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Duplex Ultrasound: 2015 Phlebology Review Course 2015 Phlebology Review Course
Duplex Ultrasound: 2015 Phlebology Review Course 2015 Phlebology Review Course
Duplex Ultrasound: 2015 Phlebology Review Course 2015 Phlebology Review Course
Duplex Ultrasound
Esther Kim, MD, MPH, RPVI
Cleveland Clinic
2015 Phlebology Review Course
Disclosures:
• Consultant ‐ Philips US
2015 Phlebology Review Course
Topics
• Duplex Ultrasound
• Instrumentation
• Ultrasound Physics and Safety
• Ultrasound Interpretation
• Limitations
• Quality Assurance
• Vascular Lab Development
2015 Phlebology Review Course
Duplex Ultrasound
• Several important roles in phlebology
• Assist in the evaluation of
• Deep venous disease
• Superficial venous disease
• Mapping prior to intervention
• Peri‐procedural imaging
• Post‐procedural imaging (success, complications, failure)
2015 Phlebology Review Course
Duplex Ultrasound
• Combination of two
imaging modalities
• Doppler
• B mode imaging
2015 Phlebology Review Course
Ultrasound Imaging
Piezoelectric crystal
Pulses of sound waves are
transmitted into the body and
the returning “echoes” from
various structures are detected
by the probe and converted into
images on a screen
2015 Phlebology Review Course
Sound
• Mechanical wave created by vibration
of a moving object; series of pressure
waves propagating through a medium
• Ultrasound is a high frequency sound
above the limits of human hearing
(>20,000 Hz)
• Diagnostic US: 2MHz‐10MHz
2015 Phlebology Review Course
Sound ‐ Definitions
• Period: time to complete a single cycle
• Frequency: number of wavelengths in 1 second (Hertz, Hz)
• Affects penetration and axial resolution
• 1/period
• Intensity (power, amplitude): concentration of energy in a
sound beam
• Wavelength: length of a single cycle
• Higher frequency, shorter wavelength
• Affects axial resolution
• Propagation Speed: rate that sound travels through a medium
• Determined by the medium
• All sound travels at the same speed through any specific medium
• Speed of sound is faster with increasing stiffness and decreasing
density
• Air << fat < soft tissue << bone
2015 Phlebology Review Course
Ultrasound Physics (in a nutshell)
• CW Doppler cannot create anatomic images; pulses of sound
are used in ultrasound imaging
• Pulse Duration: time from start to end of a pulse
• # cycles in a pulse x period of each cycle
• Spatial Pulse Length: distance from start to end of a pulse
• Determines axial resolution; shorter pulses create more accurate images
Spatial pulse length
• Pulse Repetition Period: time from the start of one pulse to Pulse Duration
the start of the next pulse
• Pulse duration + listening time
• Increase imaging depth increase PRP by increasing the listening time
• Pulse Repetition Frequency: Number of pulses that occur in
one second; 1/PRP
• Increase imaging depth decrease PRF Pulse Repitition Period
• Duty Factor: Fraction of time the system transmits sound
Period
• (100% for CW Doppler, <1% for PW Doppler) Wavelength
2015 Phlebology Review Course
Ultrasound Physics (in a nutshell)
• CW Doppler cannot create anatomic images; pulses of sound
are used in ultrasound imaging
• Pulse Duration: time from start to end of a pulse Determined by the transducer
• # cycles in a pulse x period of each cycle
• Spatial Pulse Length: distance from start to end of a pulse
• Determines axial resolution; shorter pulses create more accurate images
• Pulse Repetition Period: time from the start of one pulse to
the start of the next pulse
• Pulse duration + listening time
• Increase imaging depth increase PRP by increasing the listening time
Determined by the operator by
• Pulse Repetition Frequency: Number of pulses that occur in adjusting imaging depth
one second; 1/PRP
• Increase imaging depth decrease PRF
• Duty Factor: Fraction of time the system transmits sound Shallow imaging = short PRP = high PRF
• (100% for CW Doppler, <1% for PW Doppler) = high duty factor
2015 Phlebology Review Course
Ultrasound Physics (in a nutshell)
• Attenuation: decrease in intensity, power, and amplitude of a
sound wave as it travels. Sources of attenutation are absorption,
reflection, scattering, refraction
• Attenuation limits the maximum imaging depth
• length of travel attenuation
• frequency attenuation
• Absorption: conversion of acoustic energy into heat
• Reflection: sound energy strikes a boundary between 2 media
and some bounces back to the transducer as an “echo” at an
angle of incidence identical to the angle of the reflection
• Scattering: chaotically redirected sound waves occurring when
waves encounter a medium with a nonhomogenous surface
• Refraction: sound energy traveling trhough the second medium
(tissue) is “bent” from its path with an angle of incidence www. sonoguide.com
different from the angle of transmission
2015 Phlebology Review Course
Instrumentation (affect image brightness)
• Output Power: adjusts the strength of the sound pulse sent
out by the transducer
versus
• Receiver Gain: adjusts the amplification of the ultrasound ALARA: As Low As Reasonably Achievable
signals after returning to the receiver *Adjustment in either output power or
receiver gain can correct an image that is
too dark or too bright. According to
• Compensation: amplifies deep echoes ALARA, always choose the option that
• Deeper structures are affected by attenuation minimizes bioeffects (patient exposure).
