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Magnetic Resonance Imaging and Arteriography

Basic Principles Magnetic resonance imaging (MRI) is performed using a large external magnetic field, magnetic field gradients, and an applied oscillating magnetic field known as the radiofrequency field (RF). The combination of these three applied magnetic fields produces signals from inside tissue that can be used to create MR images. The details of the external magnetic field, gradients, and RF determine many of the characteristics of…

Computed Tomography

Acknowledgment Leo Schultze Kool, Monique Brink, Gijs Bloemsma, and Maarten Truijers are greatly acknowledged for their help in preparing this chapter. Conventional contrast-enhanced arteriography is no longer considered the standard imaging modality for vascular disease. As with many technologic advances, however, the process of image creation continues to become more difficult for the average end user to understand. Although the typical vascular surgeon can perform clinical…

Venography

Despite the advances we have made in medical imaging, contrast-enhanced venography has been and is still the “gold standard” for the diagnosis of deep venous thrombosis (DVT) since the early 1970s. Meanwhile, duplex ultrasonography is the most accurate noninvasive testing modality used to diagnose DVT and it is often readily available. Early extremity venography required venous cut-down for access to the deep venous system, but this…

Arteriography

Despite many advances in the quality and availability of less invasive arterial imaging modalities, arteriography remains the “gold standard.” Alternative modalities, such as duplex arterial mapping, computed tomographic angiography (CTA), and magnetic resonance angiography (MRA), are being used with increasing frequency because of improved image quality and minimal risk. For some clinical scenarios, such as duplex surveillance of lower extremity vein bypass grafts, these imaging techniques…

Radiation Safety

Advances in radiation have led to a significant increase in its use for diagnostic, interventional, and therapeutic purposes. With the ever-increasing utilization of endovascular techniques, concern has grown regarding the potential harmful effects of radiation delivered to both the patient and the operator. Although radiation exposure from diagnostic procedures is generally low and comparable to natural background doses, therapeutic use of radiation during endovascular procedures involves…

Vascular Laboratory: Venous Duplex Scanning

Introduction Duplex scanning is readily available, noninvasive, and inexpensive. It is the primary means for diagnosis of deep vein thrombosis (DVT) and chronic venous insufficiency (CVI) (see Ch. 148 , Acute Lower Extremity Deep Venous Thrombosis: Presentation, Diagnosis, and Medical Treatment; and Ch. 156 , Chronic Venous Disorders: Postthrombotic Syndrome, Natural History, Pathophysiology, and Etiology). There are limitations, however. The accuracy and reliability of venous duplex…

Vascular Laboratory: Venous Physiologic Assessment

Venous pathophysiology in the lower extremity manifests as a spectrum of disorders (see Section 23, Chronic Venous Disorders). Reporting standards published first in 1994 and revised in 2004 recognized pathophysiologic assessment as a key feature in assessing patients with chronic venous disease (CVD) properly, as well communicating results to the venous care community. , The 2014 joint Society for Vascular Surgery/American Venous Forum clinical practice guideline…

Techniques to Assess Tissue Perfusion in Peripheral Arterial Occlusive Disease

Introduction Determination of lower limb tissue perfusion in patients with peripheral arterial occlusive disease (PAD) or critical limb-threatening ischemia (CLTI) can be challenging. In addition to the clinical examination, additional diagnostic tools, such as the ankle–brachial index (ABI), toe blood pressure, Doppler ultrasound, computed tomography (CT) angiography, magnetic resonance (MR) angiography, and digital subtraction angiography (DSA), are widely used. , However, these imaging techniques focus on…

Vascular Laboratory: Arterial Duplex Scanning

Duplex ultrasound (DUS) is an integral component of diagnostic testing for the evaluation and management of arterial disease. This technology, which combines the acquisition of blood flow (pulsed Doppler spectral analysis) and anatomic (B-mode and color Doppler imaging) information, was developed under the guidance of D. Eugene Strandness, Jr., at the University of Washington in the 1970s. The initial clinical application of arterial duplex scanning assessed…

