bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
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.
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.
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.