• Compensation makes all echoes from similar • Ex: image too bright decrease
reflectors the same brightness regardless of depth output power
• Aka “time gain compensation (TGC), depth • Ex: image too dark increase
compensation (DGC) receiver gain
2015 Phlebology Review Course
Instrumentation (affect resolution) Width of beam changes as sound travels.
• Focal zone: where the sound beam reaches its minimum diameter
• Improves lateral resolution ‐ Lateral resolution is directly related to beam
width, which is related to US frequency (↑frequency ↓beam width).
Lateral resolution
• Axial resolution (ability to distinguish between two structures along the Axial resolution
beam’s main axis)
• Improved with fewer cycles per pulse
• Improved with higher frequency 4 MHz transducer 11 MHz transducer
• Can only be changed by using a higher frequency transducer. Pellerito/Polak Introduction to Vascular Ultrasonography 2012
2015 Phlebology Review Course
Doppler Shift
• Doppler shift occurs when reflectors move
relative to the transducer
• The frequency (fr) of echo signals from moving
reflectors (blood cells) is higher or lower than http://en.wikibooks.org/wiki/Basic_Physics_of_Nuclear_Medicine
the frequency transmitted by the transducer
(ft), depending on whether the blood cells are
moving toward or away from the transducer fd = fr‐ft = 2ftVcos
c
• The Doppler shift frequency is the difference Angle () cosine
between the received and transmitted Optimal imaging angle 90 0
frequencies 60 0.5
Optimal velocity angle 0 1
2015 Phlebology Review Course
CW Doppler PW Doppler
• 2 crystals in the transducer, constant transmit,
• At least 1 crystal alternates between transmitting
constant receive
and receiving
• Can capture very high velocities
• Can sample a particular area of interest with the
• Range (depth) ambiguity (echoes from the entire sample volume (receive gate) range resolution
length of the transmitted and received beams)
• Subject to aliasing of high velocities
2015 Phlebology Review Course
Duplex Ultrasound
• Combination of two
imaging modalities
• B mode imaging
• Doppler
2015 Phlebology Review Course
Duplex Ultrasound
Color Doppler
Spectral Doppler
Grayscale (B‐mode) imaging
Color Power Doppler
• No velocity or direction information
• Any Doppler shift is colorized
• Good for detection of low velocity
2015 Phlebology Review Course
Ultrasound Interpretation ‐ DVT
• DUS is the test of choice for diagnosis Patient, thrombus‐free vein will have complete Loss of compressibility is the most reliable
vein coaptation with compression indicator of the presence of thrombus in the vein
of proximal DVT
• Sensitivity >95%, Specificity >95%
• Diagnostic components
• Transducer compression maneuvers
• Doppler evaluation (color and
spectral Doppler waveform analysis)
• Augmentation maneuvers
• Acute DVT
• Loss of compression
• Dilated vein (diameter > artery)
• Intraluminal echoes from thrombus Respirophasic Doppler Absent Doppler signal
• Abnormal/absent color Doppler
• Abnormal/absent PW spectral Augmentation
Doppler waveform 1. N Engl J Med. 1989;320(6):342.
2. Bruit. 1982;7:41–42.
2015 Phlebology Review Course
Ultrasound Interpretation ‐ DVT
• Acuity of thrombus
• Acute (<2 weeks)
• Subacute (2 weeks – 6 months)
• Chronic (>6 months)
• Ultrasound parameters
• B‐mode appearance (hypoechoic,
isoechoic, hyeprechoic)
• Vein lumen size
• Vein wall appearance
• Venous compressibility
• Function of venous valves
• Presence of collaterals
Circulation. 2014;129:917‐921
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Remote
Age indeterminate?
