2019 2 10 vascular criteria final - clinicalultrasound.net 10 vascular criteria final.pdf•...

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Vascular Ultrasound

Criteria Update“A pulsating

numbers game”

• Use of Numbers• “What is good criteria”• Current: Literature, Monash & Why

Overview

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric

CVI

AVF

• Not a “gut” instinct- Change ++ since 80-90’s• Consistent• Evidence based

In US-What’s the good thing about numbers

Old Evidence Minimal evidence Tiny threshold/ Big significance

Applies to Vascular Ultrasound

In US- Problem with numbers?

• Poor evidence/ Ltd trials• Changing intervention• Quality & type

• Impacts thresholds

• Two Major Contributors• Patient variability• Circulatory characteristic

Vascular US- Problem with numbers?

• Basic flaw in spectral Doppler• Angle correction• Presume – Know the direction flow• High grade stenoses- Marked turbulence• No way of knowing –Which angle ? Colour doesn’t help• WARNING Error – Up to twofold

Vascular US- Problem with numbers?

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• Begin with the premise…

• Ultrasound Criteria:• Poor evidence

•High variability

• Imperfect technology

The place to begin…

• High Sensitivity• Pick up as many as possible

• High Specificity• All that test positive- Are abnormal

• Ultrasound• Primary imaging modality• Correlated with 2° testing

• Slight bias- “Sensitivity”

• Best Practise• Evidenced based criteria• Validated: Local Audit

Criteria

Example - >230cm/s 70-99% stenosis

At the end of every test…

Apply the

“does it make sense rule”


Apply the

“does it make sense rule”

? Classification

0-50% High end of range or 50-6%

CCA- 92 cm/s

ICA- 155 cm/s


ICA- 155 cm/s

• “What is good criteria”• Current: Literature, Monash & Why

Overview

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric

Chronic Venous Insufficiency

AVF

ICA

ICA – Post Endarterectomy

CCA

ECA

Stents

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Why do we perform a “carotid colour duplex”

• Paradigm• Stroke• Haemorrhagic (15%)

• Embolic/Ischaemic (85%)• Cardio-embolic/ Carotid

Criteria: ICA stenosis

• Plaque• Composition

• Shearing forces• Stenosis (PSV)

ICA

• Paradigm• Stroke• Haemorrhagic (15%)

• Embolic/Ischaemic (85%)• Cardio-embolic/ Carotid


• Symptomatic / > 70-99%• Benefit CEA NASCET 2009

• Symptomatic / > 50-69%• Increased med surveillance

Need US Criteria: Predict stroke

• 5 Key Recommendations

• ASUM Revised 2008

• US Consensus Grant 2003

• Meta-analysis Jahromi 2005

• DEGUM 2010 Deutsche Gesellschaft fu�r Ultraschall in der Medizin

• Multiparametric

• Neurosonology Research Group Stroke 2012


• US Consensus (Grant et al)

•

• 50-69%: 125 cm/s• 70-99%: 230 cm/s

Criteria: ICA

• US Consensus (Grant et al) Meta-analysis (Jahromiet)

•

• 50-69%: 125 cm/s 130 cm/s

• 70-99%: 230 cm/s 200 cm/s

• V similar• Using the same evidence

Criteria: ICA

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Criteria: Back to this case…?

91 cm/s

155 cm/s

63 yo TIA

Rt ICA

• 50-69%: 125 cm/s 130 cm/s

• 70-99%: 230 cm/s 200 cm/s

CTA < 50% • Monash Audit Data• PSV alone

• Monash Data• ICA: CCA ratios-Worse

• EDV-Worse

• What else: The B-mode?

Criteria: ICA

Overcalled

Undercalled

1759 ICA’s

n= 92 inclusions

• Morales 2018

• We know this…. What to do?

Criteria: ICA

• Measure B-mode• % diam- poor predictor

• % area- poor predictor

• NASCET measurement

• Issues• Shadowing

• Accurate represetative image

• But... contains information

Criteria: ICA

• DEGUM 2010

• Deutsche Gesellschaft fur Ultraschall in der Medizin

• Multiparametric

• 10th % iles• Uses • NASCET• Ave PSV

• PS PSV• Collats• EDV• Turbulance

• Emphasis- B-mode / Colour

Criteria: ICA

• Neurosonology Research Group Stroke 2012

• Confusing

• V interpretive

• Trend• Multiparametric

• 10 % iles

Criteria: ICA

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• Monash• US Consensus + B-mode NASCET

• Low/ High end of range

• Future-• 10 % iles

• More sophisticated analysis• ? AI

Criteria: ICA

• Sweden is famous for…

ICA Criteria: A Final Word

• National Swedish Trial

• 10 Centres c/- Angiography

>80 % stenosis

0-49 degrees - > 210 cm/s50-62 degrees - > 320 cm/s

The Literature: ICA Stenosis

Recommendations

Swedish Quality Board for Carotid Surgery

30 degrees 169 cm/s60 degrees 272cm/s

Classification is angle dependant !

