P.L. Antignani Dept. of Angiology, (Director: C. Allegra) s.Giovanni Hospital, Rome, Italy

1. Palermo 2009 Non invasive diagnostic methods: how have they modified the therapeutical indications? P.L. Antignani Dept. of Angiology, (Director: C. Allegra) s.Giovanni Hospital, Rome, Italy

2. The non invasive diagnostic methods have modified our therapeutical decision in several vascular diseases.Particularly, many forms of surgical treatment, both endovascular and open, are performed based exclusively on evaluation with duplex scanning.

3. We discuss the main conditions in which this change is more evident: Carotid stenosis Abdominal aortic aneurysm Deep venous thrombosis Superficial venous thrombosis Chronic venous insufficiency

4. Definition of carotid lesion • Investigation techniques • High-resolution B-mode imaging • Color Doppler flow imaging • Power Doppler imaging • Compounded imaging • Four-Dimensional ColorDoppler flow imaging • Contrast ultrasonic agents • Transcranial Doppler • IVUS • Spiral CT scan • Contrast-enhanced MR angiography • Diffusion weighted MR imaging (DWI)

5. A carotid color flow duplex scanning allows: • to quantify the stenosis • to assess its morphological • characteristics

6. Evaluation of stenosis • Degree of stenosis indiameter • Degree of stenosis in cross-sectionalarea • Evaluation ofvelocity

7. Degree of stenosis

8. Color Flow Duplex imagingCAROTID PLAQUE THICKNESS ECHOGENICITY STRUCTURE SURFACE mm HYPOECHOIC HYPERECHOIC HOMOGENEOUS HETEROGENEOUS REGULAR IRREGULAR

9. Color flow duplex imaging • Plaque Classification • Type I (uniformly echolucent) • Type II (predominately echolucent) • Type III (predominately echogenic) • Type IV (uniformly echogenic) • Type V (heavy calcification)

10. Carotid plaque and Risk of stroke Other criterion:PLAQUE MORPHOLOGY Structure Fibrous cap Intraplaque hemorrhage, surface ulceration, rupture

11. Morphology of plaque “The higher the degree of stenosis, the more likely it is associated with ultrasonic heterogeneous and hypoechoic plaque” ( MM Sabetai, J Vasc Surg 2000)

12. Guidelines of ISVI and ACC- AHA-EVES Diagnosis of presence and grading of carotid stenosis Colour-flow duplex scanning is the investigation of choice for the diagnosis and measurement of carotid stenosis, provided that objective criteria are used, by experienced operators. The velocities detected should be mentioned in the report as well as whether the percent stenosis reported refers to the angiographic ECST or NASCET method.

13. Guidelines of ISVI and ACC- AHA-EVES Plaque characteristics Surface ulceration, low GSM (<25), heterogeneous appearance of the plaque and the juxta-luminal location of the echolucent area after image normalisation are ultrasonographic indicators of plaque vulnerability and should be considered in the selection of appropriate therapy and the frequency of follow up. Carotid Stenosis 50% GSM 17

14. A carotid color flow duplex scanning allows to evaluate in the follow up: • surgical results • the restenosis • the efficacy of medical treatment

15. Angio CT/MR allow to evaluate: Cohexisting aortic arch lesions Intracranial vessels anatomy Avoiding angiography

16. Diffusion-weighted magnetic resonance imaging (DWI) allows a fast evaluation ofISCHEMIC LESIONS before after

17. Transcranial color Doppler can be used before CE/CAS to evaluate: • Cohexisting lesions of intracranial vessels • Circle of Willis efficiency • Intracranial haemodynamic effects of extracranial carotid lesions • Cerebrovascular reserve • Microembolic events due to ulcerated plaques • Crossclamping risk and indication for shunting INDICATION FOR SURGERY IN ASYMPTOMATIC SUBJECTS OR IN PATIENTS WITH BILATERAL CAROTID LESIONS

18. Surgical indications • CE could be better in patients with: • Long multifocal lesions • Echolucent plaque • Severe ulceration • Heavy circumferential calcifications of carotid bifurcation • Severe tortuosities • Extensive aortic or brachiocephalic trunk lesions • If a clot is suspected

19. Carotid surgery without angiography Experience of Dept. of Vascular Surgery – La Sapienza University (prof. F. Benedetti Valentini – B. Gossetti) 1991-2007 Angiography Without angiography 8.3 91.7 100 80 60 40 20 % 100 10.3 89.7 94.5 5.5 15.0 85.0 19.1 80.9 79.1 20.9 64.1 35.9 36.4 63.6 ‘91-’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 -’04 ’05-’07 ys

