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<Playing Devils Advocate> So your 70 y/o mother has a 1-49% velocity measurement and a 25% diameter reduction in her ICA. Asymptomatic. It has taken her 70 years to develop this asymptomatic 1-49% velocity and  25% diameter reduction. It will probably take her another (just throwing out make believe numbers) 15 years to develop another 10-25 % diameter reduction.
Are you saying you want her to have an annual screening so follow this even while being asymptomatic? To what purpose? Will this not cause undue worry not to mention the financial burden with no real improvement in health or outcomes?
What has happened to using evidenced based medicine? 
I will also posit that local diameter reduction is very operator dependent, as is all sonography, I do advocate using a combination of diagnostic criteria and see the bigger picture. A symptomatic person with non-calcified irregular plaque is a different  than an asymptomatic person with a calcified or mixed plaque and a 40% diameter reduction. 
But, hey, I have time on my hands today ......LOLAudrey
      From: Bill Schroedter <[log in to unmask]>
 To: [log in to unmask] 
 Sent: Wednesday, October 21, 2015 12:16 PM
 Subject: Re: carotid plaque standards
   
#yiv0034946794 #yiv0034946794 -- _filtered #yiv0034946794 {font-family:Helvetica;panose-1:2 11 6 4 2 2 2 2 2 4;} _filtered #yiv0034946794 {panose-1:2 4 5 3 5 4 6 3 2 4;} _filtered #yiv0034946794 {font-family:Calibri;panose-1:2 15 5 2 2 2 4 3 2 4;} _filtered #yiv0034946794 {font-family:Tahoma;panose-1:2 11 6 4 3 5 4 4 2 4;}#yiv0034946794 #yiv0034946794 p.yiv0034946794MsoNormal, #yiv0034946794 li.yiv0034946794MsoNormal, #yiv0034946794 div.yiv0034946794MsoNormal {margin:0in;margin-bottom:.0001pt;font-size:12.0pt;}#yiv0034946794 a:link, #yiv0034946794 span.yiv0034946794MsoHyperlink {color:blue;text-decoration:underline;}#yiv0034946794 a:visited, #yiv0034946794 span.yiv0034946794MsoHyperlinkFollowed {color:purple;text-decoration:underline;}#yiv0034946794 p.yiv0034946794MsoAcetate, #yiv0034946794 li.yiv0034946794MsoAcetate, #yiv0034946794 div.yiv0034946794MsoAcetate {margin:0in;margin-bottom:.0001pt;font-size:8.0pt;}#yiv0034946794 span.yiv0034946794EmailStyle18 {color:#1F497D;}#yiv0034946794 span.yiv0034946794BalloonTextChar {}#yiv0034946794 .yiv0034946794MsoChpDefault {} _filtered #yiv0034946794 {margin:1.0in 1.0in 1.0in 1.0in;}#yiv0034946794 div.yiv0034946794WordSection1 {}#yiv0034946794 To my way of thinking, using US gray scale imaging provides a different appearance of plaque as opposed to wall or intimal thickening which we will mention as such but not call is plaque or stenosis. However, I would disagree with you Denise.  We are not just looking to see if there is a surgical lesion but does the patient have disease and plaque, even a small amount is disease.  (we can debate is intimal thickening is a disease).  A 20-30% stenosis is a stenosis, just perhaps not what we tend to call hemodynamically significant which as you know can also be somewhat of a nebulous term.  I could potentially agree that we call it diameter reduction as opposed to a stenosis.  But here is my point - if it’s my mother, I would like to know is there a plaque that results in an approximately 10% diameter reduction or 45% diameter reduction.  I think that does make a clinical difference in terms of follow-up and potential risk management.  I would also argue that a 20% stenosis in fact does increase velocity past the stenosis, just far below the level of our ability to consistently and reproducibly determine velocity in an vessel in-vivo.    One of my big complaints about the SRU consensus is the comments on plaque.  The velocity criteria for various categories of stenosis use the NASCET measurement methodology and not the local diameter reduction which in practice changed the definition of a stenosis.   {For those not completely familiar with these values, they have never been validated and in fact have been shown to be probably too low a threshold. For example, Moneta showed that the risk of event in patients with a PSV of 230- 290 cm/sec had only a 1.1% stroke risk and therefore would probably not justify intervention.}  In the consensus there is  also the section on plaque diameter reduction and this appears to mix apples (velocity – distal ICA reference) and oranges (local diameter reduction measurement). To my mind, this fact went a long way towards confusing the community on the definition of stenosis.  I have some hope in the current IAC undertaking to conduct a multi-center study to update to a more standardized criteria.    To throw another little curve out to everyone, we recently came across a rather large mobile plaque in a carotid artery.  Now we have occasionally seen this before but this was particualrly notable. I posted a couple clips on our Google + page if you are interested in checking it out – pretty impressive!     https://plus.google.com/103499296162773084404/posts  In looking at the literature, there does not seem to be a whole lot of data regarding this finding.  Intuitively, this would seem bad but there is no validated criteria to make that statement AND the patient was asymptomatic…..         Anyone know of any articles or like to give some thoughts, personal experiences with similar.      Ain’t this stuff fun!Bill    William B Schroedter, BS, RVT, RPhS, FSVUQuality Vascular Imaging, IncVenice, Florida(941) 408-8855www.qualityvascular.comwww.compressionsocks.pro www.virtualveincenter.com    

