How noninvasive investigation has modified our therapeutic approach in vascular medicine

Abstract

Italian Society for Vascular Investigation Noninvasive diagnostic methods have modified our therapeutic decision-making in several vascular diseases. In particular, many forms of surgical treatment, both endovascular and open, are performed based exclusively on evaluation with duplex scanning. The purpose of noninvasive ultrasound testing is to distinguish normal from pathological vessels, to classify a wide range of disease states, to assess the collateral circulation, and to do so in a safe and cost-effective manner. The primary aim is to identify patients who are at risk for acute and chronic vascular disease and who may require specific treatment. A secondary aim is to document progressive or recurrent disease in patients already known to be at risk. Of course, individual vascular laboratories must validate their own results against a suitable gold standard, and they have to guarantee the best quality and maximum accuracy. With regard to diseases of the carotid artery, color flow duplex scanning is the investigation of choice for diagnosis and measurement of carotid stenosis, provided that objective criteria are used and scanning is done by experienced operators. Several velocity criteria used to detect the presence and severity of carotid artery disease and the morphological evaluation of lesions allow us to have a specificity of 90% and a sensitivity of 99% when all categories of carotid disease are considered. On the basis of these criteria, we can identify the best therapeutic approach for specific pathological conditions. Concerning plaque characteristics, surface ulceration, low gray-scale median (,25), heterogeneous appearance of the plaque, and juxtaluminal location of the echolucent area after image normalization are ultrasonographic indicators of plaque vulnerability, and should be considered in selection of appropriate therapy and frequency of follow-up after surgical treatment, ie, carotid endarterectomy or carotid artery stenting. Transcranial color Doppler can be used before carotid endarterectomy or carotid artery stenting to evaluate coexisting lesions of the intracranial vessels, efficiency in the circle of Willis, the intracranial hemodynamic effects of extracranial carotid lesions, cerebrovascular reserve, microembolic events due to ulcerated plaques, cross-clamping risk, and indication for shunting. Duplex ultrasonography is the ideal method of determining the adequacy of renal artery revascularization, and is helpful in detecting important areas of restenosis after endovascular therapy, ie, percutaneous angioplasty with stent deployment. The renal duplex examination includes spectral Doppler velocities for the renal arteries, renal parenchyma, and abdominal aorta. Peak systolic and end-diastolic velocities obtained Correspondence: PL Antignani President of Italian Society for Vascular Investigation, Vascular Center Nuova Villa Claudia, Via Germanico 211, 00192 Rome, Italy Email antignani@mclink.it Dovepress