Vascular Ultrasound Protocol guides

Expanding your
Clinical Experience
Contents

2 Classification of ICA Stenosis

4 Classification of Lower Extremity

Artery Disease

3 Classification of Renal Artery Stenosis

8 Infrainguinal Vein Bypass Graft Assessment

10 Venous Imaging Techniques

12 Criteria for Intraoperative Color

Duplex Diagnosis

14 Normal Techniques and Criteria for

Transcranial Doppler

18 Techniques and Criteria for the Diagnosis of

Vasculogenic Impotence

20 Color Duplex Ultrasonography of Renal Artery

Stents

22 Transcranial Doppler in the Evaluation of

Pediatric Patients with Sickle Cell Anemia:
The STOP Protocol

24 Aortic Endovascular Stent Graft Assessment

Classification of ICA Stenosis

Gathering Spectral Waveforms for Classification

of ICA Disease
• Gather all signals at an angle of 60 degrees to the vessel
distal axis for both frequency and velocity measurements.
Internal Carotid In tortuous vessels where obtaining a 60 -degree angle
mid
may be difficult, take the most favorable angle close to
Flow Separation pr 60 degrees and always document it for future reference.
ox
im
al Never take spectral waveforms at angles above 60 degrees.

External Carotid • Keep the sample volume as small as possible to obtain

1 2 3 the most discrete spectral information. In the case of an
occlusion or a very tight lesion, the sample volume may
distal
be increased to help locate the flow channel.
Common Carotid
mid
• Use the area of the maximum velocity increase or the
Vertebral most flow disturbance to classify disease.
Subclavian
• Place the sample volume in the center of the vessel or
the flow channel.

• Adjust the Doppler gain to a threshold level just below

the level at which background noise and/or mirror
imaging begins to appear for each spectral waveform
that is generated.
Cerebrovascular Recording Sites • Document boundary layer separation existing in
the area of the normal carotid bulb. Take spectral
waveforms across the bulb to show the unidirectional
flow pattern near the flow divider and the reversal
of flow at the outer wall. Include a B -mode image
showing the sites of interrogation.

• Always identify the ICA and the ECA by comparing the

characteristic Doppler waveforms: low resistance in
the ICA and high resistance in the ECA. Do not rely on
the image alone to identify these two vessels; find both
vessels before taking spectral waveforms.

• Never take “spot” recordings. Survey the entire length of

the vessels to ensure detection of very focal lesions that
may not be easily visualized and above which the flow
may normalize.

• Be very cautious about sample volume placement and

Doppler angle measurements in vessels that are not
easily visualized, i.e., the distal ICA or tortuous vessels.
If there is diagnostic uncertainty, make a note in the
patient’s record and on the spectral waveform so as
not to over or underestimate the disease state.

• Always look at the entire extracranial carotid system

and compare side to side. Observe hemodynamic
changes that may occur due to very proximal or very
distal lesions and contralateral disease.

2
 Class Diameter Peak Diameter End Flow
Reduction Systole Reduction Diastole Characterization

A 0% <4 kHz 0% * Minimal or no spectral broadening during the deceleration phase of

<125 cm/sec systole. Boundary layer separation within the carotid bulb is usually
present. No plaque visualized.

B 1 - 15% <4 kHz 1 - 15% * Minimal spectral broadening during the deceleration phase of
<125 cm/sec systole. Plaque visualized in long and short axis views.

C 16 - 49% <4 kHz 16 - 49% * Increased spectral broadening during systole until the entire
<125 cm/sec systolic window is filled. Plaque visualized in long and short
axis views.

D 50 - 79% >4 kHz 50 - 79% * Marked spectral broadening is usually associated.

>125 cm/sec

D+ 80 - 99% * 80 - 99% >4.5 kHz Marked spectral broadening.

>140 cm/sec

E Total N/A Total N/A No flow signal in an adequately visualized ICA (especially distal)
Occlusion Occlusion with characteristic low or reversed diastolic component in the
CCA. A characteristic “thump” may be noted at the stump, or
origin of the occlusion.

Note 1: All signals taken at 60° angle to vessel axis.

Note 2: This classification is only accurate for predicting the amount
of diameter reduction in the first 3 cm of the ICA. It is not reliable for
accurately predicting disease in the ECA or the CCA (or the very distal
portion of the ICA, above 3 cm from the origin).
Criteria for ICA Stenosis based on
NASCET † measurement method Note 3: All frequency and velocity values are based on using a 5 MHz
pulsed Doppler carrier frequency with a 1.5 mm cubed sample volume
ICA at a 60 degree angle to axis of vessel.
>70% = >4.01,2,4
CCA Note 4: Diameter reductions are calculated using the bulb as the
reference vessel.
ICA
>60% = >3.23
CCA * End-diastolic frequency and velocity values are used only as stenosis
classification criteria for 80 -99% diameter reduction lesions.
Distal ICA as reference
†
CLINICAL SOURCE
Jean F. Primozich, BS, RVT, University of Washington,
Carotid Research Laboratory, Seattle, WA

REFERENCES
Edwards JM, Moneta GH, Papanicolaou G, et al. Prospective validation
of a new duplex ultrasound criteria for 70 -99% internal carotid
stenosis. JEMU, 16(1): 3-7, 1995.
Moneta GH, Edwards JM, Chitwood RW, et al. Correlation of North
America Symptomatic Carotid Endarterectomy Trial (NASCET)
angiographic definition of 70 -99% internal carotid artery stenosis with
duplex scanning. J Vasc Surg, 17:152-159, 1995.
Moneta GH, Edwards JM, Papanicolaou G, et al. Screening for
asymptomatic internal carotid artery stenosis: duplex criteria for
discriminating 60 -99% stenosis. J Vasc Surg, 21(6): 989-994, 1995.
North American Symptomatic Carotid Endarterectomy
Trial Collaborators: Beneficial effect of carotid endarterectomy in
symptomatic patients with high grade carotid stenosis. N Engl J Med,
325: 445 - 453, 1991.
Roederer GO, Langlois Y, Jager K, et al. A simple parameter for
accurate detection of severe carotid disease. Bruit 8: 174 -178, 1984.

3
Classification of Lower Extremity Arterial Disease

Waveform
Criteria

0 - 19% (Normal) 20 - 49%

Triphasic waveform, no appreciable spectral broadening. Reverse components of waveform are maintained; spectral
broadening present but mild.

Gathering Waveforms for Classification of Lower

Descending Aorta Extremity Arterial Disease
Common Iliac • Duplex scanning should not be used as a screening test
External Iliac for diagnosing peripheral vascular disease (PVD). It
Internal Iliac
is most helpful as a guide to localizing and grading the
Common Femoral
severity in patients with known PVD. Duplex scanning
Profunda Femoral
can aid in determining the appropriate interventional
procedure and should be used in conjunction with SLP/
Superficial Femoral PVR/Doppler analog waveforms. The exam may take
two hours to complete. However, a much shorter exam
Lateral Circumflex time is required if examining selected areas only.

