Thanks Dr. Schneider. I looked at the article the Steve referenced with interest and while fascinating, was far from convincing. I am largely with you. While theoretically valid in terms of what we think may happen when a carotid lesion embolizes, it is just that theoretical.
Additionally, to make my specific instance a moot point, the symptomatic patient in question had a classical left hemisphere TIA, had less than 40% stenosis on the left side but was a month out from a 3 cardiac valve replacement and had a very irregular atrial fibrillation.
Bill
-----Original Message-----
From: UVM Flownet <[log in to unmask]> On Behalf Of Schneider, Joseph MD
Sent: Monday, November 5, 2018 9:25 AM
To: [log in to unmask]
Subject: Re: UVMFLOWNET Digest - 2 Nov 2018 to 4 Nov 2018 (#2018-127)
Although there has been interest in this for many years, my view of the literature is that there is very little evidence to support this and much evidence to refute it. Your surgeon may make decisions based on his or her view of the literature, I would not proceed to CEA based on ulcer alone without severe stenosis.
Joseph R. Schneider, M.D., Ph.D., D.F.S.V.S.™, F.A.C.S., R.V.T., R.P.V.I.
Vascular Surgery and Interventional Radiology Partners/VSIR Northwestern Medicine Professor of Surgery, Northwestern University Medical School
-----Original Message-----
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Sent: Sunday, November 04, 2018 11:00 PM
To: [log in to unmask]
Subject: UVMFLOWNET Digest - 2 Nov 2018 to 4 Nov 2018 (#2018-127)
WARNING: External email, please be mindful before clicking or replying.
There are 17 messages totaling 2395 lines in this issue.
Topics of the day:
1. Carotid stenosis question (3)
2. PVR with stents (14)
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Date: Sun, 4 Nov 2018 11:42:41 -0500
From: Bill Schroedter <[log in to unmask]>
Subject: Carotid stenosis question
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, FSVU
4120 Woodmere Park Blvd
Suite 8B
Venice, Florida 34293
www.virtualvascularlab.com <http://www.virtualvascularlab.com>
www.virtualveincenter.com <http://www.virtualveincenter.com>
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------------------------------
Date: Sun, 4 Nov 2018 13:27:20 -0500
From: Brian Sapp <[log in to unmask]>
Subject: 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, RPhS
Registeredvascular.net
404-667-9417
800-385-2790
> On 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, FSVU
> 4120 Woodmere Park Blvd
> Suite 8B
> Venice, Florida 34293
> www.virtualvascularlab.com
> www.virtualveincenter.com
>
> To unsubscribe or search other topics on UVM Flownet link to:
> http://list.uvm.edu/archives/uvmflownet.html
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------------------------------
Date: Sun, 4 Nov 2018 14:02:31 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: Carotid stenosis question
Whole point of CREST IIDr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Brian Sapp <[log in to unmask]> Date: 11/4/18 1:27 PM (GMT-05:00) To: [log in to unmask] Subject: 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 symptom!
atic 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:<!--
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-->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
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------------------------------
Date: Sun, 4 Nov 2018 21:29:04 +0000
From: "Schneider, Joseph MD" <[log in to unmask]>
Subject: PVR with stents
Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
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------------------------------
Date: Sun, 4 Nov 2018 16:49:25 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: PVR with stents
We only do art duplex at this point.We are a private lab and most patients have stents and the rest are limb salvage.No reason to screen, we know they are vasculopaths. We have however included 02 color map imaging on our wound care patients .PVR holds value, just not in our setting.Dr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: "Schneider, Joseph MD" <[log in to unmask]> Date: 11/4/18 4:29 PM (GMT-05:00) To: [log in to unmask] Subject: PVR with stents
Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
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------------------------------
Date: Sun, 4 Nov 2018 17:06:20 -0500
From: Andrew Bebry <[log in to unmask]>
Subject: Re: PVR with stents
Joe. I do not perform pressures over stents, grafts or atherectomies....
