Ultrasound in Vascular Surgery - NTNUfolk.ntnu.no/bragea/pdf/PhD kurs i UL i karkirurgi 2010.pdf ·...
Transcript of Ultrasound in Vascular Surgery - NTNUfolk.ntnu.no/bragea/pdf/PhD kurs i UL i karkirurgi 2010.pdf ·...
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Ultrasound in Vascular Surgery
Torbjørn Dahl
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The field of vascular surgery
Arteries – dilatationand narrowing(aneurysms andatherosclerosis)
Veins – dilatationand obstruction(varicose veinsand valvedysfunction)
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Use of ultrasound in vascular surgery
• Diagnostic purposes• Therapeutic purposes• Perioperative control• Surveillance after surgery
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Ultrasound equipment
• Linear and curvedlinear probes in therange of 2 – 15 MHz
• Multifrequency probes• Transportable and
portable machines
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How is the ultrasound service organized?
• Department of Radiology• Vascular laboratories (mostly abroad)• Clinicians in fields of interest (gynecology,
cardiology, vascular surgery)
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How could ultrasound be easier to use?
• Improved userinterface
• Less buttons –”nothing is too simple for doctors”
• Image quality
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Limitations of vessel visualization
• Anatomy• Tortuous vessel• Heavy calcification• Gas (bowel, lungs)
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What kind of ultrasound?
• B-mode for tissueimaging
• Colour flow for vesselidentification
• Velocity doppler for grading of stenosis
• Contrast agents to enhance image quality
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Doppler Ultrasonography (”triplexUS) of the Carotid Artery
• Colour dopplerindicates direction offlow and turbulence
• Angle correcteddoppler for velocitymeasurements
• Spectral dopplerindicating blood flowvelocity profile
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Velocities for grading of stenosis
Table after Rutherford, p. 1779 Stenosis in % < 50 50-79 80-99 Occlusion Velcocity PSVICA
<125 cm/sec >125 cm/sec >125 cm/sec No flow*
Velocity EDVICA
<140 cm/sec >140 cm/sec
*Additional features like high resistance pattern in the CCA with low or zero EDV, reversal of flow in the bulb area, increase in contralateral flow
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Clinical problems in vascularsurgery
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Abdominal aortic aneurysms
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What is an aneurysm?
• Segmental dilatationof an artery twice thesize of the normal adjacent artery
• Mainly seen in aorta, iliac arteries and thepopliteal artery
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Abdominal aortic aneurysm(AAA)
• Easily visualized by ultrasound
• Growth is monitored• Planned operation
when AAA reaches5,5 cm in diameter
• Rupture can be lethal
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Aneurysm growth and rupture risk
Rupture risk
Vessel diameter
5,5 cm
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Surgical treatment
Open repair Endovascular repair
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National Center of Excellence, 3D Ultrasound in surgeryNational Center of Excellence, 3D Ultrasound in surgery
Guide wire for Guide wire for secondsecond--limblimbprosthesisprosthesis in EVARin EVAR
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National Center of Excellence, 3D Ultrasound in surgeryNational Center of Excellence, 3D Ultrasound in surgery
Multimodal imagingMultimodal imaging
• Preoperative planning in complicated anatomy• CT/MRI/US in the same scene• Intraoperative navigation
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Endovascular repair is currentlymonitored by annual CT
• Ultrasound couldreplace CT, providing:
• Aneurysm diameter• Leakage into the
aneurysm sac
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Could we identify and treat theaneurysms at risk for rupture?
Analysis of aortic vessel wallmotion
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Cyclic stress of the aortic wall
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Strain in the aortic wall
Courtesy of R. Brekken SINTEF Health
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Reduced strain after EVAR
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Narrowing (stenosis) of the carotidartery
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What is the cause of stroke?• Thromboembolic cause in 80% of the cases – the origin ef emboli could be
precrebral vessels in 20% of the patients
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Surgical treatment of carotid artery stenosis
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How is a carotid artery stenosisdetected?
DSA angiography Ultrasound MRI
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What are the objectives of carotidplaque imaging?