• Study each vessel along its entire length. Minimally,

velocity waveforms should be recorded from the
distal aorta, CIA, EIA, CFA, PFA, SFA proximal, mid
Popliteal and distal, (special attention to Hunter’s canal), and the
popliteal artery.

Anterior Tibial • Use the smallest sample volume (SV) possible. At the
Peroneal point of an occlusion or stenosis, you may want to
Posterior Tibial increase the SV. Place the SV in the center of the vessel
or flow stream.

• Gather all velocities at or near 60 degrees to the vessel

axis or flow stream (not to exceed 70 degrees).

• Keep Doppler gain just below the threshold of noise.

Use a low wall filter (50 Hz).

• Utilize the “heel/toe” technique with the transducer

Lower Extremity Arterial Anatomy to optimize angles and minimize steering in different
directions.

• Externally rotate patient’s leg to image SFA and PFA. To

visualize popliteal artery, turn patient prone and elevate
legs 20 degrees. Use a high frequency transducer for
best visualization at this level.

4
50 - 99% Occlusion
Loss of reverse component beyond stenosis waveform is Monophasic, preocclusive “thump” is heard proximal to
monophasic and has a reduced systolic velocity. the occlusion; velocities are diminished and waveforms are
monophasic beyond the occlusion.

Classification of lower extremity arterial stenosis

Tips for Interrogating Aorta and Diameter Peak Systolic

Iliac Arteries Reduction Velocity
• On the evening preceding the exam, the patient
should take nothing by mouth after dinner except clear 0 - 19% Less than double that of the closest proximal
liquids and any required medications, and remain NPO
normal segment
after midnight.
20 - 49% Less than double that of the closest proximal
• Use 2 - 5 MHz transducers.
normal segment
• Whenever a triphasic waveform with a clear window
(no spectral broadening) is documented at any level, it is 50 - 99% Double the proximal adjacent segment or
unlikely that there is any severe disease proximal. PSV >200 cm/sec
• There is no need to subdivide 50 - 99% stenosis. Once Occlusion No flow in the imaged artery
the lesion exceeds 50% diameter reduction (75% area),
it is a critical stenosis and will induce intermittent
claudication. In our experience, monitoring the EDV
has been inconsistent and unreliable in predicting >80%
stenosis (in contrast to the ICA criteria).

Color Doppler Hints

• High frame rate and low color velocity range will
give the best visualization of triphasic color flow.

• Use low color wall filter and limit the use of persistence
so you are seeing true flow dynamics.

• Remember color Doppler requires good Doppler

or beam-to-vessel angle to obtain optimal color
shift (filling).

• Use color aliasing pattern to locate stenosis. Adjust

color gain to help in low flow states, small vessels or
technically limited angles.

• Color will help identify reversal of flow and

reconstitution of occluded vessels. CLINICAL SOURCE:
Marsha M. Neumyer, BS, RVT, Milton S. Hershey Medical Center,
Department of Surgery, Hershey, PA

REFERENCES:
Kohler TR, Strandness DE. Jr, Jager KA, et al: Recent
Advances in Noninvasive Diagnostic Techniques in Vascular Disease,
18:182-189, 1990.

5
Classification of Renal Artery Stenosis

Color Duplex Scanning for Evaluation of Renal • Using a lateral decubitus approach, measure the pole-
Arteries and Renal Parenchymal Flow to-pole length of the kidney and record the Doppler
• The patient should fast for at least six hours prior velocity signals from the medulla and cortex of the
to evaluation. organ. As discrete parenchymal vessels are not always
seen, the sample volume size may be increased. The
• The examination may be performed with the patient in signals with the highest amplitude and velocity are used
either the supine or lateral decubitus position for optimal to calculate the end-diastolic to peak systolic ratio
interrogation of the renal arteries and kidneys. to determine parenchymal renovascular resistance.
An end-diastolic to peak systolic ratio <0.2 indicates
• With the patient in the supine position, the Doppler intrinsic renal parenchymal disease. The calculation is
velocity signal is recorded from the center stream of the performed on at least four waveforms.
abdominal aorta at the juxtarenal position using a long- End-diastolic Velocity = Parenchymal
axis view and maintaining a 60 -degree angle of insonation. Peak Systolic Velocity Resistance
The peak systolic velocity is retained for calculation of the
renal-aortic ratio. • Doppler velocity signals may also be recorded from the
renal hilum and acceleration time and index calculated to
• Using a transverse view, the left renal vein is located as complement the determination of significant renal artery
it passes anterior to the aorta and continues postero- stenosis. An acceleration time >100 milliseconds and an
laterally to the left kidney. The right renal artery follows acceleration index <3.78 kHz/sec indicates significant
the course of the right renal vein moving posterior to renal artery stenosis. The acceleration time period is
the IVC to enter the kidney. Color Doppler imaging may between the onset of acceleration and the initial systolic
facilitate localization of the renal vessels. peak. The acceleration index is calculated using the
following formula:
• Using the smallest sample volume possible, ask the Systolic Upslope = Acceleration Index
patient to suspend breathing for short periods to Carrier Frequency
collect satisfactory velocity signals. If vessel occlusion
or tight stenosis is suspected, try increasing the sample Systolic Upslope = Systolic Frequency/Sec
volume size and color flow sensitivity to help locate the
flow channel. • In the presence of renal artery occlusion, no Doppler
signal will be obtained from any segment of the renal
• The Doppler velocity signal is first collected from artery. If the kidney is vascularized through collateral
the origin of the renal artery as it arises from the channels, low amplitude, low velocity signals may be
postero-lateral wall of the aorta. It is then swept demonstrated throughout the renal parenchyma, using
slowly throughout the course of the proximal, mid color Doppler imaging or pulsed Doppler. The pole-to-
and distal renal artery with continuous documentation pole length of the kidney may measure less than 8 cm.
of velocity signals.
• Accessory and multiple renal arteries may not be
• Angle correction over a narrow range of angles may be identified with duplex technology. The presence of
used to accurately determine renal artery velocity. Multiple higher amplitude signals in one pole of the organ
planes of view and patient positions may be required to than in the other, and collection of signals of varying
visualize the renal arteries. The classification of disease is velocities in the same scan plane may suggest multiple
frequently based on the recorded Doppler signal. or accessory vessels. Color Doppler imaging may
facilitate positive identification.
• If flow-reducing stenosis (>60% diameter reduction) is
present, a high velocity signal is demonstrated by pulsed
and color Doppler and post-stenotic turbulence can be
demonstrated. Renal artery stenosis will most likely
be found at the origin of the vessel or in the proximal
segment; however, disease may be located in any segment
of the artery.

