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Diagnostic Ultrasound Criteria forDiagnostic Ultrasound Criteria for
CarotidCarotid StenosisStenosis
ConsenusConsenus for a new Standardfor a new Standard
John Gocke MD, MPH , RVTJohn Gocke MD, MPH , RVTMedical Director, Midwest Heart SpecialistsMedical Director, Midwest Heart Specialists
Vascular LaboratoryVascular Laboratory
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We all need open passagewaysWe all need open passageways
Which have no impediments
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High Grade ICAHigh Grade ICAstenosisstenosis
Sagittal or long view Transverse view
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The relationship betweenThe relationship between stenosisstenosis &&
velocityvelocity
The tighter theThe tighter the stenosisstenosis, the higher the Peak systolic, the higher the Peak systolic
velocity (PSV), & the greater the turbulencevelocity (PSV), & the greater the turbulence ------until youuntil you
get so tight a narrowing that only a trickle comesget so tight a narrowing that only a trickle comesthrough the orifice, or eventually nothing at all.through the orifice, or eventually nothing at all.
Somewhere between 65 % and 75% diameter luminalSomewhere between 65 % and 75% diameter luminal
narrowing, the end diastolic velocity (narrowing, the end diastolic velocity (edvedv) begins to) begins toincrease noticeably, then substantially.increase noticeably, then substantially.
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DuplexDuplex ..meansmeanstwotwomodalitiesmodalities
ImageImage
VelocityVelocity
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The Saga of the Garden Hose & itsThe Saga of the Garden Hose & its
NozzleNozzle
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Color Duplex andColor Duplex and angioangio
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Methods of calculatingMethods of calculating stenosisstenosisangiographicallyangiographically
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Dr. EugeneDr. Eugene StrandnessStrandness
University of WashingtonUniversity of Washington
First Carotid Duplex CriteriaFirst Carotid Duplex Criteria--early 1980early 1980ss
Validated based on comparing the highestValidated based on comparing the highest
DuplexDuplex--derived velocities to the angiographicderived velocities to the angiographicrelationship between the point of narrowing torelationship between the point of narrowing to
the estimated normal diameter of the Carotidthe estimated normal diameter of the Carotid
BulbBulb
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Methods of calculatingMethods of calculating stenosisstenosisangiographicallyangiographically
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Dr. EugeneDr. Eugene StrandnessStrandness
University of WashingtonUniversity of Washington
His criteria worked splendidly for many yearsHis criteria worked splendidly for many years
and still do, but 2 problems arose withand still do, but 2 problems arose withcontinued primary use:continued primary use:
Most if not all standard measurements comparisonsMost if not all standard measurements comparisons
for velocity/for velocity/stenosisstenosis correllationcorrellationwere switchingwere switchingover to NASCET criteriaover to NASCET criteria
His criteria were criticized for havingHis criteria were criticized for having too wide of atoo wide of a
moderatemoderate stenosisstenosis rangerange in the > 50% categoryin the > 50% categoryofofnot being able to discern the ACASnot being able to discern the ACAS cutpointcutpoint of 60%of 60%or the NASCET criteria of 70%.or the NASCET criteria of 70%.
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StenosisStenosis ranges (ranges (StrandnessStrandness))
00
11--15 %15 %
1616-- 49%49%
5050 --79%79% (too large of a range)(too large of a range) 8080--99%99%
100% (occlusion)100% (occlusion)
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Dr. EugeneDr. Eugene StrandnessStrandness
University of WashingtonUniversity of Washington
NormalNormal = no plaque, no turbulence PSV 125 cm/second, greater spectral
broadening throughout systole, heavier, more prominent plaquebroadening throughout systole, heavier, more prominent plaque
formation present.formation present.
8080--99%99% stenosisstenosis = PSV > 125 cm/sec, marked spectral= PSV > 125 cm/sec, marked spectral
broadening and turbulence, severe plaque formation,broadening and turbulence, severe plaque formation, and endand enddiastolic velocity elevated > 140cm/seconddiastolic velocity elevated > 140cm/second
OcclusionOcclusion
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Over the years, many hybrid andOver the years, many hybrid and
differentdifferent stenosisstenosis measurementmeasurement
algorithms arosealgorithms arose
Each with their own set cut points of validity, mostEach with their own set cut points of validity, most
appropriately based on ROC curve analysis.appropriately based on ROC curve analysis.
