Michigan Vascular Association 2012 Conference Case studies from Massachusetts General Hospital. Our lab

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1 Michigan Vascular Association 2012 Conference Case studies from Massachusetts General Hospital Kathleen Hannon, MS, RVT, RDMS Our lab #1 in the nation! 15 full time RVT s 11 MD s IAC certified: cerebrovascular, arterial, venous, visceral and transcranial exams Established in 1960 s by Clement Darling, MD Affiliated with ~13,000 patient visits on main campus ~2,000 patient visits satellite center Waltham 2 Medical Director, Michael R. Jaff, DO, RPVI Technical Director: Me. khannon@partners.org 3 1

2 Case studies 4 Renal artery duplex 26 yr female History of iliofemoral DVT IVC Filter 1 yr later presents with new onset of hypertension A renal artery duplex was performed 5 Renal artery duplex 6 2

3 Kidneys were normal size 7 Proximal right renal artery 85cm/ sec 8 Mid renal artery 573 cm/ sec 9 3

4 Distal renal artery 154 cm/ sec 10 Proximal left renal artery 130 cm/ sec 11 Mid left renal artery 89 cm/ sec 12 4

5 Distal left renal artery 65 cm/ sec 13 FMD? Renal artery stenosis? RRA 573 cm/ sec LRA 130 cm/ sec 14 How about her medical / surgical history? Young woman, no prior renal c/o History of IVC filter 1 year ago Is this a well localized stenosis? Do you think she has FMD? Highest velocity was mid RRA 15 5

6 CTA of abdomen Tynes of IVC filter adjacent to aorta Note the absence of contrast in a very focal segment of the right renal artery 16 CTA of abdomen Transverse view of the of the abdomen CTA Note the absence of contrast or defect in filling of the right renal artery 17 CTA of abdomen Transverse view of the of the abdomen CTA Note the absence of contrast or defect in filling of the right renal artery Note the tynes of the IVC filter and their proximity to the aorta 18 6

7 Diagnosis and intervention IVC displacement from the inferior vena cava Tyne of IVC filter impinging on flow to right kidney Tyne of IVC filter creating mechanical right renal artery stenosis Treatment: open operative retrieval of displaced IVC filter 19 Upper extremity arterial stent 24 yr female s/p subclavian artery stent for treatment of vascular mass involving the right subclavian vessels. Unresolved persistent RUE pain Duplex of RSCA stent was performed to evaluate for patency 20 Upper extremity arterial stent 21 7

8 Upper extremity arterial stent 22 Upper extremity arterial stent 23 Upper extremity arterial stent 24 8

9 Upper extremity arterial stent 25 Upper extremity arterial stent 26 Upper extremity arterial stent 27 9

10 Upper extremity arterial stent 28 Upper extremity arterial stent 29 Upper extremity arterial stent 30 10

11 Upper extremity arterial stent 31 Upper extremity arterial stent 32 Upper extremity arterial stent 33 11

12 Upper extremity arterial stent 34 Upper extremity arterial stent 35 Upper extremity arterial stent 36 12

13 Upper extremity arterial stent 37 Upper extremity arterial stent See anything? Anything unusual going on here? 38 Upper extremity arterial stent Is this normal? 39 13

14 Upper extremity arterial stent Is this normal? 40 Upper extremity arterial stent The stent looks like it s floating doesn t it? Is that normal? 41 Upper extremity arterial stent 42 14

15 Upper extremity arterial stent 43 Upper extremity arterial stent 44 Upper extremity arterial stent 45 15

16 Upper extremity arterial stent 46 Upper extremity arterial stent 47 Upper extremity arterial stent 48 16

17 Upper extremity arterial stent 1. Image arterial stents in long and in short/ Check for stent fracture, stent opposition 2. Inflow and outflow 3. Patient presentation. Why did she still have pain? Treatment: sternotomy and repair of right subclavian artery aneurysm 49 Right LE edema 50 year old athlete with history of iliac vein aneurysms Open repair of right iliac venous aneurysm with interposition bypass graft using 14 mm PTFE 1 year earlier. New onset right leg swelling A bilateral venous duplex exam was performed to r/o DVT 50 Right LE edema 51 17

