bluuebunny/crossref_metadata_2025_split huggingface dataset:
Expansion of the SAAAVE Protocol with Addition of Ultrasound Scans of the Femoral and Carotid Arteries to Prevent Heart Attacks and Strokes
Authors: Lavenson George S. 
Published: March 2018

Introduction Heart attacks and strokes are the leading cause of death and disability. Most occur without warning. To prevent heart attacks and strokes in seniors, in this article I propose an expanded SAAAVE program that includes an ultrasound scan of the carotid and femoral artery along with that of the aorta. A positive scan of any of these would trigger a metabolic and cardiac evaluation, allowing early management of systemic arteriosclerosis and preemptive intervention for critical disease of the coronary artery as well as the carotid artery and aorta. Method The carotid artery, femoral artery, and aorta are rapidly scanned. Positive studies are referred for full follow-up examinations and metabolic/cardiac evaluations. Medicare does cover some aortic scans and the indicated follow-up tests and care that result from all scans. Results Medical and interventional management can prevent fatal heart attacks from known coronary artery disease. Intervention for significant carotid disease that is present in 7.5% of seniors could prevent more than 200,000 strokes and save nearly 13 billion dollars annually. Screening for abdominal aortic aneurysm has decreased deaths from ruptured aneurysms, and statin therapy for dyslipidemia can reduce future cardiac events. Conclusions This simple, rapid, one-stop screen for seniors has the potential to prevent death and disability from heart attack, stroke, and ruptured abdominal aortic aneurysm
Application of Duplex Ultrasonography in the Midaortic Syndrome
Authors: Wilson Stephanie , Atnip Robert , Turner Tricia , Wilson Ryan 
Published: March 2018

Objective Midaortic syndrome is a rare condition found primarily in children that causes stenosis of the abdominal aorta and its proximal branches. Duplex interpretation criteria derived from adults do not necessarily apply to the pediatric population but are sometimes used empirically in specific cases. We report the case of a 5-year-old girl whose aorta and renal arteries were studied by duplex ultrasound, with anatomic and radiologic correlation. Case Report The patient was a 5-year-old girl with refractory hypertension on multiple antihypertensive medications. Her initial diagnosis of midaortic syndrome was made via duplex ultrasound. The findings were confirmed by angiography and showed smooth narrowing of the mid- to distal abdominal aorta with concomitant bilateral renal artery origin stenosis. Surgical repair of the aorta was performed with the use of a patch angioplasty technique with pulmonary artery homograft. The left renal artery was re-implanted onto the infrarenal aorta and an aorta to right renal artery bypass graft was placed using autogenous left internal iliac artery. Duplex ultrasound was then used to evaluate the success of the surgical repair. Conclusion Duplex ultrasound proved effective in the preoperative and postoperative care of this small child with midaortic syndrome and renal artery stenosis. The standard adult criteria for renal artery stenosis can be used selectively in children to assist in the diagnosis of unusual vascular conditions.
Profound Calf Muscle Dysfunction following Hip Dislocation Monitored by Air Plethysmography
Authors: Baker Nichole K. , Clay Amber L. , Brown Sandra L. , Eliason Jonathan L. , Wakefield Thomas W. 
Published: March 2018

Introduction Calf muscle atrophy is commonly noted after lower-extremity immobilization. Air plethysmography (APG) provides an easily reproducible, noninvasive diagnostic test that is useful in measuring calf ejection fraction. Quantitative measurements can be preformed before and after physical therapy as a tool to evaluate effectiveness of treatment. Method We report the case of a 26-year-old woman who presented to the vascular surgery clinic with right lower extremity cyanosis, paresthesias, and swelling after hip dislocation. The patient had been immobile for a month. An arteriogram was performed to rule out arterial injury and a lower-extremity ultrasound was performed to rule out deep venous thrombosis and venous reflux. APG revealed a profoundly abnormal ejection fraction of 36%. Physical therapy was recommended, with special attention towards calf muscle strengthening. Results After 3 months of physical therapy, the APG ejection fraction increased to a normal value of 74%. In addition to normalization of the APG, all symptoms of cyanosis, paresthesias, and swelling were resolved. Conclusion APG may be a useful tool in measuring the restoration of calf muscle function in patients with injuries requiring extended immobilization.
Three-Dimensional Reconstruction of the Vessel Lumen as an Adjunct to the Cerebrovascular Duplex Evaluation
Authors: Porreca Francis J. , Rodriguez-Wong Angela , Hughes Joseph P. 
Published: March 2018

