HDI preserves the quantity and quality of tissue signature through the capture and preservation of the entire bandwidth. Meanwhile, the sector-type imaging of a curved array or the smaller footprint phase array may be needed in an examination of the distal internal carotid artery and the vessels in the supraclavicular area. The critical design requirements of the beam former are to preserve the entire bandwidth, which contains all of the acoustic information, and to prevent distortion of the signal during delay. A special jelly is placed on the area being examined while a wand-like device called a transducer is passed lightly over the skin above the artery. Evaluation of patients with hemispheric neurologic symptoms, including stroke, tran-sient ischemic attack, and amaurosis fugax1–4; 2. A series of animal studies were conducted to determine the relationship between varying degrees of stenosis and spectral changes as identified by pulsed Doppler and fast Fourier spectrum analysis [. The test may also look at the vertebrobasilar artery. Beam formation is accomplished by pulsing the transducer elements in the scan head to insonify the target. What is Carotid Artery Stenosis? Accuracy is critical, so ultrasound testing should ALWAYS be performed by a credentialed sonographer in an accredited vascular laboratory. This test examines blood vessels and blood flow in the abdominal area. The characteristic features of normal internal carotid artery spectra are shown in Fig. The accuracy of duplex scanning in the examination of the carotid artery bifurcation has resulted in its use for detecting significant carotid stenosis in symptomatic patients, the evaluation of patients with neck bruits, postoperative imaging of endarterectomized vessels, and the sequential examination of asymptomatic patients to document progression of disease. If a large sample volume size is used in the evaluation of small-diameter vessels, a wide range of velocities will be detected under normal circumstances, which on spectral analysis will appear as spectral broadening. The color box should be kept to a size that is adequate for visualizing the area of interest, and should be kept small enough to keep the frame rate at a reasonable number. Sound waves reflected by the target return to the elements of the transducer, generating signals that are essentially separated in time. You have 2 carotid arteries in your neck that bring blood from your heart to your brain. The end-diastolic frequency or velocity is also increased in very severe stenoses. Duplex ultrasound image of the carotid artery showing homogeneous plaque (arrow). DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED STUDY: ICD-10 Codes that Support Medical Necessity. The desaturation of the color from darker to lighter hues on the color bar indicates increasing velocities. More recently, SonoCT real-time compound imaging was incorporated into duplex technology. Color sensitivity (ensemble length) should be around 12 in systems where there is an adjustable control. The left and right sides of the extracranial circulation are not symmetrical (Fig. To evaluate temporal and axillary arteries for vasculitis (Giant Cell Arteritis) . Presently, we are using the iU22 xMATRIX system (Philips Healthcare, Bothell, WA) (Fig. Carotid and subclavian arteries … Abnormalities in the velocity spectra displayed on the screen are noted for subsequent reference. A … As shown in Fig. The region of the carotid bifurcation is identified by the presence of two vessels and visualization of the superior thyroid artery branch of the external carotid artery. With the pulsed instrument, the examiner could be certain that the data were being obtained from the vessel of interest. The ensemble length can be increased in regions where more sensitive color representation is needed. In 1994 we carried out 1389 carotid examinations of which 929 (66.9%) showed either no abnormality or no more than a 50% stenosis in one vessel. The peak systolic and end-diastolic velocities of common carotid, internal carotid, and external carotid arteries, right and left subclavian arteries, and vertebral arteries Duplex scanning was inaccurate when compared to conventional angiography in six instances. B. Overview . So actually the term “extracranial cerebrovascular Duplex sonography” would be more appropriate. Occasional patients have radicular symptoms. Calcification: very bright, highly reflected echoes are noted. The color wall filter should also be set as low as possible, and you may need to decrease the wall filter manually when decreasing the color PRF. detection of duplex scans (or ultrasound dopplerography) of extracranial divisions of brachiocephalic arteries of stenotic / occlusive pathology - a potential source of cerebral blood flow disorders; the presence of indirect signs of intracranial arteries; SCOPE: Applies to all US Doppler studies of the temporal arteries performed in Imaging Services / Radiology . Duplex Imaging for Extracranial Arterial Disease The following diagnostic indications for Duplex imaging for Extracranial Arterial Disease are accompanied by pre-test considerations as well as supporting clinical data and prerequisite information: Patients with suspected extracranial arterial disease (any one of … Spectral