The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Peripheral Vascular Disease (PVD) in the United States affects approximately 8 million to 12 million patients a year; some experts in the field believe this number may be underestimated. The disease is associated with significant cardiovascular morbidity and mortality, with a high rate of fatal and non-fatal cardiovascular events, such as myocardial infarction, stroke, renal failure, limb amputations, abdominal aortic aneurysms, pulmonary embolus, and progressive ischemic end-organ dysfunction. The reduction in quality of life from global vasculopathy in many patients can thus be significant.

George Berdejo

George Berdejo, BA, RVT, FSVU

Prompt and accurate diagnosis of these disease processes is of utmost importance and high-quality vascular ultrasound plays an essential role. In fact, vascular ultrasound and the role of the vascular ultrasound professional has evolved and expanded rapidly and is at the core of modern vascular disease care in the United States and is emerging around the world.

Vascular ultrasound can be seen at the intersection of imaging, physiology, physiopathology, interventional medicine, and surgery and is utilized widely by healthcare providers from many specialties, including but not limited to vascular technologists and other subspecialty sonographers, vascular surgeons, vascular interventional radiologists, vascular medicine physicians, cardiologists, radiologists, and other vascular specialists with an interest in vascular disease.

At the core of any thriving vascular surgery practice is high-quality vascular ultrasound imaging. Duplex vascular ultrasound (DU) is used to evaluate all of the major vascular beds outside of the heart. The use of duplex ultrasonography for the study of vascular disease is firmly established but is also rapidly expanding. Thanks to continued improvements in the performance of ultrasound devices, vascular ultrasound can be used to perform a greater range of assessments in a noninvasive manner in some cases excluding the need for more invasive, expensive, contrast-based imaging modalities.

The recent proliferation of “less and minimally invasive” endovascular options currently available and offered to patients with various vascular disease processes has mandated better, less invasive, preferably noninvasive methods, to diagnose the disease that is being treated. Advances in technology have increased the diagnostic capabilities of vascular ultrasound and its role not only in diagnosis but also in planning and performing interventions and in patient follow-up and surveillance after intervention. Indeed, vascular ultrasound has become the standard “go-to” diagnostic imaging technique prior to most vascular interventions and has certainly emerged as the imaging technique of choice for following patients after most vascular interventions.

Endograft Evaluation. Duplex vascular ultrasound has emerged as the standard of care for surveillance after endovascular repair of abdominal aortic aneurysms. A major complication of this procedure is endoleak (persistent or recurrent flow within and pressurization of the residual aneurysm sac). This results in persistent risk of aneurysm rupture and potential death. Ultrasound assessment allows imaging and Doppler interrogation of deep structures and low-flow detection capabilities needed in patients with low-volume/low-velocity endoleak. Duplex vascular ultrasound, in good hands, has supplanted computed tomographic angiography as the primary surveillance technique in these patients. In addition, DU allows for the ability to resolve the deep structures of the abdomen to measure aneurysm sac size.

Hemodialysis Access Mapping and Surveillance. Higher frequency, better resolution, smaller footprint transducers that are currently available provide the high-resolution images that are needed to assess the veins and arteries of the upper extremity in order to plan the optimal access sites and also to provide the surveillance often needed postoperatively in order to maximize the life of the access and the quality of life for the dialysis patient.

Lower Extremity Vein Reflux Testing. Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. An estimated 40 percent of people in the United States have CVI. The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. Duplex ultrasound is integral in the evaluation, treatment and follow-up of these patients. Absent the appropriate equipment, the initial duplex reflux scan is among the most physically challenging, labor-intensive scans performed in vascular ultrasound. These exams account for 20%–25% of all the ultrasound scans performed in our practice.

Lower Extremity Arterial Mapping. Our philosophy regarding the practical evaluation of patients with known peripheral arterial disease who require intervention includes the use of duplex ultrasound as the primary first-line imaging modality precluding the use of more expensive, invasive, and nephrotoxic diagnostic arteriography in most patients.

Vascular ultrasound is now being used by increasing numbers of specialists who are employing both traditional and newer cutting-edge methods and techniques to improve patient care and management and who are dedicated to the delivery of quality care to their patients.

The future is bright for both vascular ultrasound and the vascular sonography professional!

 

Do you have any tips for performing vascular ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

 

 

George Berdejo, BA, RVT, FSVU, is Director of Vascular Ultrasound Outpatient Services at White Plains Hospital in White Plains, New York. He is the Chair of the AVIDsymposium (www.AVIDsymposium.org) and is the current Chair of the Cardiovascular Community of the AIUM.

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