and brain stem function. Although transcranial Doppler may be helpful in establishing the diagnosis, conventional carotid duplex ultrasound is not typically used in this condition.

Case Report

We describe the case of a 43-year-old woman with a past medical history of cardiac transplantation who was transferred from an outside hospital for hemodynamic monitoring and treatment. The patient had bladder surgery 1 day previously and suffered a prolonged cardiac arrest postoperatively. On arrival, she was comatose and ventilator dependent. Clinical examination revealed no brain stem reflexes (absent pupillary, corneal and oculocephalic reflexes). Brain death was suspected, although right upper-extremity flexion movements were noted. A carotid duplex ultrasound was ordered by the neurological service and performed using an Advanced Technology Laboratory HDI 5000 (Philips, Ultrasound, Bothell, Washington) machine with a linear 7–4 MHz transducer. Abnormal pulsed Doppler signals were detected demonstrating low velocity, bidirectional flow in the common and external carotid and the vertebral arteries. The internal carotid arteries demonstrated bizarre bidirectional and high resistive signals. Computed tomography showed diffuse cerebral edema and loss of gray-white matter differentiation. An electroencephalogram performed the next day demonstrated seizure activity correlating to her right upper extremity movements and indicative of some brain function retention. The patient died soon after.

Conclusion

Carotid duplex ultrasonography is not usually used in the diagnosis of brain death. Findings are characterized by a lack of diastolic flow or reverberating (to-and-fro pattern) flow and small systolic peaks in early systole on transcranial Doppler. This pattern is caused by a lack of adequate arterial perfusion. Cerebral angiography may reveal nonfilling of the intracranial arteries. Other diagnostic modalities, including computed tomography and electroen-cephalography, can be used with clinical findings to confirm brain death. In our case, carotid duplex ultrasonography was useful in assessing for brain death, although the patient (as later found) did not meet all neurological criteria. Vascular technologists should be aware of these unusual duplex findings in the evaluation of the comatose patient.
Differences in Venous Function of the Lower Limb by Time of Day: A Comparison of Chronic Venous Insufficiency between an Afternoon and a Morning Appointment by Duplex Ultrasound
Authors: Tarrant Gayle , Clarke Jill
Published: March 2018

Objective

To determine the importance of the time of the day in relation to the accuracy of duplex ultrasound studies of lower limb chronic venous insufficiency (CVI).

Method

Using duplex ultrasound techniques, 40 participants (48 limbs), which included 26 women and 14 men ranging from 24 to 76 years of age, were recruited. All participants tested positive to primary CVI in a 4- to 6-pm afternoon timeslot and returned the next morning between 8- and 9-am for a follow-up retest of their incompetent vein sites.

Results

A total of 32.5% (13) of participants or 29.2% (14) of limbs demonstrated a degree of change in results from incompetence in the afternoon to competent the next morning. Most significant were the perforator veins; 38% of those tested showed a change of results, followed by a 9% change in the short saphenous veins, a 2% change in the long saphenous veins, and no change was demonstrated from the alternative superficial vein pathways or the saphenofemoral/popliteal junctions.

Conclusion

Venous function can change from an afternoon to the next morning. The extent of venous incompetence is better diagnosed in the late afternoon, with the perforator veins most susceptible to a change of competence.
The Hypothenar Ulnar Artery: A Case Series of Aneurysm, Tortuosity and Thrombosis
Authors: Bender Melinda , Whitelaw Susan , Sakarwala Abizer , Joseph Douglas
Published: March 2018

Presented is a case series of duplex ultrasound examination for evaluation of the hypothenar ulnar artery. Because of its superficial location, the distal ulnar artery is well characterized by duplex ultrasound. Aneurysm, thrombosis, and ectasia are the most common abnormal findings. The study is a single-center database query of all arterial duplex examinations performed from January 1, 2000 through December 31, 2006, and containing the words ulnar artery. A total of 2766 upper-extremity arterial duplex scans were queried yielding 155 scans meeting the search criteria. A total of 9 ulnar arteries were interrogated into the hypothenar area of the hand. Seven of them were abnormal, and 2 were follow-up studies of a patient who had undergone repair of bilateral ulnar artery aneurysms. Reported symptoms include pain, digital lesions, pallor or a pulsatile mass. Of the 7 abnormal ulnar arteries, 3 arteries were aneurysmal (diameter greater than 1.5 times the proximal segment), and 3 were ectatic (increase in diameter less than 1.5 times the proximal segment). Two arteries were tortuous, and one was occluded. All but one patient was a past or present smoker. All abnormalities were attributed to occupational repetitive trauma and one patient experienced a single traumatic event. The mean patient age was 42 years (median 37) and all were male. Of the 3 aneurysms, the largest was 17 mm and was associated with mural thrombus and a biphasic Doppler signal. The other 2 aneurysms were 5.0 and 6.9 mm with mural thrombus and triphasic Doppler signals. One patient underwent successful thrombolysis, 3 patients were followed conservatively, and 2 of the aneurysms and one of the thrombosed arteries were surgically repaired. Although abnormal findings of the distal ulnar artery are rare, they may be well visualized and characterized with duplex ultrasound. Duplex ultrasound is an ideal diagnostic modality for evaluation and follow-up of distal ulnar artery abnormalities in experienced vascular laboratories.