20. Abdominal aortic aneurysm

21. Abdominal aortic aneurysm Among asymptomatic patients, ultrasound detects the presence of an abdominal aortic aneurysm accurately, riproducibly an at low cost. Sensitivity and specificity approach 100 %. Ultrasound is ideal for screening and in determination of aneurysm growth rate. A growth rate of > 0,7 cm per sex months or 1 cm per years has been suggested as a threshold for proceeding to surgery, irrespective of size. Chaikof EJ et al: The care of patients with abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J. Vasc. Surg. 2009;50 suppl October: 8S

22. Color flow duplex imaging Morphology: • Endovascular wall thrombus • Ulceration and calcification • “true” vessel lumen • Size and longitudinal extension

23. Color flow duplex imaging Hemodynamics • Decrease of flow velocity • Color: “mosaic” immaging

24. Color flow duplex imaging Acute conditions: Wall dissection Wall rupture Rapid growth Acute thrombosis

25. Follow up of endovascular treatment Position and patency of endograft Diameters and pulsatility of aneurysm Endoleak (sensitivity 81-100 %, specificity 74-99 %) Patency of other vessels Infections Fistulas

26. Deep venous thrombosis

27. VTE and symptoms EachofthesestagesofVenousThromboembolism (calf DVT, proximalDVT, PE) may or maynotbeassociatedwithsymptoms. The developmentofsymptomsdepends on theextentofthrombosis, the adequacyofcollateralvessels, and the severityofassociatedvascularocclusion and inflammation. For the diagnosis and monitoringof VTE theclinicalfindingsareusefulbutinadequate (accuracy no more than 30 %).

28. DEEP VENOUS THROMBOSIS Diagnosis and monitoring CLINICAL DIAGNOSIS: inadequate VENOGRAPHY: gold standard (?) DUPLEX SCANNING: high accuracy COLOR-FLOW IMAGING: NEW GOLD STANDARD PLETHYSMOGRAPHY: complementary (quantitative evaluation)

29. Colour Flow Duplex Scanning can provide both morphologic and haemodynamicfindings and represent now aquick and non-invasive alternative method of diagnosing deep vein thrombosis in the lower limbs. Colour Flow Duplex Scanning

30. Colour Flow Duplex Scanning Colour Flow Duplex Scanning represents a valid clinical tool, not only for theinitial diagnosisof DVT but also to assesslong-term outcomeof thrombus. This test can guide initial patient management, providing information aboutclot attachmentto the vein wall and resolution. In addition, it can identify those patients with a potential high risk forpost-thrombotic syndrome. Finally, CFDS may be used to compare and evaluate theresults of different regimensof anticoagulant and fibrinolytic drug therapy on thelong-term outcomeof venous thrombi in the lower extremity.

32. Compression manouvre Accuracy 100 %

33. Thrombus “at risk”

34. CHARACTERISTICS OF THE THROMBI AND INCIDENCE OF PULMONARY EMBOLISM (354 patients with DVT -28.5%- out of 1238 cases with suspected DVT) cases PE - free-floating thrombi: 40 (11,2%) 25 (60.2%) (----> 2 cm) - “cutted” thrombi: 81 (22.8%) 81 (100%) - “peduncle” thrombi: 5 ( 1,4%) 5 (100%) (free head in venous confluence) - “moving” thrombi: 2 ( 0.5%) 2 (100%) (only fixed base) - adhered thrombi: 226 (63.8%) 35 (15.4%) WFUMB 2000

35. LOCALIZATION OF THE THROMBI AND INCIDENCE OF PULMONARY EMBOLISM (354 patientswith DVT -28.5%- out of 1238 cases with suspected DVT) DVT EP % m EP fEP -iliac+inferior cava v. 35 19 54.2% 24 14 11 5 -femoral+ex. iliac v. 144 52 36.1% 77 32 67 20 -popliteal+femoral v. 107 6661.6% 65 40 42 26 -popliteal v. 18 6 33.3% 9 5 9 1 -gastrocnemious v. 34 4 11.7% 7 - 32 4 -long saphenous v. 16 5 31.2% - - 16 5 Antignani PL, WFUMB, 2000

