Duplex Ultrasound Findings Research Articles

Duplex Ultrasound Protocol and Findings in Common Carotid Artery Dissection Extending from the Aortic Arch

Introduction Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid duplex ultrasound (CDU) in DeBakey I acute aortic dissection to identify characteristics and establish a protocol to ensure appropriate evaluation. Method From 2002 to 2011, patients with CDU and proximal aortic dissection were identified. The protocol included color Doppler in both long and short axis, spectral waveforms of true and false lumens, and imaging of the aortic arch, when appropriate. Imaging was performed on a Philips iE33 or iu22 using a 9–3 MHz linear array probe for the cervical carotid arteries and a curved array 5–1 MHz probe for the aortic arch. Waveforms were analyzed for signs of proximal dissection. Results CDU was performed in 87 of 288 patients and comprised the study group. Intimal flaps were noted in 26 common carotid arteries (CCAs) in 20 patients. The false lumen was thrombosed in nine arteries (35%). Eight CCAs had stenosis >50%, with seven having increased velocities >200 cm/sec. All patients with elevated velocities in the true lumen had false-lumen thrombosis. We noted that carotid artery dissections were not visualized in all planes and that more false lumens were found to be patent on CDU than on computed tomography. Characteristic waveforms included a second pulsed systolic waveform, a wide and jagged systolic peak, intermittent flow reversal, and visualization of a dissection flap. Conclusion Carotid imaging in transverse and axial planes is important in dissection cases. We found that a 5–1 MHz curved-array probe may be helpful in imaging the proximal brachiocephalic arteries and aortic arch. Several characteristic waveforms were noted. We recommend a standardized protocol that includes near-complete CCA visualization, multiplane views, and Doppler waveform analysis of both true and false lumens. The clinical significance of false-lumen patency or true-lumen stenosis remains unclear.

Duplex Surveillance After Endovascular Revascularisation for Critical Limb Ischaemia

Despite the popularity of endovascular therapy (EVT) for critical limb ischaemia (CLI), there are few studies investigating the efficacy of duplex ultrasound (DUS) surveillance after endovascular interventions. The aim of this study was to evaluate DUS surveillance after EVT for CLI. 146 endovascular procedures in 134 consecutive patients with CLI between 2011 and 2012 were included. Follow-up visits with ankle-brachial index (ABI), toe pressure, and target vessel DUS were performed at 1, 3, and 6 months after revascularisation. The median age of the study population was 79 years, 58% were males, and 55% had diabetes. The target artery was at the iliac, femoro-popliteal, and infrapopliteal level in 2%, 54%, and 44% of cases, respectively. There were 282 follow-up visits. In 15 (5.3%) DUS examinations, the target vessel was not seen properly. In the remaining 267 DUS, the majority of the target arteries were patent with no or mild restenosis (n = 169, 63.3%), but in 98 (36.7%) examinations, the target artery was stenosed or occluded. When DUS was compared with the clinical presentation, there was no correlation in 30% and when DUS and toe pressure were compared, discrepancy was seen in 29%. A re-angiogram was performed for 29 patients, and the DUS finding was verified in each case. During the mean follow-up of 11 months, a new endovascular intervention was performed on 37 (25.3%) limbs, and 4 (2.7%) underwent surgical bypass. Four (3.0%) patients died and 6 (4.5%) underwent major amputation. Clinical status or toe pressure alone were adequate markers of endovascular revascularisation failure in the majority of the patients, but would have missed up to one-third of the clinically significant re-stenoses or occlusions. DUS is therefore a valuable aid in surveillance after EVT for CLI, especially for patients with an ischaemic tissue lesion.

