Color Duplex Imaging Research Articles

The Additional Value of Angiography After Colour-coded Duplex on Decision Making in Patients with Critical Limb Ischaemia. A Prospective Study

Objective: to investigate prospectively the additional value of intra arterial digital subtraction arteriography (IADSA) for decision making in patients with critical limb ischemia (CLI). Treatment plans based on colour-duplex imaging (CDI) were compared with treatment plans based on IADSA.Methods: ninety-eight consecutive patients with 112 legs with CLI were investigated by CDI and IADSA. Treatment plans based on CDI and IADSA were made separately during a multidisciplinary meeting. Both plans were retrospectively analysed with the outcome of the operation or the endovascular procedure as a reference.Results: eighty-eight patients with 101 legs could be analysed. In 91 out of the 101 legs (90%) CDI offered the same strategy as the IADSA. In 10 legs IADSA provided additional information. Most of the additional information concerned the crural vessels.Conclusion: the preoperative planning of treatment in patients with chronic critical ischaemia of the lower limbs can be based on CDI alone in most patients. For planning crural revascularisation additional information may be needed. If severe calcification prevents adequate visualisation of the crural vessels or no patent anterior or posterior tibial artery with outflow across the ankle is present, IADSA should be performed.

Contrast Enhanced Duplex Ultrasound Imaging of the Mesenteric Arteries

Duplex ultrasound of the visceral arteries is a technically challenging procedure. We examined the clinical usefulness of perflutren intravenous ultrasound contrast to improve the diagnostic accuracy of such studies. Seventeen patients were prospectively studied. A color duplex imaging study of the visceral vasculature was performed with and without the contrast agent. Vessels were imaged and peak systolic velocity and Doppler waveforms of the aorta, celiac artery, superior mesenteric artery, and the inferior mesenteric artery were examined. These results were independently compared to those of contrast angiography. From this analysis we concluded contrast-enhanced duplex imaging of the mesenteric arteries is safe but not routinely required when performed by an experienced sonographer. Ultrasound contrast may be helpful in difficult patients when the vessels are not initially successfully visualized.

Vascular 07

Aims: Elderly patients with chronic venous ulceration may benefit from venous surgery, but often wish to avoid general anaesthesia. The aim of this study was to compare the effectiveness of sapheno-femoral disconnection (SFJD) under local anaesthesia and SFJD plus stripping of the long saphenous vein under general anaesthesia in legs with chronic venous ulceration. Methods: Patients with chronic venous ulceration were assessed with colour duplex imaging to identify those with sapheno-femoral junction reflux. Patients underwent either SFJD alone under local anaesthetic or SFJD with stripping under general anaesthetic. Twenty-four-week ulcer healing rates and 12-month ulcer recurrence rates were compared. Results: The median (range) age of patients undergoing SFJD alone was 81 (46–90) years (n = 30) and of patients undergoing SFJD plus stripping was 68 (31–86) years (n = 83). Age-adjusted 24-week ulcer healing rate was 62 per cent for both groups. Twelve-month ulcer recurrence rates were 14 and 12 per cent, respectively (P = 0.39, Kaplan–Meier survival analysis). Conclusions: SFJD plus stripping has no additional short-term benefit over SFJD alone in legs with chronic venous ulceration.

The value of colour duplex sonography in the assessment of surgical resectability of pancreatic tumors