36. The presence of anantiphospholipid antibody(lupus anticoagulant or anticardiolipin antibody) is associated with a2-fold increase in risk of recurrent VTE. Deficiencies ofantithrombin, protein C, and protein S, homozygous factor V Leiden and elevated levels of homocysteine and coagulation factor VIII(> 234 IU/L) have also been associated with higher recurrence rates. Heterozygous forms of factor V Leiden and the G20210A prothrombingene mutation confer relatively little increased risk of recurrent VTE. (Kryle P. et al. N Engl J Med 2000; Eichinger S et al. Thromb Haemost.1999; Miles JS et al. J Am Coll Cardiol. 2001; Simioni P et al. Blood 2000) Monitoring of coagulative factors Risk of Recurrent VTE

37. Risk of recurrent VTE Although not predictive of the location of thrombosis, the risk ofrecurrenceis greater when anticoagulants are stoppedwhile there is still evidence of residual DVT on ultrasound imaging. Recurrent DVT may be caused by a disturbed balance between propagation and thrombus regression. Recurrent DVT was reported in17%of the patients after 2 years. (Kearon C. Clin Chest Med. 2003; Heit JA et al. Arch Intern Med. 2000) Monitoring with ultrasound

38. About60 %of patients with the history at one episode of proximal deep vein thrombosis develop post-thrombotic syndromewithin two years. Compression stockings have reduced this rate by about50 %. The post-thrombotic syndrome is strongly related to recurrent ipsilateral deep vein thrombosis. monitoring of deep venous system with ultrasound Post-thrombotic syndrome after DVT

39. Post thrombotic syndromeInstrumental evaluation The pathophysiology of PTS is not entirely understood. Factors that are probably important in the development of PTS are venous reflux, deep vein obstruction and calf muscle pump dysfunction. The presence and location of venous reflux and obstruction can be measured withultrasound with high accuracy.

40. Differential diagnosis Neoplasia in inferior cava vein Venous popliteal aneurysm

41. Superficial venous thrombosis

42. Superficial venous thrombosis Extension and involvement Clinical assessment underestimates the thrombus

43. Superficial venous thrombosis …is estimated like a thrombus on risk if its distance from SF-J is 2 cm (guidelines by Italian Society for Vascular Investigation - 2007): Treatment of SVT as DVT.

44. Murgia AP et al: Int Angiol. 1999 Dec;18(4):343-7. • Surgical management of ascending saphenous thrombophlebitis. METHODS: We retrospectively reviewed 146 patients referred to our Vascular Laboratory for acute superficial thrombophlebitis from 1987 to 1997. Duplex scanning identified 85 cases of superficial thrombophlebitis involving at least a segment of the saphenous vein localized below the knee (58.2%); 37 of thrombophlebitis extending into both the superficial and deep venous systems (25.3%) and 24 of saphenous thrombosis extending to within 5 cm of the saphenofemoral junction (16.4%). The latter group underwent saphenofemoral disconnection. CONCLUSIONS:Duplex scanning showed 100% accuracy both in determining the presence of thrombosis and its extent. Saphenofemoral disconnection for thrombosis involving the saphenofemoral junction is a safe procedure and can be performed on an outpatient basis.

46. Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution.Hingorani AP et al. PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") ………potentially lethal complication, deep venous thrombosis (DVT). Seventy-three lower extremities were treated…. All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure The duplex scanning documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). None of these patients had pulmonary embolism. Early postoperative duplex scanning are essential, and should be mandatory in all patients undergoing RFA of the GSV.

47. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.Puggioni A et al. J Vasc Surg. 2005 Sep;42(3):488-93. Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. No cases of pulmonary embolism occurred. …we recommend early duplex scanning in all patients after endovenous saphenous ablations.

48. Venous disorders: treatment with foam sclerotherapy.Bergan J at al This report describes initial experience in treating 332 patients DVT (1.8%) was limited to gastrocnemius veins (3 cases) and posterior tibial veins (3 veins). No pulmonary emboli or lung complications occurred. CONCLUSIONS: Treatment of a variety of venous disorders can be accomplished using foam sclerotherapy with results comparable to surgery and with an acceptably low rate of adverse events. These results, however, must be confirmed by larger experience in other institutions.

49. Chronic venous insufficiency

50. Introduction • Pre-operative evaluation is best performed by means ofduplex scanningand physical examination. • Duplex scanning for venous insufficiency is simple and cost-effective. • Duplex mapping defines individual patientanatomy with considerable precision and provides valuable information that supplements the physician's clinical impression.