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 Diagnostic Techniques

David S. Sumner, M.D., John Blebea, M.D.

Includes:

  • Hemodynamic Assessment of Arterial and Venous Disease
  • Duplex Evaluation of Carotid, Venous, Mesenteric, Renal and Extremity Vascular Disease
  • Arteriography
  • Computerized Tomography
  • MRI/MRA
  • Intraoperative Duplex Evaluation
  • Additional Important/Non-Core Cirriculum Topics:
  • Intravascular Ultrasound
  • Goals

I. History

1. To understand the essential components of a comprehensive vascular history.

2. To recognize symptoms relevant to vascular disease, identify salient points and understand their significance.

3. To use the information to formulate an initial diagnosis and to evaluate the severity of the likely disease process.

4. To identify confounding symptoms of similar nature produced by non-vascular diseases.

5. To obtain historical information pertinent to the evaluation of patients for operation or information that would militate against operative intervention or dictate the choice of therapy.

II. Physical Examination

1. To understand the significance of observational signs, such as skin color and texture, swelling, gangrene, and ulcers.

2. To detect and evaluate peripheral pulses, bruits, thrills, skin temperature, edema, tissue turgor , and vascular dimensions.

3. To develop the skills necessary to palpate the abdomen, neck, and extremities in order to localize sites of tenderness and to recognize the presence of masses and abnormal pulsations.

4. To be capable of performing basic neurological evaluations.

5. To interpret physical findings, understand how they contribute to the diagnosis, recognize their limitations, and be aware of other diseases that might mimic the findings.

III. Noninvasive Tests

1. To be familiar with commonly used noninvasive instruments and modalities, such as Doppler ultrasound, duplex and color-flow scanning, B-mode imaging, plethysmography (air, mercury, and impedance), magnetic resonance imaging (MRI), magnetic resonance angiogra­phy (MRA), and computerized X-ray tomography (CT), and to understand the basic principles involved in their design and operation.

2. To be familiar with noninvasive pressure measurements (including ankle/brachial indices, segmental pressures, digital pressures), arterial and venous velocity tracings, Doppler frequency spectral analysis, segmental and digital plethysmography , transcutaneous oxygen tension measurements (TcPO 2 ), venous outflow plethysmography , calf venous air- plethysmography ( Nicolaides method) and to understand the hemodynamic principles underlying exercise testing (treadmill walking and claudication times, post-exercise ankle pressure) and reactive hyperemia.

3. To understand the physiologic basis of these tests and their limitations, know when to order noninvasive tests, which to select and how to interpret the results.

4. To perform simple noninvasive assessments (such as Doppler venous and arterial surveys and measurement of ABIs ) and be able to interpret duplex scans, MRIs , MRAs , and CT scans.

IV. Invasive Diagnostic Methods

1. To be highly skilled in the interpretation of angio­grams of all arterial and venous segments.

2. To understand the limitations and inherent risks of angiography, be aware of sources of error, and know how to minimize complications.

3. To be adept at obtaining and interpreting intraoperative arteriograms and, whenever possible, to acquire the skills necessary to perform percutaneous arteriography , including catheter manipulation techniques required for selective visualization of visceral and brachiocephalic vessels.

4. To be familiar with the intraoperative use of Doppler and duplex surveys in order to answer specific questions (location and patency of vessels, stenotic sites) and to detect technical errors at the completion of the reconstruction (residual valves, arteriovenous fistulas, thrombi, anastomotic problems).

5. To be familiar with the intraoperative applications of the angioscope .

6. To perform intraoperative and preoperative percutaneous arterial and venous pressure measurements involving the use of pressure transducers.

7. To have some knowledge of other less frequently performed tests, such as intravascular ultrasound, isotope clearance studies and uptake tests, and scintillation scans.

Site Specific Goals

I. Lower Extremity Arterial Disease

1. To identify the symptoms of intermittent claudication and differenti­ate them from those of orthopedic or neurological conditions.

2. To recognize symptoms of severe ischemia, (such as rest pain, tissue loss, ulcers, and gangrene); differentiate these symptoms from those of diabetic neuropathy, neurologic , venous, infectious, and other problems; and determine the relative importance of several etiologies when more than one is present.

3. To recognize and differentiate the symptoms and signs of acute arterial occlusion (pain, pallor, numbness, and motor dysfunction) from those of chronic arterial occlusive disease; to assess the urgency of the condition and the threat to limb loss; and to distinguish findings suggestive of embolic occlusion from those of arterial thrombosis.