due to the unlikely event of damage to the procedure and subsequent stenosis/thrombosis. This happened to one of my predecessors. Even though one doc said I can put pressure post-op, but not periop, I don't do it, unless ORDERED. I've been at this 36 yrs and don't plan on sending anyone to the ER. My mentors and the luminaries I know agree with me. Andy Bebry,RVT
On Sun, Nov 4, 2018, 4:30 PM Schneider, Joseph MD <[log in to unmask]
wrote:
> Hello
>
> We do not do PVRs in our lab (this seems to be a favorite in the
> Northeast, probably the lingering influence of John Mannick and Jeff
> Raines, we are Midwestern and likely are still influenced by Jimmy Yao
> and Eugene Strandness) so I would like to ask how labs approach the
> problem of pressure cuffs in subjects with previous interventions,
> especially with stents. We would not do full segmental pressures in
> such patients and would limit pressure measurements to the ankle (ABI)
> to avoid possible compression of the treated/stented arteries. I am
> wondering if those of you who use PVR (where the base pressure of 65
> mmHg is much less than would be required in segmental pressure
> measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>
> Thanks
>
> Joe
>
>
>
>
>
> This message and any included attachments are intended only for the
> addressee. The information contained in this message is confidential
> and may constitute proprietary or non-public information under
> international, federal, or state laws. Unauthorized forwarding,
> printing, copying, distribution, or use of such information is
> strictly prohibited and may be unlawful. If you are not the addressee,
> please promptly delete this message and notify the sender of the delivery error by e-mail.
> To unsubscribe or search other topics on UVM Flownet link to:
> http://list.uvm.edu/archives/uvmflownet.html
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------------------------------
Date: Sun, 4 Nov 2018 17:09:28 -0500
From: Steve Knight <[log in to unmask]>
Subject: Re: PVR with stents
I never hesitated to do a PVR over a stent.
Steve K
On Sun, Nov 4, 2018, 4:30 PM Schneider, Joseph MD <[log in to unmask]
wrote:
> Hello
>
> We do not do PVRs in our lab (this seems to be a favorite in the
> Northeast, probably the lingering influence of John Mannick and Jeff
> Raines, we are Midwestern and likely are still influenced by Jimmy Yao
> and Eugene Strandness) so I would like to ask how labs approach the
> problem of pressure cuffs in subjects with previous interventions,
> especially with stents. We would not do full segmental pressures in
> such patients and would limit pressure measurements to the ankle (ABI)
> to avoid possible compression of the treated/stented arteries. I am
> wondering if those of you who use PVR (where the base pressure of 65
> mmHg is much less than would be required in segmental pressure
> measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>
> Thanks
>
> Joe
>
>
>
>
>
> This message and any included attachments are intended only for the
> addressee. The information contained in this message is confidential
> and may constitute proprietary or non-public information under
> international, federal, or state laws. Unauthorized forwarding,
> printing, copying, distribution, or use of such information is
> strictly prohibited and may be unlawful. If you are not the addressee,
> please promptly delete this message and notify the sender of the delivery error by e-mail.
> To unsubscribe or search other topics on UVM Flownet link to:
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------------------------------
Date: Sun, 4 Nov 2018 17:17:38 -0500
From: Luz Guzman Restrepo <[log in to unmask]>
Subject: Re: PVR with stents
In our lab Patients with Bpg/stent We do segmental pressures and ABI.
If bpg/stent involves a tibial artery we do segmentals and tbi.
> On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
>
> Hello
> We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
> Thanks
> Joe
>
>
>
> This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
>
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------------------------------
Date: Sun, 4 Nov 2018 17:31:34 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: PVR with stents
Most stents now a days can withstand total compression 10 years ago not so much, but what info do you get from a pvr that you would not get from a resting art duplex , vs pvr in a severe patient? This is more clinical versus diagnostic.PVR quantitative not qualitative. Art duplex is qualitative and combined with clinical, 100% useful. PVR is a dated modality IMHODr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Luz Guzman Restrepo <[log in to unmask]> Date: 11/4/18 5:17 PM (GMT-05:00) To: [log in to unmask] Subject: Re: PVR with stents In our lab Patients with Bpg/stent We do segmental pressures and ABI.If bpg/stent involves a tibial artery we do segmentals and tbi.On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
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Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
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Date: Sun, 4 Nov 2018 17:43:27 -0500
From: Andrew Bebry <[log in to unmask]>
Subject: Re: PVR with stents
PVR no problem. Just not SBP.