The Value of Colour Duplex Sonography in the Assessment of Surgical Resectability of Pancreatic Tumors. The aim of this study was to evaluate the assessment by modern colour duplex imaging (CDI) concerning the relation between tumour and vessels including haemodynamic parameters in the main abdominal arteries and the portal system, and to evaluate the influence of these results on surgical decision making. From January 1997 to October 1998, 146 patients with a tumour of the pancreas were included in a prospective study. Tumour contact to vessels and to the retroperitoneum, data on the flow in the main abdominal arteries and the portal circulation (regional topography) as well as the detection of liver metastases, enlarged lymph nodes and peritoneal carcinomatosis were defined as representing criteria of resectability. The results were compared with the intraoperative situation and with the definite histological findings. In 57 resectable tumours, the portal system was found to be infiltrated by the tumour up to a length of 1.5 cm. The flow velocity reached between 4 and 53 cm/s (mean flow) and 9 to 105 cm/s (maximum flow). Out of 146 pancreatic tumours, 89 were found as being non-resectable. In these cases, the measured parameters differed depending on the degree of tumour infiltration in to the portal circulation. We measured values from 0 to 96 cm/s (mean flow) and from 0 to 201 cm/s (maximum flow) with loss of breath-dependent modulation. The contact area between tumor and portal vessel was longer than 2 cm. Pathological flow in the main abdominal arteries was only found in 2 of 13 cases. The local situation was assessed correctly in 140 out of 146 cases by CDI (sensitivity of 93.0 %, specificity of 97.8 %, positive predictive value of 96.4 %, negative predictive value of 95.6 %). Regarding the complete oncological status (local situation, metastases, lymph node involvement and peritoneal carcinomatosis), a sensitivity of 82.5 % and a specificity of 92.1 % (positive predictive value of 87.0 %, negative predictive value of 89.1 %) was found. Modern CDI can reliably assess the resectability of pancreatic tumours by the evaluation of morphological and haemodynamic parameters. There are still difficulties in the assessment of lymph node involvement as well as in the detection of small liver metastases and of peritoneal carcinomatosis without ascites.

Management of penetrating injuries to carotid artery.

The diagnosis and management of penetrating injuries to the cervical carotid arteries continue to be controversial. Most patients with stab or gunshot wounds to the common or internal carotid artery in cervical zone II (sternal notch to angle of mandible) are symptomatic with external or intraoral hemorrhage, a rapidly expanding hematoma, evidence of a carotid-jugular arteriovenous fistula at an obvious site, or loss of the carotid pulse with a neurologic deficit. Immediate airway control and arterial repair are indicated in such patients. Other patients present with stab or gunshot wounds with proximity only to the carotid sheath, a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, or loss of the carotid pulse without a neurologic deficit. Diagnostic options in this latter group include duplex ultrasound, color duplex imaging, and standard arteriography, while the role of CT or MRI angiography in evaluating patients with penetrating cervical wounds is unclear at this time. Certain arterial injuries discovered on diagnostic tests are currently managed with observation, endovascular stenting (for intimal or wall irregularities), and arteriographic embolization (for small pseudoaneurysms or high carotid-jugular fistulas). Operative repairs for injuries in zone II are performed through an oblique cervical incision and include all the options used with peripheral vascular injuries. Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than ligation of the injured carotid artery. When the patient is truly comatose with a Glasgow Coma Scale score < 8, an unsatisfactory neurologic outcome is likely with either arterial repair or ligation. Injuries to the extracranial internal carotid artery in cervical zone III (above the angle of the mandible) may require innovative approaches to control hemorrhage and then maintain flow to the ipsilateral cerebral cortex.

Can an Algorithm Predict Appropriate Utilization of Emergency Venous Studies?

Venous duplex evaluation (VDE) has virtually supplanted venography in the diagnosis of deep vein thrombosis (DVT). To control low yield of VDE of ambulatory patients, performed at “off-hours,” we adopted an algorithm to improve the selection process and to increase efficiency. “Off-hours” studies are those performed after the normal daily working hours, weekends, or holidays. From January 1, 1996, through December 31, 1998, we performed 5393 lower extremities VDE, utilizing color duplex imaging with video taping. 2535 studies were done during the eighteen months prior to adoption of the algorithm on July 1, 1997 and 2858 studies were performed during the subsequent eighteen months. During the first 18 months, 314 requests for emergency studies came from the Emergency Department (ED). 132 were “off-hours” and 24 (18.2%) were positive for DVT compared to 427 after adoption of the algorithm, of which 79 were “off-hours” with 24 being positive for DVT (30.3%). Using an algorithm for dealing with requests for VDE originating in the ED on outpatients at “off-hours” resulted in an overall decrease in requests as well as a greater yield of positive studies without apparent compromise of the quality of care.

Short-term results of femoropopliteal subintimal angioplasty.

