Diagnostic Ultrasound Criteria for Carotid Stenosis Consenus for a new Standard

John Gocke MD, MPH , RVT Medical Director, Midwest Heart Specialists Vascular Laboratory

We all need open passageways

Which have no impediments

High Grade ICA stenosis

Sagittal or long view

Transverse view

The relationship between stenosis & velocity

The tighter the stenosis, the higher the Peak systolic velocity (PSV), & the greater the turbulence ---until you get so tight a narrowing that only a trickle comes through the orifice, or eventually nothing at all. Somewhere between 65 % and 75% diameter luminal narrowing, the end diastolic velocity (edv) begins to increase noticeably, then substantially.

Duplex .means two modalities

Image Velocity

The Saga of the Garden Hose & its Nozzle

Color Duplex and angio

Methods of calculating stenosis angiographically

Dr. Eugene Strandness University of Washington

First Carotid Duplex Criteria-early 1980s Validated based on comparing the highest Duplex-derived velocities to the angiographic relationship between the point of narrowing to the estimated normal diameter of the Carotid Bulb

Methods of calculating stenosis angiographically

Dr. Eugene Strandness University of Washington

His criteria worked splendidly for many years and still do, but 2 problems arose with continued primary use:
Most if not all standard measurements comparisons for velocity/stenosis correllation were switching over to NASCET criteria His criteria were criticized for having too wide of a moderate stenosis range in the > 50% categoryof not being able to discern the ACAS cutpoint of 60% or the NASCET criteria of 70%.

Stenosis ranges (Strandness)

0 1-15 % 16- 49% 50 -79% (too large of a range) 80-99% 100% (occlusion)

Dr. Eugene Strandness University of Washington

Normal = no plaque, no turbulence PSV <125 cm/sec 1-15 % stenosis = minimal plaque, PSV < 125 cm/sec 16-49 % stenosis = moderate plaque, mild spectral broadening throughout systole, PSV < 125 cm/second 50-79 % stenosis = PSV > 125 cm/second, greater spectral broadening throughout systole, heavier, more prominent plaque formation present. 80-99% stenosis = PSV > 125 cm/sec, marked spectral broadening and turbulence, severe plaque formation, and end diastolic velocity elevated > 140cm/second Occlusion

Over the years, many hybrid and different stenosis measurement algorithms arose
Each with their own set cut points of validity, most appropriately based on ROC curve analysis. The problem was, there were just so many different velocity criteria being used that there was substantial difficulty getting comparisons and standardization in readings between facilities.

Enter the Society of Radiologists in Ultrasound.2002

They invited a number of vascular ultrasound experts from around the country, representing different specialties all practicing in the field for the purpose of distilling the worlds literature on the topic, and, based on the science presented and discussed, their charge was to come up with a set of consensus panel recommendations for assessing carotid stenosis using ultrasound that could be used as guidelines for practitioners.

SRU Consensus Conference

In short, we were locked into a hotel in San Francisco in October 2002 with Dr. Ed Grant (Consenus panel chair) for 2 days and were not allowed out until we had a written document.

Radiology November 2003 229: 340-346

Duplex .means two modalities

Image Velocity

Methods of calculating stenosis angiographically

Methods of calculating stenosis angiographically

Additional Doppler parameters other than ICA PSV

Useful as internal checks When for certain reasons, relying on ICA PSV alone may not be best or most accurate.

Additional Doppler parameters other than ICA PSV

The ICA/CCA ratio becomes important to use in situations where the ICA PSV may not be by itself, representative of the extent of ICA disease due to:
Tandem ICA stenosis Elevated CCA velocities or stenosis Contralateral high-grade ICA stenosis Discrepancy between visual assessment of plaque and ICA PSV Significantly altered Cardiac output states (high or low)

Additional Doppler parameters other than ICA PSV

For example, in the case of significantly low cardiac output states, ICA PSV may be disproportionately low when compared to the ICA/ CCA ratio. In such cases, heavy reliance on the importance of the ICA/CCA ratio is important.

Additional Doppler parameters other than ICA PSV

The panel believed that inclusion in the final report of reasons why the interpreting physician may not have used the ICA PSV as the primary diagnostic criterion is important.

Additional Doppler parameters other than ICA PSV

End diastolic velocity
Really starts to increase at higher levels of stenosis, usually at or above 75% diameter luminal narrowing.

Additional criteria recommended

The presence of plaque or other intimal irregularities is essential for the presence of true stenosis. This gray scale finding should be used as a reality check on the velocities. Color Doppler appearance of the lumen should be used.

Tortuosity related Bruit

Consensus criteria apply to the native carotid bifurcation only

Why is the new criteria so important ?

It represented the first real consensus on acceptable guidelines that could be used nationally for setting standards internally in a vascular laboratory. Furthered the concept that adherence to scientific principles and standardiztion of certain instrumentation, technique, and diagnostic criteria leads to better quality vascular ultrasound and patient care.

Why is the new criteria so important ?

Reality most vascular surgeons and interventionalists wont touch the patient until the stenosis > 70 % and approaches 80 % and more people were asking to have either a 60 % or a 70% cutpoint on ultrasound.

Important point from the Consensus Panel

These consensus criteria do not in any way invalidate nor are meant to discourage an individual vascular laboratorys modification of these criteria based on sound internal validation strategies.

MHS Percent Stenosis Ranges

Normal < 50 %
1- 15 % subcategory 16-49 % subcategory

50 69 % > 70 %
> 80 % subcategory

String sign or near occlusion Occluded

MHS

Dr. Strandness always stressed and the Consensus Panel reiterates

Accuracy predicated upon

Proper angle of insonation = always less than or equal to 60 degrees. Proper placement of the Doppler cursor in the center of the flow stream with the cursor in the direction of flow.

Normal carotid bifurcation

50 - 69 % Stenosis

Velocities of > 70 % stenosis

(subset > 80 % )

Simply put:
While multiple investigators have found that mean Doppler velocities consistently rise as the stenosis becomes tighter in comparison with angiography, there are wide ranges of Doppler values around those means.

Angiographic stenosis compared to Carotid Duplex velocities

Grant et al. Radiology 2000: 214 p 247 -252

Why do we report stenosis in a Range ?

Significant overlap of velocities at the same level of stenosis existsthis is the reason that stenoses are reported in ranges and not specific %. The higher the velocity, the tighter the stenosis.up to about 97 %, then the velocities start to decrease (string sign)trickle of flow.

New diagnostic criteria

Radiology November 2003 229: 340-346

Welcome to the 13th Annual MIIT Interventional Radiology and Endovascular Therapy Seminar October 28-30, 2004
Chicago Westin River North Hotel Downtown Chicago
Guidant 2004