Vascular Laboratory: Arterial Physiologic Assessment

Arterial physiologic testing adds a degree of objectivity to the subjective clinical evaluation of peripheral arterial disease (PAD). The advances in direct physiologic testing of specific arterial sites by duplex scanning and noninvasive imaging evaluation provide the approximate localization of extent of disease and therefore indirect physiologic testing is now less critical (see Chapter 22 , Vascular Laboratory: Arterial Duplex Scanning). However, physiologic testing is helpful…

Clinical Evaluation of the Venous and Lymphatic Systems

Anatomic Considerations The anatomy of the veins and lymphatics provides the basis for understanding the pathophysiology of common disease states. With the primary purpose of the veins to return blood to the heart in a unidirectional fashion and for the lymphatics to carry excess interstitial fluid and particulate matter back to the central circulatory system, any interruption or alteration in normal flow patterns forms the basis…

Clinical Evaluation of the Arterial System

This chapter focuses on the role of patient history and physical examination in evaluating the various disease states secondary to arterial pathology. In general, the lower extremities provide a model for the clinical evaluation of patients with vascular disease and can be used to demonstrate the value of an organized approach to the history and physical examination of the patient. Overview of the Clinical Evaluation The…

Noninvasive Vascular Laboratory Quality Assurance and Accreditation

Introduction The cost of medical care is far greater in the United States of America than in similar developed nations, while other data indicate the health outcomes in the United States lag. These observations have shifted the focus of heath policy to health outcomes or value, and have prompted an ongoing effort by funders of heathcare services to convert from volume-based payment to value-based payment. Despite…

International and Ethnic Trends in Vascular Disease

The 21st century has ushered in a number of changes in the distribution of vascular disease worldwide, primarily due to demographic changes and trends in atherosclerotic risk factors. These global trends require concerted efforts at the patient, provider, and public health level to adequately care for the increasing burden of vascular disease worldwide. Similarly, significant advancements in the understanding of ethnic differences in the epidemiology of…

Less Commonly Considered Causes of Atherosclerosis

Atherosclerotic disease is the leading cause of mortality in developed countries. Better understanding of the pathophysiology of atherosclerosis has led to successful therapies and preventative strategies; however, treatment of conventional risk factors for atherosclerotic disease may only prevent 50% of cardiovascular events. A more complete understanding of atherosclerotic risk factors and the atherosclerotic process has the potential to yield improved therapies and preventative strategies. Several less…

Familial Arteriosclerosis

Atherosclerosis is a disease in which plaque builds up inside of the artery wall, causing the thickening and narrowing of arteries, thereby reducing blood supply to the end organs. Plaque is made up of fatty substances, cholesterol, cellular waste products and debris, calcium, fibrin, inflammatory cells, and platelets. , It can affect any artery in the body, including arteries in the heart, brain, kidneys, and legs.…

Hypertension

Hypertension is a key risk factor in the pathophysiology of atherosclerosis and the development of cardiovascular diseases (CVD) including peripheral artery disease (PAD). Available evidence related to PAD and hypertension is largely extrapolated from subgroup analyses of larger trials of patients with atherosclerotic vascular disease and cardiovascular risk factors. Consequently, there are no current concrete within-class comparison studies of the effects of the treatment of hypertension…

Hyperlipidemia

Cardiovascular disease is the leading cause of death in industrialized countries and accounts for over 31% of deaths globally. Over the last century, a multitude of discoveries and intense research have elucidated the mechanisms of atherosclerosis, a word derived from the Greek atheros , meaning gruel and sclerosis , meaning hard. It has been well established, for over six decades now, that the major atherosclerotic risk…

Diabetes

Diabetes is characterized by chronic hyperglycemia resulting either from a lack of insulin production (type 1) or from insulin resistance (type 2). In the past several decades an alarming rise in the global prevalence of diabetes has been seen. The cost to the healthcare system is enormous because the medical expenditures of people with diabetes are 2 to 3 times higher than those of the rest…

Smoking

Called “one of the greatest public health catastrophes” of the 20th century in the Surgeon General’s semicentennial report, smoking has had profound health consequences that continue to be felt even as its North American prevalence decreases. For vascular surgeons in particular, the association with aneurysm formation and arterial occlusive disease means that smoking remains one of the most critical modifiable risk factors. Epidemiology Smoking is the…