No financial or commercial relationships to disclose

Transcription

1 Deanna New, RVT

2 No financial or commercial relationships to disclose

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4 IAC REQUIREMENTS:

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6 The main duty of a sonographer is to make the physician or radiologists job easier by capturing images and doing preparatory work before the doctor sees the patient

7 I perform the correlations in our lab so when I m not scanning, I look at ultrasound studies/images I have seen many good and poor studies I have also seen many matches and misses When we have a miss, we can look back at our exam and really assess what happened (reporting error, poor imaging, etc) as well as what steps we can take in the future to prevent it In performing this task, it has become easier to understand exactly why it is important to give the information we give

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9 NATIVE CAROTID CRITERIA IN OUR LAB: PSV EDV RATIO 1-49% < 150cm/s < 90cm/s < % >150cm/s <90cm/s % >150cm/s >90cm/s > 4

10 PLAQUE MORPHOLOGY: Use descriptive words when referring to plaque characteristics The docs are counting on you to tell them a story

11 PLAQUE MORPHOLOGY: Irregular heterogeneous plaque Irregular heterogeneous & homogeneous plaque (or mixed)

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14 MPB SUGGESTS GREATER THAN VELOCITIES: Measure plaque in long and transverse to support that plaque may suggest greater degree of stenosis Put diameters in your Sonographer notes for the doctor to see

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16 ULCERATIVE PLAQUE: Crater type irregularity on the posterior wall of the ICA with color Doppler filling into the space Remember-some docs will treat these plaques more aggressively so it makes description even more important

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18 CALCIFIC PLAQUE OTHER TERMS: Dense plaque Calcific plaque Heavy plaque burden Plaque shadow

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20 FMD: Wall irregularity string of beads appearance with color Doppler

21 WAVEFORM CHARACTERISTICS: Use descriptive words when describing waveforms Early systolic deceleration To-fro Dampened waveforms Rounded or blunted peaks Tardus parvus Markedly abnormal Monophasic waveforms noted in the.

22 How would you describe this waveform? dampened abnormal blunted peak early systolic deceleration

23 In this case, investigate to find problem or suggest more proximal obstruction

24 THIS CASE WAS INNOMINATE ARTERY STENOSIS

25 IN SUMMARY Use explanatory words when referring to plaque characteristics Irregular/smooth plaque Heterogeneous/homogeneous or mixed plaque Crater type irregularities with color filling into the space Heavy plaque burden Calcific plaque with shadow Wall irregularity

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27 VDS CRITERIA: < 50% stenosis: No focal velocity elevation greater than 100% Multi phasic waveform with reverse flow component 50-99% stenosis PSV increase more than 100% from pre stenotic segment (VR > 2) Absent reversal of flow component Presence of PST Occlusion: Absence of color or spectral Doppler signals Pre occlusive thump proximally Monophasic distal waveforms

28 PROVING YOUR % STENOSIS: Our lab has implemented some new ways of reporting to ensure that we give most adequate % stenosis We are going into more detail: Instead of saying elevated velocities, we are using more evidence to support our 50-99% stenosis: Elevated velocities Color changes Narrowing Plaque PST Dampened waveforms distally Elevated VR On the other hand, if we feel like our findings suggest < 50% stenosis, we are using more evidence to support those findings as well Elevated velocities are noted, however, no visual narrowing or significant PST is identified. Elevated velocities are noted, however, waveforms distally remain triphasic.

29 OBTAIN VELOCITY PRX TO STENOSIS FOR VELOCITY RATIO:

30 OBTAIN HIGHEST VELOCITY:

31 OBTAIN A DST WAVEFORM TO PROVE PRESENCE OR ABSENCE OF PST:

32 ANOTHER EXAMPLE:

33 509/66cm/s VR 7.7

34 Elevated velocities Color changes VR 7.7 PST Findings suggest??? 50-99% stenosis

35 This particular patient had a bilateral transmetatarsal amputation and falsely elevated ABI making things tricky, so it is especially important that we grade % stenosis correctly

36 Findings suggest??? < 50% stenosis Color changes? PST? Normal waveform Downstream ABI 1.02

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40 Tibial disease Run off disease Or infrageniculate disease

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43 multilevel

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46 Femoral/popliteal

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48 VDS RENAL CRITERIA: Native renal artery: > 60% PSV > 200 cm/s EDV > 50 cm/s RAR > 3.5 Stented vessel: > 70% PSV >395 cm/s RAR 5.1 RI 0.8 or > suggests intrinsic kidney disease

49 List to the left shows normal parenchymal waveforms. Right side shows abnormal parenchymal waveforms. Remember though that these waveforms can also be found in LE, carotids, or mesenteric arteries.

50 Be aware of kidney size from right to left 2 cm difference is significant

51 Waveforms on the right: Dampened Tardus parvus Low flow

52 WHAT DO THOSE WAVEFORMS AND KIDNEY DIAMETERS TELL US?

53 More proximal disease significant stenosis occlusion Even if we couldn t visualize the renal artery on this exam, there is evidence to support disease is present

54 HOW DO WE REPORT THAT? Kidney size is smaller on the right when compared to the left Reduced color filling noted in the kidney with abnormal, dampened, and tardus parvus parenchymal waveforms Again, state that exam was difficult and limited Also use statement may suggest alternate imaging modality in this case since we didn t visualize everything

55 VDS MES CRITERIA: Native SMA > 70% PSV > 275 cm/s Native CEL > 70% PSV > 200 cm/s EDV > 45cm/s Native IMA > 70% PSV > 200 cm/s Stented SMA > 70% PSV > 412cm/s EDV 110 cm/s Ratio 8.45 Stented CEL > 70% PSV > 393 cm/s EDV 105 cm/s Ratio 5.75

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57 FINDINGS SUGGEST > 70% STENOSIS OF THE SMA: This makes things a little bit more difficult to report. While our velocities and PST support >70% stenosis, no visual narrowing is appreciated with B-mode, Color, or Power Doppler

58 WHAT DO YOU THINK OF THIS WAVEFORM? IN A NORMAL FASTING STATE, SHOULD THE SMA LOOK LIKE THIS?

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60 Elevated velocities Color changes Narrowing PST Dampened dst waveforms All of these findings support > 70% stenosis

61 Our goal is to give our doctor the most pertinent information to best treat that patient We should be extra aware of how we describe and word our findings as this can also become a legal issue Happy doctor = happy sonographer