bluuebunny/crossref_metadata_2025_split huggingface dataset:
Suspicious Extracranial Duplex Examination: A Predictor of Intracranial Disease?
Authors: Collado Esther , Hodge Megan , McCollum Charles , Noon George , Bush Ruth L. , Garami Zsolt , Lumsden Alan B. 
Published: March 2018

Introduction Moyamoya disease is a rare and progressive condition with poor long-term prognosis. A meticulous evaluation during an extracranial carotid duplex exam, with attention to subtle changes in anatomy and Doppler signals, can alert the sonographer to pathology in the intracranial circulation, which may suggest this diagnosis. Case Report A 45-year-old woman presented to our vascular lab with an episode of slurred speech, right arm weakness, right-sided numbness, and generalized weakness that lasted 15 – 20 min, with total resolution of symptoms. A carotid duplex examination was ordered and demonstrated no evidence of extracranial carotid disease; however, bilaterally the external carotid artery was larger in size than the internal carotid artery, multiple prominent external carotid artery branches were noted, the internal carotid artery and vertebral artery Doppler signals demonstrated low-resistance waveforms with high diastolic flow velocity, and the left vertebral artery was enlarged. Magnetic resonance imaging with angiography demonstrated multiple intracranial abnormalities, and conventional angiography was compatible with Moyamoya disease. A superficial temporal artery-to-middle cerebral artery bypass was performed with an uneventful postoperative course and no recurrence of symptoms. Conclusions Subtle changes in anatomy and Doppler signals observed during an extracranial carotid duplex examination can be important indicators of pathology in a location that is not under direct visualization and interrogation. It is important for the sonographer to note these changes and report them to the physician for further evaluation by more direct methods of testing. This case provides an example of the use of such indirect sonographic evidence.
Horseshoes Are Not Always Lucky: A Rare Cause of Varicose Veins
Authors: Busch Kathryn , Doyle Judith , Forbes Martin , White Geoffrey , Harris John , Stephen Michael 
Published: March 2018

Introduction Color duplex ultrasound (CDU) assessment for patients with varicose veins has increased in prevalence as new techniques for treatment continue to emerge. Occasionally, patients present with atypical varicosities that warrant the typical study to be extended to unveil the true underlying cause of the condition. Clinical Details A 41 year old man presented to our laboratory for assessment of bilateral varicose veins. He had recently developed venous eczema. Examination of the patient revealed large varicose veins associated with the long saphenous system, especially prominent on the left side. Methods Using a standard venous incompetence study protocol, CDU was performed with a Philips IU22 machine. The lower-extremity deep and superficial venous systems were assessed for patency and competency. Measurements of incompetent venous junctions and noteworthy vessel diameters were included. The examination was extended to include the pelvic and abdominal veins on the basis of unusual findings during the CDU imaging of the legs. Results Superficial venous insufficiency was detected involving the saphenofemoral junctions (SFJs), long saphenous veins (LSVs), and tributaries bilaterally. Bilateral incompetent calf perforators were identified. On the left, two large SFJs were identified and the LSV measured up to 2.1 cm in diameter. On both sides, an incompetent superficial pelvic vein arising from the SFJ was identified tracking proximally. Examination of the iliac veins revealed normal right iliac veins. On the left, the common iliac vein was extrinsically compressed as was the inferior vena cava. Further examination revealed a horseshoe kidney. The confluence of the lower poles of the kidneys were anterior to the aorta, inferior vena cava, and left common iliac vein, compressing the venous vasculature, accounting for the venous hypertension and left sided prominence. Further management included confirmatory radiological imaging and intervention. Conclusion Atypical varicose veins may be a result of a plethora of causes. It is crucial to the patient's outcome to reveal the true nature of the underlying cause. Abdominal sources of venous incompetence need appropriately tailored intervention to prevent recurrence and potential worsening of symptoms.
Expected Diameter and Velocity Parameters for Internal Mammary Artery Mapping Procedures
Authors: Mady Ehab N. , Whitelaw Susan , Gornik Heather L. 
Published: March 2018