• Using the highest peak systolic renal artery velocity,

calculate the renal-aortic velocity ratio for each
renal artery:
Peak Systolic Renal Artery Velocity = Renal/
Peak Systolic Aortic Velocity Aortic Ratio

6
 IVC Ao
RRV LRA
RRA LRV IVC
RRV LRV

RRA
AO
LRA

Figure 1: Cross-sectional image of aorta (Ao), left renal vein Figure 2: Cross-sectional image as in Figure 1. Velocity spectra
(LRV), inferior vena cava (IVC) and renal arteries (RA). Normal from left renal artery demonstrating flow-reducing stenosis
velocity spectra from renal artery and renal parenchyma. with normal parenchymal signal. Right renal artery is occluded.
Note: dampened velocity signal in right kidney consistent with
collateral flow.

Classification of renal artery stenosis

CLINICAL SOURCE
Marsha M. Neumyer, BS, RVT, Milton S. Hershey Medical Center,
Classification Renal Peak Systolic Department of Surgery, Hershey, PA

Aortic Ratio Velocity REFERENCES

Norris CS, Pfeiffer JS, Rittgers SE, et al: Noninvasive Evaluation of
Renal Artery Stenosis and Renovascular Resistance. Journal of Vascular
Normal or <60% <3.5 <180 cm/sec Surgery, 1:192-201, 1984.
Kohler TR, Zierler RE, Martin RL, et al: Noninvasive Diagnosis of
Diameter Reduction Renal Artery Stenosis by Ultrasonic Duplex Scanning. Journal of
Vascular Surgery, 4:450 - 456, 1986.

60 - 99% >3.5 >180 cm/sec Neumyer MM, Wengrovitz M, Ward T, Thiele BL: The Differentiation
of Renal Artery Stenosis from Renal Parenchymal Disease by Duplex
Diameter Reduction Ultrasonography. Journal of Vascular Technology, 205 -216, 1989.
Hansen KJ, Tribble RW, Reavis SW, Canzanello VJ, Craven TE, Plonk,
GW Jr, Dean RH: Renal Duplex Sonography: Evaluation of Clinical
Occluded — — Utility. Journal of Vascular Surgery, Volume 12, Number 3: 227-236,
1990.
Neumyer MM, Whitman ED, Atnip RG, Thiele BL: Renal Artery
Bypass Grafts: Postoperative Evaluation with Duplex Ultrasonography.
Journal of Vascular Technology, 14 (1): 25 -29, 1990.
Martin RL, Nanra RS, Wlodarczyk J, DeSilva A, Bray AE: Renal Hilar
Doppler Analysis in the Detection of Renal Artery Stenosis. Journal of
Vascular Technology, 15(4): 173-180, 1991.

7
Infrainguinal Vein Bypass Graft Assessment

Correlating factors to diagnostic criteria

• Waveform configuration
Common
Femoral Artery • Status of ABI

Inflow Vessel • B -mode image

• Maximum graft PSV from smallest normal segment

of graft
Femoral
Occlusion • Serial exam changes – >0.15 decrease in ABI or
a >30cm/sec decrease in graft PSV

• Degree of spectral broadening

In Situ Bypass
Goals
• Identification of correctable lesions before graft
thrombosis

• Determine baseline hemodynamics post

revascularization

Outflow Vessel • Provide objective clinical information to aid in decision

making regarding treatment alternatives

Indications for Color Duplex Doppler

• Routine surveillance of infrainguinal bypass grafts

• Assess clinical changes

- >0.15 drop in ABIs
Example of Bypass: Native in Situ - Evaluation of new bruits or masses
- Onset of symptoms
- Change in peripheral pulses
- Nonhealing wounds

Pertinent Patient History

• Type of graft – in situ, reversed, nonreversed
Diagnostic criteria vein, composite

% Stenosis PSV EDV VR Spectral Broadening • Graft location and placement – peri-anastomotic sites

<20% <150 NA <1.5 Mild • Length of time post-op

20 - 50% <150 NA 1.5-2.5 Moderate • Any revisions or interventions

50 - 75% >150 <100 >2.5 Complete cardiac

cycle with turbulence

>75% >300 >100 >3.5 Complete cardiac

cycle with turbulence

Occluded No detectable Doppler flow

B-mode image – visualization of vessel with
no flow
Flow in collateral vessels or native circulation

8
Scanning Protocol
• Routine scanning includes ankle brachial indices (ABls) Proximal to increased
with color duplex scan of the entire length of the graft PSV (stenosis)
B
and related inflow and outflow vessels.

• Image acquisition – transverse and longitudinal views.

Transverse views are used to add additional information A
to the B -mode image and identify anastomoses. Across the stenosis
Longitudinal views are used for the major portion of
the exam to obtain Doppler information.

• Doppler parameters are obtained using a longitudinal

view with a small sample volume placed center stream or
center to flow jet. Doppler angles of insonation are kept Velocity Ration = A/B
constant at angles of less than 60 degrees. On repeat
exams it is helpful to use the same angles of insonation
to avoid a discrepancy in velocity measurements from
the patient’s previous exam.

• Doppler parameters calculated

- Peak systolic velocity – PSV
- End diastolic velocity – EDV
- Velocity ratio
VR = PSV increase across stenosis
proximal PSV

Technical Considerations
• Normal variations in flow patterns may occur
at anastomotic sites, valve cusp areas, naturally
occurring diameter changes and in the early
post-operative period (hyperemia). The magnitude
and configuration of the waveform is affected by the
recording site, length of time post op and the outflow
resistance. It is important to identify and decipher the
difference between normal variations and pathology.

• Bypass Graft Complications

- <30 days technical, hypercoagulable state, or
inadequate outflow
- 1-6 months residual lesion
- 6 -24 months myointimal hyperplasia
- >24 months progression of atherosclerosis

• Technical complications usually occur within the first

30 days post-op and include retained valve leaflets,
arteriovenous fistula (in situ grafts only), anastomotic
stenoses, inadequate outflow, graft entrapment and
intimal flaps.

• Reported statistics
- Overall accuracy - 90%
- Sensitivity - >95%
- Specificity - 87%

CLINICAL SOURCE
Gail Sandager, RN, RVT

9
Venous Imaging Techniques

Preparation
CFA
A

CFV
B

SFA G Saph C

DFA Fem V
D
SFA
SFV
DFV E
DFA

• Tilt bed 20 degrees with patient supine.