• Pre Surgical criteria • Does NOT apply

• Morphology• Velocities• Probably higher

• Surveillance• Compare to baseline

• Neointimal hyperplasia- Be careful• Isoechoic

Carotid Endarterectomy: Criteria

www.vesalius.com

ICA – Post Endarterectomy

>50% >220cm/s ICA/ CCA > 2.7

>80% >340cm/s ICA/ CCA > 4.15

Carotid ICA Stent: Criteria

JVS 2008

ICA Stents

2:1 ratio - > 50 %3.5:1 ratio - > 85%Damped - > 60% origin

compared to

NASCET, Diameter

Criteria: CCA

JVS 2015

CCA

118 cm/s

285 cm/s

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Critera : ECA

Mild Moderate Severe

ECA

• Carotid

Questions?

• Carotid

Questions?

How long is a giraffe’s carotid artery?

• Carotid

Questions?

How long is a giraffe’s carotid artery?

1.6m

Criteria Update

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric


AVF

Native Renal Arteries

Transplant Renal Arteries

RA Stents

• Integrated• Direct Assessment

• Indirect Assessment

• Direct• RAR 3.0:1 PSV> 200cm/s (House 1999)

• Indirect• Qualitative

• Not measurements

Renal Arteries: Traditional View

Superior

Inferior

Mid

Normal Abnormal

38yo woman Severe Hypertension

(PSV> 200cm/s- Generally high- 200-300 cm/s)

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• Criteria

• PSV> 200cm/s (House 1999)• RAR 3.0:1

• 47 yo hypertensive male• Ao- 85cm/s

• PSV mid- 253cm/s

A Case

• Criteria

• PSV> 200cm/s (House 1999)• RAR 3.0:1

• 47 yo hypertensive male• Ao- 85cm/s

• PSV mid- 253cm/s

• Small increase from prox, Mid vessel, No SB,

A Case

Journal Of Vascular Surgery2012 Oct;56(4):1052-9

Largest reported study

Patients 313 Renal Arteries (606)

Exclusions 20 (inc 11 inadequate imaging)

Technical success rate- 98%

Normal 210/606 < 60% stenosis 158/606

> 60% stenosis 207 /586 + 31 occlusions

ROC curve analysisPSV 285 cm/s or

RAR of 3.7

Renal Arteries: CriteriaJournal Of Vascular Surgery

2012 Oct;56(4):1052-9



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• PSV > 285 cm/s or RAR > 3.7• High index of suspicion : RAS

• Confirm with B-mode/ Colour (Hi res)

• PSV > 200 cm/s RAR > 3.0• Moderate index of suspicion : RAS

• Confirm with B-mode/ Colour (Hi res)

• Report in context of• I/R , B-mode/ Colour, P/S turbulence

Recommendation: Criteria

16 yo Takayasu Arteritis

• If RAS- Important: Record RI

Resistive Index: RAS

RI Threshold: Intervention Radermacher 2003

RAS ultrasound +intervention: 138/5950

Successful intervention- Angioplasty/ Stent =131

RI >0.8(27%)

RI <0.8(73%)

worse renal function 80%

improvedrenal function 94%

Or 0.75Yuksel 2012

Native Renal Arteries

• Technically Difficult

• Less common• Older /Vasculopaths

• Re-stenosis rate 10-20% (Del Conde 2014)

• Similar Criteria

• PSV: 240 cm/s RAR : 2.9:1 (Del Conde 2014)

Renal Artery :Stents

RRA stent

RA Stents

• Reasonably Established• RI <0.8• Useful as a marker – dysfunction

• Useful in Surveillance

• PSV = 200-300 cm/s Haemodynamically significant

• Marker for RAS

• Closer Sx

• PSV = > 300 cm/s• Haemodynamically significant

Criteria: Renal Transplant

349cm/s

Transplant Renal Arteries

Criteria: Renal Transplant Day 1

• 2012 Audit• n = 346 transplants from 2007 – 2011• Endpoint – Re-do surgery or

Graft Failure <12 months

Criteria: Renal Transplant Day 1

Audit performed by Greg Curry

t On-going Renal Transplant

t Redo Surgeryt Renal Tx failure

(<12 months)

Redo had RI’s of 0.32, 0.4 and 0.59…”

Redo had PSV’s of 460 and 477 cm/s…”

Key Numbers Day 1RI < 0.5PSV > 400cm/s

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• Renal

Questions?