analysis of pulsed Doppler waveform: The auditory signal from a stenotic vessel is characterized by a higher than normal pitch, with a very high-pitched hissing or squealing type of signal evident at significant stenosis. Carotid Duplex Ultrasound Ultrasound is a study that uses sound waves to "see" inside your body. Accuracy is critical, so ultrasound testing should ALWAYS be performed by a credentialed sonographer in an accredited vascular laboratory. This image reflects the greatest stenosis in transverse diameter. Attention is then directed to the subclavian artery in the posterior triangle of the neck, and the vessel is visualized. Real-time spectral analysis was introduced using fast Fourier transform analysis (FFT). The tissue signature information is carried within the spectrum of ultrasound frequencies returning from the tissue. A variety of duplex scanning instruments are available, the major differences among them being in the Doppler component. The angle of the color box should also be changed to obtain the most accurate Doppler angle between the scan lines and the direction of the blood flow. Spectral waveforms must be obtained from the proximal (bulb), mid, and distal cervical internal carotid artery segments. However, the increasing awareness of the association of carotid disease and cerebrovascular symptoms, together with the recognition that carotid endarterectomy offers the possibility of prevention of a major stroke [1], means that requests for investigation are constantly … The information, tools, and resources you need to support the day-to-day needs of your office Claims that do not meet the indications of coverage and/or medical necessity will be denied. ORDERABLE: • US Doppler Carotid Bilateral / Complete . The current application of duplex scanning in the detection of carotid artery disease utilizes this principle of identification of flow disturbance patterns by Doppler velocity detection instrumentation, with the emphasis in later years being on technical improvements in instrument design. A color duplex ultrasound image of the carotid artery showing a calcified plaque (. Arterial Duplex Ultrasound - Legs Ultrasound is a procedure that uses sound waves to "see" inside your body. • The examination must be bilateral unless otherwise contraindicated The addition of high-definition imaging (HDI) technology revolutionized the front end of the ultrasound image formation process. An arterial duplex ultrasound uses sound waves to create a color map of the arteries … A complete extracranial carotid duplex examination should include the following data: The peak systolic and end-diastolic velocities of common carotid, internal carotid, and external carotid arteries, right and left subclavian arteries, and vertebral arteries, The internal carotid artery to common carotid artery peak systolic velocity ratio, Flow direction of the vertebral artery (antegrade or retrograde), Analysis of the Doppler spectral waveform of the examined vessels, The presence or absence of plaque and description of its morphology. At this range, the sample volumes have been calculated at 3 and 24 mm. It is recommended that color boxes that cover the entire vessel diameter and are approximately 1–2 cm of its length be used. This test provides information to help your vascular surgeon make a sound diagnosis and outline a treatment plan. Report duplex ultrasonography … Some include: Arterial and venous duplex ultrasound of the abdomen. Then the residual lumen diameter, or area, is measured (Fig. The outline below applies to the instrumentation available that currently uses pulsed Doppler beams for velocity detection and image generation. A valuable adjunct to B-mode imaging is the use of spectral analysis to analyze the backscattered Doppler signal. The FFT has the advantages of saving time and detecting both forward and reverse flow. abnormal blowing or swishing sound heard w/a stethscopw while auscultating over an artery such as the carotid. Brownell, MD; Edward F. Levine, MD; P. Michael McCart, MD \s=b\We reviewed extracranial carotid studies in two groups of patients. Scanning proceeds proximally with identification of the origin of the vertebral artery and subsequent sampling with the Doppler component of the orifice in the proximal centimeter of the first portion of this vessel, as this is the usual site of stenotic disease. These can be either benign or malignant. The examination is conducted with the patient supine and the head slightly extended and turned slightly away from the side being examined and supported to eliminate lateral movement. Lectures will provide essential background information and a supervised hands-on workshop will help each attendee master the fundamentals of performing a carotid duplex scan. Affected Code(s) 93880. However, since it is difficult to achieve Doppler angle parallel to the flow in the carotid arteries in the neck, an angle of up to 60° between these vessels and the Doppler beam is acceptable. All three methods were applied to 39 vessels in 20 patients. It is based on a review of local Medicare coverage policies. • 93882 Duplex scan of extracranial arteries; unilateral or limited study . It is recommended that the dynamic range be set to 40–50 dB to optimize the gray-scale image and