Carotid Duplex: Beyond Stenosis Ido Weinberg, MD Vascular Medicine Massachusetts General Hospital Assistant Professor of Medicine Harvard Medical

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1 Carotid Duplex: Beyond Stenosis Ido Weinberg, MD Vascular Medicine Massachusetts General Hospital Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts

2 Disclosures I do not have any disclosures pertaining to this talk

3 Which of the following people need a carotid ultrasound? 76 year old man who has been found to have a bruit over his right cervical area. He has known aortic stenosis 81 year old woman who has been becoming progressively demented over 3 years 24 year old woman who has recently lost consciousness after urinating 51 year old woman with difficult to control hypertension and a swooshing sound in her left ear

4 Mr. Anderson

5 Mr. Anderson s Exam Blood Pressure 160/106 mmhg bilateral Pulse 82 and regular Harsh left cervical systolic bruit at the angle of the jaw No right cervical bruit No diastolic bruit No cardiac murmur No palpable AAA Normal extremity pulses

6 When is an ultrasound indicated? A bruit is heard over the neck A patient had a stroke or transient ischemic attack or has experienced transient visual disturbances Following a carotid operation or stent

7 Carotid Duplex Ultrasonogrpahy Visualizes: Vertebral artery

8 Advantages of Ultrasound

9 Direct Arterial Visualization ECA CCA ICA

10 Plaque Visualization

11 Non-arterial Information Internal jugular vein patency Thyroid nodules Masses

12 Inexpensive

13 Portable

14 Highly Accurate and Reliable

15 In Competent Hands

16 Common Pathologies and Uncommon Findings in Carotid Duplex Ultrasound

17 Remember Mr. Anderson?

18 Proximal Internal Carotid Artery Stenosis

19 Post-Stenotic Turbulence

20 Bart Simpson Waveform

21 Let s Review the criteria again ICA Qualitative Stenosis 1) % Stenosis 2) Peak Systolic Velocity (PSV) 3) End Diastolic Velocity (EDV) ICA / CCA Ratio Normal 4) 0-19% 4) <105 cm / sec Mild 20-49% > = 105 <150 cm / sec Moderate 50-69% > =150 <250 cm / sec >2.0-<4.0 Severe 70-89% > 250 cm /sec <135 cm/ sec > 4.0 Very severe 5) 90-99% 5) > 250 cm/ sec 5) >135 cm /sec > 5.0 Occluded 100%

22 Meet Michelle She is 43 She has been hearing a whooshing sound in her left ear for the past couple of years It is driving her crazy

23 Distal internal carotid artery stenosis

24 We see Bill once a year Bill is a 78 year old retired trucker This is a picture taken when he was younger

25 Bill had a carotid endarterectomy

26 Now Bill is Post-CEA

27 Post CEA Wide Somewhat ectatic Make sure there isn t a flap Follow up routine

28 But wait, there s more

29 Bill has a stent on the other side

30 Carotid Stent Duplex US Criteria Are Different than Native Arteries % Stenosis PSV EDV ICA/CCA Ratio In stent stenosis Patent <50% <150 cm/ sec <100 <4.0 Indeterminate?>50% >150-<300 <100 <4.0 Hemondynamically significant >75% >300 with post stenotic turbulence >100 >4.0 30

31 How often do you routinely scan after a carotid intervention? A. Every 6 months B. Annually C. After 1 month, 6 months and then annually D. I don t scan after CEA and I scan annually after a stent

32 Cardiac Disease

33 Post-irradiation changes

34 Vasculitis

35 Dentists, Chiropractors and Roller Coasters have something in common

36 Anna is 17 and delicate

37 She went on a roller-coaster ride

38 After getting home she had some problems Left arm tingling Left facial droop

39 Carotid artery dissection

40 Normal Vertebral Arteries

41 Vertebral Artery Stenosis

42 I can t clean my living room Martha is 65. She is complaining she cannot clean her house anymore without fainting. This has happened 3 times. She is still smoking 1 ppd She doesn t like doctors and has not had regular checkups For years she has suffered from left arm pain

43 Vertebral Artery Flow Direction

44 Vertebral Artery Reverse Flow

45 Pre-Steal

46 Non Vascular Pathology

47 Thyroid Nodule

48 Vascular Mass

49 Artifacts

50 Aliasing

51 Shadowing

52 What are these lines?

53 What are these lines?

54 It is a snoring artifact

55 Summary Carotid artery ultrasound should be used for appropriate indications It is accurate, easy, relatively cheap Beware of artifacts Look beyond the carotid arteries