Remote with valvular incompetence
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Ultrasound Interpretation ‐ DVT
• Limitations
• May miss more proximal DVT (iliacs
veins, IVC) be alert when seeing a
monophasic waveform
• Imaging is limited by body habitus and
edema
• Duplicated femoral or popliteal veins
Monophasic Doppler signal
may be missed
Monophasic waveform: more proximal obstruction
Blunted augmentation: more distal obstruction
2015 Phlebology Review Course
• Reflux can be elicited by
• Valsalva maneuver
• Augmentation: compression and release distal to
point of examination
• Best results obtained with patient
• Standing with weight on contralateral limb
• Sitting with torso elevated >45 degrees
• Reverse Trendelenberg
Pathologic reflux
2015 Phlebology Review Course
Ultrasound – Venous Incompetency
Examination Protocol
• Deep system:
• CFV, FV, Popliteal vein
• Reflux >1.0 sec
• Superficial System: (vein diameter msmts included)
• Entire length of GSV +/‐ entire length of SSV
• Reflux >0.5 sec
• Perforators
• Examine entire calf
• Focus on areas of ulcerations
• Reflux ≥0.35 sec
• Diameter >3.5 mm likely competent
2015 Phlebology Review Course
http://intersocietal.org/vascular/standards/
IACVascularTestingStandards2015.pdf
2015 Phlebology Review Course
1. The location, competency and diameter of the saphenous junctions.
2. The distal extent of reflux in the saphenous veins in the thighs and
legs. Recording the saphenous diameter at the mid‐thigh and at the
knee is desirable.
3. The location of incompetent perforating veins as measured from the
floor
4. Other named and unnamed veins that show reflux or are varicose
should be noted.
5. The source of venous hypertension in varices if not from the veins
described above.
6. Saphenous veins that are absent, totally occluded, hypoplastic or
atretic should be noted.
7. The state of the deep venous system, including valvular competence
and evidence of current or previous venous thrombosis.
SVU/IAC Quality Assurance Guidelines for Accuracy of Examinations in the Vascular Laboratory 03/13/2012
2015 Phlebology Review Course
Quality Assurance ‐ Specifics
• There must be a written policy regarding QI for all procedures performed
• A correlation log for each test area must show >70% accuracy agreement
• Minimum of 2 facility QI meetings per year must be held to:
• Review results of comparative studies
• Address discrepancies
• Discuss difficult cases
• Address facility QI issues
• When available, appropriateness criteria published by medical
professional organizations should be utilized.
http://intersocietal.org/vascular/standards/IACVascularTestingStandards2015.pdf
2015 Phlebology Review Course
JACC 2013;62:649.
2015 Phlebology Review Course
Accreditation ‐ Benefits
• Demonstrates commitment to quality care
• Application requires QI programs, identification and correction of potential
problems, revise protocls
• Renewal process results in continued self‐assessment
• Allows quality to be evaluated through independent peer review
• Application of standards in imaging
• Acts as a recruiting tool for potential talented hires
• Demonstrates accountability
• May be required for payment by insurers
http://www.intersocietal.org/iac/accreditation/whatisaccreditation.htm
2015 Phlebology Review Course
IAC Accreditation – Initiating the Application
• IAC is there to help; not to prevent
accreditation!
• Organization is key
• Review current lab protocols and
policies, identify problems and correct
prior to application
• Ensure imaging meets current IAC
Standards
• Review process takes 12‐16 weeks
• In house review, peer review, board of
directors review
http://www.intersocietal.org/vascular/forms/VascularTestingAccreditationChecklist.pdf
2015 Phlebology Review Course
IAC Accreditation – Initiating the Application
• Information you will need
• Equipment information
• Procedure volumes
• Training Qualifications for MDs
and sonographers
• Credential information for all
medical and technical staff
• CME information for all staff
http://www.intersocietal.org/vascular/forms/VascularTestingAccreditationChecklist.pdf
2015 Phlebology Review Course
IAC Accreditation – Initiating the Application
• Documents you will need
(sample documents available)
• Primary source verification policy
• Patient complaint policy
• Personnel safety policy
• Facility‐specific Technical Protocols
• Patient safety policy
• Patient confidentiality policy
• Quality Improvement policy
• QI meeting minutes >2/year
• QI documentation – Correlation Log
http://www.intersocietal.org/vascular/forms/VascularTestingAccreditationChecklist.pdf
2015 Phlebology Review Course
IAC Accreditation – Initiating the Application
• Case Studies
• Represent best work
• All cases must be abnormal of varying
degress of pathology
• Must be from within the past 12 months
from the date of application filing
• All medical and technical staff must be
represented
• Site visit
• May occur as part of the accreditation
process but will occur during 3 year
accreditation period
• May occur as “random, investigative, or
required” visits
http://www.intersocietal.org/vascular/forms/VascularTestingAccreditationChecklist.pdf
2015 Phlebology Review Course
Thank You