Background The internal mammary artery (IMA) is the preferred conduit for coronary artery bypass grafting because of its improved long-term patency. Duplex IMA mapping may be requested as a component of preoperative assessment. We reviewed our institutional experience with IMA mapping procedures and determined expected values for IMA size and Doppler parameters. Methods Query was sent to the Cleveland Clinic Non-Invasive Vascular Laboratory database for all bilateral IMA mapping procedures performed from January 1, 2005 to June 30, 2007. Examinations were performed by the use of high-resolution B-mode and Doppler ultrasound. Mean values for IMA dimensions and Doppler parameters were determined along with reference ranges (mean ± 2 standard deviations). Results A total of 949 patients were identified. Mean age was 69.6 years, and 64.7% were men. Patients with significant subclavian stenosis were excluded from the primary analysis. Mean values and reference ranges for right and left IMA size and Doppler parameters are presented in tabular format. Bilateral IMAs were larger in men compared with women ( p < 0.0001). The mean right IMA diameter was larger than left ( p < 0.001). The presence of subclavian artery stenosis was associated with smaller vessel diameter and increased peak systolic velocity. Conclusion We report a range of expected values for preoperative IMA mapping procedures. These data may be used for development of laboratory diagnostic criteria or incorporated into future research on IMA duplex ultrasound for postoperative surveillance.
A Comparison of Transcranial Doppler and Transesophageal Echocardiography (with Conscious Sedation) in the Detection of Right-to-Left Cardiac Shunts
Authors: Alexander Thomas H. , Collins Lester B. 
Published: March 2018

Background and Purpose Transesophageal echocardiography (TEE) is used and accepted as a method for detecting right-to-left cardiac shunts, most commonly caused by patent foramen ovale (PFO). Transcranial Doppler (TCD) is an accepted alternative test involving the injection of agitated saline with a timed and gauged Valsalva maneuver. Controversy exists about the exact role of PFO in patients with cryptogenic stroke and the resultant therapeutic alternatives; however, there is no controversy about the need to accurately detect the PFO. Methods We reviewed the records of 264 consecutive patients referred for TCD with the diagnosis of cryptogenic stroke or transient ischemic attack. Results A total of 89 (33.7%) patients had a positive TCD test for PFO; 39 went on to have TEE studies. A total of 19 of the TEE results failed to confirm the PFO (48.7%). TEE in the East Texas Region is routinely performed by the use of conscious sedation, which requires the supervising cardiologist to compress the abdomen to simulate Valsalva. Conclusion In the East Texas region, transcranial Doppler is superior to transesophageal echocardiography for the detection of right-to-left shunt in stroke patients, presumably because of the Valsalva limiting effect of intravenous sedation routinely given during the latter procedure.
Occurrence of Digital Photoplethysmography Waveforms in Patients with Lower-Extremity Critical-Limb Ischemia
Authors: Scissons Robert P. , Jones Linda , Altenburg Laura , Mason Julie , Musatkina Svetlana , Snyder Todd , Tiell Todd , Wilson Amy 
Published: March 2018

Purpose Digital photoplethysmography (PPG) has been proposed as an alternative to Doppler technology for measuring ankle pressures and ankle-brachial indices (ABIs). However, in patients with critical-limb ischemia (CLI), digital waveforms may not be detectable, which would negate digital pressure measurement and ABI calculation. In this study we evaluated the presence of digital PPG waveforms in patients with lower-extremity CLI (ABI < 0.40). Methods From January through December 2007, vascular laboratory patients who had a lower-extremity physiological study, including an ankle waveform, PPG waveform analysis of their great toe, and an ABI of =0.40, were prospectively entered into a database. ABIs and waveforms were obtained in the standard fashion. Patients with incomplete waveform data and CLI follow-up examinations were excluded from the analysis. Subjects were separated into 2 groups: those with digital PPG waveforms (group 1) and those with flatline digital waveforms (group 2). Each group was evaluated for audible posterior tibial (PT) and dorsalis pedis (DP) Doppler signals. Results A total of 160 extremities (140 patients) with CLI were identified during the study period; 45 patients and 53 extremities were excluded. There were 41% (44/107) group 1 and 59% (63/107) group 2 extremities. In group 2 extremities, 67% (42/63) had flatline ankle waveforms, 40% (25/63) had absent PT and DP Doppler signals, and 60% (38/63) had one or more audible PT or DP signals. Conclusions Less than one half of the extremities with CLI had digital PPG waveforms. However, 60% of those limbs with flatline digital waveforms had one or more audible pedal Doppler signal, requiring a more detailed noninvasive evaluation with a Doppler ABI endpoint. Automated digital PPG devices may be inadequate for ABI evaluation of patients with CLI.
Effect of Harmonic and Compound Imaging on Estimates of Carotid Artery Intima-Media Thickness
Authors: Alessi-Chinetti Jean , Tran Hong , Harrington Anita , Wanke Christine , Polak Joseph F. 
Published: March 2018