Outcomes of Intralesional Interferon-α2B for the Treatment of Peyronie Disease

We evaluated the efficacy of intralesional interferon-α2b for Peyronie disease, reviewed the impact of the timing of therapy from disease onset and identified variables predictive of a response. We retrospectively reviewed the charts of patients treated with intralesional interferon-α2b from 2001 to 2012. Demographic information, disease characteristics, pretreatment and posttreatment penile duplex ultrasound findings, and objective measures were analyzed. Response was defined as a 20% or greater improvement in curvature. Statistical analysis was done to identify significant changes in variables and identify predictive factors. A total of 127 patients with a mean age of 55 years (range 25 to 76) and a mean±SD pretreatment curvature of 42.4±18.6 degrees underwent a median of 12 biweekly interferon-α2b injections (range 6 to 24). The median history of Peyronie disease was 2.0 years (range 0.5 to 23). Of the patients 54% responded to therapy with an overall mean improvement of 9.0 degrees (p<0.001). Patients with less than 30-degree curvature were most likely to experience a 20% or greater improvement with interferon-α2b (86% response, p<0.001). However, similar overall improvement in pretreatment curvature was noted in all cases. No statistically significant improvement was observed in penile vascular status or ultrasound parameters. The duration of Peyronie disease did not impact the change in curvature. Age, pretreatment curvature, vascular status, penile ultrasound findings, curvature site and International Index of Erectile Function (IIEF) score did not predict the response to therapy. Intralesional therapy with interferon-α2b resulted in significantly improved curvature without impacting penile vascular parameters. The absolute improvement in curvature was independent of pretreatment curvature or Peyronie disease duration.

Comparison of 12-W Versus 14-W Endovenous Laser Ablation in the Treatment of Great Saphenous Varicose Veins

Endovenous laser ablation (EVLA) has been demonstrated to be an effective treatment for lower limb varicose veins in the short and midterm results. This study reports the 5-year outcomes of EVLA technique at different power settings. Patients with primary symptomatic, unilateral varicose veins secondary to saphenofemoral junction (SFJ) incompetence and great saphenous vein (GSV) reflux were recruited and randomized to either 12W (intermittent laser withdrawal) or 14W (continuous laser withdrawal). They were assessed at baseline, 1, 6, 12, 52, 104 weeks, and 5 years. Outcome measures included: Venous Clinical Severity Score (VCSS), pain scores, time taken to return to normal functions, complications, recurrence, quality of life (QoL), and duplex ultrasound findings. 76 consecutive patients, M: F 30:46, median age 54(IQR: 37.3-59) years were randomized. Intragroup analysis: Significant improvement was seen in both groups in VCSS, pain scores, Aberdeen varicose vein questionnaire (AVVQ) scores, Shortform-36 (SF-36) and Euroqol (EQ-5D) domains over the follow-up period (P < 0.05). Intergroup analysis: Over 5 years, clinically recurrent varicosities and duplex detected SFJ incompetence was less frequent and patient satisfaction with cosmetic outcome significantly higher in the 14W group (P < 0.05). There was no significant difference between the groups in duration of procedure, postoperative pain scores, return to normal functioning, complications, VCSS, disease specific (AVVQ) and generic (SF36, EQ-5D) QoL measures (P > 0.05). Late outcomes following EVLA were superior for the 14W continuous power settings achieving better long term venous occlusion and lowered recurrence rates without increasing post-operative morbidity. Hence 14W continuous setting should be the energy delivery mode of choice.

Carotid Duplex Findings in Patients With Acute Type A Dissection

Many patients with acute type A aortic dissection present with neurologic symptoms and have abnormal carotid duplex ultrasound (CDU) findings. We performed an analysis to determine the characteristics of CDU in acute type A aortic dissection. A prospectively maintained aortic database was queried for consecutive patients who underwent repair of acute type A aortic dissection between January 2002 and December 2011. Patients who had CDU during their hospitalization were reviewed. Analysis was performed to determine risk of pre- and postoperative stroke. We repaired 288 acute type A aortic dissection patients of which 87 patients had CDU during their hospitalization. Of the 87 patients, 61 (70%) had findings consistent with proximal dissection. Abnormalities noted on CDU included dissection flap on B-mode imaging, a second pulsed waveform after the initial systolic upstroke, and a widened and jagged systolic peak (Fig). A dissection flap extending into the common carotid arteries was visualized in 18 (21%) patients and was associated with preoperative stroke in 4 (22%) compared with 7 (10%) in those without a visualized dissection flap (P = .108). Overall, 20 of 288 (7%) patients had evidence of stroke at presentation. Aortic dissection should be considered in the presence of certain abnormal carotid waveforms-even in the absence of a visualized dissection flap. Recognition of these abnormal waveform patterns may expedite accurate diagnosis.

