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3/6/19
1
Vascular Ultrasound
Criteria Update“A pulsating
numbers game”
• Use of Numbers• “What is good criteria”• Current: Literature, Monash & Why
Overview
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
CVI
AVF
• Not a “gut” instinct- Change ++ since 80-90’s• Consistent• Evidence based
In US-What’s the good thing about numbers
Old Evidence Minimal evidence Tiny threshold/ Big significance
Applies to Vascular Ultrasound
In US- Problem with numbers?
• Poor evidence/ Ltd trials• Changing intervention• Quality & type
• Impacts thresholds
• Two Major Contributors• Patient variability• Circulatory characteristic
Vascular US- Problem with numbers?
• Basic flaw in spectral Doppler• Angle correction• Presume – Know the direction flow• High grade stenoses- Marked turbulence• No way of knowing –Which angle ? Colour doesn’t help• WARNING Error – Up to twofold
Vascular US- Problem with numbers?
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2
• Begin with the premise…
• Ultrasound Criteria:• Poor evidence
•High variability
• Imperfect technology
The place to begin…
• High Sensitivity• Pick up as many as possible
• High Specificity• All that test positive- Are abnormal
• Ultrasound• Primary imaging modality• Correlated with 2° testing
• Slight bias- “Sensitivity”
• Best Practise• Evidenced based criteria• Validated: Local Audit
Criteria
Example - >230cm/s 70-99% stenosis
At the end of every test…
Apply the
“does it make sense rule”
At the end of every test…
Apply the
“does it make sense rule”
? Classification
0-50% High end of range or 50-6%
CCA- 92 cm/s
ICA- 155 cm/s
At the end of every test…
ICA- 155 cm/s
• “What is good criteria”• Current: Literature, Monash & Why
Overview
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
Chronic Venous Insufficiency
AVF
ICA
ICA – Post Endarterectomy
CCA
ECA
Stents
3/6/19
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Why do we perform a “carotid colour duplex”
• Paradigm• Stroke• Haemorrhagic (15%)
• Embolic/Ischaemic (85%)• Cardio-embolic/ Carotid
Criteria: ICA stenosis
• Plaque• Composition
• Shearing forces• Stenosis (PSV)
ICA
• Paradigm• Stroke• Haemorrhagic (15%)
• Embolic/Ischaemic (85%)• Cardio-embolic/ Carotid
Criteria: ICA stenosis
• Symptomatic / > 70-99%• Benefit CEA NASCET 2009
• Symptomatic / > 50-69%• Increased med surveillance
Need US Criteria: Predict stroke
• 5 Key Recommendations
• ASUM Revised 2008
• US Consensus Grant 2003
• Meta-analysis Jahromi 2005
• DEGUM 2010 Deutsche Gesellschaft fu�r Ultraschall in der Medizin
• Multiparametric
• Neurosonology Research Group Stroke 2012
Criteria: ICA stenosis
• US Consensus (Grant et al)
•
• 50-69%: 125 cm/s• 70-99%: 230 cm/s
Criteria: ICA
• US Consensus (Grant et al) Meta-analysis (Jahromiet)
•
• 50-69%: 125 cm/s 130 cm/s
• 70-99%: 230 cm/s 200 cm/s
• V similar• Using the same evidence
Criteria: ICA
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Criteria: Back to this case…?
91 cm/s
155 cm/s
63 yo TIA
Rt ICA
• 50-69%: 125 cm/s 130 cm/s
• 70-99%: 230 cm/s 200 cm/s
CTA < 50% • Monash Audit Data• PSV alone
• Monash Data• ICA: CCA ratios-Worse
• EDV-Worse
• What else: The B-mode?
Criteria: ICA
Overcalled
Undercalled
1759 ICA’s
n= 92 inclusions
• Morales 2018
• We know this…. What to do?
Criteria: ICA
• Measure B-mode• % diam- poor predictor
• % area- poor predictor
• NASCET measurement
• Issues• Shadowing
• Accurate represetative image
• But... contains information
Criteria: ICA
• DEGUM 2010
• Deutsche Gesellschaft fur Ultraschall in der Medizin
• Multiparametric
• 10th % iles• Uses • NASCET• Ave PSV
• PS PSV• Collats• EDV• Turbulance
• Emphasis- B-mode / Colour
Criteria: ICA
• Neurosonology Research Group Stroke 2012
• Confusing
• V interpretive
• Trend• Multiparametric
• 10 % iles
Criteria: ICA
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• Monash• US Consensus + B-mode NASCET
• Low/ High end of range
• Future-• 10 % iles
• More sophisticated analysis• ? AI
Criteria: ICA
• Sweden is famous for…
ICA Criteria: A Final Word
• National Swedish Trial
• 10 Centres c/- Angiography
>80 % stenosis
0-49 degrees - > 210 cm/s50-62 degrees - > 320 cm/s
The Literature: ICA Stenosis
Recommendations
Swedish Quality Board for Carotid Surgery
30 degrees 169 cm/s60 degrees 272cm/s
Classification is angle dependant !
