The largest independent provider of specialist vascular ultrasound services in Europe, Independent Vascular Services Limited (IVS), United Kingdom, has pre-ordered PIUR IMAGING´s soon-to-be-released tomographic ultrasound system PIUR tUS Infinity. IVS has been a clinical user of PIUR´s first generation tomographic ultrasound device for several years, providing safe and cost-effective diagnostic imaging to their patients at the University Hospital South Manchester. With the purchase of six new mobile Infinity systems, IVS wants to enhance their clinical services in Blackpool, Bolton, Bury, North Manchester, Stockport, and Warrington.
Carotid Plaque Volume (CPV) as an indicator of high-risk plaque.
Miss Alison Phair, Vascular Specialist Registrar and Clinical Research Fellow. BSc (Hons), MBBS (Hons), MRCS. Department of Academic Surgery, University of Manchester.
The degree of stenosis has been the method of defining the necessity of surgery in symptomatic carotid stenosis since the NASCET and ECST randomized trials of the 1990’s. But a greater degree of stenosis does not correlate to a greater risk of stroke. Atherosclerotic plaque burden in the coronary and carotid arteries is reported to be a more important risk factor for future event than severity of stenosis. Measuring carotid plaque volume (CPV), as a measure of atherosclerotic burden, may be of more importance in predicting likelihood of further event than degree of stenosis alone. The case presented highlights the added benefit of assessing CPV prior to surgery to appreciate the risk of stroke.
A 75-year-old male presented with a history of left arm weakness and left facial droop which lasted 20 minutes and had fully resolved. His past medical history included Atrial Fibrillation currently treated with Apixiban and adequately rate controlled. A computed tomography (CT) scan of the brain showed no evidence of an acute infarct so the diagnosis of a single Transient Ischaemic Attack (TIA) was made. Carotid Doppler examination showed a right internal carotid artery stenosis of >70% based on grey scale measurement and peak systolic velocity.
The plaque was noted to be composed of echo-lucent material on standard duplex (Figure 1). 3-D tomographic ultrasound (tUS) followed by contrast enhanced tomographic ultrasound (CEtUS) assessment was performed as part of recruitment to an ongoing research study. On tUS the full extent of the large, echo-lucent plaque could be appreciated (Figure 2). Measurement of the CPV was performed based on these assessments.
The patient underwent a right carotid endarterectomy (CEA) within 24 hours of admission. Intraoperative findings confirmed a plaque composed of liquefied lipid with intra-plaque haemorrhage (Figure 3). The surgeon commented in the operative notes that this was a plaque with extremely adverse features at high risk of causing a future event had surgery not been performed promptly.
The CPV measured from the endarterectomy specimen was exceptionally high at 1.754cm3. Carotid plaque volume as calculated by tUS was accurate to within 0.1cm3 of the endarterectomy specimen.
Based on the clinical history of TIA and the identification of significant carotid stenosis contralateral to the patient’s symptoms, prompt surgical management was unarguably the correct course of action in this case. However, the standard two-dimensional duplex did not fully appreciate the high-risk nature of this plaque, as unequivocally seen at endarterectomy.
In this unit, carotid plaque volume has been measured in 400 patients prior to endarterectomy. There are statistically significant differences between the volumes measured in symptomatic and asymptomatic plaques; symptomatic plaques having higher plaque volumes (Vascular Society, Nov 2018). This carotid plaque was in the highest quartile for volume, a feature which correlates with high risk plaque features, as was proved by the visual assessment completed by the surgical team.
Adding CPV to the information provided by standard duplex could supplement the clinical team’s understanding of the risk of stroke from a plaque. Furthermore, tUS calculation of Carotid plaque volume can be accurately performed prior to surgery. CPV could be used to predict those symptomatic plaques at greatest embolic potential pre-operatively so that expedited surgical management can be arranged.
Colour Duplex Ultrasound combined with 3D Tomographic Ultrasound as a potential sole imaging modality prior to lower limb arterial reconstruction
Dr Cleona Gray PhD Chief Vascular Physiologist, Mater Misericordiae University Hospital, Dublin 7
Mr Edward Mulkern PhD FRCSEd, Consultant Vascular Surgeon, Mater Misericordiae University Hospital, Dublin 7
The limitations and complications associated with conventional angiography (CA) and MR Angiography (MRA) prior to lower limb revascularization have led to an increased need for a suitable alternative imaging modality.
Colour Duplex Ultrasound (CDU) with 3D Tomographic Ultrasound may be an appropriate alternative modality. In patients with limb ischemia a well-performed CDU offers several advantages over traditionally used imaging modalities. CDU is noninvasive and does not require the use of nephrotoxic agents. It is readily available with color flow and waveform analysis providing a better estimation of the hemodynamic significance of disease unlike MR angiography which risks overestimation of disease. It allows visualization of the entire artery and not only of the lumen of the vessel, enabling plaque characterization. Unlike conventional Angiography Color flow and power Doppler techniques have the ability to identify patent native arteries subjected to chronic disease with low flow states. CDU with 3D Tomographic Ultrasound performed by a skilled Vascular Physiologist may represent an alternative to conventional angiography for patients with lower limb ischemia.