18 Right LE edema 52 Right LE edema 53 Right LE edema No spontaneous color No spontaneous power color 54 18

19 Right LE edema 55 Right LE edema 56 Right LE edema 57 19

20 Right LE edema Partially compressible CFV Abnormal flow Very little flow in the thigh Who thinks acute DVT? 58 Right LE edema Let s look again at that REIV 59 Right LE edema What the heck is this? 60 20

21 Right LE edema That is the PTFE bypass! 61 Right LE edema RECAP of presentation: 50 year old athlete with history of iliac vein aneurysms No history of DVT Open repair of right iliac venous aneurysm with interposition bypass graft using 14 mm PTFE 1 year earlier. Tech did not identify the PTFE bypass or the femoral anastomosis in the groin no visible thrombus disparity in R vs L CFV flow no DVT was identified on venogram 62 Interventional procedure: stenting across femoral and iliac vein anastomoses 63 21

22 Right LE edema Interventional procedure: stenting across femoral and iliac vein anastomoses 64 Right LE edema Prelim stated no visible thrombus, abnormal venous flow in the right lower extremity consistent with outflow obstruction probably due to vein bypass graft stenosis 65 Arm pain 54 yr male with patent AVF for dialysis left upper extremity c/o left arm pain when going from dialysis to physicians office and when doing volunteer work around hospital 66 22

23 Arm pain Venous and arterial duplex exams were negative bilaterally Subclavian arteries were widely patent no change with maneuvers Subclavian veins were widely patent no change with manuevers 67 Arm pain 68 Arm pain 69 23

24 Arm pain Upon further questioning, it was determined that the patient had a backpack he wore inbetween dialysis and the doctors office He only wore this backpack while doing volunteer work and on dialysis days I asked him to put the backpack on, walk around the hospital and come back 70 Arm pain Patient returned about 10 minutes later, I re scanned him with the back pack on 71 Arm pain 72 24

25 Arm pain 73 Arm pain No DVT No TOS Recommendations: switch to fanny pack 74 LE DVT 17 yr old male Juvenile Diabetes Inflammatory Bowel Disease Abdominal CT with incidental finding of delayed contrast enhancement of left iliac vein 75 25

26 LE DVT Venous duplex study demonstrated: Bilateral iliac vein thrombi IVC thrombus 76 LE DVT 77 LE DVT 78 26

27 LE DVT 79 LE DVT 80 LE DVT Iliofemoral thrombolysis 81 27

28 IVC filter and stents of iliac veins 82 LE DVT : post intervention duplex 83 LE DVT follow up.picc Line Due to IBS and inability to eat, a PICC line was inserted in the right UE for the administration of TPN (total parental nutrition) 84 28

29 Right UE edema developed after PICC line insertion 85 MR of chest with no contrast in ax / scv 86 Venography right UE 87 29

30 Thrombectomy right SCV 88 Proximal right SCV stenosis was discovered: Probable thoracic outlet syndrome! 89 Cervical rib 90 30

31 Resection of 1 st rib for decompression right subclavian vein 91 Discharged home Resumed fragmin regimen 92 EVLT 53 year old female History of EVLT left lower ext. Here for her yearly post op surveillance Prior exams demonstrated superficial venous reflux

32 Post EVLT Duplex 94 Post EVLT Duplex 95 Compared to Pre EVLT venous duplex 96 32

33 Compared to Pre EVLT venous duplex 97 Why did the pt suddenly develop reflux? IVC or iliac vein occlusion Mechanical compression 98 A full bladder is the culprit? The pt was asked to void and then return for repeat femoral vein evaluation 99 33

34 Post Void 100 Post Void 101 Conclusion Compare pre and post op flow Always compare side to side Include mechanical compression as a reason for outflow obstructions

35 Rest pain right hand Persistent right hand pain worsening when undergoing dialysis Right brachial to cephalic AVF Arterial evaluation of right arm was ordered 103 Axillary and brachial artery were patent without stenoses 104 Abnormal bidirectional flow in right radial artery near the wrist, ulnar artery patent