Background Carotid artery intima-media thickness (IMT) is a marker of atherosclerosis linked to cardiovascular outcomes. These outcome studies were made before advanced imaging techniques such as harmonic imaging (HI) and compound (CrossBeam) were available. We study the effects of these new imaging approaches on estimates of carotid artery IMT. Materials and Methods A total of 26 subjects (44 common carotid arteries) with an average age of 49.3 years were imaged with fundamental imaging (FI) presets, HI, and compound imaging (CrossBeam; XB). Images were the evaluated with a commercially available edge detector. Comparisons of group means were made with analysis of variance and the Tukey-Kramer test. Associations with age were studied with linear regression analysis. Results Mean values of carotid artery IMT of the common carotid far wall were different ( p < 0.04) between groups (FI: 0.63 ± 0.09 mm; HI: 0.66 ± 0.16 mm; crossbeam imaging: 0.59 ± 0.13 mm). XB gave significantly lower IMT values than HI. XB IMT was not significantly associated with age whereas FI and HI IMT were. Conclusion We conclude that advanced imaging approaches need to be evaluated against traditional imaging approaches to insure concordance with published IMT values. Failure to do so may result in significant differences with published normative IMT values.
Carotid Artery Pseudoaneurysm
Authors: Ayoub Kathryn , May Nacion Kristine , Bartholomew John R. 
Published: March 2018

Introduction The development of a carotid artery pseudoaneurysm (PA) after carotid endarterectomy is a rare complication with a reported incidence of 0.25% to 0.74%. It results from suture line failure or disruption, degeneration of the arterial wall, or patch material and/or infection. Patients present with neck swelling and pain that can be complicated by thrombosis, rupture, or infection. Case Report We describe a 72-year-old man who underwent bilateral carotid endarterectomies in 1987. He presented with bilateral upper-extremity swelling after a kidney transplant. An upper-extremity venous duplex performed with a Philips iU22 (Bothell, WA) with an 8-4 MHZ linear transducer revealed normal phasic pulsed Doppler waveforms. Compression images of the patient's left side of the neck revealed acute thrombus within the internal jugular vein. An incidental finding of bilateral common carotid PAs at their proximal patch surgical sites was noted. The right carotid PA measured 1.8 × 2.6 cm, whereas the left measured 2 × 1.3 cm. Discussion Carotid artery PA has been reported within 2 days or as late as 22 years after surgery. A true carotid aneurysm is usually caused by atherosclerosis or arteritis, whereas a carotid artery PA develops after endarterectomy as the result of infection, suture line disruption, or degeneration of the arterial wall or at the patch angioplasty site. A potential for rupture, embolization, thrombosis, or compression of the cranial nerves requires urgent attention. The conventional treatment approach is excision and repair via a vein graft. However, the risk of complications, especially cranial nerve injury, is high. A reasonable alternative to open surgery is covered carotid artery stenting if infection is excluded as the etiology of the pseudoaneurysm. Conclusion Although the diagnosis of carotid artery PA is usually suspected clinically, an imaging procedure is necessary for confirmation. Duplex scanning is the gold standard that can be augmented by arteriography or magnetic resonance imaging.
Twins Lead to the Prevention of Atherosclerosis: Preliminary Findings of International Twin Study 2009
Authors: Tarnoki Adam Domonkos , Tarnoki David Laszlo , Stazi Maria Antonietta , Medda Emanuela , Cotichini Rodolfo , Lucatelli Pierleone , Boatta Emanuele , Zini Chiara , Baracchini Claudio , Meneghetti Giorgio , Nisticó Lorenza , Fagnani Corrado , Fanelli Fabrizio , Giannoni Maria Fabrizia , Gazzetti Marianna , Osztovits Janos , Jermendy Gyorgy , Préda István , Kiss Róbert Gábor , Littvay Levente , Metneki Julia , Horvath Tamas , Karlinger Kinga , Pharm Agnes Lannert , Yang Eric Y. , Nambi Vijay , Molnar Andrea Agnes , Berczi Viktor , Garami Zsolt 
Published: March 2018

