Doppler ultrasound as noninvasive diagnosis of peripheral arterial disease Poster No.: C-0246 Congress: ECR 2012 Type: Scientific Exhibit Authors: C. Ballester Valles, F. Aparici-Robles; Valencia/ES Keywords: Vascular, Extremities, Ultrasound, Stents, Arteriosclerosis, Obstruction / Occlusion DOI: 10.1594/ecr2012/C-0246 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 32
Purpose Describe our experience with Doppler ultrasound in limb arteries; analyze their signals and the technical difficulties. Page 2 of 32
Methods and Materials The ultrasonic imaging provides a non-invasive assessment of artery circulation in lower extremities, the main indications being the evaluation of the common femoral artery (CFA), superficial femoral artery (SFA) and popliteal artery (PA). The association of real-time study with gray scale, allows visualization of the vessel wall and disturbed areas, showing atherosclerotic plaques (Figure 1 and 2). The combination of gray scale and the pulsed Doppler allowed us to determine the grade of the stenosis and was useful in differentiating severe stenosis of occlusion (Figure 3). With the introduction of colour Doppler scan time reduction was achieved, as it allows longer vascular segments to be examined in a shorter time. (Figure 4 and 5) The colour flow Doppler study is now considered a necessity for peripheral arterial ultrasound. Allows to quickly identify areas of flow alteration, which could be characterized by spectral Doppler. The normal Doppler flow pattern in limb arteries is a triphasic high resistance wave. The Doppler ultrasound is useful to identify the vascular anatomy (Figure 6), determine presence and quantity of stenosis, type of stenosis and stenotic type of plaque, give complete information on the circulation proximal to the stenosis (Inflow) and distal to the stenosis (Outflow). The best and most reliable method of assessing the degree of stenosis is to compare peak systolic velocity (PSV). The evaluation with color Doppler allows quick location of the stenosis (Figure 7) and / or occlusion (Figure 8), and the duplex objectifies the velocity of the blood and assessment of blood flow morphology (Figure 9). Page 3 of 32
Images for this section: Fig. 1: CFA and bifurcation without plaques Page 4 of 32
Fig. 2: Calcified plaque in SFA Page 5 of 32
Fig. 3: Ultrasound dupplex: simultaneous exposure doppler information and grayscale image. Page 6 of 32
Fig. 4: Color Doppler normal SFA Page 7 of 32
Fig. 5: Image simultaneous grayscale and color Doppler diseased arteries withatherosclerotic plaques. Aliasing with color. Page 8 of 32
Fig. 6: A-Normal phase curve SFA PSV of 105 cm / sec. within normal limits. B-Normal phase curve PA PSV of 55 cm / sec. within normal limits. Normal values: PSV CFA and SFA 0.9 to 1.1 m / sec., PSV AP 0.4 to 0.7 m / sec. Page 9 of 32
Fig. 7: Atherosclerotic plaques and color Doppler aliasing Page 10 of 32
Fig. 8: Chronic Occlusion SFA Page 11 of 32
Fig. 9: Spectral Curve with pathologic loss of normal phase morphology and increased PSV. Page 12 of 32
Results The diagnosis of peripheral disease is established through the registration of a change in the pattern of flow in the Doppler spectrum proximal or distal to the site of arterial injury. The long-term arterial occlusions are associated with development of collaterals. Hemodynamically significant arterial injuries, which drops the period of early diastolic flow reversal to disappear as the lesion becomes more severe. Late diastolic component antegrade flow magnitude increases with increasing severity of the proximal lesions becoming a monophasic pattern with antegrade flow rates and low diastolic velocity range between 30-50% of peak systolic values (Figures 10-12). At the site of stenosis there is