Introduction Color-flow duplex ultrasound is effective in the detection and quantification of carotid artery disease; however, diameter reduction estimates are most commonly derived by Doppler velocity measurements. In addition, direct visualization of the vessel lumen is only possible through the use of more expensive potentially invasive imaging procedures, such as computed tomography angiography, magnetic resonance angiography, and conventional angiography. Described here is a method to determine vessel diameter of the internal carotid artery (ICA) by the use of three-dimensional (3D) reconstruction of b-mode data to generate luminal diameter estimates. Materials and Methods A prospective review of 40 consecutive cerebrovascular duplex studies was performed. Testing protocols required transverse sweeps of the common carotid artery (CCA) and ICA in b-mode. Motion files were analyzed using software, which segmented the vessel lumen as the area of interest. The software created a 3D rendering of the lumen of the CCA and ICA. Vessel diameter reduction estimated by Doppler-derived velocities was then compared with the 3D rendering of the vessel lumen diameters. Results There was a 99% (n = 79, ρ = < 0.001) correlation between velocity estimates and 3D visualization for estimating diameter reduction. Correlation for cases with less than 50% diameter reduction by duplex was 100% (n = 66, ρ = < 0.004), whereas correlation for cases with 50% or greater diameter reduction by duplex was 92% (n = 13, ρ = < 0.03). Conclusion 3D reconstruction of the vessel lumen shows a statistically significant correlation with velocity-derived diameter reduction measurements. Although more investigation with a larger group of patients is necessary, 3D reconstruction may be a valuable adjunct and may enhance the diagnostic capabilities of color-flow duplex ultrasound.
Intraluminal Soft-Tissue Mass versus Pedunculated Thrombus of Internal Jugular Vein in a Neonate
Authors: Methvien Janet , Moore Colleen , Brann Elizabeth 
Published: March 2018

Introduction —A 2 month old baby boy presented to the vascular lab for evaluation of left sided neck swelling. This case study details the use of duplex ultrasound in the evaluation and diagnosis of left internal jugular vein thrombus a rare condition in infants. Case Report —The patient had a CT scan which showed marked distention of the left jugular vein, as well as an intraluminal mass measuring approximately 2.3 × 1.8 × 2.7 cm. The study was interpreted as an intraluminal mass. Subsequent upper extremity duplex imaging was ordered for correlation. By duplex exam the patient was noted to have a 2–3 cm partially obstructing filling defect within the left jugular vein consistent with a pudunculated thrombus not excluding other etiologies. The patient was referred to a larger institution for further imaging. This confirmed the diagnosis of a pudunculated thrombus in the internal jugular vein. Conclusion —The incidence of internal jugular vein thrombus is unknown due to the limited number of studies available in this area.
Description of a Phenomenon Resembling Spontaneous Echocardiographic Contrast in the Venous System
Authors: Cartman Gerry , Trachemontagne Helene , Yelle Marie-Claire , Abraham Cherrie Z. 
Published: March 2018

Introduction. —According to Beppu et al., spontaneous echocardiographic contrast (SEC or smoke) is a pattern of “spontaneous swirling echoes originally visualized by transthoracic echocardiography in the enlarged left atrium of patients with mitral stenosis” (J Am Cardiol 1985;6:744–749). It has since been primarily associated with atrial fibrillation and flutter. The clinical significance of SEC is its association with left atrial thrombus, increased thromboembolic complications, and death. The pathogenesis of SEC seems to involve Rouleau formation between red cells and fibrinogen at low shear rates, which is an in vitro equivalent of blood stasis. Black noted that “Red cell aggregation, manifested as SEC, appears to be a precursor to thrombosis. Left atrial thrombi are rich in fibrin and red cells, resembling venous more than arterial thrombi” (Echocardiography 2000;17(4):373–382). Methods. —If left atrial thrombi are associated with SEC and resemble venous thrombi, it was hypothesized that actual venous thrombi in previously undescribed locations, most notably deep vein thrombosis, may equally be associated with SEC. We asked our coauthors (H.T. and M-C.Y.) to search for such a phenomenon among patients referred to the vascular laboratory for suspected venous thrombosis. Case Presentation. —In the following case series, we report an original phenomenon of swirling echogenicity in the venous system that we believe is SEC. The phenomenon was fairly rare (maximum 1.5% of referred patients, whereas deep venous thrombosis itself was 15-20%). The clinical significance of this phenomenon is discussed.
Identifying Iliac Vein Stenosis with Duplex Ultrasonography
Authors: Ayoub Kathryn , Churgovich Carolyn , Mahlay Natalia Fendrikova 
Published: March 2018