Introduction Atherosclerosis is an inflammatory process in which the artery wall thickens as a result of plaque deposition, but this process may be preceded by increased arterial stiffness. We sought to evaluate the influence of genetics and shared and unshared environmental components on the onset of atherosclerosis. Methods A total of 135 monozygotic (MZ) and 70 dizygotic (DZ) twin pairs (mean age 49 ± 16 years) underwent carotid intima media thickness (IMT; carotid analyzer) and arterial stiffness (augmentation index on brachial artery [ Aixbra], pulse wave velocity on aorta [ PWVao]; TensioMed Arteriograph) measurements. Results Age-adjusted intraclass correlations were greater in MZ than in DZ pairs for proximal right common carotid artery (CCA; MZ = 0.19, DZ = 0.06), proximal and distal left CCA (MZ = 0.27, DZ = 0.06; MZ = 0.27, DZ = 0.13, respectively), and proximal left internal carotid artery (ICA; MZ = 0.39, DZ = −0.54), suggesting a moderate genetic effect. Heritability was estimated to be 18% (95% confidence interval [CI] = 3–33) for proximal right CCA, 26% and 27% for proximal and distal left CCA, respectively, and 38% (95% CI = 26–49) for proximal left ICA. Regarding distal right CCA and proximal right ICA, no genetic effects were detected. Age-adjusted intraclass correlation of Aixbra and PWVao were 0.65 (95% CI = 0.55–0.72) and 0.46 (95% CI = 0.33–0.57) in MZ, 0.42 (95% CI = 0.24–0.57) and 0.28 (95% CI = 0.08–0.47) in DZ pairs; heritability 45% (95% CI = 12–71%) and 42% (95% CI = 2–57%) adjusted by age, respectively. Conclusions The investigated parameters appeared to be only moderately influenced by genetic factors. Environmental factors of relevance for these measures appeared not to be shared within family but related to individual experience (e.g., smoking habits, diet, and physical activity). Atherosclerosis detection at an early stage is necessary for treatment to prevent serious complications such as stroke and heart attack.
Does Distal Venous Hypertension Affect Lower-Extremity Venous Pulsatility?
Authors: Schroedter William B. , White Jean M. , White Brian D. , Mauriello John D. , Sanchez E. J. , Izzo Edward G. 
Published: March 2018

Introduction Pulsatile flow in the lower-extremity venous system is commonly attributed to various cardiac abnormalities. In patients with significant venous insufficiency and resultant venous hypertension, venous capacitance may be drastically reduced. We have noted multiple patterns of venous pulsatility and theorized that the hemodynamic state of the lower-extremity venous system could in fact play a role in these patterns. If venous reflux is isolated to the superficial system, ablation of these veins could resolve the venous hypertension and potentially influence the pulsatile flow pattern. Methods We compared the presence and pattern of lower extremity venous pulsatility in 293 consecutive patients suffering from chronic venous insufficiency (Mean CEAP 3.2). Of these, 242 limbs underwent endovenous thermal ablation (EVTA) of a refluxing truncal vein. Duplex ultrasound was used to evaluate these limbs approximately 3 days post procedure and the results of 101 limbs were available for comparison with the initial exam and provide the basis of this study. Results Of the 101 limbs, 47 (46.5%) had evidence of pulsatile flow in the lower extremity venous system preoperatively which was graded into one of three categories. Forty-eight (47.5%) had deep venous insufficiency of either the femoral vein (n = 16) or popliteal vein (n = 32), which was graded as normal, >1 second, or >2 seconds. The remaining had no evidence of deep vein reflux. Paired observations using the Wilcoxon method showed no difference in the venous pulsatility post ablation. Additionally, isolating patients with no evidence of deep venous reflux also revealed no difference in pulsatility following ablation. Conclusion Ablation of refluxing truncal veins did not appear to influence the presence or pattern of venous pulsatility in the lower extremities regardless of deep system valve function.
Paradoxical Thromboembolism: A Trip Better Left Untraveled
Authors: Witte Richard G. , Burgess William A. , Vasquez Marla D. , Hanan Tracy L. , Charlton-Ouw Kristofer M. 
Published: March 2018