• To assess the degree of stenosis• To assess the risk of embolization• To suggest the right intervention
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Nature 2002
Plaque development – a dynamic process
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Carotid plaque appearance
• Echogenic – calcified• Echolucent – lipid-rich• Visual scale• Digital scale (GSM)
Gray-Weale´s classification from 1-4
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NasjonaltNasjonalt kompetansesenterkompetansesenter for 3D for 3D ultralydultralyd i i kirurgikirurgi
GrayGray--scale analysis of carotid artery plaquescale analysis of carotid artery plaque
Gray scale median – low valuesfor soft plaques
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Soft plaque• Overall increased risk
for stroke (Mathiesen)• Increased stroke risk
in symptomaticpatients unfit for surgery (Grønholdt)
• No hard evidence as an indication for CEA in asymptomaticpatients yet
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Possible triggers of plaque rupture and embolization
Inflammation Movement
Thrombosis, embolization
?
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National Center of Excellence, 3D Ultrasound in surgeryNational Center of Excellence, 3D Ultrasound in surgery
Longitudinal image Longitudinal image (24 fps = 2/3 of actual speed)(24 fps = 2/3 of actual speed)
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Perioperative control
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Transcranial ultrasound to detectperoperative emboli
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Postoperative occlusion of bypass
• Early postoperative phase – technicalerror or intimal injury
• After months –excessive scar tissueor occlusion by thrombosis
• After years –progression ofunderlying disease
Intimal hyperplasia in anastomosis
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Venous access for medication or dialysis
• To place a centralvenous line or port
• To visualize arteries and veins
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Surveillance and follow-up after surgery
• Ensure patency ofbypass grafts
• Detect and treatrestenosis
• Follow-up ofarteriovenous fistulafor dialysis
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Ultrasound in the operating room
Perioperative control and anatomicalvisualization
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Limited space in the OR
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Perioperative ultrasound
• Quality control ofreconstruction
• Anatomical and functional view
• Surgical guidanceduring reoperations
• Operator dependent• Probe requirements
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Image quality – during and 30 daysafter surgery
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National Center of Excellence, 3D Ultrasound in surgeryNational Center of Excellence, 3D Ultrasound in surgery
IntraoperativeIntraoperative ultrasoundultrasound
Carotid bifurcationwith plaqueformation
3-D visualizationof carotid artery
GE VingmedSystem fiVe
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Ultrasound in diagnosis and treatment
Leakage from therapeuticpuncture site in the groin
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Diagnosis and ultrasound-guided treatmentof a pseudoaneurysm in the groin
Thrombin injection
Site of leakageFemoral artery
False aneurysm
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Better images
SURF-technique
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Artefacts in B-mode scanning
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Visualization of the vessel wall
Intimal flap in carotid dissectionCarotid artery plaque
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Other applications for ultrasound in vascular surgery
Venous disease and intravascularutlrasound
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Ultrasound in venous disease
• Varicose veins• Identify patent veins
(DVT)• Identify valvular
insuffisiency• To tailor surgical
treatment• Guide endovascular
treatment
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Thermal ablation of veins
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Intravascular ultrasound
• Evaluate the result ofan endovascularintervention
• Peroperative control• Identify intravascular
changes where othermodalities fail to givesufficient information
• High costs
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What about 3D ultrasound?
May be used for vessel anatomy, preoperative planning og
hemodynamic studies
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ES08
3D ultrasound3D ultrasound
Display local flow vectorsLi et al. 06
![Page 56: Ultrasound in Vascular Surgery - NTNUfolk.ntnu.no/bragea/pdf/PhD kurs i UL i karkirurgi 2010.pdf · cardiology, vascular surgery) ... of the Carotid Artery • Colour doppler indicates](https://reader035.fdocuments.us/reader035/viewer/2022062922/5f0724307e708231d41b82d2/html5/thumbnails/56.jpg)
ES08
3D ultrasound3D ultrasound
Display local flow vectors
![Page 57: Ultrasound in Vascular Surgery - NTNUfolk.ntnu.no/bragea/pdf/PhD kurs i UL i karkirurgi 2010.pdf · cardiology, vascular surgery) ... of the Carotid Artery • Colour doppler indicates](https://reader035.fdocuments.us/reader035/viewer/2022062922/5f0724307e708231d41b82d2/html5/thumbnails/57.jpg)
Conclusion
• Could be used for diagnosis, treatmentand follow-up of vascular interventions
• Operator dependent