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UVMFLOWNET  June 2007

UVMFLOWNET June 2007

Subject:

Re: Doppler vs measurement criteria for grading carotid disease.

From:

Norma Bourne <[log in to unmask]>

Reply-To:

UVM Flownet <[log in to unmask]>

Date:

Thu, 7 Jun 2007 13:06:46 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (105 lines)

Some of the posts were kind of rough, but we have to ask the hard questions.  QA is, for me, not a flip about what ICAVL thinks, but in the end run, does that surgical pathology match what we saw on our scan??, because THAT is what is in the best interest for the patient, the ONLY reason we all have a job.  I have worked in 3 different careers in the hospital, and without a doubt the things that actually work in PRACTICE, never work out in theory. 

>>> "Audrey Fleming" <[log in to unmask]> 6/7/2007 10:33 AM >>>
I think we should be careful criticizing any one single specialty physician in this. I know some facilities have major turf issues and don't work well together. This is not the case everywhere.
   
  I know of radiologists that are extremely good and some of them have even made significant contributions to vascular sonography. I also know of vascular surgeons who couldn't read their name off a request unless the sonographer used big print letters. Ok, that last may be a bit of an exaggeration but I hope you get the idea.
   
  There are those that follow published criteria and then there are those that don't. There are those that understand the hemodynamics of vascular studies and those that don't. I have met physicians of all specialties that fall into both categories.
   
  Remember that this topic was started by a sonography instructor and the responses were from their clinical instructor. It was never said whether this was in a radiology department, vascular department, echo department, or internal medicine department. It was also never said what type of physician was interpreting the exams. I know lots of sonographers that give information the interpreting physicians never look at because they think it's not relevant. but the sonographers continue to do it. This may be a radiology department, or it may not.
   
   
  Audrey Fleming, RDMS RVS
  Norma Bourne <[log in to unmask]> wrote:
  Amen! And does anyone know if they (Rad) actually have any standard criteria, if they physically measure anything on the image, or if they are working on subjectives alone? It is so very frustrating when we have a good case that meets all our criteria called at 80-99%, then review Rad results of 75%, or worse yet when we are "noncorrelating" on our matrix due to ONE percentage point. Norma RVT

Oh yeah- I meant to share this earlier, one of my retired MD's who still reads for me was consulting on a medical claim for an insurance comany and had to call me to get me to read out the ratio chart to him for the case, because the interpreting physician at that facility read on RATIOS ALONE. 

>>> "Jack Gray" 6/6/2007 3:26 PM >>>
I've always thought radiology based departments were the culprits when I read a report stating a 27% stenosis (or some other specific number). I think it comes from radiologists working from still shots rather than from movement.

-----Original Message-----
From: UVM Flownet [mailto:[log in to unmask]]On Behalf Of Audrey Fleming
Sent: Wednesday, June 06, 2007 2:19 PM
To: [log in to unmask] 
Subject: Re: Doppler vs measurement criteria for grading carotid disease.


I have worked in one or two places where the reading physician wants area reductions. No amount of persuasion ever changed their minds. You can give them all the articles you want, they have decided they know best. It doesn't happen as much as it used to, but it does still happen.

The worst was when I was required to perform area measurements on all carotids that had any plaque. The reports read as "13% stenosis seen in the ICA". Yeah, what a disaster. I was a temp and agreed to work my already commited week, but just laughed when they wanted to extend me. This would have been 6-7 years ago so don't know if this person is still reading.

Audrey Fleming RDMs, RVS

"Ross, Diana" wrote:

Hi, Linda


Diameter reduction and area reduction are only useful when doppler doesn't correlate with something seen visually. Mostly this is only useful in a wide bulb or maybe in the CCA. I have found this useful in maybe 4 or 5 cases over the thousands I have performed.....

OTHERWISE PULSED WAVE DOPPLER RULES...STRANDNESS OR OTHERWISE.

I find it scary that this is what people are doing anywhere in the USA. Is anyone of these people an RVT? Or even RDMS? Angiography is not ultrasound. The RESULTS of angio should be compared with the RESULTS of doppler ultrasound, but they can not use the same methods...

This is an old topic on these boards..... Always good for a few flames!

Diana


_____ 

From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of linda sulzdorf
Sent: Tuesday, June 05, 2007 1:07 PM
To: [log in to unmask] 
Subject: Doppler vs measurement criteria for grading carotid disease.


Dear flownetters;
I'm teaching an online sonography program and as part of the coursework, I'm introducing the students to venous and carotid exams. My first discussion assignment asked what criteria the students' departments were using to grade carotid lesions and how the surgeons used this criteria for patient treatment decisions.
One department is essentially using the Stavros Doppler criteria for grading the degree of the diameter-reducing stenosis, but added the ICA/CCA ratio of 4.0 (Moneta) to differentiate between greater or lesser than 70% diameter reduction. Then, if severe plaquing is identified, a transverse image is used to determine the percent of area stenosis. When I asked how these two criteria were integrated, these are the explanations I received from the clinical instructor and student:
Clinical Instructor: "Area measurements are used at virtually every facility I have worked at, and as a traveler I have worked at many. With the advent of pdi obtaining transverse area measurements is more accurate and precise than older methods i.e. Diameter measurements which do no account for lateral plaques......I personally think that area measurements are more precise albeit more time consuming than diameter measurements. These measurements are more easily compared to cta/mra images which are measured in the same manner..... I am trying to help ****** understand that Doppler is a poor indicator of low grade stenosis and is not accurate in establishing a reasonable estimation of the actual percentage of stenosis. We currently use the criteria established by The society of Radiologist in ultrasound." 
Student: "The manner that these measurements are obtained is identical to that used in echocardiography and is also used in the cardiac cath lab to determine ejection fraction, I believe it is based on the Simpson's equation so I think that these measurements are accurate and my clinical instructor believes them to be more precise than velocity alone. He says that diminished cardiac output, aortic insufficiency and overall poor arterial health effect velocity but have no effect on the area stenosis. I am told it is one of the many tools used to a thorough carotid study. Diameter stenosis is much less involved and much more innaccurate because of lateral plaques not in the line of measurement.... makes little sense to me that what is an acceptable measurement in echo would be invalid in vascular ultrasound. According to my clinical instructor this is a common practice at several large nationally known vascular labs he has worked at.
OK, so the question I have is obviously, what is common practice in vascular labs? I confess to have been brought up to use Doppler criteria for diameter reduction and essentially follow the Strandness criteria with the addition of Moneta's ICA/CCA ratio to select those patients with a greater than 70% diameter-reducing stenosis. When we were performing angios, we internally validated this criteria and realized the difficulties with trying to add the Moneta criteria to the Strandness criteria, because one measured one thing and one measured another. (i.e., at the site of stenosis as opposed to a comparison with a normal ICA at a site distal to the lesion). So, am I way behind the times and should be put out to pasture? Please feel free to flame me....I'd much rather be enlightened than ignorant.
Thanks in advance and forgive me for my long post.
Linda Sulzdorf, RDMS, RVT, BSVT
Sonographer and Instructor





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