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1 Marsha M. Neumyer, BS, RVT, FSVU, FSDMS, FAIUM International Director Vascular Diagnostic Educational Services Vascular Resource Associates Harrisburg, PA Disclosure Statement: CME Calendar QR Code Marsha Neumyer, BS, RVT, FSVU, FSDMS, FAIUM has identified the following potential conflicts of interest: Speaker for Unetixs Vascular, Inc. and Gulfcoast Ultrasound, Inc. Independent Consultant for Pegasus Lectures All other persons involved in this CME Activity do not have any financial relationships with any commercial interest related to the content of this activity. This activity has not received any commercial support. Carotid Artery Duplex Scanning Recognized as the most accurate, noninvasive, costeffective method for diagnosis of extracranial cerebrovascular disease It is also recognized that optimal technique and quality instrumentation are of paramount importance in performing high quality examinations 1

2 Carotid Artery Duplex Scanning The vessels are superficial Every conceivable flow pattern Common vascular disorders observed Carotid Artery Duplex Scanning Anterior and posterior cerebral hemispheres are connected side-toside via the circle of Willis Evaluate vertebral and carotid arteries Obtain brachial systolic blood pressures Carotid Artery Duplex Scanning Two important technical components: B-Mode imaging May be complemented with color flow imaging Doppler velocity spectral analysis 2

3 B-Mode Imaging Intimal thickening Presence of plaque Plaque morphology Surface characteristics Abnormal anatomy B-Mode Imaging Normal Intimal Thickening Plaque Characterization 3

4 Plaque Characterization Acoustic characteristics Surface properties Multiple planes of view Plaque Characterization Acoustic pattern Homogeneous Heterogeneous Complex calcified Surface Characteristics Smooth Irregular Ulcerated (if crater more than 2 x 2 mm) Plaque Characterization Plaque Mobility Acoustically Homogeneous Plaque Acoustically Heterogeneous Plaque 4

5 Plaque Characterization Common Carotid Artery Acute Thrombus Plaque Characterization Occlusion??? Intraplaque Hemorrhage??? Complicated Lesions Plaque Characterization Hemorrhage into the plaque Subintimal necrosis Loss of intimal continuity Ulcer formation Calcification 5

6 Planes of View Normal Blood Flow Patterns 6

7 Normal Blood Flow Patterns Normal Blood Flow Patterns ICA ECA Normal Blood Flow Patterns Vertebral Artery Resembles ICA Rapid systolic upstroke Forward diastolic flow 7

8 Blood Flow Patterns Laminar Flow Minimal Flow Disturbance Blood Flow Patterns > 60% Stenosis 8

9 Post-stenotic Turbulence Found immediately distal to flow-limiting stenosis (> 60%) Decrease in peak systolic velocity compared to stenotic segment Disturbed outer frequency envelope Blood Flow Patterns Blood Flow Patterns Occluded Internal Carotid Artery Associated Common Carotid Spectral Waveform 9

10 Blood Flow Patterns Occluded Common Carotid Blood Flow Patterns CCA-distal obstruction Normal ICA ICA distal obstruction Blood Flow Patterns Cardiac arrhythmia 10

11 Spectral Doppler Analysis The Basis For Diagnosis Peak systolic velocity (PSV) End diastolic velocity (EDV) ICA / CCA peak systolic velocity ratio Post-stenotic turbulence B-Mode Image Measure the highest velocity where the intensity of the signal is maximal Measure EDV just before the next systolic upstroke PSV and EDV 11

12 ICA / CCA Velocity Ratio Measure the CCA velocity in the distal segment, 2-4 cm before the bulb Measure the highest PSV in the stenotic segment of the ICA Ratio is invalid if the CCA is abnormal Watch the Angle!!!!! The angle of insonation must be 60 degrees or less Doppler cursor parallel to the vessel wall Velocity estimation is inaccurate when angle of insonation is greater than 60 degrees 12

13 Carotid Artery Dissection Carotid Dissection Carotid Artery Dissection 13

14 14

15 No. Laboratories UWA UWA+Moneta UWA modified Bluth Zweibel Thiele Faught Internal validation Carroll Mayo Daigle Unpublished data courtesy of ICAVL No. Laboratories 27.0% SRU based 23.0% Bluth based 21.1% UWA based 20.4% Unreferenced or hybrid of 3+ named criteria % home grown criteria Gornik H, Hutchisson, M, et al. Presented at AHA UWA UWA modified UWA + Moneta Bluth + UWA Bluth Bluth modified Bluth + Moneta SRU SRU modified Faught Carroll Moneta modified CCF Sidhu and Allen Stanford Wake Forest Internally developed Other 15

16 Radiology 2003; pp DISEASE SEVERITY ICA PEAK SYSTOLIC VELOCITY ICA/CCA PSV RATIO ICA END DIASTOLIC VELOCITY NORMAL < 125 CM/SEC < 2.0 < 40 CM/SEC < 50% < 125 CM/SEC < 2.0 < 40 CM/SEC 50-69% CM/SEC CM/SEC > 70% > 230 CM/SEC > 4.0 > 100 CM/SEC NEAR OCCLUSION TOTAL OCCLUSION MAY BE LOW OR UNDETECTABLE UNDETECTABLE PLAQUE NONE < 50% DR >50% DR >50% DR VARIABLE VARIABLE SIGNIFICANT LUMEN DETECTED NOT APPLICABLE NOT APPLICABLE SIGNIFICANT LUMEN NOT DETECTED Uptake SRU Consensus Criteria: by Year 1 st Accredited 27% of laboratories in overall sample use SRU-based criteria % Labs Using SRU Based Criteria 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Gornik H, Hutchisson, M, et al. Presented at AHA % 50.0% Before Year of 1st Accreditation P<0.001 for comparison 16

17 IAC Recommended Interpretive Criteria Q8: In your opinion, should there be only one set of diagnostic criteria for ICA stenosis for all facilities performing carotid duplex ultrasonography? 31.9% No N=725 Yes 68.1% Gornik H, Needleman L, et al. Presented at ACC Q9: In your opinion, if IAC Vascular Testing (ICAVL) developed one set of standardized diagnostic criteria that were researched and validated should laboratories be required to incorporate their use for accreditation? 31.6% No N=722 Responses for one set and required use of criteria highly correlated R=0.756, P<0.001 Yes 68.4% Gornik H, Needleman L, et al. Presented at ACC

18 How Do We Know What Criteria To Use?. The IAC Vascular Testing Board has recommended use of the SRU Criteria Laboratories may continue to use their own criteria as long as rigorous internal validation of those criteria can be confirmed. Future actions: The IAC plans to internally validate and make recommendations for specific ICA diagnostic criteria to be used by all facilities applying for accreditation. The future recommended diagnostic criteria may or not be identical to the SRU consensus criteria. A multi-disciplinary Carotid Diagnostic Criteria Committee has been formed by IAC Vascular Testing and will convene regularly to move this effort forward. Periodic status updates regarding the progress of this important initiative will be provided to IAC accredited vascular testing facilities. With this action, the IAC Vascular Testing BOD hopes that the documented variances in carotid stenosis interpretation can begin to be resolved 18

19 Although the technical protocols for carotid duplex evaluations have remained essentially unchanged for the past four decades, other factors influence current practice Addition of color and power Doppler imaging Refined definitions for plaque morphology and surface characteristics Changes in classifications of disease severity A call for standardization of ICA diagnostic criteria Recommendations from the ICAVL on adoption of new diagnostic criteria 19

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