Noninvasive Vascular Diagnosis

Second Edition

Ali F. AbuRahma and John J. Bergan, Eds.

Noninvasive VascularDiagnosisA Practical Guide to Therapy

Second Edition

Ali F. AbuRahma, MD, FACS, FRCS, RVT, RPVI John J. Bergan, MD, FACS, Hon FRCSProfessor UCSD School of MedicineChief, Vascular/Endovascular Surgery La Jolla, CADepartment of Surgery USARobert C. Byrd Health Sciences CenterWest Virginia UniversityandMedical Director, Vascular LaboratoryCo-Director, Vascular Center of ExcellenceCharleston Area Medical CenterCharleston, WV, USA

British Library Cataloguing in Publication DataNoninvasive vascular diagnosis : a practical guide to therapy. – 2nd ed.

1. Blood-vessels – Diseases – Diagnosis 2. Diagnosis, NoninvasiveI. AbuRahma, Ali F. II. Bergan, John J., 1927–616.1′3′0754

ISBN-13: 9781846284465ISBN-10: 1846284465

Library of Congress Control Number: 2006924879

ISBN-10: 1-84628-446-5 2nd edition e-ISBN 1-84628-450-3 2nd edition Printed on acid-free paperISBN-13: 978-1-84628-446-5 2nd editionISBN 1-85233-128-3 1st edition

© Springer-Verlag London Limited 2007

First published 2000Second edition 2007

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be repro-duced, stored or transmitted, in any form or by any means, with the prior permission in writing of thepublishers, or in the case of reprographic reproduction in accordance with the terms of licences issuedby the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should besent to the publishers.The use of registered names, trademarks, etc. in this publication does not imply, even in the absence ofa specific statement, that such names are exempt from the relevant laws and regulations and thereforefree for general use.Product liability: The publisher can give no guarantee for information about drug dosage and applica-tion thereof contained in this book. In every individual case the respective user must check its accuracyby consulting other pharmaceutical literature.

9 8 7 6 5 4 3 2 1

Springer Science+Business Mediaspringer.com

To my loving children,Zachary, Chelsea, and Joseph,for their patience and support

during the preparation of this book.Ali F. AbuRahma

I join in that dedication because of my admiration forAli and his splendid family.

John Bergan

Foreword to the Second Edition

Rapid development of sophisticated technology, as well as efforts by vascular surgeons to improve vascular care, has resulted in the widespread proliferation ofvascular laboratories throughout the United States in the last three decades.Prior to that, only a handful of vascular laboratories were available, and all servedas space for an academic surgeon to study peripheral circulation in humans. Earlyinstrumentation included the use of various types of cumbersome plethysmographs.The introduction of ultrasound technology in the 1970s ushered in a new era in non-invasive diagnosis. At present, noninvasive vascular diagnostic techniques havemuch wider applications, and there is a need for a book on noninvasive vasculardiagnosis to guide therapy. After all, effective treatment follows precise diagnosis.Noninvasive Vascular Diagnosis: A Practical Guide to Therapy, edited by Ali AbuRahma and John Bergan, is a welcome addition to the field of noninvasive diagnosis.

The continued refinement of duplex ultrasound technology has led to the gradualreplacement of indirect tests using plethysmography in the diagnosis of deep vein thrombosis or carotid artery disease. Duplex scan is now the dominant technology in vascular laboratories, and its use has extended to the diagnosis of chronic venous insufficiency, mesenteric ischemia, and disease of the renal artery. In addition to diagnostic use, duplex ultrasound has also found use in surveillance of patency of bypass or hemodialysis grafts and following carotidendarterectomy or stent placement. It also is helpful to map saphenous veins priorto infrainguinal bypass. In addition, use of duplex scan has evolved to therapeuticapplications, such as sclerotherapy for varicose veins, newer minimally invasive abla-tion procedures, injection of thrombin into pseudoaneurysms of the femoral arteryafter catheterization, and bedside placement of vena cava filter. Meanwhile, anklesystolic pressure recorded by a handheld Doppler probe, first introduced in 1969,has stood the test of time as a simple diagnostic test for arterial occlusive diseaseof extremities. Doppler ankle pressure is now widely used to grade degree ofischemia objectively and as a screening test for peripheral arterial disease and epidemiology study. Newer ultrasound technologies, such as transcranial Doppler,intravascular ultrasound, and 3-D ultrasound, have found new application in noninvasive vascular diagnosis.

