Journal for Vascular Ultrasound

The use of the internal carotid artery (ICA) to common carotid artery (CCA) peak systolic velocity ratio (ICA^psv/CCA^psv) to quantitate ICA stenosis has been challenged based on the variability of Doppler-derived velocities at various locations within the CCA. We investigated these alleged differences to determine whether they affect actual classification of significant ICA stenoses.

Data from consecutive patients for an 18-month period were prospectively entered into a database. Only initial studies were included in this investigation. Follow-up examinations, postendarterectomy vessels, ICA occlusions, and CCA vessels with a PSV of >150 cm/sec were excluded from analysis. CCA^psvand ICA^psv/CCA^psvwere obtained and based on Doppler analysis at both the proximal most visualized CCA segment (proximal), and 1.5 cm proximal to the ICA flow divider (distal). ICA^psv/CCA^psv values of ≥ 2, ≥ 3, and ≥ 4 were used as threshold values for ≥ 50%, ≥ 60%, and ≥ 70% diameter stenoses.

A total of 383 patients and 588 vessels were analyzed. CCA^psv-proximal values, 75 ± 20 cm/sec, were significantly higher than CCA^psv-distal, 68 ± 16 cm/sec (p < 0.001). ICA^psv/ CCA^psv-distal ratios, 2.36 ± 2.77, were significantly higher than ICA^psv/CCA^psv-proximal, 2.11 ± 2.46, (p < 0.001). The average absolute difference between CCA^psv-proximal and CCA^psv-distal was 15% ± 13% (range, 0%–93%). For an ICA^psv/CCA^psv ≥ 50%, proximal and distal ratios would both be < 2 in 66%, ≥ 2 in 29%, and 5% were contradictory. For an ICA^psv/CCA^psv ≥ 60%, proximal and distal ratios would both be < 3 in 78%, ≥ 3 in 18%, and 4% contradictory. For an ICA^psv/CCA^psv ≥ 70%, proximal and distal ratios would both be < 4 in 85%, ≥ 4 in 12%, and in 3% contradictory.

Significant differences in ICA^psv/CCA^psv calculation as a function of location of the CCA^psv measurement were confirmed. Proximal and distal sampling sites, however, did not affect ICA^psv/CCA^psv classifications for 95% of the vessels analyzed. For contradictory classifications, ICA^psv/CCA^psv-distal had more potential for a positive result. To improve accuracy and address sensitivity or specificity interpretation parameters, the influence of the CCA sampling site should be considered and standardized when using carotid ratio criteria.

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

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

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

Volume of an endograft-treated AAA was successfully measured multiple times with two 3-D US techniques. Volumes obtained were comparable, demonstrating feasible reproducibility.

Recent advances in ultrasound technology now allow the sonographer to obtain three-dimensional color power angiography (3D-CPA) vascular images and to enhance these images by rotation and subtraction. The purpose of this report is to demonstrate the sonographic presentation of a cerebral arteriovenous malformation (AVM) using these advanced techniques.

During an emergency operation to evacuate a large subdural hematoma, the surgeon noted several aneurysmal veins, suggesting the presence of an underlying AVM. Angiography showed a compact AVM arising from a posterior temporal branch of the right posterior cerebral artery (PCA).

Transcranial color Doppler ultrasonography (CDU) revealed an AVM in the right temporal lobe with a feeder arising from the P1 segment of the right PCA. 3D-CPA images of the AVM were then developed, rotated, and subtracted. These enhanced images provided superior definition of the arterial and venous architecture and were comparable to the angiogram.

3D-CPA provided high-resolution, accurate, noninvasive images of a cerebral AVM. The added anatomic detail allowed by this technique was complementary to the hemodynamic information provided by CDU.

Paragangliomas in the neck are infrequent tumors that most frequently require surgical resection. Their diagnosis is possible with duplex ultrasonography, which can also assist in suggesting the usefulness of preoperative endovascular embolization.