The problem was, there were just so many differentThe problem was, there were just so many differentvelocity criteria being used that there was substantialvelocity criteria being used that there was substantial
difficulty getting comparisons and standardization indifficulty getting comparisons and standardization in
readings between facilities.readings between facilities.
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Enter the Society of Radiologists inEnter the Society of Radiologists in
UltrasoundUltrasound.2002.2002
They invited a number of vascular ultrasoundThey invited a number of vascular ultrasound
experts from around the country, representingexperts from around the country, representingdifferent specialties all practicing in the field fordifferent specialties all practicing in the field for
the purpose of distilling the worldthe purpose of distilling the worlds literature ons literature on
the topic, and, based on the science presentedthe topic, and, based on the science presented
and discussed, their charge was to come up withand discussed, their charge was to come up with
a set of consensus panel recommendations fora set of consensus panel recommendations for
assessing carotidassessing carotid stenosisstenosis using ultrasound thatusing ultrasound that
could be used as guidelines for practitioners.could be used as guidelines for practitioners.
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SRU Consensus ConferenceSRU Consensus Conference
In short, we were locked into a hotel in SanIn short, we were locked into a hotel in San
Francisco in October 2002 with Dr. Ed GrantFrancisco in October 2002 with Dr. Ed Grant((ConsenusConsenus panel chair) for 2 days and were notpanel chair) for 2 days and were not
allowed out until we had a written document.allowed out until we had a written document.
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Radiology November 2003 229: 340-346
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DuplexDuplex ..meansmeanstwotwomodalitiesmodalities
ImageImage
VelocityVelocity
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Methods of calculatingMethods of calculating stenosisstenosisangiographicallyangiographically
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Methods of calculatingMethods of calculating stenosisstenosisangiographicallyangiographically
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Additional Doppler parametersAdditional Doppler parameters
other than ICA PSVother than ICA PSV
Useful asUseful as internal checksinternal checks
When for certain reasons, relying on ICA PSVWhen for certain reasons, relying on ICA PSV
alone may not be best or most accurate.alone may not be best or most accurate.
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Additional Doppler parametersAdditional Doppler parameters
other than ICA PSVother than ICA PSV
The ICA/CCA ratioThe ICA/CCA ratio becomes important to use inbecomes important to use in
situations where the ICA PSV may not be by itself,situations where the ICA PSV may not be by itself,representative of the extent of ICA disease due to:representative of the extent of ICA disease due to:
Tandem ICATandem ICA stenosisstenosis
Elevated CCA velocities orElevated CCA velocities or stenosisstenosis ContralateralContralateral highhigh--grade ICAgrade ICA stenosisstenosis
Discrepancy between visual assessment of plaque and ICADiscrepancy between visual assessment of plaque and ICA
PSVPSV
Significantly altered Cardiac output states (high or low)Significantly altered Cardiac output states (high or low)
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Additional Doppler parametersAdditional Doppler parameters
other than ICA PSVother than ICA PSV
For example, in the case of significantly lowFor example, in the case of significantly lowcardiac output states, ICA PSV may becardiac output states, ICA PSV may be
disproportionately low when compared to thedisproportionately low when compared to the
ICA/ CCA ratio. In such cases, heavy relianceICA/ CCA ratio. In such cases, heavy reliance
on the importance of the ICA/CCA ratio ison the importance of the ICA/CCA ratio is
important.important.
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Additional Doppler parametersAdditional Doppler parameters
other than ICA PSVother than ICA PSV
The panel believed that inclusion in the finalThe panel believed that inclusion in the final
report ofreport ofreasonsreasonswhy the interpreting physicianwhy the interpreting physician
may not have used the ICA PSV as the primarymay not have used the ICA PSV as the primarydiagnostic criterion is important.diagnostic criterion is important.
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Additional Doppler parametersAdditional Doppler parameters
other than ICA PSVother than ICA PSV
End diastolic velocityEnd diastolic velocity
Really starts to increase at higher levels ofReally starts to increase at higher levels ofstenosisstenosis,,
usually at or above 75% diameter luminal narrowing.usually at or above 75% diameter luminal narrowing.
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Additional criteria recommendedAdditional criteria recommended
The presence of plaque or otherThe presence of plaque or other intimalintimal
irregularities is essential for the presence of trueirregularities is essential for the presence of truestenosisstenosis. This gray scale finding should be used. This gray scale finding should be used
as aas a reality checkreality check on the velocities.on the velocities.