The last three decades also have seen a rapid development of imaging technique,ushering in an era in which diagnosis and early detection of arterial and venousdisease can be readily made by a host of noninvasive diagnostic techniques.High-resolution ultrasound, magnetic resonance, and CT technology have completely changed the face of imaging techniques. At present, we have manychoices in imaging techniques that can be used alone or in combination to obtainthe needed diagnostic information. Arteriography by CT or MR has providedimages similar to those obtained by the traditional invasive contrast arteriography,thus significantly decreasing the clinical use of venography or invasive contrast arteriography.

There is no question that advancement of vascular care depends on technology.Noninvasive technology is now an important component in training of future generations of vascular surgeons. However, the widespread use of vascular labora-tories calls for quality control and certification of the laboratories as well as

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the technologists and physicians. Technology, when used wisely, benefits the patient;when used indiscriminately, it results in waste of time, energy, and resources.The reader is advised to follow the excellent guidelines and advice put forth in thisvolume by the editors and the group of distinguished contributors that they haveassembled.

James S.T. Yao, MD, PhDEmeritus Professor of Surgery

Division of Vascular SurgeryDepartment of Surgery

Northwestern University, Feinberg School of MedicineChicago, Illinois

Foreword to the First Edition

This book is remarkable when compared with books concerning the vascular diag-nostic laboratory of a few years ago, one of which Dr AbuRahma co-authored. Atthe present time, noninvasive diagnosis is dominated by duplex scanning and otherimaging modalities. Physiologic studies are being down-played. This is due to theincreasing dominance of the field by radiology-based laboratories. Therefore it is apleasure to see this book which covers both imaging and physiologic studies well,and does so in a problem-oriented format.

This volume does more than that. It addresses the full gamut of vascular laboratory operations including accreditation of laboratories and their personnel;it covers the basic physics of ultrasound instrumentation; and it treats thoroughly each of the four important components of vascular laboratory accreditation:cerebrovascular, peripheral arterial, venous and abdominal studies. The book also deals with a number of special areas which are peripheral to most vascular diagnostic laboratories but are included in their operations by some – three-dimensional imaging, intravascular ultrasound, magnetic resonanceangiography and Doppler flow wire to name just a few. This breadth of coverage has not been seen since the mammoth volumes of a decade ago that the late Gene Bernstein published as proceedings of his San Diego meetings.But this book differs from those volumes in that it is not a compendium of focused presentations for a meeting. It is instead a carefully organized comprehen-sive coverage of everything one would need to know and could expect to encounter in the most complete vascular laboratory operation conceivable.For example, the section on cerebrovascular diagnosis not only includes overviewsof clinical considerations and the various techniques, it provides individual chapters on carotid duplex examination, evaluation of the proximal aortic arch vessels, examination of the vertebral arteries and even descibes use of the transcranial Doppler. This then ends up with a clinical correlation chapter that critiques these competitive techniques and discusses their relative value in specific clinical settings. The intraoperative assessment of technical adequacy of carotid endarterectomy or angioplasty is described, for example;then the survey of a patient developing neurological deficits after operation is addressed; the postoperative surveillance after endarterectomy or angioplasty is detailed; the laboratory evaluation of the trauma victim is included; and examination of the patient presenting with vertebrobasilar symptoms is explained. Each major section has a final chapter such as this which brings all the preceding information together in a practical and meaningful summary forthe clinician.

As organized, this book is ideal for any physician of any specialty background,whether in training or in practice, who wants current and in-depth coverage of non-invasive vascular diagnosis from operations and administration, to credentialing, tofundamental techniques and their instrumentation or specific clinical applicationsin every conceivable setting.

The authors are to be commended for putting together such a compre-hensive text at this time of need to hold all the components of noninvasive diagnosis together as a traditional vascular diagnostic laboratory. The reader will

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benefit from their vision and from efforts of their well-selected contributing authors.

Robert B. Rutherford, MDEmeritus Professor of Surgery

University of Colorado

Preface

The purpose of this revision of what has become a very popular textbook is to high-light recent advances in the investigation of vascular disorders. The additions to thisvolume describe new methods of investigation and how they can be used to the bestadvantage of the patient by the physician. This volume is designed to instruct physi-cians on how to make a greater number of correct decisions regarding care and howto save some patients from unnecessary and expensive procedures.