65-year-old female presented in December 2018 with rest pain in the left lower limb. Ankle brachial pressures were found to be 0.35 on the right and 0.38 on the left. The patient went on to have a catheter angiogram. The supra-inguinal vessels and common femoral artery were widely patent. The superficial femoral artery was occluded from its origin and reconstituted at the level of the adductor canal. The popliteal artery was thought to be significantly diseased. The anterior tibial artery was diseased (Figure 1) and the posterior tibial artery was found to be occluded. CDU and Tomographic Ultrasound were used to quantify the disease in the infra-inguinal vessels and identify a suitable target vessel for bypass. The Popliteal artery and the Anterior Tibial artery were found to be widely patent. The Anterior Tibial artery was patent throughout the calf and crossed the ankle (Figure 2).
The posterior tibial artery was occluded throughout its’ length. The Long Saphenous vein and its tributaries was also mapped prior to the surgery using tomographic ultrasound (Figure 3).
The patient underwent left common femoral artery to above knee popliteal bypass surgery using the mapped long saphenous vein as a conduit. Despite the angiography suggesting significant popliteal disease, a decision was made to use the above knee popliteal artery based on the duplex imaging combined with 3D Tomographic Ultrasound.
Post-surgery the graft was found to be widely patent throughout. The patient was discharged free of rest pain.
CDU is already considered to be a suitable alternative to conventional angiography in selected cases, the addition of 3D tomographic ultrasound allows for safe high-quality imaging with the advantage of images similar to conventional angiography. CDU along with 3D Tomographic Ultrasound may be an alternative imaging modality prior to lower limb reconstruction and may give additional information over and above that obtained by more traditional forms of angiography, particularly in relation to the flow characteristics in target vessels.
With its presence at the VIII Congresso Brasileiro de Ecografia Vascular in Recife, Brasil, piur imaging GmbH continues with its global expansion strategy and introduces tomographic ultrasound to the South American market.
The Congresso Brasileiro de Ecografia Vascular is one of the most important vascular ultrasound meetings in the country and a great opportunity to evaluate the interest in the PIUR tUS technology in the region. Brazil is the largest market in South America, and due to its healthcare system, a country with great potential for PIUR tUS. While availability of high-end imaging technologies is high in larger metropolitan areas and to the private sector, smaller cities and the public sector often lack access to latest imaging technologies. PIUR tUS has potential to provide affordable access to high-end tomographic imaging for a greater number of patients.
During the congress, PIUR will be supported by its clinical partner Adriano Souza from Ecocenter Belo Horizonte, who will give a talk on how PIUR tUS can be used as a safe and cost-effective alternative for surveillance of AAA after EVAR intervention.
PIUR´s new sensor-based tomographic ultrasound solution could increase global access to high-resolution 3D imaging for vascular diagnostics and interventions
May 3, 2018 (Vienna, Austria) – PIUR IMAGING has presented its first working prototype of a sensor-based tomographic ultrasound solution last week at the Charing Cross Symposium in London. The innovation has been developed to provide mobile and inexpensive 3D image diagnostics and ultrasound-guided interventions to healthcare providers around the world, including those that currently lack access to advanced imaging technologies.
PIUR has closed a distribution agreement with Intermedic s.a.l. for distribution and service of PIUR tUS in Lebanon. This is another step in piur imaging´s global expansion strategy to facilitate the use of safe and cost-effective ultrasound diagnostics worldwide.
PIUR has closed a distribution agreement with SCHMIDT BioMedTech for distribution and service of PIUR tUS in Hongkong and Macau. This collaboration is the first step of PIUR´s expansion strategy to the Asian market in order to facilitate the use of safe and cost-effective ultrasound diagnostics in the region.
PIUR IMAGING GmbH announces the launch of new applications for their vascular tomographic ultrasound solution, PIUR tUS, in Europe. The new applications include three-dimensional (3D) ultrasound angiography for high-resolution imaging of carotid stenosis and multi-scan acquisitions that allow large volume imaging of peripheral vessels. A CE mark is expected for December 2017.
piur imaging has released a new software version for its tomographic ultrasound device PIUR tUS. The new software brings major improvements in usability and features new visualization methods, including automatic vessel prediction for vein maps and enhanced endoleak rendering techniques.
It is collaboration that could push vascular imaging to a new level. Researchers from the University of Manchester and IVS Ltd (Independent Vascular Services) – an independent UK company providing clinical services and running vascular ultrasound departments for the NHS – is pairing Mindray’s Resona 7 with Piur Imaging’s tomographic ultrasound device to develop 3-D tomographic ultrasound (tUS) to enhance vascular diagnosis.
Source: http://www.healthcare-in-europe.com • Vascular Imaging • 03/01/2017