Incidence, Significance and Natural History of Persistent Retrograde Venous Flow After Varicocelectomy in Children and Adolescents: Correlation with Catch-up Growth

Varying incidences and levels of persistent retrograde venous flow have been reported following adult and adolescent varicocelectomy but the significance remains unclear. We sought to determine the incidence and natural history of persistent flow and whether it had any effect on postoperative testicular catch-up growth. We retrospectively analyzed pre-varicocelectomy and post-varicocelectomy Doppler duplex ultrasound findings. Peak retrograde venous flow, maximum vein diameter, flow quality and varicocele grade were recorded at each visit. Catch-up growth was defined as less than 15% testicular asymmetry at final visit. Of 330 patients (median age 15.4 years) undergoing varicocelectomy (laparoscopic in 247, open in 83) 145 had residual retrograde venous flow after Valsalva maneuver with a mean peak of 13.3 cm per second. Of 290 patients with repeat Doppler duplex ultrasound (median followup 2.6 years) 124 had initial peak retrograde venous flow less than 20 cm per second (43%) and only 17 (6%) had flow 20 cm per second or greater. Incidence of post-varicocelectomy retrograde venous flow at last visit (48%) was similar to that at initial postoperative visit (49%). Of 330 boys 20 had recurrence of palpable varicocele (grade 2 or 3), of whom 18 (90%) had initial retrograde venous flow. Catch-up growth was more likely in patients with no retrograde venous flow, and rates of catch-up growth decreased as peak retrograde venous flow increased. All 5 patients with initial testicular asymmetry and persistent retrograde venous flow at levels greater than 30 cm per second had continued testicular asymmetry (ie none had catch-up growth). Retrograde venous flow is frequently present after varicocelectomy and is almost always associated with peak retrograde venous flow rates significantly lower than those seen in patients who are recommended for initial varicocelectomy. Retrograde venous flow tends to persist during followup at stable peak retrograde venous flow rates. Palpable recurrence and persistent testicular asymmetry are most often associated with postoperative peak retrograde venous flow rates 20 cm per second or greater.

Duplex Ultrasound Findings in Intravenous Drug Users with Femoral Vein Injection

Introduction —Intravenous drug users (IVDUs) who access their common femoral vein (CFV) repetitively are at risk for a variety of vascular complications. Duplex ultrasound is often the initial imaging modality used when these patients present for medical care. The purpose of this study was to document the duplex ultrasound findings and associated clinical outcomes in IVDU with CFV injection. Methods —This was an institutional review board-approved retrospective review of all lower-extremity duplex ultrasound examinations performed on IVDU in our laboratory from January 1, 2007 through December 31, 2009. Vascular laboratory reports and images were reviewed along with clinic and hospital records. Results —The study cohort included 29 patients, 52 lower limbs, and 102 duplex ultrasound examinations. There were 16 males and 13 females with an age range of 19 to 53 years (mean, 33 years). Follow-up intervals ranged from 0 to 24 months (mean, 11 months). The most common indication for duplex ultrasound was a swollen painful leg. Abnormalities were present on duplex ultrasound in 92% of the limbs. A CFV stricture was identified in 63% of the limbs and 44% had cystic masses associated with the proximal femoral vessels. Progression to DVT was observed in 45% of the CFV strictures. Arterial lesions were found in 21% of the limbs. One retained needle was identified. Venous or arterial interventions were required in 9 limbs. Conclusion —Femoral injection in IVDU results in a high prevalence of abnormal vascular findings on duplex ultrasound. Although venous lesions were more common, arterial and venous interventions were approximately equal in frequency. The IVDU patients also had a high prevalence of lower-limb DVT. The vascular laboratory can play an important role in the evaluation of IVDU with CFV injection. This review suggests that duplex ultrasound in these patients should include both a complete lower extremity venous examination and assessment of the iliac and femoral arteries.