Although it is nearly 200 years since John Hunter transformed vascular surgeryfrom a terrifying craft to a positive scientific success, there have been long stagnantperiods during which little progress could be seen. That is not true of the past 10years. During this time, the noninvasive vascular laboratory has become an essen-tial part of every general hospital. It is now a place where objective measurementscan be obtained on which prognosis and treatment can be based. There is a growingsophistication of methods and new terms have emerged that are at first sight unfa-miliar. This volume is designed to help guide the reader through these problems.

The rapid expansion of this field in the past several years, in terms of new modal-ities and new applications, justifies this second edition. A few examples of these arethe role of duplex technology in carotid stenting, the diagnosis of temporal arteri-tis, surveillance after percutaneous transluminal angioplasty/stenting of peripheralarteries, abdominal stent grafts for abdominal aortic aneurysms, and the use ofduplex ultrasound for bedside insertion of inferior vena cava filters. Interestingly,noninvasive vascular technology has spread from a very few early pioneers, mostlyvascular surgeons influenced by the late Gene Strandness, to a much broader groupof physicians, including neurologists, radiologists, cardiologists, and internists. Anentire corps of vascular technologists has evolved. There are now vascular sonog-raphers, a number of whom participate in the development of new and importantapplications of ever changing diagnostic equipment.With this in mind, this textbookis designed to be comprehensive enough to address the needs of all who are involvedin vascular diagnostic technology.

A new level of maturity and technological advancement in the field of noninvasivetesting has been reached and, as a result, 14 chapters of the current edition are newand 24 chapters have been radically revised.The section on cerebrovascular diagno-sis includes several new chapters: Carotid Plaque Echolucency Measured byGrayscale Median (GSM) Identifies Patients at Increased Risk of Stroke duringCarotid Stenting: The ICAROS Study, Duplex Ultrasound in the Diagnosis of Temporal Arteritis, Duplex Ultrasound Velocity Criteria for Carotid StentingPatients, Use of Transcranial Doppler in Monitoring Patients during Carotid ArteryStenting, and the Use of an Angle-Independent Doppler System for IntraoperativeCarotid Endarterectomy Surveillance. The section on peripheral arterial diseaseincludes the following new chapters: Rationale and Benefits of Surveillance afterProsthetic Infrainguinal Bypass Grafts, Rationale and Benefits of Surveillance afterPercutaneous Transluminal Angioplasty and Stenting of Iliac and Femoral Arteries,Duplex Ultrasound in the Diagnosis and Treatment of Femoral Pseudoaneurysms,Lower Extremity Arterial Mapping: Duplex Ultrasound as an Alternative to Arteriography Prior to Femoral and Popliteal Reconstruction, Noninvasive Diagno-sis of Upper Extremity Vascular Disease, and Protocol and Technique for DialysisUltrasound Surveillance. The section on venous disorders includes new chapters on

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Duplex Ultrasound Use for Bedside Insertion of Inferior Vena Cava Filters andVenous Stenting Using Intravascular Ultrasound (IVUS). In the section on deepabdominal Doppler, a new chapter was added on The Role of Color Duplex Ultra-sound in Patients with Abdominal Aortic Aneurysms and Stent Grafts.These reflectthe development of better methods and display the changing indications for use ofthe new technology. The earlier techniques must be placed in a proper perspective.

Several modalities are now described in this edition by new authors who wereselected because of their comparative knowledge of alternative and supplementaryapproaches. These new contributors and their increasingly diverse backgroundshave added immeasurably to the breadth of this volume. To these contributors, theprevious authors, and all of their staffs, the editors wish to express their full andmost sincere appreciation. We hope that the reader will enjoy dipping into thisvolume as much as we have enjoyed updating it.

Ali F. AbuRahmaJohn J. Bergan

Acknowledgments

This book owes much to our colleagues, who have contributed a great deal to thetext. Their particular interests and expertise add substance to this book. Withoutexception, they managed to submit intelligent and up-to-date contributions.

This volume survived thanks to the support of our technical staff, particularlyMona Lett in Charleston for transcribing and revising the various versions of thechapters and for maintaining contact with contributing authors regarding guidelinesand deadlines.

Our profound appreciation goes to Maynard Chapman for producing the major-ity of the illustrations used in this book. We appreciate the efforts of Kimberly S.Jarrett, Chief Vascular Technologist, Vascular Laboratory, Charleston Area MedicalCenter, Charleston, West Virginia for her assistance in providing some of the illus-trations for this book.