Subintimal angioplasty may be more successful than conventional (intraluminal) angioplasty for treatment of long femoropopliteal occlusions. This study assessed the clinical and haemodynamic outcome of subintimal angioplasty. All patients with femoropopliteal occlusions treated by subintimal angioplasty over a 3-year period at two centres were reviewed. Clinical assessment and colour duplex imaging were carried out. Sixty-nine procedures were performed in 33 men and 33 women of median age 74 (range 47-92) years. Indications for treatment were intermittent claudication in 26 (38 per cent) and critical limb ischaemia in 43 (62 per cent). Median occlusion length was 10 (range 2-50) cm. Primary technical success was achieved in 51 occlusions (74 per cent). There were 11 complications (16 per cent); the majority were minor but surgical intervention was required in two patients (3 per cent). At 6 months the cumulative symptomatic and haemodynamic primary patency rates were 60 and 51 per cent respectively, analysed on an intention-to-treat basis. The symptomatic and haemodynamic patency rates for technically successful procedures were 80 and 77 per cent respectively. In this series the short-term clinical success of subintimal angioplasty was poor because of a high incidence of reocclusion and restenosis, despite a relatively high initial technical success rate.

Effect of posture on popliteal artery hemodynamics.

Marked peripheral vasodilation and rubor characterize critically ischemic limbs on dependency. We believe that intermittent claudication is also associated with peripheral hemodynamic changes on postural alteration, which differ distinctly from normal. Evaluation of such differences and understanding of the underlying physiological derangements may be essential in the development of treatments for intermittent claudication. We comparatively assess the effect of posture on lower limb arterial hemodynamics in normal subjects and in patients with intermittent claudication (or Fontaine II) due to peripheral vascular disease, determined in the popliteal artery. A cohort study. A university-associated tertiary care hospital. Thirty-seven legs of 29 normal subjects (group A) and 50 legs of 36 patients with intermittent claudication (ankle-brachial index range, 0.39-0.76; median, 0.57) (group B). Popliteal artery volume flow (vFl), mean velocity, and luminal diameter were measured on (1) recumbency, (2) sitting, and (3) return to recumbency in groups A and B using color duplex imaging. The pulsatility index, peak systolic velocity, and end diastolic velocity (EDV) were measured on (1) recumbency, (2) sitting, and (3) return to recumbency. Popliteal artery vFl in normal subjects decreased from 110 +/- 43 mL/min on recumbency to 57 +/- 27 mL/min on sitting (P<.001) and returned to 111 +/- 46 mL/ min on resumption of recumbency (P<.001). Similarly, in patients with intermittent claudication, vFl decreased from 113 +/- 52 mL/min on recumbency to 76 +/- 41 mL/min on sitting (P<.001) and increased on resumption of recumbency to 114 +/- 53 mL/min (P<.001). There was no difference (P = .97) in the vFl between the study groups on recumbency, but sitting vFl in normal subjects was significantly lower than in patients with intermittent claudication (P = .04). The mean velocity, peak systolic velocity, and EDV displayed a similar pattern of change as vFl. The pulsatility index in both groups increased significantly on sitting (P<.001) and decreased on return to recumbency (P<.001). All data are given as mean +/- SD. Lower limb arterial vFl, mean velocity, peak systolic velocity, and EDV decrease significantly (P<.001) when posture is altered from recumbency to sitting, in normal subjects and in patients with intermittent claudication. A decrease in the EDV and an increase in the pulsatility index on sitting indicate enhancement of arterial resistance to flow secondary to peripheral vasoconstriction. Quantitative differences between the groups in vFl (P<.04), EDV (P<.01), and pulsatility index (P<.001) on dependency indicate that the orthostatic vasoactive response in patients with intermittent claudication is significantly subdued, reflecting a marked derangement in venoarteriolar response.

Analysis of flow changes in forearm arteries after raising the radial forearm flap: a prospective study using colour duplex imaging

The purpose of this study is to assess the changes in flow patterns of forearm arteries produced by excision of the radial artery when harvesting the radial forearm flap, in order to clarify its vascular morbidity rationally.Eleven patients with elective surgery using the radial flap were included in this investigation. A prospective study was designed using colour duplex imaging for quantitative flow measurement in two stages: a few days before the operation, a first colour duplex scanning examination was done recording flow velocity and vessel section area from the radial, ulnar, posterior interosseous and anterior interosseous arteries around the wrist. Volumetric parameters and relative blood flow percentages were calculated and compared to those obtained from a second similar vascular investigation accomplished in the same limb 4–5 months after the operation. Statistical analysis was done using the Wilcoxon matched pairs test.After raising the radial forearm flap there was a trend for increased overall forearm flow (from 162 to 215 ml/min, P = 0.09 N.S.), the ulnar (P = 0.04), the posterior interosseous (P = 0.004) and the anterior interosseous (P = 0.003) arteries being responsible for this tendency. The anterior interosseous artery showed the greatest increase in blood (from 8.2 to 67.7 ml/min), reaching a relative flow percentage (33%) close to that of the radial artery before its excision (39%).Results of this study indicate that another ‘major vascular axis’ based on the anterior interosseous artery develops after sacrificing the radial artery and that global arterial inflow to the hand is not impaired.