SUPPORT FOR STANDARDIZATION OF DUPLEX ULTRASOUND DIAGNOSTIC CRITERIA FOR INTERNAL CAROTID ARTERY STENOSIS: A SURVEY FROM THE INTERSOCIETAL ACCREDITATION COMMISSION (IAC)

Carotid duplex ultrasound (DUS) is widely used for diagnosis of internal carotid artery (ICA) stenosis and therapeutic decisions are made solely on the basis of DUS findings. We have previously demonstrated wide variation in carotid DUS criteria among accredited vascular laboratories. In addition,

Comparing Computed Tomographic Angiography vs Ultrasound Vein Mapping in Evaluating the Suitability of the Great Saphenous Vein for Distal Bypass

Introduction and objectives: Although computed tomography angiography (CTA) is commonly used preoperatively to determine arterial anatomy, duplex ultrasound (DUS) vein mapping is frequently used to determine the suitability of bypass conduits. The purpose of this studywas to determine the correlation between DUS and CTA in the evaluation of the great saphenous vein (GSV) with respect to diameter and usability in lower extremity bypasses. Methods: A single-center retrospective review identified patients who had both CTA and DUS in preparation for lower extremity bypass, between June 2001 and February 2012. DUS reports included GSV diameter at the saphenofemoral junction, midthigh, knee, andmidcalf. CTAs were reviewed independently by two vascular surgeons who were blinded to the DUS and surgical findings. The interobserver variability was analyzed using Pearson correlation. The relationship between CTA and DUS measurements was compared at each anatomic level using correlation coefficients. The predictive ability of CTA was analyzed using the Fisher exact test. Results: Sixteen patients (9 men [56.3%]) underwent CTA and DU in preparation for lower extremity bypass (23 limbs). The average patient age was 65.1 years, 10 (62.5%) were diabetic, and three (18.8%) had a history of DVT or phlebitis. A high degree of correlation existed between the two surgeons’ GSV measurements using CTA (r .09996, P .0001), and a strong correlation existed between CTA and DUS GSV measurements (r .07306, P .0001). CTA assessment of GSV usability correlates with actual usage as conduit (P .0099) with a sensitivity of 92% and sensitivity of 80%. Conclusions: CTA can be accurately used to evaluate the diameter and usability of the GSV for lower extremity revascularization, eliminating the need for additional testing.

Temporal Artery Compression Sign - A Novel Ultrasound Finding for the Diagnosis of Giant Cell Arteritis

In patients with suspected giant cell arteritis (GCA), a search for the perivascular halo sign, a sophisticated color duplex ultrasound (CDU) finding, at experienced centers reliably identifies inflamed temporal arteries (TA). We tested whether TA compression in patients with GCA, a simple, largely operator-independent maneuver, elicits contrasting echogenicity between the diseased artery wall and the surrounding tissue (compression sign). 80 individuals with suspected GCA were prospectively enrolled in this single-center study. In all study participants, bilateral ultrasound examination of the TA established the presence/absence of the halo and compression sign. A positive compression sign was defined as visibility of the TA upon transducer-imposed compression of the artery. Based on ACR criteria, a team of specialized physicians independently grouped patients as GCA versus non-GCA. 43/80 study participants were grouped as GCA. Both the halo sign and the compression sign were positive in 34/43 patients in the GCA group, and negative in all 37/37 of the non-GCA group, resulting in a sensitivity of 79 % and a specificity of 100 % for both the halo and the compression sign. In this cohort of individuals with suspected GCA, the halo sign and the compression sign were equal in their diagnostic performance. The simplicity of the compression sign suggests a level of reliability warranting further evaluation.