On Sun, Nov 4, 2018, 5:09 PM Steve Knight <[log in to unmask] wrote:
> I never hesitated to do a PVR over a stent.
> Steve K
>
> On Sun, Nov 4, 2018, 4:30 PM Schneider, Joseph MD
> <[log in to unmask]
> wrote:
>
>> Hello
>>
>> We do not do PVRs in our lab (this seems to be a favorite in the
>> Northeast, probably the lingering influence of John Mannick and Jeff
>> Raines, we are Midwestern and likely are still influenced by Jimmy
>> Yao and Eugene Strandness) so I would like to ask how labs approach
>> the problem of pressure cuffs in subjects with previous
>> interventions, especially with stents. We would not do full segmental
>> pressures in such patients and would limit pressure measurements to
>> the ankle (ABI) to avoid possible compression of the treated/stented
>> arteries. I am wondering if those of you who use PVR (where the base
>> pressure of 65 mmHg is much less than would be required in segmental
>> pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>>
>> Thanks
>>
>> Joe
>>
>>
>>
>>
>>
>> This message and any included attachments are intended only for the
>> addressee. The information contained in this message is confidential
>> and may constitute proprietary or non-public information under
>> international, federal, or state laws. Unauthorized forwarding,
>> printing, copying, distribution, or use of such information is
>> strictly prohibited and may be unlawful. If you are not the
>> addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
>> To unsubscribe or search other topics on UVM Flownet link to:
>> http://list.uvm.edu/archives/uvmflownet.html
>
> To unsubscribe or search other topics on UVM Flownet link to:
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Date: Sun, 4 Nov 2018 16:47:09 -0700
From: Sarah Sarlo <[log in to unmask]>
Subject: Re: PVR with stents
Our lab routinely performs PVRs over stent but not pressures even though many stents now are self-inflating.
Sent from my iPhone
> On Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo <[log in to unmask]> wrote:
>
> In our lab Patients with Bpg/stent We do segmental pressures and ABI.
> If bpg/stent involves a tibial artery we do segmentals and tbi.
>
>> On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
>>
>> Hello
>> We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>> Thanks
>> Joe
>>
>>
>>
>> This message and any included attachments are intended only for the addressee. The information contained in this message is confidential and may constitute proprietary or non-public information under international, federal, or state laws. Unauthorized forwarding, printing, copying, distribution, or use of such information is strictly prohibited and may be unlawful. If you are not the addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
>>
>> To unsubscribe or search other topics on UVM Flownet link to:
>> http://list.uvm.edu/archives/uvmflownet.html
> To unsubscribe or search other topics on UVM Flownet link to:
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------------------------------
Date: Sun, 4 Nov 2018 19:02:22 -0500
From: Andrew Bebry <[log in to unmask]>
Subject: Re: PVR with stents
PVR will last forever.
On Sun, Nov 4, 2018, 6:47 PM Sarah Sarlo <[log in to unmask] wrote:
> Our lab routinely performs PVRs over stent but not pressures even
> though many stents now are self-inflating.
>
> Sent from my iPhone
>
> On Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo
> <[log in to unmask]>
> wrote:
>
> In our lab Patients with Bpg/stent We do segmental pressures and ABI.
> If bpg/stent involves a tibial artery we do segmentals and tbi.
