In laminar flow situations, shear occurs in the zone between the blood vessel wall (velocity = zero) and the central column of flow. In vitro measurement of shear, sometimes difficult, has been achieved with laser Doppler sensors and with magnetic resonance techniques.1Yap C.H. Saikrishnan N. Tamilselvan G. Yoganathan A.P. Experimental technique of measuring dynamic fluid shear stress on the aortic surface of the aortic valve leaflet.J Biomech Eng. 2011; 133: 061007Crossref PubMed Scopus (27) Google Scholar, 2Campagnolo L. Nikolić M. Perchoux J. Lim Y.L. Bertling K. Loubiere K. et al.Flow profile measurement in microchannel using the optical feedback interferometry sensing technique.Microfluidics Nanofluidics. 2013; 14: 113-119Crossref Scopus (54) Google Scholar Casa et al diagrammed the cross section of flow velocity as parabolic for laminar flow and showed how platelets and blood clotting factors can be activated in the shear zone, the region where the velocity curve becomes asymptotic with the wall (Casa Fig 1). The thickness of this zone is related to many parameters, including viscosity. Shear forces are not uniform in the proximal internal carotid artery: under physiologic conditions, the zone of abnormal shear can vary longitudinally as well as along the circumference, as measurements with magnetic resonance techniques have demonstrated.3Markl M. Wegent F. Zech T. Bauer S. Strecker C. Schumacher M. et al.In vivo wall shear stress distribution in the carotid artery: effect of bifurcation geometry, internal carotid artery stenosis, and recanalization therapy.Circ Cardiovasc Imaging. 2010; 3: 647-655Crossref PubMed Scopus (160) Google Scholar The biologic behavior of artery walls in zones of severe stenosis is more difficult to model. Not only is there the problem of turbulence, but measurement accuracy is difficult because of physical limitations of instrumentation. A normal internal carotid artery diameter ranges from 6 to 8 mm, and a significantly stenotic segment is at or less than 1 mm. The axial gate size used to measure carotid flow velocity by duplex ultrasound is typically 1 to 3 mm. The axial resolution for this measurement is on the order of magnitude 0.1 to 0.2 mm, depending on the frequency selected, typically 9 to 12 MHz. Axial resolution is inversely proportional to frequency.4Kremkau F.W. Sonography principles and instruments.9th edition. Elsevier, St. Louis, MO2016: 66Google Scholar Because the formula for shear stress includes 1/(D3), there is potential for any value to have an inherent error between 30% and 70% based on the physics of ultrasound probes, irrespective of operator-related variability. Velocity measurements in a duplex ultrasound scan are sensitive to the beam angle, which is also operator dependent. If shear is to be used as a parameter for risk, it is therefore necessary that the measurement is conducted at the highest probe frequency and is not in an area of severely eccentric plaque, which may distort the measurements. For any vascular laboratory, the overall reproducibility of velocity measurements is not generally ascertained. Understanding that this is the case, reporting standards therefore mandate ranges, not use of precise velocities. Shear stress criteria may need to be formulated in a similar manner. Shear stress is proportional to blood viscosity. For the purposes of clarity, Casa et al did not factor variability of viscosity in their analysis, but it is well established that blood viscosity can vary significantly in any individual over time.5Wells Jr., R.E. Merrill E.W. The variability of blood viscosity.Am J Med. 1961; 31: 505-509Abstract Full Text PDF PubMed Scopus (26) Google Scholar Some literature indicates that viscosity is not really important in terms of carotid-related stroke risk,6Parkhurst K.L. Lin H.F. Devan A.E. Barnes J.N. Tarumi T. Tanaka H. Contribution of blood viscosity in the assessment of flow-mediated dilation and arterial stiffness.Vasc Med. 2012; 17: 231-234Crossref PubMed Scopus (21) Google Scholar but this should be validated in the context of the present study. Therefore, before translating from Casa to clinical utility, as proposed in this paper, it will be necessary for some significant research to occur. In particular, standards for precise vascular laboratory measurement will need to be redefined. The opinions or views expressed in this commentary are those of the author and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Shear rate is a better marker of symptomatic ischemic cerebrovascular events than velocity or diameter in severe carotid artery stenosisJournal of Vascular SurgeryVol. 69Issue 2PreviewThis study was designed to test the hypothesis that the high shear rate of flow in the area of carotid stenosis is associated with the incidence of ischemic symptoms in patients with a high degree of carotid stenosis. Full-Text PDF Open Archive