I wholeheartedly agree with you about the TCD Ridge.
To that end, I throw out a case from a good many years ago. I do however believe this is an outlier but nonetheless.
Plaque characterization by ultrasound in carotid artery disease has been the holy grail for decades.....and sadly, not solved. Here is a short case of an outlier - hope you enjoy Tuesday Technical Tip
Check it out! The Virtual Vascular Lab YouTube Channel
https://www.youtube.com/channel/UCbl___yuFu51OJNlTVVi2qA
Bill
From: UVM Flownet <[log in to unmask]> On Behalf Of Johnson, Ridge
Sent: Tuesday, November 6, 2018 4:41 PM
To: [log in to unmask]
Subject: Re: Carotid stenosis question
I think that many vascular surgeons would describe the same treatment strategy that yours did. If perhaps there isn’t enough evidence to support this strategy, shouldn’t such patients should get further workup to stratify their stroke risk?
How about if we take this discussion in a different direction and ask if the patient would benefit from Transcranial Doppler Emboli monitoring to stratify their risk and treatment strategy. Some recently published literature (below are a couple recent examples, though this isn’t really new information) suggests that the presence of microembolic signatures on transcranial Doppler is able to categorize asymptomatic patients with significantly increased risk of stroke (where intervention would be warranted). While the data pertains to asymptomatic patients with “significant” stenosis, one could hypothesize that the presence of microembolic signatures in a symptomatic patient with a potentially vulnerable (possibly ulcerated) plaque would be at least equally as concerning. Who wants to gather the data for this study?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890862/
https://www.ncbi.nlm.nih.gov/pubmed/28818260
Have a great day,
Ridge Johnson, RVT
Pacific Vascular, Inc.
From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Dr Jason Roberts
Sent: Monday, November 05, 2018 10:09 AM
To: [log in to unmask]
Subject: Re: Carotid stenosis question
I wonder how contrast enhanced ultrasound will play a role in ICA stenosis in the future.
Dr Jason Roberts
(C) 954-801-2496
Sent 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)
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 Sapp
Sent: Sunday, November 4, 2018 1:27 PM
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 symptomatic then treatment would be indicated. JMHO.
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
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