Hand-held Doppler Research Articles

Utility of the hand-held continuous wave Doppler in the vascular examination: A review

Utility of the hand-held continuous wave Doppler in the vascular examination: A review

Abstract 12714: Prevalence and Risk Factors of Peripheral Vascular Disease in Rural India: A cross Sectional Study

Background: Peripheral vascular disease (PVD) is a major cause of morbidity and mortality especially affecting the elderly. PVD is largely undetected due to its silent progression. Ankle brachial index (ABI) is a symptom independent reliable screening tool for PVD in primary care, but remains underused. Our aim was to estimate the burden of PVD in this region and correlate it to various risk factors both quantitatively and qualitatively. Materials and Methods: From an outpatient medical camp in rural India, 100 patients were recruited randomly. They were assessed for symptoms, medical history and risk factor screening that included 11 well known risk factors using a pre formatted questionnaire. ABI was measured by handheld doppler. ABI <0.9 was considered abnormal. The difference in mean distribution of ABI for risk factors was calculated by Student’s t-test and was considered statistically significant for P < 0.05. Odds ratios for various risk factors were calculated. Results: Based on ABI <0.9, PVD was diagnosed in 57 patients. There was a high prevalence of risk factors like age >55 years (67%), hypertension (66%), smoking (42%) and diabetes mellitus (35%). Mean ABI for hypertensive population is 0.85 (95% CI: 0.83-0.88, P=0.02). Mean ABI for smokers is 0.82 (95% CI:0.79-0.85, P=0.03). Mean ABI for diabetics is 0.80 (95% CI: 0.77-0.87, P=0.04). Multivariate risk analysis for PVD showed significant association with hypertension, smoking and diabetes but less significant for age, gender and family history. Conclusion: There is a very high prevalence of PVD in the Indian Population which can be attributed to modifiable risk factors as mentioned above. Defining the population at risk and using ABI as an early screening tool would help in prompt treatment and prevent further complications. A simple, inexpensive screening test like ABI is useful for diagnosing PVD in clinical practice. It helps prevent complications and consequent death by timely diagnosis and treatment.

Preoperative imaging evaluation in anterolateral thigh flap: comparison of computed tomography angiography and handheld Doppler

Objective To assess the accuracy of preoperative computed tomography angiography(CTA) and handheld Doppler (HHD) perforator body surface mapping for the point of anterolateral thigh (ALT) flap perforators through the deep fascia. Methods From March, 2014 to March, 2015, 19 patients underwent both CTA and HHD to donor site flap perforator exploration and body surface mapping before ALT flap transfer surgery, and the accuracy, sensitivity and specificity of CTA and HHD perforator body surface mapping were compared with the actual intraoperative findings. Results All of the ALT flaps survived except 1 case necrose cause by serious infection of recipient site. The 55, 55, 58 perforators were detected by CTA, HHD and actual intraoperative findings, respectively. The accuracy, sensitivity and specificity of CTA and HHD perforator body surface mapping were 89.23%, 91.38%, 71.43% and 74.24%, 82.76% and 12.50%, respectively. The distance of between the actual intraoperative findings and CTA, HHD were (11.13 ± 5.89), (13.73 ± 15.50) mm (t=-1.13, P>0.05). Conclusion This study demonstrates that CTA is a reliably and effective technology in preoperative flap perforator exploration and body surface mapping, which is more effective and accurate than HHD. Key words: Lateral femoral circumflex artery, Perforator; Anterolateral thigh perforator flap; Computer tomography angiography; Handheld Doppler

Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure.

To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion. A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site. The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67%, respectively, with neither of them in 6.67% of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6years; range 17-35years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11mm. All the patients were satisfied with the overall results. The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site. Level IV, retrospective series.

Design of Hand Held Doppler: A Potential Source of Contami-nation!!

Design of Hand Held Doppler: A Potential Source of Contami-nation!!

Viability of five different pre- and intraoperative imaging methods for autologous breast reconstruction.

SummaryBackgroundAutologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods’ efficiency and informative value were analyzed.MethodsWe retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI).ResultsCTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information.ConclusionPreoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds

BackgroundReconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions. ObjectiveWe describe a technique using internal pudendal artery perforator (IPAP) pedicled propeller flaps created from the gluteal fold. This could be a reliable surgical option that maintains a natural looking scrotal pouch with minimal donor site morbidity and optimal sexual activity. Design, setting, and participantsWe retrospectively reviewed data for 10 consecutive patients who had undergone penoscrotal reconstruction using IPAP pedicled propeller flaps between January 2011 and March 2015. Surgical procedureThe IPAP was identified using a hand-held Doppler ultrasound device. This was the pivot around which the flap was internally rotated more than 90° in a tension-free manner. The long axis of the flap was centred on the gluteal fold to provide a better-orientated donor site scar. MeasurementsComplications and patient satisfaction with respect to size, colour match, scar appearance, and sexual activity were evaluated. Results and limitationsAnatomic and aesthetic penoscrotal reconstruction was performed without any major complications in the follow-up period (mean, 19.7 mo). The mean width of the IPAP pedicled propeller flaps was 6.7cm, and the mean length was 11.7cm. Partial distal flap necrosis occurred in only one case, and healed spontaneously. All of the patients were satisfied with the cosmetic and functional results. ConclusionsOn the basis of reliable perforators, donor site morbidity, flap thickness, and a better orientated scar, our technique using IPAP pedicled propeller flaps created from the gluteal fold could be a reasonable surgical option for extensive penoscrotal reconstruction. Patient summaryThe creation of pedicled propeller flaps using an internal pudendal artery perforator could be a reliable surgical option for reconstruction of extensive penoscrotal defects. The approach yields functional and aesthetically acceptable surgical results.

Effects of Foot Reflexology Integrated with Medical use on Hemoglobin A1c and Ankle Brachial Index in Older Adults with Type 2 Diabetes Mellitus.

OBJECTIVE: To compare hemoglobin A1c (HbA1c) levels and ankle brachial index(ABI) in older adults with type 2 diabetes mellitus (T2DM) between the experimentalgroup and the control group two months after receiving the foot reflexology program, andto compare HbA1c levels and ABI in older adults with T2DM in the experimental groupbefore and two months after receiving the foot reflexology program.MATERIALS AND METHODS: A randomized experimental design with a randomizedcontrolled two-group pretest-posttest design. The purpose of the study was toinvestigate the effects of foot reflexology integrated with medication use on HbA1cand ABI in older adults with T2DM who sought treatment at the diabetes clinic ofManorom Hospital, Manorom District, Chai Nat Province. The study sample consistedof 40 older adults with T2DM who sought treatment at the diabetes clinic who metthe inclusion criteria. The subjects were recruited through random sampling, with 20assigned into the experimental group and the other 20 into the control group. The subjectsin the experimental group received foot reflexology every day for a period of twomonths, while those in the control group did not receive such treatment. All of thesubjects in both groups received pharmacological treatment of diabetes with eitheroral medication or insulin injection as prescribed in the treatment plan based on theirmeasurements with HbA1c used the ARRAY High Performance Liquid Chromatography(HPLC), and ABI level use the doppler ultrasound with handheld doppler probe.Data were analyzed using inferential statistics, Independent t-test and Paired t-test.RESULTS: The results revealed that after receiving foot reflexology, the HbA1c of theexperimental subjects was lower than that of the control subjects (t = 2.76, p = 0.009,SD = 1.37). In addition, their ABI levels in the right leg and left leg were higher thanthose of the control subjects (t = 5.921, p < 0.001, SD = 0.044 and t = 9.155, p = <0.0001, SD = .016 respectively). Also, after receiving foot reflexology, the subjects inthe experimental group had lower HbA1c (t = 10.54, p < 0.001, SD = 0.96) and ABIlevels in their right leg and left leg (t = -8.475, p < 0.001, SD = 0.044 and t = -10.249,p < 0.001, SD = 0.060 respectively).CONCLUSION: Foot reflexology can reduce HbA1c and increase ABI in older adultswith T2DM. It can be implemented as a complementary therapy to control diabetes andreduce severity of complications of diabetic foot in older adults with T2DM.

Ankle brachial index for the diagnosis of lower limb peripheral arterial disease.

Ankle brachial index for the diagnosis of lower limb peripheral arterial disease.

Buried free flaps in head and neck reconstruction: higher risk of free flap failure?

Thrombosis of the pedicle is central to free flap failure, and early revision of a compromised flap is the key to successfully salvage a flap. Therefore, the majority of free flaps in reconstructive head and neck surgery are used with the ability to visually examine the flap. Sometimes, due to intra-operative circumstances, it is necessary to use a flap that cannot be monitored externally. These flaps are called buried flaps and have the reputation of being put at risk. The current literature provides only limited data to support or disprove this position. A single institution retrospective review of patient charts between 2007 and 2015 was performed. Flap monitoring was carried out with hand-held Doppler of the pedicle hourly for the first 72h in all cases. Additional duplex ultrasound was performed in the majority of buried flaps. A total of 437 flaps were included into the study. 37 flaps (7.8%) were identified to fulfill the criteria of a buried free flap. In total, four patients had complications, three of which required operative reexploration. All interventions were successful, resulting in no flap loss in our series. An accurate operation technique combined with meticulous monitoring protocols supported by duplex ultrasound can result in satisfactory outcome of buried flaps. No enhanced risk of flap loss of buried flaps was found in our cohort.