Use of colour duplex imaging to diagnose and guide angioplasty of lower limb arterial lesions

The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA). Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters. Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle : brachial pressure index was 0. 86 (0.52-1.10) before dilatation and 1.00 (0.83-1.40) immediately after dilatation (P = 0.0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures. It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone.

Radiodiagnosis following kidney transplantation

Diagnostic imaging after renal transplantation is of high importance in the differential diagnosis of peri- and postoperative complications. Sonography with color duplex imaging is the method of choice in the diagnosis of acute transplant rejection. MRI is an additional method in the diagnosis of transplant dysfunction especially in diagnosis of perirenal fluid collections. MR angiography and MR urography are noninvasive diagnostic modalities with the potential to replace angiography and pyelography. Angiography, complemented by carbon dioxide angiography, still is the gold standard in the diagnosis of transplant artery stenosis.

AIUM technical bulletin--Color duplex imaging for graft surveillance of the autologous vein graft. American Institute of Ultrasound in Medicine.

AIUM technical bulletin--Color duplex imaging for graft surveillance of the autologous vein graft. American Institute of Ultrasound in Medicine.

Contrast-enhanced transcranial color-coded duplex sonography in ischemic cerebrovascular disease.

Echo contrast agents have been shown to provide conclusive examinations in most patients with insufficient ultrasound penetration through the temporal bone. We investigated the diagnostic value of contrast-enhanced (CE) transcranial color-coded duplex sonography (TCCD) in patients with ischemic cerebrovascular disease and insufficient temporal windows and evaluated TCCD criteria that predict whether CE-TCCD studies may become conclusive. Thirty-three patients presenting with ischemic strokes (n = 21) and transient ischemic attacks (n = 12) were investigated. Extracranial color duplex imaging showed normal findings in 24 patients, eight > or = 70% stenoses and one occlusion of the carotid arteries in 8 patients, and severe occlusive disease of both vertebral arteries in 1 patient. Seven carotid stenoses and vertebral artery obstructions were confirmed by angiography. The galactose/palmitic acid-based echo contrast agent was injected intravenously as bolus of 200, 300, or 400 mg/mL in a dosage of 10, 5, and 5 mL, respectively. Thirty-two of the 33 patients were completely examined because 1 patient who felt pain at the injection site declined further investigations. Twenty-one (66%) of 32 CE studies were conclusive and showed cross-flow through three anterior and two posterior communicating arteries, but no stenoses and occlusions. Precontrast identification of any cerebral artery provided an overall accuracy of 97% in predicting a conclusive CE investigation. Precontrast TCCD identified no arterial Doppler signals in patients with inconclusive CE studies. CE-TCCD provided conclusive examinations in two thirds of patients with ischemic cerebrovascular disease and ultrasound-refractory temporal windows. Precontrast detection of any cerebral artery reliably predicted a conclusive CE investigation.

Colour duplex and radiothermal imaging in carotid stenoses : V. Kulikov, A. Mogozov. Department of Clinical Physiology, Altay State Medical University, Russia

Colour duplex and radiothermal imaging in carotid stenoses : V. Kulikov, A. Mogozov. Department of Clinical Physiology, Altay State Medical University, Russia

Colour Duplex and Radiothermal Imaging in Carotid Stenoses

Colour Duplex and Radiothermal Imaging in Carotid Stenoses

Post Exercise Cerebral Hemodynamic Reaction According to the Colour Duplex Imaging

Post Exercise Cerebral Hemodynamic Reaction According to the Colour Duplex Imaging

Post exercise cerebral hemodynamic reaction according to the colour duplex imaging : V. Kulikov, N. Doronina. Altay Medical University, Department of Pathology, Physiology, Barnaul, Russia