SFA F Gast V Gast V
SFV
Pop V
Pop A
G G
Com Tibial Trunk
SFA
SFV
Com Peroneal Trunk

Pop V Post Tibial Vessels

H
Pop A
Peroneal Vessels
I
KEY PTs
A Common Femoral Vein (FRV) Peroneal
• Patient’s knees should be bent with hips Tibia Vessels
B Greater Saphenous Veins (GSF)
externally rotated. C Deep Femoral Vein (Profunda) Fibula
D Superficial Femoral Vein (SVF)
E Adductor Canal Post Tibial Vessels
• Doppler: CFV, SFV, popliteal vein, PT veins. F Popliteal Vein Peroneal
Listen for: G Gastrocnemius Muscular Veins Tibia Vessels
- Spontaneous Signal = Venous signal heard H Posterior Tibial Veins (PTs)
I Peroneal Veins Fibula
without augmentation.
- Phasic Signal = Signal waxes and wanes
with respiration.
- Augmentation = Velocity increases with
distal augmentation.
- Competency = Flow stops with
Valsalva maneuver.

• Scan legs in transverse.

10
Characteristics
of thrombus- A A A
free veins A

V
V
V V

No echogenic material Vein collapses completely in Normal Doppler signals. Color fills the vein
visualized within the vein. response to probe pressure. in response to distal
compression.

Characteristics
of non- A A A A
obstructive
thrombus
V
V
V
V

Echogenic material fills part Compression of the Doppler may be normal Color flows around
of the lumen of the vein. vein is limited by the or abnormal. the thrombus.
contained thrombus.

Characteristics
of obstructive A A
A A
thrombus

V V V
V

Vein is dilated and filled with Vein is totally non- Doppler signals are absent. Color is absent in vein.
echogenic material (if acute). compressible.

Observable characteristics of thrombus

Old (Chronic) New (Acute)

Brightly echogenic Lightly echogenic

Rigid texture Spongy texture

Well attached Poorly attached

Contracted vein Vein dilated (if obstructed)

CLINICAL SOURCE
Steven R Talbot, RVT

11
Criteria for Intraoperative Color Duplex Diagnosis

Indications
All patients having carotid endarterectomy (primary
closure or vein patch angioplasty). Duplex evaluation is
performed immediately after closure of the arteriotomy
and restoration of flow.

Technique
• Fill surgical wound with sterile saline.

Distal ICA • Place high frequency transducer in sterile sheath and

ECA position directly over exposed vessels, advancing
Proximal
ICA slowly cephalad.

CCA Bifurcation • Perform imaging in both transverse and

(Transverse Measurement)
longitudinal orientation.

ECA • Obtain Doppler waveforms in longitudinal view.

ICA
• Place sample volume in center of flow stream.
Intraoperative Assessment Sites
• Doppler beam angle must be at 60 degrees or less to
vessel axis.

• Record velocity waveforms from common carotid,

external carotid, and proximal and distal internal
carotid arteries.

• If the artery was surgically closed with a vein patch,

record the cross-sectional diameter measurement of
this area as a baseline for future reference.

• It is essential to optimize B -mode image, adjust the

Doppler beam angle and assure correct placement of
the sample volume throughout the procedure.

• Any abrupt color changes, increased peak

systolic velocity or spectral broadening must be
carefully scrutinized.

• Magnify B -mode image and examine lumen for presence

of residual plaque, intimal flaps, platelet aggregates,
clamp injury or other abnormality that might dictate
immediate revision.

• The surgeon may elect to obtain an intraoperative

arteriogram before revising reconstruction if the
following conditions exist:
- severe residual stenosis indicated by Doppler, but no
anatomical defect is observed
- defect is visualized exhibiting characteristics of only a
moderate flow disturbance

• If revision is required, duplex scanning should be

repeated following revision to confirm normal flow
characteristics and vessel wall integrity.

12
Interpretation Classifications of Flow Disturbance
See Classifications of Flow Disturbance chart.
Normal • Peak systolic velocity <125 cm/sec
Algorithm for Revision/Angiography
• Spectral broadening in late systole only
See Algorithm chart.

Scanning Tips and Pitfalls Moderate • Peak systolic velocity 125 - 140 cm/sec
• Procedure requires that the surgeon and the vascular • Mild spectral broadening
technologist both be skilled in the technique and
interpretation of carotid duplex ultrasonography. Severe • Localized increase in peak systolic flow above
140 cm/sec
• Since the color Doppler patterns may obscure small
defects, the vessel wall is observed in grayscale with the • Uniform spectral broadening
color off. • Simultaneous forward and reverse flow seen on
spectral waveform
• The color Doppler image serves as a guide to areas
of possible turbulent flow; however, it is not reliable for
determination of degree of stenosis. Suspicious areas
must be assessed by Doppler, since classification of flow Algorithm
disturbance and decisions regarding revision must be
Flow Ultrasound Recommended
based on peak systolic velocity and
Disturbance Image Action
spectral broadening.
None/Mild B-Mode Normal
No Further
Studies
B-Mode Normal
Moderate
B-Mode Abnormal
Arteriogram
B-Mode Normal
Severe
Immediate
B-Mode Abnormal
Revision

CLINICAL SOURCE
Ruth Cato, RN, RVT

REFERENCES
Lane RJ, Appleberg M, Real-Time Intraoperative Angio-sonography
After Carotid Endarterectomy, Surgery, 92:5-9, 1982.
Plecha FR, Paries WJ, Intraoperative Angiography in the
Immediate Assessment of Arterial Reconstruction, Arch Surgery,
105:902-907, 1972.
Zierler RE, Bandyk DF, Thiele BL, Intraoperative Assessment of
Carotid Endarterectomy, Journal of Vascular Surgery, 1:73- 83, 1984.
Cato RF, Bandyk DF, Karp KL, Edwards JW, Block JL, Seabrook, GR,
Schmitt D, Towne JB,Duplex Scanning After Carotid Reconstruction:
A Comparison of Intraoperative and Postoperative Results, Journal of
Vascular Technology, 15(2):61- 65, 1991.
Bandyk DF, Govostis DM, Intraoperative Color Flow Imaging of
‘Difficult’ Arterial Reconstructions, Video Journal of Color Flow
Imaging, Volume 1, Number 113-20, 1991.

13
Normal Techniques and Criteria for Transcranial Doppler

Overview
TCI uses a 2.0 - 2.25 MHz sector transducer. The
transtemporal, transorbital, submandibular and foramen
magnum windows are used to identify the basal cerebral
arteries. The B -mode image yields a two dimensional
depiction of the bone landmarks at the base of the skull
and of the cerebral parenchyma and vascular structures.
The vessels are identified by knowledge of the anatomy in
relationship to these landmarks and are directly visualized
by color Doppler. TCI has expanded applications, improved
vessel identification and shortened the learning curve for
intracranial vascular ultrasound. Non-imaging (TCD) uses
a 2.0 MHz pulsed wave Doppler transducer and vessels
are identified by the depth of the sample volume, direction
of flow, distance over which each artery is traced, the
orientation of the transducer and the spatial relationship
of each vessel under investigation to a specific reference
point. TCD augments the TCI exam with a higher
percentage of vessel identification and for monitoring
studies when the transducer is attached to the head and
specific arteries are examined over time.