• Pre Surgical criteria • Does NOT apply
• Morphology• Velocities• Probably higher
• Surveillance• Compare to baseline
• Neointimal hyperplasia- Be careful• Isoechoic
Carotid Endarterectomy: Criteria
www.vesalius.com
ICA – Post Endarterectomy
>50% >220cm/s ICA/ CCA > 2.7
>80% >340cm/s ICA/ CCA > 4.15
Carotid ICA Stent: Criteria
JVS 2008
ICA Stents
2:1 ratio - > 50 %3.5:1 ratio - > 85%Damped - > 60% origin
compared to
NASCET, Diameter
Criteria: CCA
JVS 2015
CCA
118 cm/s
285 cm/s
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Critera : ECA
Mild Moderate Severe
ECA
• Carotid
Questions?
• Carotid
Questions?
How long is a giraffe’s carotid artery?
• Carotid
Questions?
How long is a giraffe’s carotid artery?
1.6m
Criteria Update
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
Chronic Venous Insufficiency
AVF
Native Renal Arteries
Transplant Renal Arteries
RA Stents
• Integrated• Direct Assessment
• Indirect Assessment
• Direct• RAR 3.0:1 PSV> 200cm/s (House 1999)
• Indirect• Qualitative
• Not measurements
Renal Arteries: Traditional View
Superior
Inferior
Mid
Normal Abnormal
38yo woman Severe Hypertension
(PSV> 200cm/s- Generally high- 200-300 cm/s)
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• Criteria
• PSV> 200cm/s (House 1999)• RAR 3.0:1
• 47 yo hypertensive male• Ao- 85cm/s
• PSV mid- 253cm/s
A Case
• Criteria
• PSV> 200cm/s (House 1999)• RAR 3.0:1
• 47 yo hypertensive male• Ao- 85cm/s
• PSV mid- 253cm/s
• Small increase from prox, Mid vessel, No SB,
A Case
Journal Of Vascular Surgery2012 Oct;56(4):1052-9
Largest reported study
Patients 313 Renal Arteries (606)
Exclusions 20 (inc 11 inadequate imaging)
Technical success rate- 98%
Normal 210/606 < 60% stenosis 158/606
> 60% stenosis 207 /586 + 31 occlusions
ROC curve analysisPSV 285 cm/s or
RAR of 3.7
Renal Arteries: CriteriaJournal Of Vascular Surgery
2012 Oct;56(4):1052-9
Journal Of Vascular Surgery2012 Oct;56(4):1052-9
Journal Of Vascular Surgery2012 Oct;56(4):1052-9
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• PSV > 285 cm/s or RAR > 3.7• High index of suspicion : RAS
• Confirm with B-mode/ Colour (Hi res)
• PSV > 200 cm/s RAR > 3.0• Moderate index of suspicion : RAS
• Confirm with B-mode/ Colour (Hi res)
• Report in context of• I/R , B-mode/ Colour, P/S turbulence
Recommendation: Criteria
16 yo Takayasu Arteritis
• If RAS- Important: Record RI
Resistive Index: RAS
RI Threshold: Intervention Radermacher 2003
RAS ultrasound +intervention: 138/5950
Successful intervention- Angioplasty/ Stent =131
RI >0.8(27%)
RI <0.8(73%)
worse renal function 80%
improvedrenal function 94%
Or 0.75Yuksel 2012
Native Renal Arteries
• Technically Difficult
• Less common• Older /Vasculopaths
• Re-stenosis rate 10-20% (Del Conde 2014)
• Similar Criteria
• PSV: 240 cm/s RAR : 2.9:1 (Del Conde 2014)
Renal Artery :Stents
RRA stent
RA Stents
• Reasonably Established• RI <0.8• Useful as a marker – dysfunction
• Useful in Surveillance
• PSV = 200-300 cm/s Haemodynamically significant
• Marker for RAS
• Closer Sx
• PSV = > 300 cm/s• Haemodynamically significant
Criteria: Renal Transplant
349cm/s
Transplant Renal Arteries
Criteria: Renal Transplant Day 1
• 2012 Audit• n = 346 transplants from 2007 – 2011• Endpoint – Re-do surgery or
Graft Failure <12 months
Criteria: Renal Transplant Day 1
Audit performed by Greg Curry
t On-going Renal Transplant
t Redo Surgeryt Renal Tx failure
(<12 months)
Redo had RI’s of 0.32, 0.4 and 0.59…”
Redo had PSV’s of 460 and 477 cm/s…”
Key Numbers Day 1RI < 0.5PSV > 400cm/s
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• Renal
Questions?