The Springer-Verlag publishing team and Grant Weston recognized the worth ofthis project. Hannah Wilson provided much invaluable support and guidance.Without the support of those named here, and many others, this edition could nothave seen the light of day.

Ali F. AbuRahmaJohn J. Bergan

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Contents

Foreword to the Second by James S.T. Yao . . . . . . . . . . . . . . . . . . . . . . . . . viiForeword to the First Edition by Robert B. Rutherford . . . . . . . . . . . . . . . . ixPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiiiContributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

SECTION I VASCULAR LABORATORY OPERATIONS

1 Improving Quality in Noninvasive Testing by Certification and Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1J. Dennis Baker and Anne M. Jones

2 Qualifications of the Physician in the Vascular Diagnostic Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Michael A. Ricci and Robert B. Rutherford

SECTION II BASIC PHYSICS

3 Principles and Instruments of Diagnostic Ultrasound and Doppler Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Kirk W. Beach, Marla Paun, and Jean F. Primozich

SECTION III CEREBROVASCULAR DIAGNOSIS

4 Overview of Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 33Ali F. AbuRahma

5 Overview of Various Noninvasive Cerebrovascular Techniques . . . . . 50Ali F. AbuRahma

6 Duplex Scanning of the Carotid Arteries . . . . . . . . . . . . . . . . . . . . . . . 60Ali F. AbuRahma and Kimberly S. Jarrett

7 The Role of Color Duplex Scanning in Diagnosing Diseases of the Aortic Arch Branches and Carotid Arteries . . . . . . . . . . . . . . . 89Clifford T. Araki, Bruce L. Mintz, and Robert W. Hobson II

8 Vertebral Artery Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Marc Ribo and Andrei V. Alexandrov

9 Transcranial Doppler Sonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Marc Ribo and Andrei V. Alexandrov

10 Ultrasonic Characterization of Carotid Plaques . . . . . . . . . . . . . . . . . 127Andrew N. Nicolaides, Maura Griffin, Stavros K. Kakkos,George Geroulakos, Efthyvoulos Kyriacou, and Niki Georgiou

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11 Carotid Plaque Echolucency Measured by Grayscale Median Identifies Patients at Increased Risk of Stroke during Carotid Stenting. The Imaging in Carotid Angioplasty and Risk of Stroke Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149A. Froio, G. Deleo, C. Piazzoni, V. Camesasca, A. Liloia,M. Lavitrano, and G.M. Biasi

12 Duplex Ultrasound in the Diagnosis of Temporal Arteritis . . . . . . . . . 155George H. Meier and Courtney Nelms

13 Duplex Ultrasound Velocity Criteria for Carotid Stenting Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Brajesh K. Lal and Robert W. Hobson II

14 Use of Transcranial Doppler in Monitoring Patients during Carotid Artery Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Mark C. Bates

15 Use of an Angle-Independent Doppler System for Intraoperative Carotid Endarterectomy Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . 176Manju Kalra, Todd E. Rasmussen, and Peter Gloviczki

16 Clinical Implications of the Vascular Laboratory in the Diagnosis of Cerebrovascular Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Ali F. AbuRahma

SECTION IV NONINVASIVE DIAGNOSIS OF PERIPHERAL ARTERIAL DISEASE OF THE EXTREMITIES

17 Overview of Peripheral Arterial Disease of the Lower Extremity . . . 207Ali F. AbuRahma

18 Overview of Noninvasive Vascular Techniques in Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Ali F. AbuRahma

19 Segmental Doppler Pressures and Doppler Waveform Analysisin Peripheral Vascular Disease of the Lower Extremities . . . . . . . . . 231

Ali F. AbuRahma and Kimberly S. Jarrett

20 Pulse Volume Recording in the Diagnosis of Peripheral Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Jeffrey K. Raines and Jose I. Almeida

21 Duplex Scanning for Lower Extremity Arterial Disease . . . . . . . . . . . 253Paul A. Armstrong and Dennis F. Bandyk

22 Duplex Surveillance of Infrainguinal Bypass Grafts . . . . . . . . . . . . . . 262Patrick A. Stone and Dennis F. Bandyk

23 Rationale and Benefits of Surveillance After Prosthetic Infrainguinal Bypass Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273Stephen Kolakowski, Jr., Keith D. Calligaro, Sandy McAffe-Benett,Kevin J. Doerr, Kathy Mueller, and Matthew J. Dougherty

24 Rationale and Benefits of Surveillance after Percutaneous Transluminal Angioplasty and Stenting of Iliac and Femoral Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279Evan C. Lipsitz and George L. Berdejo