4. To understand the contribution of noninvasive tests (ABI, plethysmography , duplex surveys, treadmill exercise, and reactive hyperemia) to the diagnosis and know when arteriography , MRA, or other more complex tests are required.

5. Based on the history and physical examination, together with the results of invasive and noninvasive tests, to formulate an accurate diagnosis of arterial disease, identify the location and extent of the obstructive process, assess its severity, and determine the need for and the urgency of interventional therapy.

II. Extracranial Cerebrovascular Disease

1. To recognize and evaluate the symptoms and signs of transient hemispheric and nonhemispheric neurologic events and to differentiate them from the symptoms and signs of permanent neurologic damage (stroke) or peripheral neuropathy.

2. To decide, based on their natural history and pathophysiologic behavior, which events require immediate attention.

3. To understand the indications for common noninvasive tests (such as duplex or color-flow scanning), how they may contribute, what their limitations are, and how they are to be interpreted; and to know when to obtain and how to interpret less commonly performed tests, such as transcranial Doppler studies or oculopneumoplethysmography .

4. To know when to order (or not to order) cerebral arteriography , how to read extracranial and intracranial views, how to measure the degree of stenosis , and how to use the findings to select the proper therapeutic approach.

5. To know when to select MRA as an alternative diagnostic method and what its comparative accuracy is compared to arteriography or duplex scanning.

6. To be able to read and interpret CT and MRI scans of the brain, know when to order these studies and how the results influence diagnosis and the need for therapeutic intervention.

7. In asymptomatic patients, to assess cervical bruits, understand their significance, and know which patients without specific signs have a high propensity for extracranial cerebrovascular disease and are likely to benefit from noninvasive diagnostic screening and possible therapeutic intervention.

8. To understand the role of duplex scanning in the follow-up of nonoperated or operated patients with known cerebrovascular disease (to detect recurrent disease or disease progression).

III. Brachiocephalic and Upper Extremity Arterial Disease

1. To recognize the signs and symptoms of brachiocephalic disease, including those of hemispheric ischemia, vertebrobasilar ischemia, and arm claudication and ischemia.

2. To understand the role that brachial, segmental, and digital pressures play in screening for disease and the roles that duplex scanning, arteriography , and MRA play in establishing the diagnosis.

IV. Aneurysmal Disease

1. To recognize and interpret the signs and symptoms of abdominal aortic, iliac, femoral, popliteal , visceral, thoracic, carotid, and brachiocephalic aneurysms.

2. To be skilled in the palpation of the abdomen, extremities, and neck in order to recognize pulsatile masses, assess their dimensions, and differentiate those likely to be aneurysms from arterial tortuosity , tumors, or other nonvascular masses.

3. To recognize signs of impending or actual rupture including tenderness, ecchymoses , shock, or other evidence of acute blood loss.

4. To determine the urgency of operative intervention, and decide when ultrasonic, CT, or MRI confirmation is necessary.

5. To be acutely aware of the signs of complications, such as aortic-enteric fistula and high-output cardiac failure due to aorto-caval fistulae.

6. To know the indications for arteriography (or MRA) and how to interpret these studies.

7. To be alert to the indirect signs of aneurysms, such as unex­plained embolic phenomena (blue toes or fingers) or sudden ischemia due to acute thrombosis or dissections.

V. Visceral Arterial Disease

1. To be familiar with the symptoms of acute visceral arterial occlusion and with the post- prandial pain patterns and weight loss associated with chronic visceral ischemia.

2. To be alert to conditions (such as atrial fibrillation, recent myocardial infarction, arterial dissections) that might lead to acute occlusion of mesenteric arteries.

3. To recognize conditions (such as congestive heart failure) that predispose to nonocclusive mesenter­ic ischemia.

4. To interpret visceral angiograms and know when these are needed.

5. To understand the role and limitations of duplex scanning in the diagnosis of visceral arterial stenosis .

VI. Renal Arterial Disease

1. To recognize the signs and symptoms of renal arterial occlusive disease, as manifested by the onset and severity of hypertension, and be able to determine which patients require further workup.

2. To be familiar with the diagnostic roles of selective renal vein renins , isotope clearance tests, IVP, duplex scanning, and arteriography and know the limitations and predictive value of these tests.

VII. Arteriovenous Fistula

1. To be cognizant of the systemic manifestations of large arteriovenous fistulas, including tachycardia, Branham's sign, and high-output cardiac failure and be able to differen­tiate between acquired and congenital fistulas.

2. To understand the diagnostic significance of a history of penetrating trauma, fractures, back surgery, and vascular catheterization and know the significance of signs, such as birthmarks, limb hypertrophy, unilateral varicose veins, vascular malformations, bruits, and thrills.

