4/19/2013 Dennis Bandyk, MD I have no disclosures Is Carotid - - PowerPoint PPT Presentation

4/19/2013 1

Dennis F. Bandyk, MD Vascular & Endovascular Surgery Sulpizio Cardiovascular Center

UCSF Symposium April 19, 2013

Is Carotid Duplex Ultrasound Testing Alone Enough for Carotid Intervention

Dennis Bandyk, MD I have no disclosures

No disclosures

Donald Eugene Strandness, Jr, MD (1928-2002) Professor of Surgery – University of Washington “Father of Noninvasive Vascular Testing”

“Of course duplex testing is enough prior to CEA

Sites of Pulsed Doppler Recording for Duplex Studies of the Extra-cranial Carotid and Vertebral/Subclavian Arteries Sites for ICA/CCA ratio measurement Normal CCA Most diseased ICA segment

4/19/2013 2 Goals of Carotid Duplex Testing

Asymptomatic Patient

• accurately identify high-grade ICA stenosis
• exclude severe proximal & distal stenotic lesions
• identify disease extent and “normal” distal ICA
• serial testing; diagnose ICA disease progression

Symptomatic Patient

• identify presence of ICA stenosis – intra-plaque hemorrhage
• determine severity and extent of extracranial disease
• 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

Algorithm for the Management of Extracranial Carotid Stenosis

Stenosis Severity Clinical Indication Medical Status Surgical Risk

Estimation of ICA Stenosis Diameter Reduction

Interpretor disagreement in 8-17%

>50% DR >60% DR >70% DR >80% DR

Beach KW, et al Vasc & Endovasc Surg 2012

SOCIETY OF RADIOLOGISTS IN ULTRASOUND Consensus Conference on Carotid Ultrasound PSVICA

ICA/CCA Ratio

EDVICA Plaque Normal

< 125 cm/s

< 2

< 40 cm/s None

< 50%

< 125 cm/s

< 2

< 40 cm/s Present, < 50% DR

50-69%

125-230 cm/s

2.0 – 4.0

40-100 cm/s

Present, >50% DR

>70%

>230 cm/s

> 4

> 100 cm/s >50% DR stenosis Near Occlusion

May be low of undetectable

Variable Variable

High-grade lumen reduction

Occlusion No flow Not Applicable

Not Applicable Occluded lumen

4/19/2013 3

Duplex Scan Arteriography

<50% 50-74% 75-99% Occlusion

<50%

18

50-74% PSV>125 cm/s

6 8 3

75-99% (EDV>125cm/s)

1 10 24

Occlusion

4

Comparison of Duplex Scanning with Cerebral Arteriography In Patients Undergoing Carotid Endarterectomy Agreement with arteriography in 54 (73%) of 74 ICAs

• Over-estimation was the most common disagreement error -

Agreement with arteriography in 54 (73%) of 74 ICAs

• Over-estimation was the most common disagreement error -

>70% stenosis PSV >280 cm/s, native arteries PSV >320 cm/s, stented ICAs >70% stenosis EDV >104 cm/s, native arteries EDV >132 cm/s, stented ICAs

Beach KW, et al Vasc & Endovasc Surg 2012

National Consensus for Interpretation

• f “Significant “ ICA Stenosis?

Symptomatic Patient

Heterogenous ICA bulb plaque ICA PSV > 150 cm/s

Asymptomatic Patient

Heterogenous ICA bulb plaque ICA PSV > 300 cm/s EDV > 100 cm/s ICA/CCA ratio > 4

A Final Comment from Dr Strandness

Remember, I used EDV>140 cm/s in my asymptomatic patients as a criteria for intervention

4/19/2013 4 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.