Carotid Stenosis Differences between the internal and external carotids Characteristic Intemal carotid artery [_External carotid artery Location | Posteriorateral ‘Anterior/medial Size | Larger Smaller | Branches No Yes | Waveform Low resistance High resistance Temporal tap No Yes Note: Beware 1) Look for correct angle of 60° or less 2) Externalization of the Internal Carotid 3) Confusing ICA with ECA 4) Critical stenosis with normal velocity (but waveform should be abni-clue) CEs Consensus Panel US Criteria for Diagnosis of ICA Stenosis Primary Parameters ‘Additional Parameters ree of Stenosis | ICAPSV | Plaque Estimate” | _ICAICCA PSV ICAEDV (%) (cm/sec) (%) Ratio (cm/sec) Normal S125 None 20 <4 <50, <125, <50 <2.0 =4.0 50-69, 125-280 350, 2.0-40 40-100 270 but less than | >230 350 >4.0 >100 near occlusion Wear Occlusion | High, lowor | Visible Variable Variable Undetectable Total Occlusion | Undetectable _| Visible, no Not applicable Not applicable detectable lumen *Plaque estimate (diameter reduction) with gray-scale and color Doppler USDoppl Findings “Pitfalls/Comments | 1) Reversed or to and fro flow in vert at (toward fest) 2) Flow in vert art opp direct of carotid or same direction as jugular vein (on color or spectral). 8) High resistance VA flow + Normal VA flow low resistance ‘+ Elicit steal with exercise or | post deflation of BP cuff Portal HTN 4) PV waveform: pulsatile (Yo and fro") + hepatofugal = hepatopedal 2) HV waveform: +H flattened 3) Other: colats| ciethotic ver contour ascites 4) Enlarged PV(>13mm) Splenomegal x: Pulsatile PI fr Portal HTN (HV flattened) CHF (HV pulsatile) Fistulas TIPSS (rarely) BV Thrombosis 1) No Goior flow (partial or complete) Gilat can be lucent, need color ‘Acute or Chronic | 2) Cavernous transformation i chronic “if aterial waveform within i thrombus - malignant Budd Chiari 7) Thrombosed HV Note: AIlHVS do not have to 2) Absent HV flow 3) *Spider web intrahepatic collaterals (veno-veno) 4) Nartow HVS 5) Flattened HV waveform (ODx) 6) Caudate lobe hypertrophy 7) Occasional associated PV thrombus too be involved Dx: Flattened HV Wavetorm 1) Githosis* 2) Budd Chiarit 3) Tumor compression 4) Diffuse mets 5) Extrinsic pressure 6) Valsalva TIPS Stenosial | Ocausion: Ciot can be lucent, need color Occlusion 1) No colo low Normal velocty variable (90 — 190 emisec) Stenosis: (MIC at HV end, but anywhere) Comparison with baseline "1) Velocity < @0er/s0e oF >1B0emvse0 important. *2) Change in veloty (tor }) of > 50 emvsec from | ANGLE < 60° whenever baseline absolute velocity measured 3) Some use focal in volocty in stent (gradient _| Ree: vanagram and shunt >100em/sec) Look for color aliasing revision i abnormal (‘=more defintve criteria) ‘Survilance Regimen: Secondary cieria: 1) Flow in HV toward stent 41) Pre-Ties, 2) Stent flow away from HV 2)246H-3d Post-TIPSS. 3) Change in previous hepatopedal PV flow to 3) q6 months for 1" year, hepatotugal then annually 4) New ascites 4) If problems. 5) New collaterals (rebleeding new ascites) ‘CHF 1) HVS: Tricuspid regurgitation large HVS ‘DDx pulsatile PV “Two steps forward, GIANT step back” PHTN (flat HV) 2)PV: pusatie CHE (puisatile HV) '8) Secondary findings: large HVS, large hear, pleural | Fistulas effusion TIPS 7) Celiac PSV >200cmisec, EDV > 55 cm/sec 2) SMA PSV >275-300cm/sec, EDV >45 cm/sec 3) Occlusion 4) Collaterals,Diagnosis Pitfalls/Comments: RAS Doppler Findings: Two Methods 1) Interrogate INTRARENAL segmental branches (UP, MP, LP) Criteria: 1) tardus parvus waveform 2) SAT> .07 soc 2) interrogate main RA (peak systolic velocity) and compare to Aorta (peak velocity) Must angle correct in doing 2}look for BV thrombosis (se below) (this must be angle < 60°) RAR and PSV methodology Criteria: 1) RAR > 35 = RAS 2) PSV > 200 emi/sec at stonosis_| Multiple renal arteries = pitfall Renal hydro and Al elevated unilateral, can assume | Signfcant number of false (+) Obstruction ‘bstructed hydro and false Rl <.7 normal I> 7 abnormal But no hydro, Rlis NONSPECIFIC Pyelonephiis ‘Obstruction without calctasis Rejection — in transplants {Cyclosporine toxicity — in transplants RV thrombosis Mass effect on kidney Alis not elevated in non-obstructive pyelocalectasis (ex: old reflux, old relieved obstruction, pregnancy) ~ Unless also underiying medical renal d2, pyelo, et... then can get elevated Ri Renal <7 normal [Bull non-speciic DDxTAI Transplants R79 equivocal (I consider abnormal) 4) Rejection i >.9 defintely abnormal 2) ATN Fl-can be useful to: 8) Cyclosporine toxicity 41) follow response to tx of ATN or rejection 4) Obstruction‘Crore 1) Hyperemia of epid (= testicle) 2) Enlargement of epid (= testicle) Diagnosis | Doppler Findings Pitfalls/comments | DvT ‘DIRECT EVIDENCE OF ACUTE DVT: ‘Clot can be lucent, need 4) Git in iumen color 2) Enlarged ‘Chronic wall changes can 3} Non-compressible “chronic Dx) cause non-compressibity, ‘olor ean DD INDIRECT EVID OF ACUTE DVT: 1) Poor Aug (eval toward oothand) 2) Lack of resp variation (eval toward heart) DX: oncom in 1) Acute DVT CHRONIC DvT: 2) Chronic DVT | 1 Coliaterals 83) Technical imitation 2) complete occlusion 3) = Thick wall 4) Small vein FalsoN 5) Maynot compress" color distinguishes rom | 1) Dupicated venous system acute 2) Lucent thrombus (need colo) veDvr: Same erteria Subclavian vein not compressible due to ciavicle, se color, wavetorm analysis, a, oF Sif test to evaluate LUE veins moce pulsatile — look fr lack of pusaility Paeudsaneuryam | 1)"o and ro" flow at neck color & spectral TK wih thrombin prefered 2 Yindyang colori psaudoaneurys 4000-1500 unis into pseudoaneurysm “Teeth compression in past oeclideneck ana aevdoaneuryem but ot native rsselw/20 min sessions "AV Fiala “igh castles atoral ow 2} high velocty atonal ow 2} turbulent ow 4) pulsatile venous ow 5) color" vbraioneoor nut” Testicular Grtera: “Chien have ower fw Torsion 1) Lack of spectral flow in affected testis Doppler may be false (+) 2) Must have spectral flow contralateral to consider Skin thickening, hydrocele, tactically adequate ‘oth non-spectic Color tiash can mimic flow, ‘wavelorm mandatory False (J: ncomplet tre, etn met | Reate “Epidid may be enlarged in