3. To be aware of the role that noninvasive pressure measurements and duplex scanning have in establishing a diagnosis, know when to order CT scans, MRI, MRA, or arteriography , and be able to interpret the results.

4. To distinguish between congenital arteriovenous fistulas and primary venous malformations.

VIII. Vasospastic Disease

1. To recognize and evaluate the symptoms of episodic digital ischemia provoked by cold exposure ( Raynaud's phenomenon) and to be aware of the manifesta­tions of vasospasm, such as changes in skin color and temperature.

2. To identify signs of underlying autoimmune disease, such as digital atrophy, ulceration, or gangrene and other skin changes.

3. To be aware of the role that noninvasive tests (Doppler surveys, duplex scans, digital pressure measure­ments, plethysmographic studies, and skin temperature record­ings) play in distinguishing purely vasospastic disease from vasospasm superimposed on fixed digital arterial stenoses or occlu­sions.

4. To know when arteriography is indicated and how to interpret the findings.

IX. Acute Venous Thrombosis

1. To recognize the signs and symptoms of acute deep venous thrombo­sis (DVT) and differentiate them from the signs and symptoms of cellulitis , muscle tears, superficial venous thrombosis, arterial obstruction, and a host of other causes of unilateral limb swelling, edema, pain, and cyanosis.

2. To be aware of the significance of factors predisposing to DVT, such as recent trauma, orthopedic or major abdominal surgery, malignancy or chronic illness, pregnancy, airplane or bus trips, and hypercoagulability .

3. To understand the limitations of the history and physical examination and be aware of the critical role that noninvasive testing (primarily duplex scanning and to a declining extent, hand-held Doppler and impedance plethysmography ) now plays in the diagnosis of this disease.

4. To know when phlebograms , magnetic resonance studies, or CT scans are indicated and how to interpret the results.

5. To be aware of the indications for screening asymptomatic high-risk patients for occult DVT and know the limitations of the noninvasive methods used for this purpose.

X. Chronis Venous Insufficiency

1. To know the symptoms and signs of varicose veins, chronic venous obstruction, and deep venous incompetence and be able to differentiate these diseases from lymphedema , acute DVT, arteriovenous malformations, and arterial disease.

2. To recognize and evaluate the cutaneous manifestations of chronic venous insufficiency, including lipodermatosclerosis , pigmentation, dermatitis, and ulceration.

3. To know when objective testing is required to establish the diagnosis and understand how duplex scanning may contribute to the anatomic assessment by identifying the sites and distribution of chronic venous obstruction and incompetent venous valves; how air plethysmo­graphic , photoplethysmographic , and other physiologic tests (such as ambulatory venous pressure measurements) may assist in the evaluation and assessment of the severity of physiologic aberrations; and when to order and how to evaluate ascending and descending phlebograms .

XI. Lymphedema

1. To be familiar with the historical aspects of lymphedema , noting the time of onset and the presence of previous or coexisting infections, injuries, radiation, or malignancy.

2. To be aware of the significance of the location of swelling, the type of edema (pitting or woody), the presence of cutaneous lichenification , and associated cellulitis .

3. To understand the diagnostic roles of lymphangiography and scintillation scans and when to order and how to interpret these studies.

4. To differentiate between primary and secondary lymphedema and distinguish the various forms of lymphedema from swelling due to chronic venous insufficiency.

XII. Trauma

1. To understand the importance of obtaining a history of the injury (whether it was due to blunt or penetrating trauma, gun-shot of knife); of an expeditious physical examination noting the location of the injury (entry and exit points, multiple sites or localized), the presence of external hemorrhage, hematoma , ecchymoses , or shock, of assessing peripheral pulses, neurologic status, and respiratory compromise, and of identifying associated skeletal or visceral injuries.

2. To know when to obtain Doppler studies, peripheral pressure measurements, duplex scans, transesophageal echo studies, compartmental pressures, CT scans, X-rays, and arteriog­raphy .

XIII. Amputations

1. To recognize the need for amputation and to predict the optimum level based on a history of previous revascularization attempts, etiology of vascular obstruc­tion, the presence of infection, diabetes, or coagulation disorders, location and severity of pain, extent of ulcers or gangrene, presence or absence of pulses, the appearance and temperature of the skin, capillary refill, and overall medical status.

2. To understand the limitations and advantages of using objective tests such as TcPO 2 measurement, isotope clearance, and ankle, segmental, digital, and skin pressures to select the site of amputation.