36 Radial artery flow improves and is unidirectional with AVF manual compression 106 Ulnar artery flow nearly doubles with AVF manual compression 107 Rest pain right hand =AVF steal AVF alters hemodynamics Lowered peripheral resistance High flow through AVF Increased venous outflow By manually compressing the AVF, we were able to demonstrate the increased flow to the hand that is otherwised re-routed to the venous outflow

37 Massively swollen breast and arm A r/o DVT of the right UE was ordered Incidental finding: brachial artery to subclavian vein PTFE AVF 109 The brachial artery (inflow) was patent 110 The axillary vein was patent without evidence of thrombus

38 An AVF was noted at the antecubital fossa 112 The arterial anastomosis was patent 113 The AVF was patent at the antecubital fossa

39 The flow in the AVF was unchanged near the shoulder 115 Mosaic turbulence at the venous anastomosis at the right side of the chest at the SCV 116 Significant flow shift at the venous anastomosis

40 The proximal SCV was patent but the flow was continuous 118 The contralateral SCV for comparison No change with respiration, flow is more continuous on the right SCV when compared to the left 119 Visible tapering at the venous anastomosis

41 Distal SCV patent, but again, continuous, no flow to zero 121 Findings Due to the low flow in the proximal subclavian vein, a proximal or outflow stenosis was suspected This was demonstrated by comparing the flow to the contralateral SCV flow Due to the focal increase in flow at the venous anastomosis, a stenosis was present 122 Findings A fistulogram was performed that demonstrated near occlusion of the brachiocephalic vein and a stenosis of the venous anastomosis

42 Carotid duplex A 63 year old women who denies history of trauma or percutaneous interventions to the right neck area. The patient underwent dental work two days prior to onset of symptoms. These symptoms included right sided neck pain, sore throat and rigors with a fever of 103.7F. 124 The CTA of the neck revealed Pseudoaneurysm at the right carotid bifurcation measuring approximately 1.4 cm (AP) by 1.6 cm (TV) by 3.0 cm (SI) and moderate luminal stenosis of the proximal internal carotid arteries bilaterally. 125 In a transverse plane, the right carotid bifurcation was aneurysmal (1.5cm AP x 2.0 cm Trans) with significant mural thrombus in the bulb

43 There was no evidence of pseudoaneurysm on focused Doppler interrogation 127 The carotid duplex study demonstrated 50-69% internal carotid artery stenosis bilaterally, with a large ulcerated plaque in the right carotid bulb 128 An ultrasound image of the right and left carotid bifurcation

44 Diagnosis and treatment Resection of mycotic aneurysm of carotid artery with bypass from the common carotid to internal carotid artery utilizing greater saphenous vein. Broad-spectrum antibiotic therapy. Cultures from the aneurysm were positive for Group B streptococcus. No fungi were present. Operative findings confirmed a mycotic aneurysm of the right carotid bulb. 130 CTA of the neck showed no evidence of recurrent mycotic aneurysm during 1 month follow-up 131 Comparative images

45 Comparative images 133 Conclusion The findings on the carotid duplex study that included:. diffusely dilated intimal medial thickness aneurysmal dilatation of the carotid bulb lucent abnormality surrounding the carotid bulb 134 Left ICA occlusion in yr male with severe cardiac disease, cardiomyopathy History of left internal carotid artery dissection and total occlusion (images are unavailable) Blood flow velocity is within normal limits in the left CCA, ECA, and mid-extracranial vertebral artery. No flow is detected in the left ICA. Ophthalmic artery flow is normal in direction via the transorbital approach. Ultrasound visualization of the left carotid bifurcation is good. The CCA appears somewhat smaller in diameter than the right. Dense plaque is seen at the bifurcation. The ICA becomes narrow distally and no doppler signal is obtained within. IMPRESSIONS: 1. FUNCTIONALLY OCCLUDED LEFT ICA 2. MINIMAL DISEASE OF THE RIGHT CAROTID BIFURCATION