Introduction Pulmonary embolism is a common sequela of deep vein thrombosis (DVT). Less well documented is the occurrence of DVT and its relationship to stroke via an intracardiac shunt such as a patent foramen ovale (PFO). We report a case of DVT and stroke in conjunction to the presence of intracardiac thrombus and a moderate-sized PFO. Methods This is a case study report of a 61-year-old woman with a previous medical history of hyperlipidemia only who traveled to Mexico from the Unites States. The trip included three long bus trips of 12, 13, and 14 hours in duration. This patient presented to a hospital in Mexico with severe headache and right-sided weakness. The patient was diagnosed and treated for left hemispheric stroke and eventually transported to our hospital in Houston, Texas, for further stroke evaluation and management. With the use of a Philips IE33 8 MHz linear array probe and multi-plane TEE probe as well as a Siemens Sequoia 4V phased array probe, we were able to safely and accurately diagnose and manage the patient's condition until intervention could be safely performed. Results Multiple diagnostic imaging tests were performed, including a bilateral lower-extremity duplex venous ultrasound, duplex carotid ultrasound, transthoracic and transesophageal echocardiograms, as well as computed tomography scans of the chest and brain. With the patient's current condition and symptoms as well as the collected findings, our test results indicated that a paradoxical thromboembolic event had most likely occurred. There was right lower-extremity DVT, bilateral pulmonary embolisms, and large and highly mobile thrombus within the right-side chambers of the heart that occasionally protruded through a moderate size patent foramen ovale of 0.9 cm. The left distal common carotid artery and internal carotid artery were found to be occluded, and initial computed tomography scan of the brain showed a large left middle cerebral artery distribution infarct. Conclusion Venous thromboembolic disease can cause stroke in the presence of an intracardiac shunt such as a PFO. The use of vascular and cardiac ultrasound examinations is critical in determining the etiology of cerebrovascular events. We document a rare case of combined DVT, pulmonary embolism, intracardiac thrombus, PFO, and extracranial carotid arterial occlusion. Although the prevalence of DVT and intracardiac shunts alone is high, it is unclear from the literature which patients would benefit from PFO closure.
Inferior Mesenteric Artery Duplex in the Management of Chronic Mesenteric Ischemia
Authors: Younes Houssam K. , Broadbent Karen , Hodge Megan , Bismuth Jean , Davies Mark G. , Lumsden Alan B. 
Published: March 2018

Introduction Duplex interrogation of the mesenteric arteries is a frequent practice during the workup of chronic mesenteric ischemia (CMI). We report a case in which duplex ultrasound identified a stenosis of the inferior mesenteric artery (IMA) that was not initially detected on either angiogram or computed tomography angiography (CTA). Case Report A 72-year-old Hispanic man with a history of CMI presented with a 1-week history of vague postprandial abdominal pain that became severe and constant during the last 3 days. The patient was admitted and an aortic angiogram was performed, demonstrating a normal celiac axis and IMA, and short segment superior mesenteric artery (SMA) occlusion with reconstitution via a large meandering branch of the IMA. Aortic duplex was also performed that confirmed the occlusion of the SMA and demonstrated significant velocity elevation (>450 mm/sec) with color flow disturbances suggestive of high-grade stenosis at the origin of the IMA. This duplex ultrasound finding prompted further investigation with CTA of the abdomen and pelvis, which demonstrated a high-grade stenosis of the celiac axis, occlusion of the SMA, and an atherosclerotic plaque in the infrarenal aorta near the origin of the IMA without evidence of stenosis. Because of the patient's persistent abdominal symptoms and disparate imaging results, a repeat angiogram with multiple views was able to identify both the celiac and IMA stenoses, each of which was successfully treated with stents. The patient's abdominal symptoms resolved within 4 days. Three months after stenting, the patient remains symptom free, and a follow-up duplex examination showed patency of both the celiac artery and IMA stents. Conclusion Multiple imaging modalities are often essential in the work up for patients with CMI. This case demonstrates the sensitivity of duplex ultrasound in the identification of an IMA stenosis in a patient with a known occlusion of the SMA, and not initially identified on the angiogram or CTA.