Duplex ultrasound imaging to detect limb stenosis or kinking of endovascular device

We attempted to correlate duplex ultrasound (DU) findings with the clinical outcome of graft limb stenosis or kinking after endovascular aneurysm repair (EVAR). Between 1998 and 2010, 248 patients underwent EVAR and postoperative DU surveillance of 496 graft limbs in our accredited noninvasive vascular laboratory by one of three experienced technologists. Routine DU surveillance was performed 1 week, 6 months, and annually after EVAR. Peak systolic velocities (PSVs) were measured in the body and midportion and distal attachment site of both limbs of the graft, and adjacent PSV ratios were calculated. None of 479 graft limbs with a PSV of <300 cm/s occluded during long-term follow-up (mean, 22.3 months; range, 1-123 months). Of 17 graft limbs with a PSV >300 cm/s, seven occluded (0 of 479 vs 7 of 17, P < .01; sensitivity, 100%; specificity, 98%), five underwent prophylactic intervention (mean adjacent PSV ratio, 7.3), and five (30%) remained patent without intervention (mean PSV ratio, 3.2). This large series of DU surveillance for failing EVARs grafts suggests that graft limbs with PSVs <300 cm/s can be safely monitored. However, limbs with more elevated PSVs may benefit from prophylactic intervention or more frequent surveillance to prevent limb occlusion.

Predicting Erectile Dysfunction Following Surgical Correction of Peyronie's Disease without Inflatable Penile Prosthesis Placement: Vascular Assessment and Preoperative Risk Factors

Surgical therapy remains the gold standard treatment for Peyronie's Disease (PD). Surgical options include plication, grafting, and placement of inflatable penile prosthesis (IPP). Postoperative erectile dysfunction (ED) is a potential complication for PD surgery without IPP. We present our large series follow-up to evaluate preoperative risk factors for postoperative ED. The aim of this study is to evaluate preoperative risk factors for the development of ED following surgical correction of PD taking into account the degree of curvature, graft size, surgical approach, hypertension, hyperlipidemia, diabetes, smoking history, preoperative use of phosphodiesterase 5 inhibitors (PDE5), and preoperative duplex ultrasound findings including peak systolic and end diastolic velocities and resistive index. We identified 218 men undergoing either tunica albuginea plication (TAP) or partial plaque excision with pericardial grafting for PD following a previously published algorithm between November 1992 and April 2007. Preoperative and postoperative erectile function, curvature characteristics, presence of vascular risk factors, and duplex ultrasound findings were available on 109 patients. Our primary outcome measure is the development of ED after surgery for PD. Ten percent of TAP and 21% of plaque excision with grafting patients developed postoperative ED. Neither curve direction (P = 0.76), graft area (P = 0.78), surgical approach (P = 0.12), chronic hypertension (P = 0.51), hyperlipidemia (P = 0.87), diabetes (P = 0.69), nor smoking history (P = 0.99) were significant predictors of postoperative ED. No combination of risk factors was found to be predictive of postoperative ED. Preoperative use of PDE5 was not a significant predictor of postoperative ED (P = 0.33). Neither peak systolic, end diastolic, nor resistive index were significant predictors of ED (P = 0.28, 0.28, and 0.25, respectively). This long-term follow-up of a large published series suggests that neither preoperative risk factors nor preoperative duplex ultrasound findings are predictive of postoperative ED, thus reinforcing the use of previously published preoperative treatment algorithms.

Is Increased Mean Platelet Volume a Risk Factor in Patients with Acute Deep Vein Thrombosis?

