4/19/2013 Dennis Bandyk, MD I have no disclosures Is Carotid Duplex Ultrasound Testing Alone Enough for Carotid Intervention Dennis F. Bandyk, MD Vascular & Endovascular Surgery Sulpizio Cardiovascular Center UCSF Symposium No disclosures April 19, 2013 Sites of Pulsed Doppler Recording for Donald Eugene Strandness, Jr, MD Duplex Studies of the Extra-cranial (1928-2002) Carotid and Vertebral/Subclavian Arteries Professor of Surgery – University of Washington “Father of Noninvasive Vascular Testing” “Of course duplex testing Most diseased is enough prior ICA segment to CEA Sites for ICA/CCA ratio measurement Normal CCA 1
4/19/2013 Algorithm for the Management of Extracranial Carotid Stenosis Goals of Carotid Duplex Testing Clinical Asymptomatic Patient Indication - accurately identify high-grade ICA stenosis Stenosis - exclude severe proximal & distal stenotic lesions Severity - identify disease extent and “normal” distal ICA - serial testing; diagnose ICA disease progression Medical Status Symptomatic Patient - identify presence of ICA stenosis – intra-plaque hemorrhage Surgical - determine severity and extent of extracranial disease Risk - identify lesions that require additional arterial imaging - CCA/ICA dissection - “string sign” ICA stenosis - ICA aneurysm - lumen thrombus distal to high-grade stenosis Sacco, R. L. N Engl J Med 2001;345:1113-1118 Estimation of ICA Stenosis Diameter Reduction SOCIETY OF RADIOLOGISTS IN ULTRASOUND Consensus Conference on Carotid Ultrasound PSV ICA ICA/CCA EDV ICA Plaque >50% DR Ratio Normal < 125 cm/s < 2 < 40 cm/s None < 125 cm/s < 40 cm/s Present, < 50% < 2 >60% DR < 50% DR 125-230 cm/s 40-100 cm/s Present, 50-69% 2.0 – 4.0 >50% DR >70% >230 cm/s > 4 > 100 cm/s >50% DR >70% DR stenosis May be low of High-grade Near Variable Variable undetectable Occlusion lumen reduction >80% DR Not Occluded Occlusion No flow Not Applicable Applicable lumen Interpretor disagreement in 8-17% Beach KW, et al Vasc & Endovasc Surg 2012 2
4/19/2013 Comparison of Duplex Scanning with Cerebral Arteriography In Patients Undergoing Carotid Endarterectomy >70% stenosis PSV >280 cm/s, native arteries Arteriography PSV >320 cm/s, stented ICAs Duplex Scan <50% 50-74% 75-99% Occlusion <50% 18 0 0 0 50-74% 6 8 3 0 PSV>125 cm/s 75-99% 1 10 24 0 >70% stenosis (EDV>125cm/s) EDV >104 cm/s, native arteries Occlusion 0 0 0 4 EDV >132 cm/s, stented ICAs Agreement with arteriography in 54 (73%) of 74 ICAs Agreement with arteriography in 54 (73%) of 74 ICAs - Over-estimation was the most common disagreement error - - Over-estimation was the most common disagreement error - Beach KW, et al Vasc & Endovasc Surg 2012 A Final Comment from Dr Strandness National Consensus for Interpretation of “Significant “ ICA Stenosis? Remember, I used EDV>140 cm/s in Symptomatic Patient my asymptomatic patients as a Heterogenous ICA bulb plaque criteria for ICA PSV > 150 cm/s intervention Asymptomatic Patient Heterogenous ICA bulb plaque ICA PSV > 300 cm/s EDV > 100 cm/s ICA/CCA ratio > 4 3
4/19/2013 Conclusion • Carotid intervention based on duplex testing is safe and performed by the majority vascular surgeons. • Additional arterial imaging, typically CTA, should be patient specific and based on clinical presentation and duplex testing results. • Symptomatic patients should have routine brain imaging (CTA, MRA/MRI) and in selected cases TCD. 4
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