I wonder how contrast enhanced ultrasound will play a role in ICA stenosis in the future.Dr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Bill Schroedter <[log in to unmask]> Date: 11/5/18 1:06 PM (GMT-05:00) To: [log in to unmask] Subject: Re: Carotid stenosis question Hey Brian,Reminds me of a case from 20 years ago, I still have the images. Patient came into the hospital with repetitive classic TIA’s. Carotid showed a very smooth 50% stenosis but from a completely homogeneous plaque. He underwent a detailed workup – cardiac echo and a TEE, CT of the brain, etc, everything was negative. He was literally being wheeled out of the hospital after being discharged but just before he hit the door, another TIA. We re-scanned him and now that smooth plaque had a large crater in it. They ended up doing a CEA and TIA’s stopped. Ulcer embolization – I don’t know but the best example I had ever seen. I’ll have to look for the images. Plaque characterization with US has been the holy grail for 30 years but……. nothing that I am convinced of. The 3-D technology on the horizon would appear to perhaps hold some promise but…. I will not hold my breath. I have said more than once, the best plaque characterization terminology is an experienced sonographer coming out of the room saying, “that is a nasty looking plaque.” About as specific as I can get. Bill From: UVM Flownet <[log in to unmask]> On Behalf Of Brian SappSent: Sunday, November 4, 2018 1:27 PMTo: [log in to unmask]: Re: Carotid stenosis question Bill, This is a great topic. I don’t know of any papers but had an interesting experience 10-12 years ago. I had a patient who had a TIA and on the ultrasound the velocities were just over 50%, however the texture of the plaque was very dark and sponge (that isn’t a term). I have never seen another plaque like this. The ordering physician and radiologist both trusted me and sent to a Vascular surgeon. The surgeon ordered a MRA and didn’t intervene because it was 50%. The patient ended up having 13 more TIA’s and a CTA before they finally performed endarterectomy. The plaque was described as gooey. Is the patient in question symptomatic? If they are asymptomatic with an ulcer I would think that aggressive medical treatment would be the way to go. If they are symptomatic then treatment would be indicated. JMHO. Brian Sapp RVT, RPhSRegisteredvascular.net404-667-9417800-385-2790On Nov 4, 2018, at 11:42 AM, Bill Schroedter <[log in to unmask]> wrote:So I got into a bit of a “discussion” with a vascular surgeon about identification of carotid plaque ulceration. He suggested that the identification of ulceration in a symptomatic patient would benefit from endarterectomy regardless the severity of the stenosis. To his defense, he offered several papers ex: (CT and US in the Study of Ulcerated Carotid Plaque Compared with Surgical Results - Am J Neuroradiol 28:1061-66 July 2007) My argument as not that you could not find a ulceration (although I’m not completely convinced, our past studies with surgical comparison showed no method was all that great. Plus I’m not really sure our angio/CTA/US definition of ulceration is completely accurate). But as far I know, severity of stenosis is the only finding validated that correlates with the risk of symptoms and/or stroke. My search (albeit not exhaustive) has not really shown otherwise. Can anybody direct me to a source that that risk of stroke during endarterectomy (or angioplasty / stent) to repair a vessel with an ulcerated plaque and a diameter reduction of say 40 or 50% is less than best medical management? Dr. Beach – you still out there? Regards,Bill William B Schroedter, BS, RVT, RPhS, FSVU4120 Woodmere Park BlvdSuite 8BVenice, Florida 34293www.virtualvascularlab.comwww.virtualveincenter.com To unsubscribe or search other topics on UVM Flownet link to: http://list.uvm.edu/archives/uvmflownet.htmlTo unsubscribe or search other topics on UVM Flownet link to: http://list.uvm.edu/archives/uvmflownet.html
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