Examination Sites
• Transtemporal Window
- Middle Cerebral Artery (MCA)
- Anterior Cerebral Artery (ACA)
- Anterior Communicating Artery (ACOA)
- Terminal Internal Carotid Artery (TICA)
- Posterior Cerebral Artery (PCA)
- Posterior Communicating Artery (PCOA)

• Transorbital Window
- Cavernous Carotid Artery (Siphon)
- Ophthalmic Artery (OA)

• Retromandibular Window
- Retromandibular Internal Carotid Artery (R-ICA)

• Foramen Magnum Window

- Vertebral Artery (VA)
- Basilar Artery (BA)

14
 Anterior
Communicating Artery
Ophthalmic
Artery
Middle
Cerebral Artery Anterior
Cerebral Artery
Orbital A2
Window

Terminal Internal
Carotid Artery
A1

Posterior
M1 Communicating
P1 Artery

Posterior
Cerebral Artery
P2
Basilar Artery

Transtemporal
Window

Vertebral
Artery

Internal
Carotid Artery

Submandibular Foramen
Window Magnum
Window

Normal values (time-averaged peak velocities TAPV and standard deviation SD):

Vessel TAPV SD Depth From Transducer Flow Direction

MCA (M1) 62 +/ - 12 40 - 60 mm Towards

ACA (A1) 51 +/ - 13 65 - 75 mm Away

TICA 39 +/ - 8 65 mm Towards/Away

PCA 38 +/ - 11 65 - 75 mm Towards

Siphon 44 +/ - 13 60 - 80 mm Towards/Away

OA 22 +/ - 4 40 - 60 mm Towards

R–ICA 36 +/ - 8 50 - 60 mm Away

Vertebral 36 +/ - 10 60 - 85 mm Away

Basilar 39 +/ - 10 >85 mm Away

15
Normal Techniques and Criteria for Transcranial Doppler (continued)

Applications
• Detection of intracranial stenosis/thrombosis
• Identification of collateral vessels and steal effects
secondary to stenoses proximal to the Circle of Willis
• Detection of vasospasm secondary to subarachnoid
hemorrhage
• Evaluation of cerebral circulatory arrest
• Detection of microembolic signals
• Screening of children with sickle cell anemia to establish
stroke risk
• Assessment of arteriovenous malformations and fistulas

Interpretation Criteria
Both TCD and TCI rely on the Doppler spectral
waveforms for interpretation of normal and abnormal
exams. The diagnostic features of the signals include
(1) alterations in velocity; (2) deviations from laminar The outline of the waveform is automatically traced and
flow; (3) changes in pulsatility (Gosling’s) index for adults; TAP is quantified.
(4) changes in the direction of flow and (5) Lindegaard
ratios.

Velocity Measurements
PSV
TCD/TCI uses time averaged peak velocities (TAP), 100 A1
an average of the highest velocities over time, not peak
systolic or other values. This value is automatically
calculated in optimal signals but must be manually
measured by a visually guided reading technique when
the signals are sub optimal. The accuracy/advantages of A2
Velocity
angle correction are still being evaluated. (cm/sec) 50
EDV

Both increases in volume flow and decreases in diameter v = 70 cm/sec

will accelerate blood through an artery. To correct for
systemic or local changes in volume flow the Lindegaard
ratio is used. This ratio divides the velocity of the
intracranial MCA by the velocity of the ipsilateral, 0
Time
extracranial ICA, taken from the submandibular approach
(TAP - MCA / TAP - RICA).
Manual measurement of TAP.
Vasospasm Following
Subarachnoid Hemorrhage
TCD/TCI is useful in detecting the onset, time
course, severity and resolution of vasospasm following
subarachnoid hemorrhage. When vasospasm occurs, the
vessel lumen narrows and the velocity of the blood flow
accelerates. Using TCD/TCI the location and degree of
vasospasm can be determined and proper therapies given
before neurological deficit or infarction occurs.

16
Spectral Doppler criteria for the diagnosis of vasospasm

TAP (cm/sec) Interpretation

MCA Lindegaard Ratio (MCA/ICA)

<120 <3.0 Normal, nonspecific elevation

>120 3.0 – 5.9 MCA vasospasm mild – moderate

>200 >6.0 Severe MCA vasospasm

ACA

>130 (With no MCA/ICA vasospasm present) Vasospasm

(In the setting of MCA/ICA vasospasm) Vasospasm versus collateral flow

PCA

>110 (With no MCA/ICA vasospasm present) Vasospasm

(In the setting of MCA/ICA vasospasm) Vasospasm versus collateral flow

VA

>80 (With no MCA/ICA vasospasm present) Vasospasm

(In the setting of MCA/ICA vasospasm Vasospasm versus collateral flow

BA

>95 (With no MCA/ICA vasospasm present) Vasospasm

(In the setting of MCA/ICA vasospasm) Vasospasm versus collateral flow

CLINICAL SOURCE:
Colleen Douville, BA, RVT, Harborview and University of Washington Medical Centers, Department of
Neurological Surgery, Cerebrovascular Laboratory, Seattle, Washington

REFERENCES:
Becker G, Lindner A, Bogdahn U. Imaging of the vertebrobasilar system by transcranial color-coded real-
time sonography. J Ultrasound Med 1994;12:395 - 401.
Fujioka KA, Douville CM. Anatomy and freehand examination techniques. In: Newell DW, Aaslid R, eds.
Transcranial Doppler. New York, NY: Raven Press;1992:9-31.
Heggerick PA, Hedges TR. Color Doppler Imaging of the eye and orbit. Vasc US Today 1996;1(6):61-72.
Lysakowski C, Walder B, Costanza MC, Tramer MR. Transcranial Doppler versus angiography in patients
with vasospasm due to a ruptured cerebral aneurysm – a systematic review. Stroke 2001;32:2292-2298.
Martin PJ, Evans DH, Naylor AR. Transcranial color-coded sonography of the basal cerebral circulation
– reference data from 115 volunteers. Stroke 1994;25:390 -396.
Nichols FT, Jones AM, Adams RJ. Stroke prevention in sickle cell disease (STOP) study guidelines for
transcranial Doppler testing. J Neuroimaging 2001;11:354 -362.
Seiler RW, Newell DW. Subarachnoid hemorrhage and vasospasm. In: Newell DW, Aaslid R, eds.
Transcranial Doppler. New York, NY: Raven Press;1992:101-107.
Sloan MA, Burch CM, Wozniak MA. Transcranial Doppler detection of vertebrobasilar vasospasm following
subarachnoid hemorrhage. Stroke 1994;25:2187-2197.
Tong DC, Albers GW. Normal values. In: Babikian VL, Wechsler LR, eds. Transcranial Doppler
Ultrasonography. Boston, Massachusetts: Butterworth – Heinemann;1999:33- 46.
Wozniak MA, Sloan MA, Rothman MI. Detection of vasospasm by transcranial Doppler sonography: the
challenges of the anterior and posterior cerebral arteries. J Neuroimaging 1996;6:87-93.