25 Duplex Ultrasound in the Diagnosis and Treatment of Femoral Pseudoaneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Patrick A. Stone

Contents xvii

26 Lower Extremity Arterial Mapping: Duplex Ultrasound as an Alternative to Arteriography Prior to Femoral and Popliteal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293Enrico Ascher, Sergio X. Salles-Cunha, Natalie Marks,and Anil Hingorani

27 Preoperative Saphenous Vein Mapping . . . . . . . . . . . . . . . . . . . . . . . . 303Benjamin B. Chang, Ann Marie Kupinski, R. Clement Darling III,Philip S.K. Paty, Paul B. Kreienberg, Sean P. Roddy,Kathleen J. Ozsvath, Manish Mehta, and Dhiraj M. Shah

28 Noninvasive Diagnosis of Upper Extremity Vascular Disease . . . . . . . 312Jocelyn A. Segall and Gregory L. Moneta

29 Ultrasound Imaging of Upper Extremity Arteries: Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325Sergio X. Salles-Cunha

30 Protocol and Technique of Dialysis Ultrasound Surveillance . . . . . . . 334Niten Singh, Cameron M. Akbari, and Anton N. Sidawy

31 Noninvasive Evaluation for Congenital Arteriovenous Fistulas and Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341Robert B. Rutherford

32 Clinical Implications of the Vascular Laboratory in the Diagnosis of Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349Ali F. AbuRahma

SECTION V NONINVASIVE DIANOSIS OF VENOUS DISORDERS OF THE EXTREMITIES

33 Overview of Venous Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369John J. Bergan

34 Overview: Plethysmographic Techniques in the Diagnosis of Venous Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375M. Ashraf Mansour and David S. Sumner

35 Venous Duplex Ultrasound of the Lower Extremity in the Diagnosis of Deep Venous Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385Bruce L. Mintz, Clifford T. Araki, Athena Kritharis, and Robert W. Hobson II

36 Venous Imaging for Reflux Using Duplex Ultrasonography . . . . . . . . 394Jeffrey L. Ballard, John J. Bergan, and Lisa Mekenas

37 Duplex Ultrasound Use for Bedside Insertion of Inferior Vena Cava Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400JimBob Faulk and Thomas C. Naslund

38 Venous Stenting Using Intravascular Ultrasound . . . . . . . . . . . . . . . . 406Peter Neglén

39 Ultrasound Guidance for Venous Therapy: VNUS, Endovenous LaserTreatments, and Foam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414John J. Bergan and Luigi Pascarella

40 Clinical Implications of the Vascular Laboratory in the Diagnosis of Venous Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422John J. Bergan

xviii Contents

SECTION VI DEEP ABDOMINAL DOPPLER

41 Deep Doppler in the Liver Vasculature . . . . . . . . . . . . . . . . . . . . . . . . 431Peter N. Burns, Heidi Patriquin, and Michel Lafortune

42 Duplex Evaluation of the Renal Arteries . . . . . . . . . . . . . . . . . . . . . . 450Marsha M. Neumyer and John Blebea

43 Duplex Ultrasonography of the Mesenteric Circulation . . . . . . . . . . . 466David G. Neschis and William R. Flinn

44 The Role of Color Duplex Ultrasound in Patients with Abdominal Aortic Aneurysms and Stent Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . 476George H. Meier and Kathleen A. Carter

SECTION VII MISCELLANEOUS

45 Transcutaneous Oxygen Tension: Principles and Applications . . . . . . . 491Jeffrey L. Ballard

46 Role of Magnetic Resonance Angiography in Peripheral Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497Sandra Carr, William Turnipseed, and Thomas Grist

47 Intravascular Ultrasound Applications . . . . . . . . . . . . . . . . . . . . . . . . . 506Donald B. Reid, Khalid Irshad, and Edward B. Diethrich

48 Three-Dimensional Vascular Imaging and Three-Dimensional Color Power Angiography Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517Ali F. AbuRahma and Phillip J. Bendick

49 Contrast-Enhanced Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529Lyssa N. Ochoa, Esteban Henao, Alan Lumsden, and Ruth L. Bush

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547

Ali F. AbuRahma, MD, FACS, FRCS, RVT, RPVIProfessorChief, Vascular/Endovascular SurgeryDepartment of SurgeryRobert C. Byrd Health Sciences CenterWest Virginia UniversityandMedical Director, Vascular LaboratoryCo-Director, Vascular Center of ExcellenceCharleston Area Medical CenterCharleston, WV, USA