Objective: The purpose of this retrospective study was to compare the mean platelet volume between the patients with acute deep vein thrombosis and control subjects. Patients and Methods: Data were collected retrospectively from the patients' medical records. The study group consisted of 110 patients with newly diagnosed acute deep vein thrombosis in lower extremities. An age-, gender-, and body mass index-matched control group consisted of 98 patients with normal duplex ultrasound findings. We compared the mean platelet volume in patients with acute deep vein thrombosis and control participants statistically. Results: There were no significant differences between the study and control groups in mean platelet volume (8.8 ± 1.6 vs 8.7 ± 1.3 fl, respectively; p >0.05).Age (p = 0.899), body mass index (p = 0.43), gender (p = 0.466), and platelet count (p = 0.886) were statistically similar in both groups. Conclusion: There was no significant difference in patients with acute deep vein thrombosis in mean platelet volume compared to controls statistically. According to our result, we suggest that mean platelet volume cannot be considered as an index of acute deep vein thrombosis.

Abstract 8918: Diagnostic Criteria for Ultrasound Diagnosis of Internal Carotid Artery Stenosis Vary Widely Among Accredited Vascular Laboratories. A Survey from the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)

Background: Carotid duplex ultrasound (DUS) is widely used for diagnosis of internal carotid artery (ICA) stenosis and therapeutic decisions are often on the basis of DUS findings. There are no universal standard DUS criteria to grade the severity of ICA stenosis. A 2003 publication from the Society for Radiologists in Ultrasound (SRU) provided consensus criteria for grading ICA stenosis, but their integration into clinical practice is unknown. Methods: Random sample of 10% of vascular laboratories accredited in extracranial carotid testing. Data were abstracted from the ICAVL database, including most recent accreditation application. A single reviewer (HLG) compared laboratory diagnostic criteria to published references. Results: 152 vascular laboratories were sampled, 57.2% of which were outpatient based. Mean annual carotid volume 1,330 + 124.1 studies (range 100-9,858). There were 17 diagnostic criteria in use among 117 labs with the remaining facilities utilizing locally developed (6 labs) or unreferenced or hybrid criteria (29 labs). Mean number of categories of ICA stenosis was 5.80 + .084 (range 3-12). Cut-points for the mildest disease stratum ranged from 0 to 0-60% with normal or 0% most commonly reported (67.1% of labs). The cut-point for most severe (non-occlusive) stenosis ranged from 70 to 91% with 80% most commonly reported (64.5% of labs). SRU consensus-based criteria were used in only 27.0% of laboratories, although there was a statistically significant increase in SRU utilization among labs accredited after versus before 2005 (50.0% vs. 18.8%, P &lt;0.001). Despite divergent diagnostic criteria and severity cut-points, self-reported accuracy of DUS for diagnosis of ICA stenosis from correlation studies was high (mean 85.8 + 0.65%). Conclusion: Diagnostic criteria and cut-points for grading severity of ICA stenosis using DUS vary widely in accredited vascular laboratories. Despite this, diagnostic accuracy is acceptable. Uptake of SRU consensus criteria has been limited, but is more common among recently accredited facilities. Health care providers must be aware of the lab-to-lab variation in reporting of ICA stenosis while further efforts to achieve consensus reporting are considered by professional societies.

Inferior Mesenteric Artery Duplex in the Management of Chronic Mesenteric Ischemia

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 (&gt;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.

Time to reevaluate the role of venous hemodynamics in MS pathophysiology?