From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Denise Levy
Sent: Wednesday, October 21, 2015 11:18 AM
To: [log in to unmask]
Subject: Re: carotid plaque standards  Hi , In  agreement with Dr Schneider we only comment on an ECA if there is a stenosis with velocities elevated and possibly contributing to a n audible bruit.  Too much confusion with the referring. Also make sure to confirm it is an ECA with Temporal tap , My two cents, Denise 

On Wednesday, October 21, 2015, Audrey Fleming <[log in to unmask]> wrote:I guess my first question is, "does it matter?" 0-49% or 1-49% is still below the threshold of intervention by almost everyone. Unless there is obvious ulcerative plaque with associated clinical findings, 0-49% is a moot point. If the plaque is appraching that 50% then a note can be made as such and suggest clinical correlation.  I would never call a "stenosis" with any finding of 1-49%. It is not hemodynamically significant and certainly not op worthy ( understanding there may be rare instances of unusual clinical circumstances).   I am always amazed at the patient who returns year after year for their annual carotid exam because someone called a stenosis of 5%. Now that STENOSIS!!!!! is followed every year until death. Hmmmm, let's all wonder why there are more and more cuts in payment.  Just my 1 cent worth of thought for the day.  From: "Schneider, Joseph MD" <[log in to unmask]>
To: [log in to unmask] 
Sent: Wednesday, October 21, 2015 9:38 AM
Subject: carotid plaque standards       Ladies and gentlemen: I received the following query from a colleague and would appreciate hearing what people think about this Simple question for you- we are revising our vascular lab protocols and got into a debate about what actually defines the presence of plaque in the extracranial carotid system (which would mean the difference between calling the artery normal versus having 1-49% stenosis).  Some techs say they were taught that if the IMT is > 1mm that they should consider this to indicate the presence of plaque, whereas others are using 3 mm as a cutoff- I am finding that there is a real issue with techs and reading physicians ‘eyeballing’ the carotid to determine plaque presence or not in cases where the artery wall is maybe a bit thick, but there is no real plaque (calcification, etc.) and I am wondering if we are over calling the presence of 1-49% stenosis in normal arteries.  What is your understanding of the definition of plaque presence in the carotid when it comes to these cases of mildly thickened wall with no convincing plaque?  Incidentally, my personal answer to her was as follows: I can tell you that we are set up to do IMT, but our Cardiologists have said that they think the bloom is off the rose for IMT and they don’t ask for it. I look for plaque primarily on the B-mode transverse loops and if I see anything I will call it <50% assuming there are no elevated velocities.  As I recall the Grant articles about “consensus” standards don’t specifically address this and I’m not aware of any definitive literature on the topic.  I will ask the Flownet (primarily sonographers) and I will ask John Gocke and Greg Moneta, both of them co-authors on the Grant papers, and get back to you.    Thanks in advance Joe 


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