17
Techniques and Criteria for the Diagnosis of Vasculogenic Impotence

Anatomy • Dorsal artery (feeding the skin and glans)

The corpora cavernosa forms the main part of the • Urethral artery (supplying the corpus
body of the penis. These structures are located spongiosum and urethral tissue)
dorso-laterally and divided by a fibrous tissue, the • Bulbar artery (feeding the urethral bulb and
medium septum. Arterial supply to the penis flows bulbourethral gland)
from the internal iliac artery through the internal • Cavernous artery (cavernosal, supplying the
pudendal artery. After branching, the internal erectile tissue of the corpus cavernosum)
pudendal artery becomes the penile artery. This
artery is a short segment that divides into four
terminal branches:

Ductus Deferens
Internal
Pudendal Vein Bladder Ureter

Superficial Dorsal Vein

Bulbar Artery

Urethral Artery

Corpus Cavernosum

Cavernous Artery

Deep Penile Vein

Dorsal Artery

Circumflex Veins

Dorsal Vein
Cavernous
Internal Corpus Arteries
Pudendal Artery Cavernosa

Corpus
Spongiosum

Urethra

18
Drainage from the corpora cavernosa is provided by the The hemodynamic changes that occur in a normal
emissary or circumflex veins that empty into the deep dorsal physiologic erection result from a relaxation of the smooth
vein. The proximal portions of the corpora cavernosa are muscle of the cavernous arterioles and sinusoids resulting in
drained by deep penile veins that join with urethral veins dilation and an increase in blood flow. The distension of the
draining the corpus spongiosum and eventually draining sinusoids creates a mechanical compression of the draining
into the internal pudendal vein. The superficial dorsal vein venules restricting venous outflow.
drains the skin and subcutaneous tissue.

Penile Ultrasound to Rule Out Vasculogenic Clinical Assessment

Impotence A normal artery should demonstrate a 75 - 100 percent
Indications increase in diameter. The spectral waveform can also
• Impotence offer qualitative information in evaluating arterial disease.
• Decreased erectile duration
A normal waveform should show a peak systolic
Patient Preparation
increase of 75 - 100 percent post injection. A quick
The patient is supine with the penis placed dorsally on the acceleration phase shows a higher percentage of
pubic area. Rolled washcloths on either side of the penis change in vessel diameter and a good clinical response.
may be helpful at times for stabilization.
Technique
Measurements taken post injection should always denote
the time lapse since the drug was administered. Taking
• To examine the penile arteries, begin with the
serial measurements will ensure proper documentation
appropriate equipment setup parameters.
while the drug is demonstrating its maximum effect.
These include:
During this peak period, researchers believe that if an end
- low wall filter
diastolic component is present, and if the end diastolic
- low color PRF
component is >.05 cm/s, there is sufficient venous leakage
- color map that displays slow flow
resulting in either an inadequate erection or a diminished
- appropriate small parts or slow flow setups
erection duration.
• Begin at the base of the penis, with the penis in a flaccid
state. Images should be obtained both in transverse
and sagittal views.

• During the scan, the echogenicity of the corpora

cavernosa should appear homogeneous throughout.
Any increased echogenicity may indicate an area
of fibrosis.

• While in the flaccid state, measure the diameter of

each of the cavernous arteries. Note: These arteries vary
considerably and there are no absolute normal or abnormal
values currently being used.

• Obtain intimal diameter measurements in grayscale and

record a pulsed Doppler signal.

• At this time, a vasoactive agent, such as Prostaglandin

E-1 or Papavarine, is injected into the corpora
cavernosa. The clinical response is graded as to firmness,
rigidity and the ability to penetrate.
CLINICAL SOURCE
Allen Tabor, RVT, Sr. Clinical Specialist, Cardiovascular Clinical
• Patient is then rescanned to assess dilatation of the Marketing, Philips Ultrasound, Bothell, WA
cavernosal arteries in response to the drug.
19
Color Duplex Ultrasonography of Renal Artery Stents

Renal artery duplex scanning is used for the the patient. Some of these challenges include the
detection of renal artery stenosis and to follow ability to visualize the stent and to determine if
patients post treatment. Treatment alternatives the present diagnostic criteria applies to patients
include surgical revascularization (bypass or with stents.
endarterectomy) and angioplasty with or without
stent placement. Renal artery stenting is a Goals and objectives of scanning a renal artery
relatively new procedure and may create new stent include: the definition of the location
challenges for the technologist when scanning with special attention to the proximal and distal

Indications: Examination Procedure:

• Post stent placement/ long term follow up/ change in From an anterior approach locate the SMA, left renal vein
clinical status post stent and the abdominal aorta in a transverse view. Use these
landmarks to locate the renal arteries. Locate the treated
Equipment: renal artery. If the stent was placed for an ostial lesion the
• Color duplex ultrasound scanner proximal portion of the stent will extend into the aorta.
This provides an excellent reference point to follow the
• Low frequency transducer / select frequency appropriate course of the stent. When the stent is identified, rotate
to body habitus the transducer to obtain a sagittal view of the renal artery/
stent. Examine the stent to determine the position within
• Warm acoustic coupling gel the artery. When using color, optimize color settings to
minimize color overwrite of the stent. Obtain multiple
• Recording device images from multiple views for complete assessment of
the stent.
Patient Preparation:
• Low fiber dinner evening prior to exam The Doppler evaluation is done using a small sample with
a 60 -degree Doppler angle. If a 60 -degree Doppler angle
• NPO 8 -12 hours. cannot be maintained, angles less than 60 degrees can
be used using correct angle correction technique. Any
• Explain breath-holding techniques variation from a 60 -degree angle should be recorded so
the patient can be followed using that same angle format
Patient Position: for all follow up scans. The Doppler sample volume is
• Supine for anterior approach swept through the vessel to determine the maximum
PSV. Recordings are obtained from the proximal, mid
• Lateral decubitus for flank approach and distal segments of the stent and proximal (if possible)
and distal native renal artery. If using renal aortic ratio
criteria, calculate the PSV from the abdominal aorta at the
level of the SMA. This will be used as the denominator for
calculating the Renal Aortic Ratio (RAR). If the aortic PSV
is less than 40 or there is an abdominal aortic aneurysm
present the RAR will be inaccurate and should not be used
to determine degree of stenosis.

A complete exam includes both direct evaluation of the

renal stent and indirect evaluation at the renal hilum and
the renal parenchyma.