>
> On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD
> <[log in to unmask]>
> wrote:
>
> Hello
>
> We do not do PVRs in our lab (this seems to be a favorite in the
> Northeast, probably the lingering influence of John Mannick and Jeff
> Raines, we are Midwestern and likely are still influenced by Jimmy Yao
> and Eugene Strandness) so I would like to ask how labs approach the
> problem of pressure cuffs in subjects with previous interventions,
> especially with stents. We would not do full segmental pressures in
> such patients and would limit pressure measurements to the ankle (ABI)
> to avoid possible compression of the treated/stented arteries. I am
> wondering if those of you who use PVR (where the base pressure of 65
> mmHg is much less than would be required in segmental pressure
> measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>
> Thanks
>
> Joe
>
>
>
>
>
> This message and any included attachments are intended only for the
> addressee. The information contained in this message is confidential
> and may constitute proprietary or non-public information under
> international, federal, or state laws. Unauthorized forwarding,
> printing, copying, distribution, or use of such information is
> strictly prohibited and may be unlawful. If you are not the addressee,
> please promptly delete this message and notify the sender of the delivery error by e-mail.
> To unsubscribe or search other topics on UVM Flownet link to:
> http://list.uvm.edu/archives/uvmflownet.html
>
> To unsubscribe or search other topics on UVM Flownet link to:
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>
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Date: Sun, 4 Nov 2018 19:46:04 -0500
From: Patrick Doolan <[log in to unmask]>
Subject: Re: PVR with stents
Dr Roberts,
PVR is qualitative and not quantitative. There are no values obtained.
Segmental pressures are quantitative.
To address the question,
I would do PVRs over stents. I wouldn’t do a segmental pressure over a stent because of safety and there is no value-added information obtained.
I love arterial physiological exams and I’m surprised that they are only popular in the East and some of the Midwest. The PVR gives information on the quality of overall blood flow, and can elucidate how well collateral blood flow is helping overall perfusion. You may see collaterals on duplex, but is there any qualitative information obtained?
The quality of the duplex exam, and the quantitative velocities obtained, is dependent on the quality of the technologist. The same for the physiological exam, but the quality seems a little more apparent if the information doesn’t agree. The arterial physiological exam and then an arterial duplex seems to be a great check and verification of the quality of both exams.
I felt like jumping into the fray.
Patrick Doolan
On Sun, Nov 4, 2018 at 7:02 PM Andrew Bebry <[log in to unmask]> wrote:
> PVR will last forever.
>
> On Sun, Nov 4, 2018, 6:47 PM Sarah Sarlo <[log in to unmask] wrote:
>
>> Our lab routinely performs PVRs over stent but not pressures even
>> though many stents now are self-inflating.
>>
>> Sent from my iPhone
>>
>> On Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo
>> <[log in to unmask]>
>> wrote:
>>
>> In our lab Patients with Bpg/stent We do segmental pressures and ABI.
>> If bpg/stent involves a tibial artery we do segmentals and tbi.
>>
>> On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD
>> <[log in to unmask]>
>> wrote:
>>
>> Hello
>>
>> We do not do PVRs in our lab (this seems to be a favorite in the
>> Northeast, probably the lingering influence of John Mannick and Jeff
>> Raines, we are Midwestern and likely are still influenced by Jimmy
>> Yao and Eugene Strandness) so I would like to ask how labs approach
>> the problem of pressure cuffs in subjects with previous
>> interventions, especially with stents. We would not do full segmental
>> pressures in such patients and would limit pressure measurements to
>> the ankle (ABI) to avoid possible compression of the treated/stented
>> arteries. I am wondering if those of you who use PVR (where the base
>> pressure of 65 mmHg is much less than would be required in segmental
>> pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>>
>> Thanks
>>
>> Joe
>>
>>
>>
>>
>>
>> This message and any included attachments are intended only for the
>> addressee. The information contained in this message is confidential
>> and may constitute proprietary or non-public information under
>> international, federal, or state laws. Unauthorized forwarding,
>> printing, copying, distribution, or use of such information is
>> strictly prohibited and may be unlawful. If you are not the
>> addressee, please promptly delete this message and notify the sender of the delivery error by e-mail.