Although the cause of multiple sclerosis (MS) is not known, the consensus theory is that genetic predisposition, along with some nongenetic trigger, begins a downward spiral of immune-mediated inflammatory disease activity followed by progressive neurologic deterioration and disability. The nongenetic trigger is the subject of intense basic science as well as epidemiologic research. Paolo Zamboni, an Italian vascular surgeon, and colleagues1,2 have recently challenged the established pathophysiology of MS by postulating a new entity called chronic cerebrospinal venous insufficiency (CCSVI). CCSVI is a theoretical term used to describe a collection of intracranial and extracranial duplex ultrasound findings of CNS venous anomalies present in patients with MS. Zamboni and colleagues hypothesize that insufficient venous drainage results in iron accumulation and enhanced CNS inflammation. The authors studied 109 patients with MS and 177 controls and reported a remarkable 100% sensitivity, specificity, positive and negative predictive value correlating ultrasound findings of abnormal cerebral venous outflow with MS. In another study, Zamboni et al.1 reported MS was associated with venous outflow anomalies with an odds ratio of 43 (95% confidence interval 29–65). Selected patients in both studies underwent unblinded venography that demonstrated venous “twisting,” “membranous obstruction,” and stenosis; however, it was unclear how ultrasound techniques were employed and …

Unintended Coil Migration into the Right Ventricle During the Right Ovarian Vein Coil Embolization

The aim of this article is to report a rare case of unintended coil migration into the right (Rt) ventricle. A 36-year-old Brazilian female was referred to us for the evaluation of pelvic pain. Venous duplex ultrasound findings were consistent with incompetent venous systems of right lower extremity (RLE). The diagnosis of grade III pelvic varices was confirmed with ovarian venography, and bilateral ovarian vein coil embolization was performed. The procedure was complicated with unintended migration of a small coil into the Rt ventricle. In cases where coil or foreign body migration into the Rt heart or pulmonary circulation has occurred, endovascular retrieval or a thoracotomy has been performed. In our case, the migrated coil was left in situ without any hemodynamic disturbances in the follow-up. Coil migration to the Rt ventricle can be conservatively managed depending upon the location and coil profile.

650 PREDICTING ERECTILE DYSFUNCTION FOLLOWING SURGICAL CORRECTION OF PEYRONIE'S DISEASE WITHOUT INFLATABLE PENILE PROSTHESIS PLACEMENT: VASCULAR ASSESSMENT AND PREOPERATIVE RISK FACTORS

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease II1 Apr 2010650 PREDICTING ERECTILE DYSFUNCTION FOLLOWING SURGICAL CORRECTION OF PEYRONIE'S DISEASE WITHOUT INFLATABLE PENILE PROSTHESIS PLACEMENT: VASCULAR ASSESSMENT AND PREOPERATIVE RISK FACTORS Frederick Taylor, Michael Abern, and Laurence Levine Frederick TaylorFrederick Taylor More articles by this author , Michael AbernMichael Abern More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1024AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgical therapy remains the gold standard treatment for Peyronie's Disease (PD). Surgical options include plication, grafting, and placement of inflatable penile prosthesis (IPP). Postoperative erectile dysfunction (ED) is a potential complication for corrective PD surgery without IPP. We present our large series follow up to evaluate preoperative risk factors for the development of postoperative ED. METHODS We identified 218 men undergoing either tunica albuginea plication (TAP) or partial plaque excision with pericardial grafting (PEG) for PD between November 1992 and April 2007. Objective data was collected including preoperative and postoperative erectile function, curvature characteristics,graft size, and the presence of vascular risk factors such as hypertension, diabetes mellitus, and smoking history on 142 patients. In addition, preoperative duplex ultrasound findings on 109 of these 142 patients were analyzed with respect to resistive index, peak systolic velocity, and end diastolic velocity. Statistical analysis was performed using R (University of Vienna). RESULTS 10% of TAP and 21% of PEG patients developed postoperative ED. Neither curve direction (p=0.76), graft area (p=0.78), surgical approach (p= 0.12), chronic hypertension (p=0.51), hyperlipidemia (p=0.87), diabetes (p=0.69) nor smoking history (p=0.99) were significant predictors of postoperative ED. Likewise, no combination of risk factors was found to be predictive of postoperative ED. Preoperative use of PDE5-i was not a significant predictor of postoperative ED (p=0.33). Neither peak systolic, end diastolic, nor resistive index were significant predictors of ED (p= 0.28, 0.28, and 0.25 respectively). CONCLUSIONS This long term follow up of a large published series suggests that neither preoperative risk factors nor preoperative duplex ultrasound findings are predictive of postoperative ED and failed to improve upon previously published preoperative treatment algorithms. Chicago, IL© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e254-e255 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Frederick Taylor More articles by this author Michael Abern More articles by this author Laurence Levine More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Detection of Imminent Vein Graft Occlusion: What is the Optimal Surveillance Program?