Cameron M. Akbari, MD, MBA, RVTSenior Attending in Vascular SurgeryDirector, Vascular Diagnostic LaboratoryDepartment of Vascular SurgeryWashington Hospital CenterWashington, DC, USA

Andrei V. Alexandrov, MD, RVTDirectorStroke Research and Neurosonology ProgramBarrow Neurological InstitutePhoenix, AZ, USA

Jose I. Almeida, MD, FACSMedical DirectorMiami Vein CenterandVoluntary Assistant Professor of SurgeryUniversity of Miami Miller School of MedicineMiami, FL, USA

Clifford T. Araki, PhD, RVTAssociate ProfessorDepartment of Medical Imaging SciencesUniversity of Medicine and Dentistry of New JerseySchool of Health Related ProfessionsNewark, NJ, USA

Paul A. Armstrong, DOAssistant ProfessorDivision of Vascular and Endovascular SurgeryUniversity of South Florida College of MedicineTampa, FL, USA

Enrico Ascher, MDVascular Institute of New YorkMaimonides Medical CenterBrooklyn, NY, USA

J. Dennis Baker, MDChief, Vascular Surgery SectionWest Los Angeles VA Medical CenterandProfessor of SurgeryDavid Geffen School of Medicine–UCLALos Angeles, CA, USA

Jeffrey L. Ballard, MD, FACSClinical Professor of SurgeryUniversity of California,Irvine School of MedicineandStaff SurgeonDepartment of Vascular SurgerySt. Joseph HospitalOrange, CA, USA

Dennis F. Bandyk, MDDivision of Vascular and Endovascular SurgeryUniversity of South Florida College of MedicineTampa, FL, USA

Mark C. Bates, MDSenior ScientistCardiovascular Research CAMC Health Education and

Research InstituteClinical Professor of Medicine and SurgeryRobert C. Byrd Health Sciences Center of West Virginia

UniversityCharleston, WV, USA

Kirk W. Beach, PhD, MDResearch ProfessorDepartment of SurgeryUniversity of WashingtonSeattle, Washington, USA

Contributors

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xx Contributors

Phillip J. Bendick, PhDDirector of Surgical ResearchDirector, Peripheral Vascular Diagnostic CenterDepartment of SurgeryWilliam Beaumont HospitalRoyal Oak, MI, USA

George L. Berdejo, BA, RVT, FSVUDirector, Vascular Diagnostic LaboratoriesMontefiore Medical Center and Jack D. Weiler HospitalsVascular LaboratoryBronx, NY, USA

John J. Bergan, MD, FACS, Hon FRCSProfessor of SurgeryUCSD School of MedicineLa Jolla, CA, USA

G.M. Biasi, MD, FACS, FRCSDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

John Blebea, MD, FACSProfessorChief, Section of Vascular SurgeryTemple University Health Sciences CenterPhiladelphia, PA, USA

Peter N. BurnsDepartment of Medical Biophysics and RadiologyImaging ResearchSunnybrook Health CentreUniversity of TorontoToronto, Ontario, Canada

Ruth L. Bush, MDAssistant ProfessorDivision of Vascular SurgeryandEndovascular TherapyMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

Keith D. Calligaro, MDChief, Section of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

V. Camesasca, MDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

Sandra C. Carr, MDDepartment of SurgeryUniversity of WisconsinMadison, WI, USA

Kathleen A. Carter, BSN, RN, RVT, FSVUTechnical DirectorVascular LaboratoryVascular and Transplant Specilists Virginia Beach, VA, USA

Benjamin B. Chang, MDAssociate ProfessorThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical College, Albany Medical Center

HospitalAlbany, NY, USA

R. Clement Darling III, MDProfessorChief, The Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

G. Deleo, MDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

Edward B. Diethrich, MDMedical DirectorArizona Heart Hospital and FoundationPhoenix, AZ, USA

Kevin J. Doerr, RVTSection of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Matthew J. Dougherty, MDSection of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Contributors xxi

JimBob Faulk, MDVascular Surgery FellowDepartment of Vascular SurgeryVanderbilt University Medical CenterNashville, TN, USA

William R. Flinn, MDDepartment of SurgeryDivision of Vascular SurgeryUniversity of Maryland School of MedicineBaltimore, Maryland, USA