Post exercise cerebral hemodynamic reaction according to the colour duplex imaging : V. Kulikov, N. Doronina. Altay Medical University, Department of Pathology, Physiology, Barnaul, Russia

Duplex assessment of run-off before femorocrural reconstruction

This study was a prospective evaluation of colour duplex imaging for the assessment of distal run-off before femorocrural reconstruction. Patients with critical ischaemia who required a distal bypass underwent preoperative run-off assessments using dependent Doppler, arteriography and duplex imaging by a vascular surgeon, radiologist and technologist respectively; each was blinded to the findings of the others. Preoperative data were compared with intraoperative clinical findings and completion flow studies/ arteriograms. Forty-three consecutive patients (33 men, ten women; mean age 78 (range 53-95) years; 12 diabetic) undergoing 44 femorocrural reconstructions for critical ischaemia were assessed. The 30-day primary cumulative graft patency for the series was 86 per cent. Dependent Doppler correctly predicted a suitable run-off vessel in 21 limbs but was indeterminate in four and unrecordable in 19. Arteriography correctly predicted a suitable run-off vessel in 32 cases, but was indeterminate in six and failed to demonstrate run-off in three patients. Arteriography suggested an inferior vessel in three cases. Duplex correctly predicted a suitable run-off vessel for all 44 grafts. Duplex imaging is superior to arteriography for preoperative assessment of distal run-off for femorocrural reconstruction.

Harmonic imaging of the vertebrobasilar system.

Gas bubbles of ultrasound contrast agents resonate at frequencies used for diagnostic ultrasound and produce harmonics or multiples of the transmitted frequency. Processing of the second harmonic frequency results in a reduction of the signal-to-noise ratio and the signal-to-tissue artifacts. This study is the first to evaluate second harmonic imaging in the cerebral circulation. We used a duplex system (HP SONOS 2500) in connection with a 1.8/3.6-MHz (second harmonic) and a 2.5-MHz (conventional) sector transducer. Levovist (6.5 mL; 400 mg/mL) was injected intravenously for second harmonic and conventional color duplex imaging in 13 healthy volunteers (age range, 23 to 34 [median, 29] years). When second harmonic imaging was compared with conventional color duplex imaging, more cerebellar arteries were detected (35 versus 31), the duration of blooming artifact was significantly reduced (7.9 versus 29.9 seconds; P = .03), and the duration of diagnostically useful signal enhancement was increased (248.5 versus 117.4 seconds; P = .0003), but the maximal investigation depth was reduced (8.4 versus 9.3 cm; P = .001). When conventional and second harmonic duplex were compared, there was a significant (P < .04) difference in the systolic blood flow velocity in the vertebral and basilar arteries. Second harmonic color duplex imaging in the vertebrobasilar system increases the time of diagnostic useful signal enhancement and produces a better spatial resolution compared with conventional color duplex imaging.

Duplex imaging findings predict stenosis after carotid endarterectomy.

This study was performed to determine whether early duplex findings predicted restenosis after carotid endarterectomy. One hundred ninety-two symptomatic patients who underwent carotid endarterectomy were studied with color duplex imaging at 1 day and 1 week after surgery to identify minor residual disease (causing < 50% stenosis), arterial kinking, and suture stricture, and to measure the external and luminal diameters of the carotid bulb and distal internal carotid artery. Patients were then observed prospectively with duplex surveillance for a median of 24 months to identify > 50% restenosis. Twenty-five stenoses > 50% of the operated carotid artery (13%) were identified, four at 1 day (residual) and 21 at a median follow-up of 6 months (restenosis). On multiple logistic regression analysis, > 50% restenosis was found to be associated with minor day-1 residual stenosis (p = 0.01) and with small luminal diameter of the distal internal carotid artery (p = 0.03) as measured 1 week after carotid endarterectomy. Life table analysis showed restenosis at 24 months to be more common for patients with below-median than patients with above-median carotid bulb external diameter (18% vs 5%, respectively; p = 0.01). Duplex scanning within a week of carotid endarterectomy identifies > 50% residual stenosis, in addition to minor residual 25% to 50% stenosis and small carotid dimensions, which are good predictors of > 50% restenosis at 6 months.