Introduction. —Deep vein thrombosis should be considered as one of the differential causes of unilateral lower-extremity swelling. When the lower-extremity venous duplex ultrasound is negative for a deep vein thrombosis and a proximal occlusion is suspected, investigation should be completed with interrogation of the pelvic veins. Case Report. —We describe a 66-year-old man with a history of rectal carcinoma treated with chemotherapy, radiation, and proctosigmoidectomy who presented to the vascular laboratory with left lower-extremity swelling and erythema. A lower-extremity venous duplex was performed with a Phillips iU22 9–3 MHZ linear transducer, which revealed monophasic flow in the distal left external iliac vein with normal compression images. Further evaluation with a 5–1 MHZ curved array probe revealed a velocity shift within the external iliac vein consistent with iliac vein stenosis. A venogram confirmed a critical stenosis in the mid left external iliac vein with associated thrombus. The patient underwent mechanical thrombectomy and placement of 10 by 40 mm Smart stent. Post-interventional venogram demonstrated excellent antegrade flow and no evidence of residual thrombus. Discussion. —If left untreated, venous stenosis may predispose the patient to persistent lower extremity swelling, venous thrombosis, and venous stasis ulcers. Because of the underlying anatomic defect, symptoms may not improve with conservative management, including anticoagulation. Several diagnostic modalities can be considered for diagnosis of the venous stenosis, including venous duplex ultrasound, magnetic resonance venography, computed tomography with venous phase, venography, and intravascular ultrasound. Conclusion. —Cost considerations makes venous duplex a valuable, noninvasive, first-line method to investigate suspected venous stenosis.
Is a Low End-Diastolic Velocity Parameter Enough to Exclude an 80–99% Internal Carotid Artery Stenosis?
Authors: Parein Craig S. 
Published: March 2018

Introduction —High resistive internal carotid artery (ICA) waveforms (high peak systolic velocity >250 cm/sec with low end-diastolic velocity (EDV) <125 cm/sec, having an external carotid artery waveform appearance) are uncommon and present a diagnostic challenge for intervention. Most ICA stenotic classifications rely on a greater EDV to delineate a critical stenosis of 80–99%. Methods —Review of a multiple-laboratory, single-center, Intersocietal Accreditation Commission-accredited, noninvasive vascular laboratory database for ICA carotid examinations performed from January 1, 2008 to November 1, 2012, with a positive stenotic range >60%. Medical records, archived ultrasound images, and correlative imaging studies were reviewed. Results —A total of 843 carotid duplex studies (1,686 arteries) positive for >60% stenoses of at least one side were reviewed. There were 102 duplex studies with high resistive ICA waveforms that were identified. Of these, 35 duplex studies had 40 correlative results, and 67 duplex studies did not have any correlative results. Of the 35 correlated duplex studies, median age was 78 years (range, 53–86 years). Gender distribution was 57% male. The median age of the male subjects was 77 years with a range of 63–82 years and the median age of female subjects was 73 years old with a range of 53–86 years. Seven of the 35 patients presented with symptoms of visual disturbance, transient ischemic attack, or syncope (21% symptomatic). Side distribution was 12 males and 8 females had right-side involvement, and 7 males and 7 females had left-side involvement. There was one female patient who had bilateral involvement. This provides us with 36 duplex ultrasound studies to correlate. Mean PSV was 369 cm/sec (range, 187–492 cm/sec). Mean EDV was 89 cm/sec (range 18–130 cm/sec). Average ICA/common carotid artery ratio was 6.2 (range, 3.2–12.5). Correlative computed tomography angiography was available for 12 of the studies, angiography for 10 of the studies, and surgical findings for 18 of the 35 studies. Conclusion —Assessing all Doppler parameter used to categorize an ICA stenotic range may be beneficial in determining the need for patient intervention. Sonographer impression of audible clues and cardiac history is helpful to the interpreting physician reviewing 2D images and waveforms.
Popliteal Vein Aneurysm: A Case Report
Authors: Shaub Michael , Akbari Cameron 
Published: March 2018