Color Doppler appearance of the lumen shouldColor Doppler appearance of the lumen should
be used.be used.
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TortuosityTortuosity related Bruitrelated Bruit
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Consensus criteria apply to the nativeConsensus criteria apply to the native
carotid bifurcation onlycarotid bifurcation only
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Why is the new criteria so important ?Why is the new criteria so important ?
It represented the first real consensus onIt represented the first real consensus on
acceptable guidelines that could be usedacceptable guidelines that could be usednationally for setting standards internally in anationally for setting standards internally in a
vascular laboratory.vascular laboratory.
Furthered the concept that adherence toFurthered the concept that adherence toscientific principles andscientific principles and standardiztionstandardiztion of certainof certaininstrumentation, technique, and diagnosticinstrumentation, technique, and diagnostic
criteria leads to better quality vascular ultrasoundcriteria leads to better quality vascular ultrasoundand patient care.and patient care.
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Why is the new criteria so important ?Why is the new criteria so important ?
RealityRealitymost vascularmost vascular
surgeons andsurgeons and
interventionalistsinterventionalistswonwontt
touch the patient until thetouch the patient until the
stenosisstenosis> 70 % and> 70 % andapproaches 80 % and moreapproaches 80 % and more
people were asking to havepeople were asking to have
either a 60 % or a 70%either a 60 % or a 70%
cutpointcutpointon ultrasound.on ultrasound.
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Important point from the ConsensusImportant point from the Consensus
PanelPanel
These consensus criteria do not in any wayThese consensus criteria do not in any wayinvalidate nor are meant to discourage aninvalidate nor are meant to discourage an
individual vascular laboratoryindividual vascular laboratorys modification ofs modification of
these criteria based on sound internal validationthese criteria based on sound internal validationstrategies.strategies.
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MHS PercentMHS Percent StenosisStenosis RangesRanges NormalNormal
< 50 %< 50 % 11-- 15 % subcategory15 % subcategory
1616--49 % subcategory49 % subcategory
505069 %69 %
> 70 %> 70 %
> 80 % subcategory> 80 % subcategory String sign or near occlusionString sign or near occlusion
OccludedOccluded
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MHSMHS
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Dr.Dr. StrandnessStrandness always stressed and the Consensus Panelalways stressed and the Consensus Panelreiteratesreiterates
Accuracy predicated uponAccuracy predicated upon
Proper angle ofProper angle ofinsonationinsonation = always less than or= always less than or
equal to 60 degrees.equal to 60 degrees.
Proper placement of the Doppler cursor in theProper placement of the Doppler cursor in thecenter of the flow stream with the cursor in thecenter of the flow stream with the cursor in the
direction of flow.direction of flow.
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Normal carotid bifurcationNormal carotid bifurcation
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5050 -- 69 %69 % StenosisStenosis
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Velocities of > 70 %Velocities of > 70 % stenosisstenosis(subset > 80 % )(subset > 80 % )
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Simply put:Simply put: While multiple investigators have found thatWhile multiple investigators have found that
mean Doppler velocities consistently rise as themean Doppler velocities consistently rise as thestenosisstenosis becomes tighter in comparison withbecomes tighter in comparison with
angiography,angiography, there are wide ranges of Dopplerthere are wide ranges of Doppler
values around those means.values around those means.
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Grant et al. Radiology 2000: 214 p 247 -252
Angiographic stenosis compared to Carotid Duplex velocities
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Why do we reportWhy do we reportstenosisstenosisin ain aRange ?Range ?
Significant overlap of velocitiesSignificant overlap of velocitiesat the same level ofat the same level ofstenosisstenosisexistsexiststhis is the reason thatthis is the reason thatstenosesstenosesareare
reportedreportedin rangesin rangesand not specific %.and not specific %.
The higher the velocity, the tighter theThe higher the velocity, the tighter thestenosisstenosis.up to.up toabout 97 %, then the velocities start to decrease (stringabout 97 %, then the velocities start to decrease (string
sign)sign)trickle of flow.trickle of flow.
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New diagnostic criteriaNew diagnostic criteria
Radiology November 2003 229: 340-346
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Guidant 2004
October 28-30, 2004
Chicago Westin River North Hotel
Downtown Chicago