A. Froio, MDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

Niki Georgiou, RNVascular Ultrasonographer/NurseVascular Screening and Diagnostic CentreAyios Dhometios, Nicosia, Cyprus

George GeroulakosDepartment of SurgeryCharing Cross HospitalLondon, UK

Peter Gloviczki, MDDivision of Vascular SurgeryMayo Clinic College of MedicineRochester, MN, USA

Maura Griffin, MSc (Hons), PhDChief Clinical ScientistVascular ClinicVascular Noninvasive ScreeningandDiagnostic CentreLondon, UK

Thomas Grist, MDDepartment of RadiologyUniversity of WisconsinMadison, WI, USA

Esteban Henao, MDVascular FellowDivision of Vascular Surgery and Endovascular TherapyMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

Anil Hingorani, MDVascular Institute of New YorkMaimonides Medical CenterBrooklyn, NY, USA

Robert W. Hobson II, MDProfessorDepartment of Surgery and PhysiologyUMDNJ-New Jersey Medical SchoolNewark, NJ, USA

Khalid Irshad, FRCSConsultant Vascular and Endovascular SurgeonKing Edward Medical CollegeLahore, Pakistan

Kimberly S. Jarrett, RVTTechnical Director, Vascular LaboratoryDepartment of SurgeryCharleston Area Medical CenterRobert C. Byrd Health Sciences Center of West Virginia

UniversityCharleston, WV, USA

Anne M. Jones, RN, BSN, RVT, RDMSInstructor in NeurologyTranscranial Doppler Consultant to Clinical TrialsDepartment of NeurologyMedical College of Georgia-AugustaAugusta, GA, USA

Stavros K. Kakkos, MD, MSc, PhDDepartment of Vascular SurgeryImperial CollegeLondon, UK

Manju Kalra, MBBSAssistant Professor Department of SurgeryDivision of Vascular SurgeryMayo Clinic College of MedicineRochester, MN, USA

Stephen Kolakowski, Jr.Section of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Paul B. Kreienberg, MDAssociate Professor Department of SurgeryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

xxii Contributors

Athena Kritharis, BAMedical StudentNew York University School of MedicineNew York, NY, USA

Ann Marie Kupinski, PhD, RVTDirector, Karmody Vascular LaboratoryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Efthyvoulos Kyriacou, PhDVisiting LecturerDepartment of Computer ScienceUniversity of CyprusNicosia, Cyprus

Michel Lafortune, MDUniversity of MontrealHôpital Saint-LucMontreal, Quebec, Canada

Brajesh K. Lal, MDAssistant ProfessorDivision of Vascular SurgeryUMDNJ-New Jersey Medical SchoolNewark, NJ, USAandAssistant ProfessorDepartment of Biomedical EngineeringStevens Institute of TechnologyHoboken, NJ, USA

M. Lavitrano, PhDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

A. Liloia, MDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

Evan C. Lipsitz, MDAssociate Professor Department of SurgeryMedical Director, Vascular Diagnostic LaboratoryMontefiore Medical CenterandThe Albert Einstein College of MedicineVascular LaboratoryBronx, NY, USA

Alan Lumsden, MB ChB, RVT, FACSProfessor and Chief Baylor College of MedicineDivision of Vascular Surgery

and Endovascular TherapyMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

M. Ashraf Mansour, MDDepartment of Surgery–Division of Vascular SurgerySpectrum Health Butterworth HospitalGrand Rapids, MI, USAandSouthern Illinois University School of MedicineSpringfield, IL, USA

Natalie Marks, MD, RVTVascular Institute of New YorkMaimonides Medical CenterBrooklyn, NY, USA

Sandy McAffe-Benett, RVTSection of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Manish Mehta, MD, MPHAssistant Professor Department of SurgeryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

George H. Meier, MD, RVT, FACSChief of Vascular SurgeryProgram Director–FellowshipDepartment of Vascular SurgeryEastern Virginia Medical SchoolandVascular and Transplant SpecialistsNorfolk, VA, USA

Lisa Mekenas, RVTVein Institute of La JollaLa Jolla, CA, USA

Bruce L. Mintz, DOClinical Assistant Professor of MedicineUniversity of Medicine and Dentistry of New Jersey

(UNDNJ)New Jersey Medical School (NJMS)andDirector, Venous Discase Clinic UMDNJ-NJMS University Hospital Nework, NJ, USA