Introduction —Although popliteal vein aneurysms are the most common of all venous aneurysms, they are exceedingly rare. In fact, there have only been approximately 150 reported cases to present. We present a case of a popliteal vein aneurysm found in a patient with right lower-extremity symptoms. Patient Description —A 51-year-old woman presented with right lower-extremity pain and swelling and was evaluated for deep venous thrombosis via venous duplex ultrasound. Methods —Venous duplex ultrasound of the bilateral lower extremities was performed upon presentation to an outside hospital and again after referral to our vascular surgery service. Results —Original duplex as well as repeat after referral to our vascular surgery service were found to be negative for deep venous thrombosis but revealed a 2.7 by 2.1-cm fusiform popliteal vein aneurysm on the right (symptomatic) side. Discussion —Although many venous aneurysms are clinically insignificant, popliteal vein aneurysms present a poorly characterized risk for pulmonary embolism (some estimates are as high as 70–80%), which can be potentially fatal. Therefore, surgical repair is generally warranted, especially in cases in which the diameter is greater than 2.0–2.5 cm, as in this case. Our patient, however, declined surgical intervention despite this information. Thus, in addition to presenting our case as well as mentioning standard surgical techniques, we will briefly comment herein on the limited nonsurgical treatment options for popliteal venous aneurysms found in the literature.
Presence of Lower-Extremity Venous Pulsatility is not always the Result of Cardiac Dysfunction
Authors: Schroedter William B. , White Jean M. , Garcia Amy R. , Ellis Megan E. 
Published: March 2018

Introduction The presence of peripheral venous pulsatility is widely recognized and commonly attributed to cardiac dysfunction; however, the precise cause(s) have been poorly defined in the literature. We have noted multiple patterns of venous pulsatility, often in patients with no history of heart disease. In a normal, high compliance venous system, cardiac pulsatility is continually dampened with distance from the heart. We theorized that in a low-compliance system, the pulsatility would be transmitted throughout and its presence is a reflection of the hemodynamic state of the lower extremity venous system. Methods We evaluated the right popliteal vein in 30 normal volunteers (average age 35) with no history of heart disease and minimal venous disease (C-Class range 0–2, average 0.4). The right popliteal vein was chosen for its distal anatomic location and to avoid any potential of left iliac vein compression. Three spectral waveforms were obtained in the following manner: (1) a left lateral supine position with the right popliteal vein at the level of the right atrium, (2) after standing for >3″ with no right leg weight bearing or muscle contraction, and (3) after 10 seconds of vigorous plantar/dorsiflexion. Results In a supine position, all 30 limbs had normal respiratory phasicity with minor variation. In every patient, after quiet standing there was very low velocity forward flow with a discernable pulsatility. Immediately after dorsiflexion, flow became highly pulsatile. Conclusion A total of 100% of patients demonstrated highly pulsatile flow when the lower extremity venous system was filled to resting hydrostatic pressure. Although cardiac dysfunction may result in venous hypertension, reducing system compliance, the presence of pulsatile venous flow in the lower extremity can be demonstrated in all persons and is therefore a function of venous hemodynamics.
Duplex Ultrasound Protocol and Findings in Common Carotid Artery Dissection Extending from the Aortic Arch
Authors: Charlton-Ouw Kristofer M. , Sandhu Harleen K. , Burgess William , Vasquez Marla , Estrera Anthony L. , Azizzadeh Ali , Coogan Sheila M. , Safi Hazim J. 
Published: March 2018

