Knowing these limitations, in your opinion, do you feel contrast sonography holds the key in future detection of such events? Probable versus stable?


Sent from MARS 

-------- Original message --------
Subject: Re: carotid correlations 
From: "K. Beach" <[log in to unmask]> 
To: [log in to unmask] 

Dear Bill,

Yes, this is the same Moniz that developed X-ray angiographic contrast 
agents for cerebral studies, and the frontal lobotomy
(I'd rather have a bottle in front of me than a frontal lobotomy).
He received the Nobel Prize for the Frontal Lobotomy in 1949, just a year 
prior to the introduction of the first drugs for the treatment of mental 

Regarding Doppler vs Angioigraphy.
What we want to know is which patients will stroke from carotid 
atheroembolic events (not thromboembolic).
Angiography does as poorly in predicting carotid atheroembolic stoke as 
the discarded Oculoplethysmography methods, but identifies different 
patients at risk.  So, the correlation between anatomy and physiology does 
not completely resolve the question of who is at risk of stroke.
That is why some talk about vulnerable plaque, which maybe neither Doppler 
nor Angiography identify.
Logic does not always lead to truth.


On Sat, 20 Oct 2012, Bill Johnson wrote:

> Bill Johnson, Port Townsend, WA.
> Kirk, Thanks as always for staying on this list and your continuing contributions. 
> Egaz Moniz?  The same doctor that proposed lobotomy for mental illness?  (Mine never worked. but how would I know?)  ;-)
> I do not entirely think Anatomy/Velocity Correlation is "futile" but would suggest that we still try to look at flow with multiple vectors
> and assume we can "pick" the correct angle to calculate velocities.  What ever happened to the "infinitely gated Doppler"?  Not sure that
> would help, but I have always been suspicious of spectrum analysis, and probably have less confidence than most.  I have also been
> suspicious regarding non-economic "gold standards".   Ultrasound and angiography are such very different exams, that I am not very much
> surprised that correlation is elusive. 
> I am not entirely a pessimist though, and do believe noninvasive vascular exams do provide useful information.  As you wrote; "...Doppler
> velocity criteria have been successfully used to classify the severity of stenosis...) Thanks again.
> On Sat, Oct 20, 2012 at 9:01 AM, K. Beach <[log in to unmask]> wrote:
>       Dear Ruth,
>       The question of how to classify carotid stenosis has been vexing us since Egaz Moniz.
>       Unfortunately, Anatomy/Velocity Correlation is futile, in spite of our confidence to the contrary.
>       ----------------------
>       Beach KW, Leotta DF, Zierler RE., Carotid Doppler velocity measurements and anatomic stenosis: correlation is futile., Vasc
>       Endovascular Surg. 2012 Aug;46(6):466-74.
>       from the Ultrasound Reading Center and the D.E. Strandness Jr. Vascular Laboratory at University of Washington Medical Center,
>       University of Washington, Seattle, WA 98195, USA.
>       Abstract
>       BACKGROUND: Duplex ultrasound with Doppler velocimetry is widely used to evaluate the presence and severity of internal
>       carotid artery stenosis; however, a variety of velocity criteria are currently being applied to classify stenosis severity.
>       The purpose of this study is to compare published Doppler velocity measurements to the severity of internal carotid artery
>       stenosis as assessed by x-ray angiography in order to clarify the relationship between these 2 widely used approaches to
>       assess carotid artery disease.
>       METHODS: Scatter diagrams or "scattergrams" of correlations between Doppler velocity measurements and stenosis severity as
>       assessed by x-ray contrast angiography were obtained from published articles for native and stented internal carotid arteries.
>       The scattergrams were graphically digitized, combined, and segmented into categories bounded by 50% and 70% diameter
>       reduction. These data were combined and divided into 3 sets representing different velocity parameters: (1) peak systolic
>       velocity, (2) end-diastolic velocity, and (3) the internal carotid artery to common carotid artery peak systolic velocity
>       ratio. The horizontal axis of each scattergram was transformed to form a cumulative distribution function, and thresholds were
>       established for the stenosis categories to assess data variability.
>       RESULTS: Nineteen publications with 22 data sets were identified and included in this analysis. Wide variability was apparent
>       between all 3 velocity parameters and angiographic percent stenosis. The optimal peak systolic velocity thresholds for
>       stenosis in stented carotid arteries were higher than those for native carotid arteries. Within each category of stenosis, the
>       variability of all 3 velocity parameters was significantly lower in stented arteries than in native arteries.
>       CONCLUSION: Although Doppler velocity criteria have been successfully used to classify the severity of stenosis in both native
>       and stented carotid arteries, the relationship to angiographic stenosis contains significant variability. This analysis of
>       published studies suggests that further refinements in Doppler velocity criteria will not lead to improved correlation with
>       carotid stenosis as demonstrated by angiography.
>       ------------------------
>       Kirk
>       -----------------------
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