The prediction of infrainguinal vein bypass failure remains an inexact judgment. Patient demographics, technical factors, and vascular laboratory graft surveillance testing are helpful in identifying a high-risk graft cohort. The optimal surveillance program to detect the bypass at risk for imminent occlusion continues to be developed, but required elements are known and include clinical assessment for new or changes in limb ischemia symptoms, measurement of ankle and/or toe systolic pressure, and duplex ultrasound imaging of the bypass graft. Duplex ultrasound assessment of bypass hemodynamics may be the most accurate method to detect imminent vein graft occlusion. The finding of low graft flow during intraoperative assessment or at a scheduled surveillance study predicts failure; and if associated with an occlusive lesion, a graft revision can prolong patency. The most common abnormality producing graft failure is conduit stenosis caused by myointimal hyperplasia; and the majority can be repaired by an endovascular intervention. Frequency of testing to detect the failing bypass should be individualized to the patient, the type of arterial bypass, and prior duplex ultrasound scan findings. The focus of surveillance is on identification of the low-flow arterial bypass and timely repair of detected critical stenosis defined by duplex velocity spectra criteria of a peak systolic velocity 300 cm/s and peak systolic velocity ratio across the stenosis >3.5-correlating with >70% diameter-reducing stenosis. When conducted appropriately, a graft surveillance program should result in an unexpected graft failure rate of <3% per year.

Hybrid Endovascular Surgical Repair in Takayasu's Arteritis: Duplex Ultrasound Follow-up

Introduction Takayasu's arteritis (TA), a rare condition occurring primarily in young women, is a granulomatous vasculitis usually affecting the aorta and its branches. Our case report describes the duplex ultrasound findings in a 16-year-old Hispanic woman after a hybrid endovascular procedure. Patient Description TA in this patient was diagnosed in 2005 after a pulsatile neck mass developed on the right side of her neck. To date, she has required four vascular interventions in less than 3 years. The first procedure was an aortic root, ascending aorta and aortic arch replacement with Dacron graft replacement of the left common carotid and innominate arteries. She then developed a pseudoaneurysm in the distal left common carotid artery replacement graft, which was excluded with a stent-graft. The third procedure was a balloon angioplasty of an anastomotic stenosis of the aorto-innominate artery graft. This, however, recurred and there was also a small anastomotic pseudoaneurysm at this site. Revascularization was complicated by the fact that the left subclavian artery was occluded, with reversed flow in the left vertebral artery. Consequently, preservation of antegrade flow in the right vertebral artery was a priority. Transposition of the right common carotid artery to the subclavian artery with placement of a balloon expandable stent graft from the aortoinnominate artery graft into the subclavian artery (proximal to the vertebral artery) was performed. Methods All available imaging exams and operative reports were reviewed. Bilateral carotid duplex evaluation in addition to duplex examination of all bypasses and the distal native arteries were performed using high resolution ultrasound equipment and probes of varying frequency. Results Normal caliber wall thickness was identified in bilateral common carotid arteries. No evidence of intimal hyperplasia could be detected in stented areas. All open surgical or endovascular repair sites were well visualized, with the exception of only the proximal most innominate artery bypass graft and the aortic arch. Primarily retrograde left vertebral artery flow feeds the left subclavian artery. There was no evidence of restenosis or pseudoaneurysm formation. Discussion Long-term follow-up of the patient with TA after open surgical or endovascular procedures is extremely important because of the chronic nature of the disease process. Duplex ultrasound is a safe, effective adjunct to the standard radiologic arsenal usually used to follow these high-risk patients.