Stent

20
ends as the distal segment is related to increased incidence Classification of Renal Artery Stenosis
of restenosis, and to determine stent patency. Potential There are two widely accepted sets of criteria for classification
complications post stent placement include: incomplete of renal artery stenosis. One set is based upon the renal aortic
deployment, renal artery dissection, and distal embolization ratio while the second utilizes absolute velocity criteria and
to the kidney and thrombosis. The post procedure renal post-stenotic turbulence. Each set of criteria has advantages
artery should be evaluated for these complications. and disadvantages, therefore it is important to determine
which criteria yields the best results for the user, and employ
those criteria.

University of Washington Criteria

TIPS Classification Renal Aortic Peak Systolic

• The distal end of the renal stent may cause angulation Ratio (RAR) Velocity (PSV)
of the artery causing an increased Doppler shifted
frequency. Correlate any increase in PSV with the 0 - 60% Diameter <3.5 <180 cm/sec
B -mode image findings.
Reduction
• Ultrasound characteristics of stents vary in appearance
from echogenic to poorly echogenic. 60 - 99% >3.5 >180 cm/sec

• Confirm all PSV calculations from two different views. Occluded No detectable 0
This helps to minimize errors from poor Doppler angles Doppler signal
or improper cursor alignment.
Dean RH, Hansen KJ, Bowman Gray Criteria
• The renal artery stent and its effect on the PSV have not
yet been determined and should be considered when
Classification Renal Aortic Peak Systolic
interpreting the exam findings.
Ratio (RAR) Velocity (PSV)
• The most common cause of a false negative exam,
when the artery is well visualized, is missing the jet of 0 - 60% Diameter <200 cm/sec No PST
the stenosis. If the maximum PSV is not detected, the Reduction
degree of disease will be underestimated.
60 - 99% Diameter >200 cm/sec PST present
• The most common cause of a false positive angle is
Reduction
overestimation of PSV due to Doppler angle errors.
Occluded No detectable None
Doppler signal

SMA

LRV
AO
CLINICAL SOURCE
Gail Sandager, RN, RVT
RRA Michael R Jaff, DO
LRA The Heart and Vascular Institute, Morristown, NJ

REFERENCES
Stent placement within left renal artery Hansen KJ, Tribble RW, Reavis SW, Canzanello VJ, Cravente, Plonk GW Jr, Dean RH: Renal duplex
sonography: evaluation of clinical utility, Journal of Vascular Surgery, Vol. 12, Number 3: 227-236, 1990
Dean RH. Renovascular hypertension. In Moore WE, ed. Vascular Surgery: A Comprehensive Review, 2nd
edition. Orlando: Grune & Stratton, 1986, pp 561-592
Kohler TR, Zierler RF, Martin RI, et al: Noninvasive diagnosis of renal artery stenosis by ultrasonic duplex
scanning. J. Vasc Surg 1986:4:450 - 456
Olin JW, Piedmonte MR, Young JR, et al: The utility of duplex ultrasound scanning of the renal arteries for
diagnosing significant renal artery stenosis. Ann Intern Med 122:833- 838
Blum U, Krumme B, Flugel P, et al: Treatment of ostial renal artery stenoses with vascular endoprostheses
after unsuccessful balloon angioplasty. N Engl J Med 336:459- 465, 1997

21
Transcranial Doppler in the Evaluation of Pediatric Patients with
Sickle Cell Anemia: The STOP Protocol

Introduction Protocol
Sickle cell anemia is an inherited blood disorder that alters • After measuring the BTD and explaining the procedure
the genetic coding of hemoglobin, resulting in deformation to the patient, position the child comfortably on their
of the red blood cells and disruption of oxygen delivery back, and place a rolled towel under the neck for support
to the body’s organs. The shape of the red blood cells and stability; it is advised that the TCD sonographer sit
changes from the normal doughnut shape to a sickle at the head of the bed to assure access to the patient and
shape, causing the red blood cells (RBCs) to become rigid, instrumentation.
clump together, and block normal flow pathways. Patients
with sickle cell anemia are more susceptible to ischemic • Document proper instrumentation settings; suggested
episodes, including stroke or thrombotic pain crisis as to use a 4 -6 mm sample volume size, spectral display set
well as infection, kidney infection and other symptoms. to at least 250 cm/sec (PSV), focal depth and grayscale
Ischemic stroke occurs in about 11% of patients with display should be adjusted to approximately 8 cm to
sickle cell anemia; the most vulnerable children are those assure visualization of patient’s midline.
between the ages of 2 and 16. The Stroke Prevention
Trial in Sickle Cell Anemia (STOP) demonstrated that • Place the transducer over the right temporal “window”
transcranial Doppler could reliably identify those at (see illustration on next page); optimize the best MCA
highest risk for stroke because the sites of intracranial spectral display, with the depth of the sample volume
stenosis, primarily the intracranial internal carotid artery set at 50 mm. After locating the strongest MCA signal,
(ICA) bifurcation and proximal middle cerebral artery decrease the depth to 38 mm and record the first MCA
(MCA), are assessable by TCD. As demonstrated in the signal at a depth of 36 - 38 mm. (This waveform is
STOP study, children with time averaged mean of the labeled “M-1” according to the STOP protocol, first or
maximum (TAMM) flow velocities > 200cm/sec have a shallowest MCA recording.) Flow direction in the MCA
significantly increased risk of stroke. The time averaged will be “forward” or toward skull (transducer).
peak (TAP) maximum flow velocity, calculated by the
ultrasound system, tracks the envelope of the waveform • Trace the entire course of the MCA by increasing the
and calculates velocities that are equal to the TAMM data, depth of the sample volume, optimizing the signal and
if the calculations are derived from optimized waveforms. recording the spectral waveform at 2 mm increments.
Flow in the MCA usually produces the strongest and
Background highest velocity signal. (see waveform illustration on
The protocol for TCD and TCDI in children with sickle next page).
cell anemia is very specific, and is based on the results of
the Stroke Prevention Trial in Sickle Cell Anemia (STOP). • Track the course of the MCA to the bifurcation(BIF),
The STOP protocol was designed to insure correct where the intracranial ICA terminates and forms
arterial segment identification based on depth of sampling, the MCA and ACA; this landmark is identified by a
direction of flow, and the spatial relationship between bi-directional signal; optimize and record. The BIF is a
arterial segments. Although TCDI has the advantage reference point for all other measurements
of visualizing intracranial structures, these parameters (see illustration on next page).
are still used in vessel identification. Prior to initiating
the study, the child’s bi-temporal diameter (BTD) is • Trace the ACA (flow away from transducer, toward
measured using calipers, so that the midline (BTD/2) midline) 4 mm deeper than the BIF, optimize and record.
and expected depths of intracranial structures can be
calculated. The STOP data found that the ICA bifurcation • After identifying the ACA, decrease the depth of the
was usually about 10 mm from the midline. During or after sample volume to BIF, angle the transducer inferiorly, as
measuring the BTD, the procedure should be explained if you were focusing the beam toward the floor of the
to the patient, emphasizing the need to remain awake but skull, and increase the sample volume by 4 mm to assure
cooperative throughout the exam. If the patient becomes insonation of the dICA; optimize signal, record. The
sleepy, the CO2 levels rise, artifactually elevating the mean ICA signal is frequently turbulent and harsh, due to flow
flow velocities; this could result in a false positive result. dynamics and angle of insonation.