How long is a elephants kidney?
• Renal
Questions?
How long is a elephants kidney?
34cm
Criteria Update
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
Chronic Venous Insufficiency
AVF
• Peripheral Vascular Ultrasound• Complicated by• Multi-segment • Small vessel disease• Branching / collaterals
• Intervention• Not precise %
• ABI’s• Excellent• Primary Diagnosis/ Surveillance
Criteria: Peripheral Vascular
Cystic Adventitial Disease BS
• Criteria• Composite Small trials (mid 80’s)
• Three basic rules• Waveforms: Important
• Ratio- Contained system works
• Ration- Not contained system• Eg Bifurcation, Collaterals- Doesn’t work
Criteria: Peripheral Vascular
xx2
• Primary criteria (x / x2 )• Ratio > 2 (1.8-2.5) >50% Cossman 1989
• Ratio > 3 more likely to early occlude Whyman 1993
• Ratio > 4 >75% Cossman 1989
• Ratio criteria >7 90% Ranke C 1992
• Aorto-iliacs• >200cm/s >50 %
• >400cm/s >75 % de Smet 1996
• Sens. 96% Spec 55%
Criteria: Peripheral Vascular
xx2
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Criteria Update
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
Chronic Venous Insufficiency
AVF
SMA
Coeliac Axis
IMA
• Established
• Coeliac Axis• PSV > 200 cm/s >70%
• SMA• PSV > 275 cm/s >70%
• IMA• 200cm/s > 60%
> 3.5:1 Moneta 1986
Mesenteric
65yo SMA stenoses
• Relatively new
• Celiac Axis
• PSV > 200 cm/s >70% PSV 240cm/s >50% PSV 320 cm/s >70%
• SMA
• PSV > 275 cm/s >70% PSV 295cm/s >50% PSV 400 cm/s >70%
• IMA• PSV > 200cm/s > 60% No Update
• EDV Can be used / Not as good
Mesenteric
• Post prandial – Not required
• Imaging• Inspiration, expiration, & erect
• Describe : Median Arcuate Ligament syndrome
Mesenteric
https://radiopaedia.org/articles/coeliac-artery-compression-
syndrome
Criteria Update
Carotid
Renal Arteries
Peripheral Arterial
Mesenteric
Chronic Venous Insufficiency
AVF
• Lifeline • End Stage Renal Failure
• Surveillance• Troubleshooting
• Old paradigm• Use velocities
AVF
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• Current paradigm• Not PSV’s
• Don’t grade stenosis
• Measurement• >3mm – Normal
• 1.5-3.0 mm – At risk (Could impact function)• (Not mild moderate)
• <1.5 mm – High risk / Severe
AVF
Narrowing – CV/ SCV
• Volume • Predict dysfunction
• RC fistula < 500 cc/ min
• High quality documentation
AVF
Looks about right….? Same vessel in same spot.. With correct calliper placement
1277 cc/min vs 551 cc/min.. Overestimated by >2 times!!
Criteria Update
Carotid
Renal Arteries
Peripheral Arterial
Chronic Venous Insufficiency
AVF
Mesenteric
• Identify• Patterns of CVI – Guide Tx
• Traditionally• Definition : Reflux – > 0.5 or 1sec
• Size of perforator- > 3 or 4 mm
Criteria: Chronic Venous Insufficiency CVI
• Reflex times/ Perforator size• Depends of clinical presentation
• Change: Treatment Options
• EVLT +/- sclerotherapy• Careful documentation • Reflux patterns
• Vein size (Threshold – too small / too big)• Intra or extra-fascial
• Minimum -10cm Intrafascial GSV
Criteria: Chronic Venous Insufficiency
• Vascular Criteria• Small series
• Very slow evolution
• Snapshot• Haven’t discussed -Technical impacts • Spectral Doppler angle.
• Large Variability• Physiologic states
• “Does it make sense”• B-mode Colour Spectral
“The Wrap-Up”
Typical SFA stenosis
3/6/19
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Questions?
Greg Curry
MH:Sonographers
MH Radiologists
Acknowledgements