A 53-year-old woman was seen with a mildly symptomatic left neck mass. An extracranial cerebrovascular duplex ultrasound examination revealed a mass near the carotid bifurcation. It seemed to be splaying the internal and external carotid arteries and was highly vascularized with multiple small feeding vessels. This suggested a carotid body paraganglioma. An MRI, CT scan, and angiogram were supportive of a diagnosis of a carotid body tumor. Because of its rich vascularity, preoperative embolization was performed. The patient was subsequently taken to surgery, and the mass was successfully excised. Pathologic microscopic examination confirmed a carotid body paraganglioma.

The diagnosis of a carotid body paraganglioma is possible with duplex ultrasonography. The size of the tumor and the finding of multiple small vessels feeding the tumor can assist in suggesting the usefulness of preoperative embolization to reduce operative blood loss.

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

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

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

This report demonstrates the sensitivity of CDU to arterial compromise associated with PCD in a case of upper extremity DVT. Vascular technologists should consider including arterial Doppler signals in their venous duplex protocols in cases of extensive deep and superficial vein thrombosis.

Diagnosis and repair of arterial injury from penetrating trauma is critical because the lack of intervention can result in limb loss or death. Patients that have conspicuous arterial injuries can be explored and repaired in the operating room with or without preoperative diagnostic imaging. Patients without definite clinical evidence of vascular injury (i.e., hematoma, pulsatile mass, bruit, or pulse deficit) generally undergo angiography because of proximity of injury. Arteriography is an expensive and invasive procedure for patients; it carries some discomfort and has potential complications associated with its use. In our experience, ankle/brachial index (ABI) alone has not been a dependable study to rule out significant arterial injury of extremities. Color flow duplex imaging is a painless procedure, has no risk to the patient, is not as expensive as arteriography and is readily available in most institutions. We present two patients who had normal pulses and ABIs after gunshot wounds to extremities. Both patients had significant arterial injury detected by color flow duplex imaging as the initial diagnostic modality and subsequently proceeded on to arteriography based on the findings of the duplex studies.

The findings of the duplex imaging were in direct correlation with arteriography. These two cases demonstrate the sensitivity of color flow duplex ultrasonography to detect extremity arterial injuries in a community hospital.

The osteochondroma is the most common benign tumor of bone. Typically asymptomatic bony protuberances are discovered in childhood or adolescence. Although vascular complications are rare, these bony spikes can course along an artery and cause severe arterial complications. Reported here is a case involving the use of color duplex ultrasonography (CDU) to identify a superficial femoral artery (SFA) pseudoaneurysm as a result of an osteochondroma.

A 12-year-old girl had been experiencing left lower extremity pain for approximately 2 months. The pain became progressively severe, and her parents noticed that she was limping. Magnetic resonance imaging (MRI) demonstrated a mass in the left thigh, suggesting the possibility of a femoral aneurysm. A bony spicule was noted on x-ray at the distal femur, projecting posteriorly.

Clinical evaluation revealed an impressive pulsatile mass in the left distal medial thigh. The left thigh was noticeably larger than the right with poor pedal pulses compared with the asymptomatic limb. CDU was performed and identified an aneurysm of the SFA at the adductor canal. There was unusual oscillatory flow in the SFA proximal to the aneurysm with monophasic signals distally. The large aneurysm size displaced the normal anatomic course of the SFA and vein. Ankle-brachial indices (ABI) were 0.72 and monophasic in the affected limb and >1.0 and triphasic in the contralateral limb.

Angiography confirmed the CDU and MRA findings, demonstrating a large pseudoaneurysm at the adductor canal caused by an osteochondroma of the femur. At time of surgical repair, the bony spicule was noted to have eroded into the femoral artery.

Vascular complications as a result of an osteochondroma are rare. Rapid diagnosis is necessary to prevent serious arterial compromise in these young patients. CDU can quickly and accurately confirm the presence of a pseudoaneurysm when an osteochondroma is suspected.