Contributors xxiii

Gregory L. Moneta, MDProfessor and ChiefDivision of Vascular SurgeryOregon Health Science UniversityPortland, OR, USA

Kathy Mueller, RVTSection of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Thomas C. Naslund, MDAssociate Professor Chief, Vascular SurgeryDepartment of Vascular SurgeryVanderbilt University Medical CenterNashville, TN, USA

Peter Neglén, MD, PhDVascular SurgeonRiver Oaks HospitalFlowood, MS, USA

Courtney Nelms, BS, RVT, RDMSSenior Vascular TechnologistVascular and Transplant SpecialistsVirginia Beach, VA, USA

David G. Neschis, MDDepartment of SurgeryDivision of Vascular SurgeryUniversity of Maryland School of MedicineBaltimore, MD, USA

Marsha M. Neumyer, BS, RVT, FSVU, FAIUMInternational DirectorVascular Diagnostic Educational ServicesVascular Resource AssociatesHarrisburg, PA, USA

Andrew N. Nicolaides, MS, FRCS, FRCSEEmeritus Professor of Vascular SurgeryImperial CollegeLondon, UKandSpecial ScientistDepartment of Biological SciencesUniversity of CyprusNicosia, CyprusandDirectorVascular Screening and Diagnostic CentreNicosia, Cyprus

Lyssa N. Ochoa, MDSurgery ResidentMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

Kathleen J. Ozsvath, MDAssistant Professor Department of SurgeryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Luigi Pascarella, MDDepartment of BioengineeringUCSD School of MedicineLa Jolla, CA, USA

†Heidi Patriquin, MDDepartment of RadiologyUniversity of MontrealHôpital Sainte-JustineMontreal, Quebec, Canada

Philip S.K. Paty, MDAssociate Professor Department of SurgeryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Marla Paun, BS, RDMS, RVTResearch Trauma SonographerDepartment of SurgeryUniversity of WashingtonSeattle, WA, USA

C. Piazzoni, MDDepartment of Surgical Sciences and Intensive CareUniversity of Milano-BicoccaVascular Surgery UnitSan Gerardo HospitalMonza (MI), Italy

Jean F. Primozich, BS, RVTResearch Vascular TechnologistDepartment of SurgeryUniversity of WashingtonSeattle, WA, USA

†Deceased

xxiv Contributors

Jeffrey K. Raines, PhDDirectorVascular Laboratory and ResearchMiami Vein CenterandProfessor Emeritus of SurgeryUniversity of Miami Miller School of MedicineMiami, FL, USA

Todd E. Rasmussen, MDWilford Hall USAF Medical CenterLackland Air Force BaseTX, USA

Donald B. Reid, MD, FRCSConsultant Vascular and Endovascular SurgeonWishaw HospitalScotland, UK

Marc Ribo, MD, PhDUnitat Neurovascular Vall d’HebronBarcelona, Spain

Michael A. Ricci, MD, RVTProfessor of SurgeryDivision of Vascular SurgeryUniversity of Vermont College of MedicineBurlington, VT, USA

Sean P. Roddy, MDAssociate Professor Department of SurgeryThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Robert B. Rutherford, MDEmeritus Professor of SurgeryFormerly at University of Colorado Health Science

CenterColorado, USA

Sergio X. Salles-Cunha, PhD, RVT, FSVUClinical Research DirectorJobst Vascular CenterToledo, OH, USA

Jocelyn A. Segall, MDVascular FellowDivision of Vascular SurgeryOregon Health and Science UniversityPortland, OR, USA

Dhiraj M. Shah, MDProfessorDepartment of SurgeryDirectorThe Vascular Group, PLLCThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Anton N. Sidawy, MD, MPH, FACSChief, Surgical ServicesVA Medical CenterandProfessorDepartment of SurgeryGeorge Washington and Georgetown UniversitiesWashington, DC, USA

Niten Singh, MD, MSVascular FellowDepartment of Vascular SurgeryWashington Hospital Center/Georgetown UniversityWashington, DC, USA

Patrick A. Stone, MDAssistant ProfessorVascular and Endovascular SurgeryRobert C. Byrd Health Sciences CenterCharleston, WV, USA

David S. Sumner, MDDepartment of Surgery–Division of Vascular SurgerySpectrum Health Butterworth HospitalGrand Rapids, MI, USAandSouthern Illinois University School of MedicineSpringfield, IL, USA

William D. Turnipseed, MDDepartment of SurgeryUniversity of WisconsinMadison, WI, USA