Walif Chbeir Radiology Notes December 14, 2016 Grai Peripheral Artery Steno: ig by Doppler Ultrasound * DISCLAIMER: The-eisany actual o: potential confit of interest to disclose incline any nana personal orotherrelitionshias with other people or organizations “The articles ard notes n this website ae intended tobe used for educaticnal purposes only. The mesical informations previded corespond simply ta personal nates aased an the ment oned bbliceraphy and cannct be guaranteed for accuracy and completeness. Therefore they dont represent a reference source for scientific andes, nethera medal advice and cannot therefore substitute forthe advice ofa medical professional. f errarsare encountered please cen a message ta me, sa can make the changes. * ‘The Peak Systolic Velocity across the stenosis and the Velocity Ratio are the best predictors of peripheral arterial stenosis severity when exoressed as % Diameter Reduction. ‘The Velocity Ratio isthe ratio of the PSV a he stenosis compared with the velocity 1-2 e upstream in a non-diseased segment. * Normal arterie! caliber '* Triphasic waveform. “No spectral broadening . * Normal PSV < 150 cm/sec. + Velocity Ratio (VR) <1,5 * 4.19% diameter reduction + Triphasic waveform with * Minimal spectral broadening. '* PSV increase < 30% relative to adjacent proximal segment (VR< 1, ‘= Proximal and distal waveforms remain normal* Less than 50% (20-49%) + Plaque visualized on grayscale imaging + Tripivesic/biphasic waveforms. Triphasic waveform usually maintained, but reverse flow dirinished + Spectral broadening prominent: Filling in of clear area under the systolic peak + PSV'150-200. ‘+ 30% to 100% increase in PSV compared with that immediately proximal to the site of stenosis. VR: 1,5-2 + Proximal ang distal waveforms remain normal * 50% to 75 % diameter reduction ~ Prestenotic segment: Normal + Intrastenotic segment «+ Prague visualized + Color flow representation of narrowed flow Channel = Monophasic waveform, loss of reverse flow ( variable) and forward flaw throughout cardiac cycle (sijusqua 99%). + Elevated PSV >180 cm/s (200-300). + More than 100% increase in peak systolic low velocity compared with that immediately proximal to the site of stenosis. VR 2-4 = Partial post:-stenotic turbulence: Systolic spectral broadening = Distal waveform: Manephasic waveform , Reduced PSV * 76-99%stenosis,~Prestenctic segment: Increased pulsatility - Intvastenotic segment: « the real time color Doppler flow will appear as a whitenad, color desaturated “flow jet” = with mosaic color flow extending for several vessels diameters downstream, comesponding to post-stenotic turbulence + monophasic waveforms + PSV>300, EDV>40, Increased PSV > 4xnormal: VI ~Poststenoticsegment: Marked turbulence with Extensive spectral broadening & Simultaneous Forward and retrograde velocity spectra during systole & damped waveforms with high-grade obstruction. The spectral broadening (turbulence) may be seen throughout, the spectrum ifthe stenosis is clase to the point of meacurement; as the distance from the stenosis increases, the spectral broadeningis seen in the postsystolic deceleration phase only. - Distal Waveform: Damped, Monophasic, Reduced. > As stenosis severity increases to >90% DR, the volume flow through the stenosis trends toward zero, which can produce a PSV at the stenosis in a minimally elevated range (100 to 200 cm/s} and «+ low velocity (<10 cm/s) “trickle” flow downstream. * Occlusion Occlusion Segment No flow (Absence of color and spectral Doppler signals) « Intraluminal echoes observed throughout vessel - Preocdusive thump may be present just proximal to occlusion Distal waveform is damped, monophasic with reduced PSV. '* Post Occlusion Reconstitution:Resumption of flow visualized by color Doppler + Spectral Doppler flow patter usually contains both forward and reverse flow elements [influenced by reentry vessel flow) = Lengh of occlusion estimated based on distance from exit and re-entry collaterals, * - Some patients will show extensive diffuse disease along the superficial femoral artery but do not show any specific, localised stenoses. This appearance may be severe encugh to produce a significant pressure drop along the vessel, thereby reducing limb perfusion. Patients may have several stenoses along the length of the vessel, each of which is not haemodynamically significant but the effects of these are additive, so that there is stilla significant drop in perfusion pressure distal to the affected segment. ~ The presence of serial stenoses can affect the estimation of the degree ofa distal stenosis ificant proximal stenosis or occlusion will result in # drop in perfusion pressure and velocity which makes application of the PSV and VR problematical Otherwise, the use of velocity ratios in multiple stenoses is somewhat controversial Energy Doppler and echo-enhancing agents may allow an estimate of severity of the distal stenosis butif there is clinical doubt, other imaging (CTA, MRA, DSA) should be considered. * BIBLIOGRAPHY 4 Kelley D. Hodgkis-Herlowa, ancl Dennis F. Bandyk, Interpretation of arterial duplex testing of lower ‘extremity arteries and interventions, SEMINARS IN VASCULAR SURGERY26(2014)95-10 4 2. Simon S. M. Ho, Arterial Occlusive Disease, Periphoral, STATds (Ultrasound > Diagnosis > Vascular > Extremities) bnepis//my. state com/document/arteral-acclusive-disease:perighe-f8S5t08bS-4624-4247-abch. cSffa9fe5389 fsearchTeim=Arterial2200cclusve220Disease,%20Peripheral, 3-T. Gregory Walker, Femoropopliteal Artery Occlusive Disease, STATAx Vasculature > Diagnesis > Peripheral Vasculature > Lower Extremity Vasculature ) bteps://my statdk.com/document/femoroponlitea-artery-occlusive-d_/S06fsfe-1be3-4755 92a8- boc Talece?esarchTerm=Femeropopliteal20/ reer) ODcclusiveN20Dizeace.