>> To unsubscribe or search other topics on UVM Flownet link to:
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------------------------------
Date: Sun, 4 Nov 2018 20:09:28 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: PVR with stents
Disagree completely, no need to argue the point.Dr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Patrick Doolan <[log in to unmask]> Date: 11/4/18 7:46 PM (GMT-05:00) To: [log in to unmask] Subject: Re: PVR with stents Dr Roberts,PVR is qualitative and not quantitative. There are no values obtained. Segmental pressures are quantitative. To address the question, I would do PVRs over stents. I wouldn’t do a segmental pressure over a stent because of safety and there is no value-added information obtained. I love arterial physiological exams and I’m surprised that they are only popular in the East and some of the Midwest. The PVR gives information on the quality of overall blood flow, and can elucidate how well collateral blood flow is helping overall perfusion. You may see collaterals on duplex, but is there any qualitative information obtained?The quality of the duplex exam, and the quantitative velocities obtained, is dependent on the quality of the technologist. The same for the physiological exam, but the quality seem!
s a little more apparent if the information doesn’t agree. The arterial physiological exam and then an arterial duplex seems to be a great check and verification of the quality of both exams.I felt like jumping into the fray.Patrick Doolan On Sun, Nov 4, 2018 at 7:02 PM Andrew Bebry <[log in to unmask]> wrote:PVR will last forever. On Sun, Nov 4, 2018, 6:47 PM Sarah Sarlo <[log in to unmask] wrote:Our lab routinely performs PVRs over stent but not pressures even though many stents now are self-inflating.Sent from my iPhoneOn Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo <[log in to unmask]> wrote:In our lab Patients with Bpg/stent We do segmental pressures and ABI.If bpg/stent involves a tibial artery we do segmentals and tbi.On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
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------------------------------
Date: Sun, 4 Nov 2018 20:13:30 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: PVR with stents
Why do both test? You do a pvr then a duplex to confirm pvr..no sense in that. I get you like pvr, but its not specific. Generally I dont argue this point, but you devalued RVTs with you statement.Ultrasound in the right hands is very qualitative..Dr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Patrick Doolan <[log in to unmask]> Date: 11/4/18 7:46 PM (GMT-05:00) To: [log in to unmask] Subject: Re: PVR with stents Dr Roberts,PVR is qualitative and not quantitative. There are no values obtained. Segmental pressures are quantitative. To address the question, I would do PVRs over stents. I wouldn’t do a segmental pressure over a stent because of safety and there is no value-added information obtained. I love arterial physiological exams and I’m surprised that they are only popular in the East and some of the Midwest. The PVR gives information on the quality of overall blood flow, and can elucidate how well collateral blood flow is helping overall perfusion. You may see collaterals on duplex, but is there any qualitative information obtained?The quality of the duplex exam, and the quantitative velocities obtained, is dependent on the quality of the technologist. The same for the physiological exam, but the quality seem!