References

General

1. Abbott WM, Kempczinski RF, Macdonald NR. Core Curriculum for Resident Training in the Vascular Diagnostic Laboratory . Association of Program Directors in Vascular Surgery, 1996.

2. Bernstein EF (ed.) Vascular Diagnosis , 4th ed. St. Louis : CV Mosby , 1993.

3. Kempczinski RF, Yao JST ( eds ). Practical Noninvasive Vascular Diagnosis (2nd ed ) . Chicago : Year Book Medical Publishers, Inc., 1987.

4. Hershey FB, Barnes RW, Sumner DS ( eds ): Noninvasive Diagnosis of Vascular Disease. Pasadena : Appleton Davies, 1984.

Peripheral Arterial

1. Mattos MA, van Bemmelen PS, Hodgson KJ, et al. Does correction of stenoses identified with color duplex scanning improve infrainguinal graft patency ? J Vasc Surg 17:54-66, 1993.

2. Moneta GL, Yeager RA, Antonovic R, et al. Accuracy of lower extremity arterial duplex mapping. J Vasc Surg 15:275-84, 1992.

3. Raines JK. The pulse volume recorder in peripheral arterial disease. in Bernstein EF (ed.) Vascular Diagnosis , 4th ed. St. Louis : CV Mosby ; 534-543, 1993.

4. Reidy NC, Walden R, Abbott WM, et al. Anatomic localization of atherosclerotic lesions by hemodynamic tests. Arch Surg 116:1041-1044, 1981.

5. Rutherford RB, Lowenstein DH, Klein MF. Combining segmental systolic pressures and plethysmography to diagnose arterial occlusive disease of the legs. A m J Surg 138:211, 1979.

Arteriography, MRI

1. Baum RA, Rutter CM, Sunshine JH, Blebea JS, et al. Multicenter trial to evaluate vascular magnetic resonance angiography of the lower extremity. JAMA 274: 875-880, 1995.

2. Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology 138:273-281, 1981.

Carotid

1. Anderson CM, Saloner D, Lee RE, et al. Assessment of carotid artery stenosis by MR angiography: comparison with x-ray angiography and color-coded Doppler ultrasound. Am J Neuroradiol 13:989-1003, 1992.

2. Blackshear WM, Phillips DJ, Thiele BL, et al. Detection of carotid occlusive disease by ultrasonic imaging and pulsed Doppler spectrum analysis. Surgery 86:698-706 , 1979.

3. Carpenter JP, Lexa FJ, Davis JT. Determination of sixty percent or greater carotid artery stenosis by duplex Doppler ultrasonography . J Vasc Surg 22:697-705, 1995.

4. Seiler RW, et al. Cerebral vasospasm evaluated by transcranial ultrasound correlated with clinical grade and CT-visualized subarachnoid hemorrhage. J Neurosurg 64:594-600, 1986.

5. Thiele BL, Jones AM, Hobson RW, Bandyk DF, et al. Standards in noninvasive cerebrovascu­lar testing. J Vasc Surg 15:495-503, 1992.

Abdominal, Visceral

1. Moneta GL, Yeager RA, Dalman R, Antonovic R, et al. Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion. J Vasc Surg 14:511-20, 1991.

2. Pavone P, DiCesare E, DiRenzi P, et al. Abdominal aortic aneurysm evaluation: comparison of US, CT, MRI, and angiography. Magn Reson Imaging 8: 199-204, 1990.

3. Taylor DC, Moneta GL, Kohler TR, et al. Duplex ultrasound in the diagnosis of renal artery stenosis : a prospective evaluation. J Vasc Surg 7: 363-369, 1988.

Venous

1. Blebea J, Schomaker WR, Hod G, Fowl RJ, Kempczinski RF. Preoperative Duplex venous mapping: A comparison of positional techniques in patients with and without atherosclerosis. J Vasc Surg 20: 226-234, 1994.

2. Mattos MA, Londrey GL, Leutz DW, Hodgson KJ, et al. Color-flow duplex scanning for the surveillance and diagnosis of acute deep venous thrombosis. J Vasc Surg 15:366-376, 1992.

3. Porter JM, Moneta GL, et al. Reporting standards in venous disease: An update. J Vasc Surg 21:635-645, 1995.

4. Rose SC, Zwiebel WJ, Nelson BD, et al. Symptomatic lower extremity deep venous thrombo­sis: Accuracy, limitations, and role of color duplex flow imaging in diagnosis. Radiology 175:639-644, 1900.

5. van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning. J Vasc Surg 10:425-431, 1989.

Posted June 2010