22
 • After identifying the dICA, return sample volume to the Comments
BIF, and angle posteriorly/inferiorly to locate the PCA Children with sickle cell anemia are often anemic,
(forward flow in P1 segment). The PCA can be traced resulting in higher mean flow velocities than usually
from depths of 50 - 58 in most pediatric patients encountered in children with normal hematocrits.
Therefore, the TAP in all intracranial vessels may
• Track PCA to the midline, where both PCAs normally exceed 100 - 140 cm/sec. Children with a
originate from the BA. Record the bi-directional focal increase in velocity should be carefully evaluated.
signal documenting the ipsilateral (flow toward) and If the lesion occurs in the distal ICA or proximal MCA,
contralateral (flow away) PCAs; this signal is identified the severity of disease is determined by the mean flow
as the top of the basilar (TOB) signal in the STOP velocity (TAP). The STOP classification, listed below,
protocol. applies to the intracranial ICA and MCA:

• Repeat entire protocol on left side. Normal: <170 cm/sec

Conditional: 170 - 199 cm/sec
• After completing both temporal studies, turn the Abnormal: >200 cm/sec
patient to one side, chin to chest, and place the
transducer at the base of the skull. Angle the transducer Basic: normal findings (140 - 169 cm/sec);
so that the ultrasound beam is directed toward the follow up annually.
bridge of the nose; the sample volume should be set
to default at a depth of 74 mm. Flow in the BA is Conditional (170 -199 cm/sec): varies with age; young
toward the transducer. Record 3 to 4 waveforms at children should be reevaluated every 6 months to verify
2 mm increments. their Doppler results have not converted to abnormal.
• The protocol must be followed precisely to
assure accuracy. According to the STOP protocol, children with abnormal
findings should be reevaluated within 2- 4 weeks to
Children with two confirmed abnormal studies might reconfirm abnormal findings. This prevents false positives
be candidates for transfusion therapy, as determined by and unnecessary treatments.
local policy.
Children with a “conditional” TCD exam should be re-
evaluated in 6 months to determine if there has been
progression. All studies must be bilateral and complete,
as defined by the STOP protocol.

Anterior
Communicating Artery
Ophthalmic
Artery
Anterior Cerebral
Middle Cerebral Artery
Artery
A2
Orbital
Window Terminal Internal
Carotid Artery
A1
Posterior
M1 P1 Communicating
Artery

P2 Posterior
Cerebral
Artery
Basilar
Transtemporal Artery
Window
Vertebral
Artery

Internal
Carotid
Artery
Foramen CLINICAL SOURCE
Submandibular Magnum Anne Jones, RN, RVT, RDMS
Window Window
REFERENCES
Robert J Adams, MD, Virgil C McKie, MD, Lewis Hsu, MD, PH.D, et al: Prevention of a First Stroke
by Transfusions in Children with Sickle Cell Anemia and Abnormal Results on Transcranial Doppler
Ultrasonography. The New England Journal of Medicine, Volume 12

23
Aortic Endovascular Stent Graft Assessment

The treatment of abdominal aortic aneurysms Some are completely externally supported while
(AAA) with endovascular stent graft techniques others are only supported at the attachment or
has gained popularity since Parodi first introduced fixation sites. Some are modular in design while
it in 1991. These devices are placed transluminally others are single body construction. There are
through small femoral incisions and then deployed several forms of devices including bifurcated,
remotely. There are different types of endografts. tube and aorto-uni-iliac configurations.

Nonsupported
stent graft

Superior
stent leak

Modular
supported IMA leak
stent graft
Lumbar
Inferior artery leak
stent leak

Diagram of Type I (Attachment/Fixation endoleak) and

Type II (Branch vessel endoleak)

24
Scanning Protocol Technical considerations
The purpose of the duplex ultrasound evaluation is to • Patients should be fasting to minimize the amount
aid in the assessment of complications such as endoleak, of bowel gas. A bowel prep is usually not needed.
limb dysfunction, stenosis, enlarging aneurysmal size or
other anatomical or hemodynamic impairment that might • It is important to know the details of the procedure
adversely affect endograft function. prior to performing the duplex ultrasound. This will
assist in understanding structural details of what has
• Routine post-placement ultrasound includes high been placed, what normal anatomy may have been
resolution B -mode assessment of the entire endograft, altered and what complications may be associated with
attachment sites and entire residual aneurysm sac. the particular
device placed.
• Color and spectral Doppler are used routinely to
identify and confirm endoleaks, source of endoleak, • Careful assessment using B -mode, color and spectral
limb dysfunction, graft patency and outflow vessels. Doppler is necessary. Optimize B -mode and color
settings so as to be sensitive enough to identify small
• Image acquisition – transverse views, measuring endoleaks but without excessive artifact. Color artifact
maximum transverse diameter of the residual can be pulsatile and appear to be true endoleak and must
aneurysm size, document color and spectral evidence be confirmed using spectral Doppler. True leaks will have
of endoleak, incomplete deployment of the device. reproducible waveforms that usually differ from those
Longitudinal views to document location and patency of in the endograft. The endoleak should have a different
the endograft, color and spectral evidence of endoleak, characteristic waveform from that of the endograft.
limb dysfunction, incomplete deployment and
attachment sites. • Power Doppler may be helpful in identifying endoleak.

• Doppler parameters are obtained in the longitudinal • Look for potential sites of endoleak: attachment sites,
view to assess the flow through the entire endograft, branch endoleak (IMA & lumbar), transgraft and modular
native aorta and outflow iliac vessels as well as disconnect leaks.
assessment of the entire residual aneurysm sac. Using a
small sample volume, place the cursor center stream and • Look for limb dysfunction: twisting, telescoping,
parallel to the flow at less than 60 degrees. All suspected crimping, kinking or other deformity that could lead
endoleaks should be confirmed with spectral Doppler. It to limb stenosis or thrombosis. The same criteria for
may be helpful to characterize the spectral flow pattern. infrainguinal graft stenosis may be used to define stenosis
in the graft limbs.

• Identify flow characteristics in the native outflow

iliac arteries and document patency of the
hypogastric arteries.

CLINICAL SOURCE
Kathy Carter, BSN, RN, RVT.
Technical Director, Norfolk Surgical Group,
Norfolk, VA

25
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