How long is a elephants kidney?

• Renal

Questions?

How long is a elephants kidney?

34cm

Criteria Update

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric


AVF

• Peripheral Vascular Ultrasound• Complicated by• Multi-segment • Small vessel disease• Branching / collaterals

• Intervention• Not precise %

• ABI’s• Excellent• Primary Diagnosis/ Surveillance

Criteria: Peripheral Vascular

Cystic Adventitial Disease BS

• Criteria• Composite Small trials (mid 80’s)

• Three basic rules• Waveforms: Important

• Ratio- Contained system works

• Ration- Not contained system• Eg Bifurcation, Collaterals- Doesn’t work


xx2

• Primary criteria (x / x2 )• Ratio > 2 (1.8-2.5) >50% Cossman 1989

• Ratio > 3 more likely to early occlude Whyman 1993

• Ratio > 4 >75% Cossman 1989

• Ratio criteria >7 90% Ranke C 1992

• Aorto-iliacs• >200cm/s >50 %

• >400cm/s >75 % de Smet 1996

• Sens. 96% Spec 55%


xx2

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Criteria Update

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric


AVF

SMA

Coeliac Axis

IMA

• Established

• Coeliac Axis• PSV > 200 cm/s >70%

• SMA• PSV > 275 cm/s >70%

• IMA• 200cm/s > 60%

> 3.5:1 Moneta 1986

Mesenteric

65yo SMA stenoses

• Relatively new

• Celiac Axis

• PSV > 200 cm/s >70% PSV 240cm/s >50% PSV 320 cm/s >70%

• SMA

• PSV > 275 cm/s >70% PSV 295cm/s >50% PSV 400 cm/s >70%

• IMA• PSV > 200cm/s > 60% No Update

• EDV Can be used / Not as good

Mesenteric

• Post prandial – Not required

• Imaging• Inspiration, expiration, & erect

• Describe : Median Arcuate Ligament syndrome

Mesenteric

https://radiopaedia.org/articles/coeliac-artery-compression-

syndrome

Criteria Update

Carotid

Renal Arteries

Peripheral Arterial

Mesenteric


AVF

• Lifeline • End Stage Renal Failure

• Surveillance• Troubleshooting

• Old paradigm• Use velocities

AVF

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• Current paradigm• Not PSV’s

• Don’t grade stenosis

• Measurement• >3mm – Normal

• 1.5-3.0 mm – At risk (Could impact function)• (Not mild moderate)

• <1.5 mm – High risk / Severe

AVF

Narrowing – CV/ SCV

• Volume • Predict dysfunction

• RC fistula < 500 cc/ min

• High quality documentation

AVF

Looks about right….? Same vessel in same spot.. With correct calliper placement

1277 cc/min vs 551 cc/min.. Overestimated by >2 times!!

Criteria Update

Carotid

Renal Arteries

Peripheral Arterial


AVF

Mesenteric

• Identify• Patterns of CVI – Guide Tx

• Traditionally• Definition : Reflux – > 0.5 or 1sec

• Size of perforator- > 3 or 4 mm

Criteria: Chronic Venous Insufficiency CVI

• Reflex times/ Perforator size• Depends of clinical presentation

• Change: Treatment Options

• EVLT +/- sclerotherapy• Careful documentation • Reflux patterns

• Vein size (Threshold – too small / too big)• Intra or extra-fascial

• Minimum -10cm Intrafascial GSV

Criteria: Chronic Venous Insufficiency

• Vascular Criteria• Small series

• Very slow evolution

• Snapshot• Haven’t discussed -Technical impacts • Spectral Doppler angle.

• Large Variability• Physiologic states

• “Does it make sense”• B-mode Colour Spectral

“The Wrap-Up”

Typical SFA stenosis

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Questions?

Greg Curry

MH:Sonographers

MH Radiologists

Acknowledgements

2019 2 10 vascular criteria final - clinicalultrasound.net 10 vascular criteria final.pdf•...

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