an increase of PSV and the color Doppler aliasing. To assess the degree of stenosis place the cursor in a 2 to 4 cm proximal to the stenosis and measure the PSV. Then move the cursor to the point of maximum flow disturbance and take the PSV Pico Systolic Velocity. To calculate the degree of stenosis calculate ratio B / A (Figures 13-15). Other indications are: Pulsatile mass: hematomas, pseudoaneurysms (Figures 16-19), and AVF (Figure 20) Diagnosis and monitoring of peripheral artery aneurysms (Figure 21 and 22) Monitoring of angioplasties and stents (Figures 23-26) Monitoring bypass grafts (Figure 27 ) Assessment of dialysis fistulas The limitations of Doppler ultrasound are: This technique is an operator-dependent technique Time-consuming No angiographic images It is not an easily reproducible technique Page 13 of 32
Images for this section: Fig. 10: Pathological Doppler spectral curve. Loss of early diastolic flow reversal and increased late diastolic with a decreased PSV. Page 14 of 32
Fig. 11: How to calcule grade of stenosis Doppler. Aplicaciones Clinicas de la Ecografia Doppler. Kenneth J.W.Taylor, Burns P y Wells P. Ed.Marban 1998 Page 15 of 32
Fig. 12: Doppler in the 1/3 half SFA showing aliasing area, and PSV increased with pathological wave. Ratio B/A 3.3, according to 75% stenosis Page 16 of 32
Fig. 13: Doppler in the 1/3 half SFA showing aliasing area, and PSV increased with pathological wave. Ratio B/A 3.3, according to 75% stenosis Page 17 of 32
Fig. 14: Doppler in the 1/3 half SFA showing aliasing area, and PSV increased with pathological wave. Ratio B/A 3.3, according to 75% stenosis Page 18 of 32
Fig. 15: Gray Scale pseudoaneurism after femoral catetherism. Page 19 of 32
Fig. 16: Colour Doppler pseudoaneurism after femoral catetherism. Page 20 of 32
Fig. 17: Colour Doppler at the neck of pseudoaneurism after femoral catetherism. Page 21 of 32
Fig. 18: Doppler at the neck of pseudoaneurism after femoral catetherism. Page 22 of 32
Fig. 19: Post-traumatic AVF Page 23 of 32
Fig. 20: Fusiform aneurysm with mural thrombus in popliteal artery Page 24 of 32
Fig. 21: Control popliteal aneurysm stent Fig. 22: Gray-scale control of patients with a 4 stents overlaped in SFA Page 25 of 32
Fig. 23: Color-Doppler control of patients with a 4 stents overlapped in SFA Page 26 of 32
Fig. 24: Doppler control of patients with a 4 stents overlapped in SFA Page 27 of 32
Fig. 25: Plain film of patients with a 4 stents overlapped in SFA Page 28 of 32
Fig. 26: Control ultrasound patient with By-Pass thrombosed femoral-popliteal (And overlapping stent was carryied in thrombosed SFA) Page 29 of 32
Conclusion Doppler ultrasound is the most sensitive non-invasive technique for the initial extension study in patients with ischemia of lower limbs. Provides all the information needed to plan medical treatment, endovascular or surgical. Must be used to select patients suitable for surgery or angioplasty prior to arteriography Operator-dependent technique, experience of the radiologist is essential for a good diagnostic yield Page 30 of 32
References Eco-Doppler arterial de miembros inferiores: la paradoja de la informacion cuantitativa y cualitativa. S.Lujan-Huertas. Angiologia 2005,57(1) 77-85 Guia completa de ultrasonografia vascular. Peter H.Arger, Suzanne DeBari Iyoob. Ed Journal Doppler. Cuello y extremidades. Joseph P.Polak. Ed.Marban 2008. Ultrasonografia Vascular. Laszlo J.Molnar, Giovanni Guido Cerri. Ed. Amolca Doppler. Aplicaciones Clinicas de la Ecografia Doppler. Kenneth J.W.Taylor, Burns P y Wells P. Ed.Marban 1998 Peripheral Arterial Disease: evaluation with color flow and duplex sonography. Polak JF. Radiologic Clinics of North America 1995; 33:71-90 Page 31 of 32
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