Perforator Peroneal Artery Flap for Tongue Reconstruction.

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar. Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm. Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of angiosome proposed by Taylor paved the way for development of new flaps. True perforator flaps are those where the source vessel is left undisturbed and overlying skin flap is raised. Yoshimura proposed cutaneous flap could be raised from peroneal artery (Br J Plast Surg 42:715-718, 1989). Wolff et al. (Plast Reconstr Surg 113:107-113, 2004) first used perforator based peroneal artery flap for oral reconstruction. Location of perforators vary, hence pre operative localisation can be done by ultrasound doppler, CT angio or MR angiography. Disadvantages over radial flap include varying anatomic location of perforators, need for imaging and difficult dissection of delicate vessels through muscles and hence a learning curve. Our patient had an arterial thrombus within few hours post-operatively which was successfully salvaged with immediate re-exploration and re-anastomosis of artery. Post-operative healing was uneventful and donor site was closed primarily without the need for graft. Perforator peroneal flap serves as a useful armamentarium for reconstruction of moderate size defects of tongue, buccal mucosa and floor of mouth with advantages of thin pliable flap, minimal donor site morbidity and hidden scar.

Reseach development of vascular anatomy and preoperative design technology of anterolateral thigh flap

?To summarize the present status and progress of vascular anatomy and preoperative design technology of the anterolateral thigh flap. ?The relative researches focused on vascular anatomy and preoperative design technology of the anterolateral thigh flap were extensively reviewed, analyzed, and summarized. ?Vascular anatomy of the anterolateral thigh flap has been reported by numerous researchers, but perforators' location, origin, course, and the variation of the quantity have been emphasized. Meanwhile, the variation of descending branch, oblique branch, and lateral circumflex femoral artery has also been widely reported. Preoperative design technology of the anterolateral thigh flap includes hand-held Doppler, Color Doppler, CT angiography (CTA), magnetic resonance angiography, digital subtraction angiography, and digital technology, among which the hand-held Doppler is most widely used, and CTA is the most ideal, but each method has its own advantages and disadvantages. ?There is multiple variation of vascular anatomy of the anterolateral thigh flap. Though all kinds of preoperative design technologies can offer strong support to operation of anterolateral thigh flap, a simple, quick, precise, and noninvasive technology is the direction of further research.

Measurement of neonatal heart rate using handheld Doppler ultrasound

ObjectiveThis pilot study aimed to determine whether handheld Doppler ultrasound is feasible and reliable for measuring neonatal heart rate (HR) when compared with ECG.SettingStable newborns were recruited from the neonatal...

Smoking increases donor site complications in breast reconstruction with DIEP flap

Objective: Reconstruction with deep inferior epigastric perforator flap (DIEP) is considered to be the first choice for autologous breast reconstruction. The primary aims of this retrospective study were to find out if differences in smoking habits and BMI are useful predictors for postoperative complications in DIEP surgery.Methods: Three hundred and one patients were included. Data regarding smoking habits, BMI, age at surgery, total and final flap weight, abdominal scars, parity, number of perforators, chemotherapy, post mastectomy radiation therapy, and preoperative mapping of perforators with either Computer Tomography Angiography or hand-held ultra sound Doppler were collected. Complications that occurred in the first 30 postoperative days were taken into account.Results and conclusions: It was found that former smokers had a risk for donor site complication more than double that of never smokers (OR =2.12, CI =1.10–4.10, p = 0.025). Differences in BMI within the range from 18–33.7 did not have any significant impact on complication rates, neither at the donor site nor at the breast.