the time gain compensation (TGC) as needed in regard to the depth of the carotid and vertebral arteries examined. As the lesion becomes progressively more occlusive (50–<80% diameter reduction), the velocity of the red blood cells traversing the stenosis increases, producing an increase in peak velocity at systole (Fig. Duplex scans require the three pairs of codes as follows: • Lower extremity arterial: 93925 — Duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study; 93926 — Duplex scan of lower extremity arteries or arterial bypass grafts, unilateral or limited study. The presence of these features is generally seen in laminar flow (Fig. The color wall filter may automatically increase as the PRF is increased. Unidirectional flow patterns are normally found in the carotid bulb, along the flow divider of the carotid bifurcation, and because there is transient reversal of flow at peak systole near the center stream and at the outer wall opposite to the flow divider, this area of reverse flow is often seen in color Doppler and commonly called an area of boundary layer separation or flow separation. INDICATIONS: This time is dependent on examiner experience and skill, severity of disease, and patient cooperation. Color duplex ultrasound image of the internal carotid artery. The first group consisted of 200 patients who had been evaluated by both duplex scanning (DS) and direct arch-selective carotid arteriography (SCA). 2004 Feb;39(2):366-71; discussion 371. doi: 10.1016/j.jvs.2003.08.018. Care must always be taken during sampling to ensure that the sample volume cursor is located in the center stream of the vessel and the incident angle of the Doppler beam to the long axis of the vessel is as close as possible to 60°. The colors are darkest close to the zero baseline, and as the velocities increase, the colors become lighter. The changes in spectra obtained from the common, internal, and external carotid arteries provide quantitative information for the determination of the severity of disease in these locations. We compared duplex scanning, “bright blood” and “black blood” magnetic resonance angiography, and conventional angiography for evaluation of the extracranial carotid arteries. The center stream flow pattern in a normal artery is uniform or laminar, and a spectral waveform taken with the pulsed Doppler sample volume in the center of the lumen shows a relatively narrow band of frequency. Vascular surgeons (28%), Internal Medicine physicians (27%) and Family practice physicians (15%) ordered the duplex scan most frequently, but 39% of the positive scans were ordered by vascular surgeons. With rapid shifting from B-mode to Doppler mode imaging, the evaluation is continued through and into the proximal internal carotid artery, looking for abnormal spectral displays. We compared duplex scanning, “bright blood” and “black blood” magnetic resonance angiography, and conventional angiography for evaluation of the extracranial carotid arteries. Duplex scans require the three pairs of codes as follows: • Lower extremity arterial: 93925 — Duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study; 93926 — Duplex scan of lower extremity arteries or arterial bypass grafts, unilateral or limited study. A 7.5- or 5-mHz transducer is usually used. 8.1). Underestimation of disease can be noted if it fails to appreciate very-low-level echoes of soft plaque, or the examiner does not carefully interrogate the vessel and misses accelerated flow; or in patients with long, smooth plaque formation, which does not have the accelerated, turbulent flow pattern usually associated with the hemodynamically significant stenoses, or if an inappropriate Doppler angle is used (e.g., above 60°). 1. Complex plaque (heterogeneous): low-, medium-, and high-level echoes indicating soft and dense areas (Fig. An additional feature of the current instruments is the dedicated use of the pulsed signal to the Doppler component, which avoids the problem of aliasing encountered in the original prototypes. The original technique was utilized off-line and employed a Kay sonograph, which although providing more information than was previously available with analog displays, was time-consuming and did not depict forward and reverse flow. Indications for an ultrasound examination of the extracranial carotid and vertebral arteries include but are not limited to: 1. Diffuse spectral broadening is also present during the whole of the cycle, and with these lesions, the diastolic velocity at the lower frequencies approaches zero (Fig. Baroreceptors assist in: reflex blood pressure control. The medium-focus scan head, operating at 5 mHz, has a 40-mm focal point, while the short-focus scan head, at a transmitting frequency of 5 mHz, has a 20-mm focal point. The diastolic notch is clearly seen, and tapping of the superficial temporal artery causes oscillations in the waveform (. Indications for the applications of color-coded duplex sonography comprise congenital vascular anomalies, arteriosclerotic lesions, dissections, aneurysms, arteriovenous fistulas and glomus tumors. Carotid duplex scanning offers a quick and non-invasive method for detecting extracranial carotid arterial disease. Duplex Scan Basics. 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