46 4 year follow up Left Carotid-date of study Left Carotid-date of study

47 5 year follow up year follow up year follow up

48 10 year follow up year follow up year follow up

49 Velocity data Left CCA Prox ICA Mid ICA Dist ICA Left ICA occlusion in 2002 What do you think is the status of the LICA? Patent? Occluded? Would you do any other tests? 146 Can you figure this one out? A 32 year old female Asymptomatic abdominal bruit. 4 months prior to this visit, her most recent pregnancy was complicated by a coronary artery dissection of the left anterior descending artery and myocardial infarction at approximately three weeks post delivery. She was managed initially in the coronary care unit on an intraaortic balloon pump and did not require percutaneous coronary intervention. Post discharge, the patient was managed medically and successfully completed cardiac rehabilitation

50 Duplex images 148 Duplex images 149 Duplex images

51 Duplex images 151 Duplex images 152 Duplex images

52 What do you think? Celiac artery stenosis? Technologist error? 154 Answer! Median Arcuate Ligament Compression (MALC) 155 Median Arcuate Ligament Compression (MALC) The CA artery peak systolic flow / diastolic flow at rest during suspended respiration was 318/ 170 cm/ sec. With deep inspiration the celiac artery flow decreased significantly to 200 / 70 cm/ sec. Using gray scale interrogation, the celiac artery trunk demonstrated evidence of luminal narrowing that resolved with deep inspiration

53 Carotid duplex 26 yr woman with abnormal carotid duplex at outside institution 157 Carotid duplex 158 Carotid duplex

54 Carotid duplex 160 Carotid duplex 161 Carotid duplex

55 Carotid duplex 163 Carotid duplex 164 Carotid duplex

56 Carotid duplex Proximal Mid Distal RICA 75 cm / sec LICA 72 cm / sec 122 cm / sec 137 cm / sec 232 cm / sec 212 cm / sec 166 Carotid duplex 167 Carotid duplex RICA LICA

57 Carotid duplex 169 Carotid duplex Fibromuscular dysplasia FMD elevated flow velocities in the mid distal portions of the artery suggests FMD 170 Carotid duplex 60 year old female, asymptomatic Known carotid artery disease presents for her annual evaluation. Previous study demonstrated bilateral 40-59% internal carotid artery stenoses and right external carotid artery stenosis. Patent vertebral arteries

58 Carotid duplex 172 Carotid duplex 173 Carotid duplex

59 Carotid duplex 175 Carotid duplex 176 Case 1 Severe stenosis at the origin of the left common carotid artery. Severe stenosis at the origin of the left internal carotid artery. Moderate stenosis at the origin the left external carotid artery.the left common carotid artery is asymmetrically smaller than the right. The left internal carotid artery has a string sign configuration. Moderate stenosis of the distal right common carotid artery. Severe, focal stenoses involving both right internal and external carotid artery origins. Severe stenosis of the brachiocephalic artery, at the junction of the right subclavian and right common carotid artery origins. Mild poststenotic dilatation of the right subclavian artery

60 Case 1 Severe stenosis at the origin of the left common carotid artery. Severe stenosis at the origin of the left internal carotid artery. Moderate stenosis at the origin the left external carotid artery.the left common carotid artery is asymmetrically smaller than the right. The left internal carotid artery has a string sign configuration. Moderate stenosis of the distal right common carotid artery. Severe, focal stenoses involving both right internal and external carotid artery origins. Severe stenosis of the brachiocephalic artery, at the junction of the right subclavian and right common carotid artery origins. Mild poststenotic dilatation of the right subclavian artery. 178 Carotid duplex 66 year old male with known carotid artery disease presents for his annual evaluation 179 Carotid duplex

61 Carotid duplex 181 Carotid duplex 182 Carotid duplex

62 Carotid duplex 184 Carotid duplex Severe stenosis and likely occlusion of the proximal brachiocephalic artery, with distal reconstitution.mild to moderate stenosis at the origin of the right subclavian artery, which is otherwise patent. Long segment severe (> 70%) and critical (> 90%) stenosis. Mild stenosis at the origin of the left vertebral artery, which arises from the aortic arch. 185 Thank you!