Evaluation of Distal Hemodynamic Changes of Lower Extremity after Endovascular Treatment: Correlation between Measurements of Color-Coded Quantitative Digital Subtraction Angiography and Ankle-Brachial Index

PurposeTo confirm the feasibility of using time-to-peak (TTP) measurements derived from color-coded digital subtraction angiography (ccDSA) imaging to assess improvements in distal circulation in relation to the ankle-brachial index (ABI). Materials and MethodsNineteen patients who underwent percutaneous transluminal angioplasty and/or stent placement (in 20 lower extremities) were evaluated. A region of interest (ROI) at the proximal superficial femoral artery (SFA) was selected for a reference TTP for quantitative assessments. The ROI measurements of the TTP interval between medial and lateral plantar/dorsalis pedis relative to the reference was regarded as the ΔTTP and used to assess distal hemodynamic improvement achieved by the revascularization. The ABI was obtained with a handheld Doppler ultrasound machine with a manually operated blood-pressure cuff. Correlation between the two methods was analyzed. ResultsThe ABI improved significantly from 0.44 ± 0.18 to 0.79 ± 0.20 (t = 10.11; P < .0001) after the intervention. TTP, which reflected the blood flow time from the proximal SFA to the foot, became much faster, from 11.86 seconds ± 4.26 to 6.75 seconds ± 2.03 (t = 6.57; P < .001). A good correlation was observed between the improvement ratios of ΔTTP and ABI (r = 0. 863). ConclusionsTTP measurements derived from ccDSA provide an easy and objective method for assessment of distal hemodynamic changes after endovascular treatment of lower-extremity peripheral arterial disease (PAD). It may provide a quantitative method to assess the adequacy of endovascular interventions and provide more objective suggestions for procedure endpoints, with potentially better clinical outcomes for patients with PAD.

Utility of multi-detector row computed tomography angiography versus Doppler in localization of perforators of anterolateral thigh flaps

Aim: Anterolateral thigh (ALT) flap is widely used in reconstruction of various defects. Preoperative imaging facilitates perforator mapping, overcoming intraoperative uncertainty. The purpose of this study was to investigate the utility of multi-detector row computed tomography angiography (MDCTA) and a handheld Doppler in locating ALT perforators.

A novel method to correctly place the fasciotomy incision for decompression of the anterior and peroneal compartments of the leg

Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately.A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI. MethodsFourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves. ResultsHand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators. ConclusionThis new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.

Society for Vascular Surgery Calls for Caution in PAD Care

Society for Vascular Surgery Calls for Caution in PAD Care

Prevalence of Peripheral Arterial Disease among Adult Patients Attending Outpatient Clinic at a General Hospital in South Angola.

Background. Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis, whose prevalence is increasing worldwide, and is associated with all-cause mortality. However, no study has assessed this disease in Huambo. The aim of this study was to evaluate the prevalence of PAD in patients attending an outpatient clinic at a general hospital in Huambo, South Angola. Methods. A cross-sectional study, including 115 patients aged 40 years and older attending an outpatient service. The evaluation included a basic questionnaire for lifestyle and medical history and ankle-brachial index (ABI) measurement using hand-held Doppler. PAD was defined as an ABI ≤0.9 in either lower limb. Results. Of 115 patients, 62.60% were women with a median age of 52.5 (range of 40 to 91) years. The prevalence of PAD was 42.6% (95% confidence intervals [CI]: 95%: 33.91–52.17%). Among patients with PAD, 95.92% had mild disease and 4.08% moderate to severe disease. The main risk factor for PAD was age (≥60 years) (χ 2 = 3.917, P ≤ 0.05). The prevalence was slightly higher in men and hypertensive subjects, but without statistical significance with ORs of 1.5 (95% CI: 0.69–3.21) and 1.42 (95% CI: 0.64–3.17), respectively. Hypertension was also high in the group (66.95%). Conclusion. The prevalence of PAD was 42.6%, higher in those aged 60 years and older. More studies, with representative samples, are necessary to clarify PAD prevalence and associated risk factors.

Perforator flaps for reconstruction of lower limb defects

Background: Reconstruction of soft tissue defects in the lower third of the leg remains challenging. Anatomical constraints limit the local options available for complex defects especially lower third of leg. Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. We present our experience with perforator flaps for reconstruction of soft tissue defects in the lower limb . Methods: The study was carried prospectively and 23 patients with lower limb defects treated with various perforator flaps (both elective as well as emergency) were included in the study. A hand-held Ultrasound Doppler was used preoperatively and intraoperatively to detect the perforator vessels . Results: Out of 23 patients, we witnessed partial flap loss in 1 and distal flap necrosis in 3 patients. 4 patients had minor complications which included infection, wound dehiscence and congestion of flap . Conclusions: Perforator flaps may represent a good alternative to the free flaps in the areas were other local reconstructive procedures are not possible. This is a versatile technique and with decreased donor site morbidity limited to a single body area. There is a specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. The main drawback of the perforator flaps however is the higher risk of venous congestion .