s a little more apparent if the information doesn’t agree. The arterial physiological exam and then an arterial duplex seems to be a great check and verification of the quality of both exams.I felt like jumping into the fray.Patrick Doolan On Sun, Nov 4, 2018 at 7:02 PM Andrew Bebry <[log in to unmask]> wrote:PVR will last forever. On Sun, Nov 4, 2018, 6:47 PM Sarah Sarlo <[log in to unmask] wrote:Our lab routinely performs PVRs over stent but not pressures even though many stents now are self-inflating.Sent from my iPhoneOn Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo <[log in to unmask]> wrote:In our lab Patients with Bpg/stent We do segmental pressures and ABI.If bpg/stent involves a tibial artery we do segmentals and tbi.On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
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------------------------------
Date: Sun, 4 Nov 2018 20:30:13 -0500
From: Dr Jason Roberts <[log in to unmask]>
Subject: Re: PVR with stents
Why?Dr Jason Roberts (C) 954-801-2496(E) [log in to unmask] from my mobile phone, please excuse any typos
-------- Original message --------From: Andrew Bebry <[log in to unmask]> Date: 11/4/18 7:02 PM (GMT-05:00) To: [log in to unmask] Subject: Re: PVR with stents PVR will last forever. On Sun, Nov 4, 2018, 6:47 PM Sarah Sarlo <[log in to unmask] wrote:Our lab routinely performs PVRs over stent but not pressures even though many stents now are self-inflating.Sent from my iPhoneOn Nov 4, 2018, at 3:17 PM, Luz Guzman Restrepo <[log in to unmask]> wrote:In our lab Patients with Bpg/stent We do segmental pressures and ABI.If bpg/stent involves a tibial artery we do segmentals and tbi.On Nov 4, 2018, at 4:29 PM, Schneider, Joseph MD <[log in to unmask]> wrote:
Hello
We do not do PVRs in our lab (this seems to be a favorite in the Northeast, probably the lingering influence of John Mannick and Jeff Raines, we are Midwestern and likely are still influenced by Jimmy Yao and Eugene Strandness) so I would like to ask how labs approach the problem of pressure cuffs in subjects with previous interventions, especially with stents. We would not do full segmental pressures in such patients and would limit pressure measurements to the ankle (ABI) to avoid possible compression of the treated/stented arteries. I am wondering if those of you who use PVR (where the base pressure of 65 mmHg is much less than would be required in segmental pressure measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
Thanks
Joe
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------------------------------
Date: Sun, 4 Nov 2018 20:55:14 -0500
From: Ann Marie Kupinski <[log in to unmask]>
Subject: Re: PVR with stents
Hi Dr. Schneider,
Many people have already given their points of view and I agree with most.
I think it is fine to do PVRs over a stent or bypass graft as generally the pressure is between 65-70 mmHg. I like multi-level PVRs for the waveform component of my physiologic exams as I think it is easier to do with less technologist dependence as compared to CW Doppler. I've done 1000's of PVRs personally and never had an issue.
As has been stated in this thread, physiologic testing is important in that is tells you about function - which is really what we want to know. We don't care if a patient has one vessel run-off as long as they can walk to the end of their driveway and get their mail. However, the test we choose depends on the question we want answered. Global perfusion needs to be known to correlate with symptoms and determine the next step. We and others showed a long time ago that physiologic testing is not as sensitive in detecting stenosis in a bypass graft and I would guess the same is true for stents. So in many patients you must combine imaging with indirect testing. Even Dr. Bandyk's stent criteria includes ABI drops. Since you wouldn't want to do segmental pressures over a stent, doing PVRs will give you the added info on the global perfusion at various levels.
All the best,
Ann Marie
On Sun, Nov 4, 2018 at 4:30 PM Schneider, Joseph MD <[log in to unmask]>
wrote:
> Hello
>
> We do not do PVRs in our lab (this seems to be a favorite in the
> Northeast, probably the lingering influence of John Mannick and Jeff
> Raines, we are Midwestern and likely are still influenced by Jimmy Yao
> and Eugene Strandness) so I would like to ask how labs approach the
> problem of pressure cuffs in subjects with previous interventions,
> especially with stents. We would not do full segmental pressures in
> such patients and would limit pressure measurements to the ankle (ABI)
> to avoid possible compression of the treated/stented arteries. I am
> wondering if those of you who use PVR (where the base pressure of 65
> mmHg is much less than would be required in segmental pressure
> measurements) limit your PVR measurements to the ankle and foot to avoid any compression of the stents?
>
> Thanks
>
> Joe
>
>
>
>
>
> This message and any included attachments are intended only for the
> addressee. The information contained in this message is confidential
> and may constitute proprietary or non-public information under
> international, federal, or state laws. Unauthorized forwarding,
> printing, copying, distribution, or use of such information is
> strictly prohibited and may be unlawful. If you are not the addressee,
> please promptly delete this message and notify the sender of the delivery error by e-mail.
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------------------------------
End of UVMFLOWNET Digest - 2 Nov 2018 to 4 Nov 2018 (#2018-127)
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