Introduction Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid duplex ultrasound (CDU) in DeBakey I acute aortic dissection to identify characteristics and establish a protocol to ensure appropriate evaluation. Method From 2002 to 2011, patients with CDU and proximal aortic dissection were identified. The protocol included color Doppler in both long and short axis, spectral waveforms of true and false lumens, and imaging of the aortic arch, when appropriate. Imaging was performed on a Philips iE33 or iu22 using a 9–3 MHz linear array probe for the cervical carotid arteries and a curved array 5–1 MHz probe for the aortic arch. Waveforms were analyzed for signs of proximal dissection. Results CDU was performed in 87 of 288 patients and comprised the study group. Intimal flaps were noted in 26 common carotid arteries (CCAs) in 20 patients. The false lumen was thrombosed in nine arteries (35%). Eight CCAs had stenosis >50%, with seven having increased velocities >200 cm/sec. All patients with elevated velocities in the true lumen had false-lumen thrombosis. We noted that carotid artery dissections were not visualized in all planes and that more false lumens were found to be patent on CDU than on computed tomography. Characteristic waveforms included a second pulsed systolic waveform, a wide and jagged systolic peak, intermittent flow reversal, and visualization of a dissection flap. Conclusion Carotid imaging in transverse and axial planes is important in dissection cases. We found that a 5–1 MHz curved-array probe may be helpful in imaging the proximal brachiocephalic arteries and aortic arch. Several characteristic waveforms were noted. We recommend a standardized protocol that includes near-complete CCA visualization, multiplane views, and Doppler waveform analysis of both true and false lumens. The clinical significance of false-lumen patency or true-lumen stenosis remains unclear.
Common Femoral Artery Pseudoaneurysm Associated with Arteriovenous Fistula
Authors: Bulauitan Constantine S. , McKean Robert , Cook Judith W. 
Published: March 2018

Background Thrombin injection (TI) is a common modality for the treatment of femoral artery pseudoaneurysm (PSA) of arterial access sites. It has decreased the need for open repair in this cohort of patients who often have increased surgical risk. Deep venous thrombosis and venous thromboembolism (VTE) have been reported after TI for PSA in the presence of an arteriovenous fistula (AVF). A combined treatment modality using ultrasound-guided TI with concomitant balloon occlusion of the AVF is described. Patient A high cardiac risk patient presented with a large pulsatile right groin mass after cardiac catheterization. Ultrasound identified a PSA arising from the right common femoral artery. The anatomy was suitable for TI; however, a large AVF also was present. The patient was a poor surgical candidate because of cardiac morbidity and body habitus. Methods The patient was taken to the hybrid vascular operative suite. Conscious sedation was administered. Venous access was obtained via the right internal jugular vein. Venography identified the AVF in the right common femoral vein. Thrombin was injected into the right groin PSA using direct ultrasound visualization. Simultaneous fluoroscopic-guided balloon inflation was used to occlude the common femoral vein and prevent flow through the AVF. Postinjection venography and Doppler examination of the femoral vessels were performed. Results The PSA was successfully occluded. There was no identifiable venous thrombus. Doppler examination also showed resolution of the AVF. There were no clinical signs or symptoms of pulmonary embolism. Conclusion TI of femoral artery PSA associated with AVF has increased risk of VTE. Concomitant venous occlusion during TI of a PSA may decrease the risk of VTE in the setting of a large AVF. This has the potential to expand the indications for TI in the high-risk surgical patient.
Analysis of Lost Sonographer Productivity in a University Hospital Vascular Laboratory
Authors: Hoffman Kaitlin , Evans Julie , Kershner Preston , Haurani Mounir J. , Satiani Bhagwan 
Published: March 2018

Introduction Improved efficiency is necessary to deliver cost effective services in today's healthcare environment. Details of how a vascular sonographer's (SG) time is allocated during an average working day have not been adequately described previously. Our objective was to provide insight into the SG average day, and therefore investigate ways at becoming more efficient. This improved efficiency may not only result in cost savings, but better patient and SG satisfaction. Methods SG at two hospitals affiliated with our university (Hospital A and B) tracked their activities daily during five consecutive weekdays. Scan time, delays in patient arrival, preparation for the test, computer entry, lunch breaks, and administrative time (patient and nonpatient related) were logged. Results Eleven SG performed 113 tests at Hospital A and 60 at Hospital B. On average, there were 5.4 full time equivalent (FTE) and 1.8 FTE SG working daily at Hospitals A and B respectively. Hospital A performed 62 portable studies, Hospital B performed none. Each SG performed between 14 and 32 tests (mean 21.4) in the study period. This was equivalent to 6.35 tests per FTE per day. Excluding portable studies, actual scan time occupied only 38.8% of the SG day. Nonpatient related but essential activities (23.7%) and nonscan nonessential activities (27.9%) took up the rest of the SG time. Conclusion In order to maximize efficiency in the vascular lab, nonpatient related activities, which occupy about a quarter of the daily workday, must be eliminated. Off-loading of these responsibilities to ancillary staff may improve SG efficiency. Portable studies consume a significant amount of time, and thus are a drag on efficiency as well.