Non-Invasive Vascular Lab

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The Vascular Laboratory at First Coast Cardiovascular Institute uses ultrasound diagnostic imaging and other non-invasive testing methods to provide objective and reliable assessments for most types of vascular problems. Our accredited vascular labs are the only labs in Jacksonville, solely dedicated only to vascular testing. Many regional and community providers send their patients to the First Coast Cardiovascular Institute when accurate vascular testing is required.

Many types of testing services are offered, and each patient is individually evaluated with the specific type of exam that best answers the doctor’s question. Follow the links for information about the most common Vascular Laboratory studies.

Carotid artery (Cerebrovascular Examination)

Carotid artery disease is one of the most common causes of stroke. Identifying potentially treatable causes of stroke, such as severe carotid artery disease, is a key step in stroke prevention.

Evaluation of the arterial supply to the brain is a common study in the Vascular Lab. A complete extracranial cerebrovascular examination includes measurement of blood pressure in both arms and duplex scanning of the carotid arteries, vertebral arteries and the subclavian arteries on both sides.

A cerebrovascular study in the Vascular Laboratory may be requested to evaluate neurologic symptoms that might be due to vascular disease (such as one-sided loss of strength or sensation, difficulty speaking or transient loss of vision in one eye), a bruit in the neck (a sound heard with a stethoscope), or for other indications. Carotid artery duplex scanning is also used for post-procedure evaluation after surgery, such as carotid endarterectomy or carotid artery stenting.

No special preparation is required. A complete study usually takes about thirty minutes.

Evaluation by a specialist in at First Coast Cardiovascular Institute will generally be recommended if there is a carotid artery narrowing of or if there have been neurologic symptoms and the carotid artery is found to be narrowed. Further evaluation or treatment may be recommended.

Many patients will be found to have only mild to moderate carotid artery disease. A follow-up study in the Vascular Lab offers a safe, non-invasive and accurate means to assess for progression of disease over time.

Renal Artery Duplex (Kidney Artery Examination)

The renal arteries provide blood flow to the kidneys. Renal artery disease, including narrowing (stenosis) due to atherosclerosis, can result in reduced blood-flow to the kidney. This can cause hypertension (high blood pressure). Renal artery stenosis is the most common correctable cause of hypertension. Long-standing, untreated renal artery disease is also an important cause of kidney failure.

Renal artery disease cannot be diagnosed without specific tests. Renal artery duplex scanning is accurate, non-invasive and cost-effective. Unlike angiography or CT scanning, no injection of contrast material is required, avoiding the risk of kidney damage from the contrast.

Blood-flow velocities and flow patterns in the aorta and renal arteries are evaluated with Doppler ultrasound. Imaging of the kidneys can provide information about secondary damage to the kidneys from chronic poor blood-flow. Flow patterns (resistance indices) in the small vessels within the kidneys can provide additional information about kidney damage and the potential for recovery of kidney function with therapy.

Some preparation is needed. The study examines arteries deep in the abdomen. Gas in the intestinal tract can interfere with ultrasound evaluation. It is therefore best to have the examination performed after an overnight fast, and it is important to avoid tobacco and caffeine prior to the test. A complete study can take an hour or two. Scanning may be performed from the front or sides of the abdomen and can be facilitated by the patient lying on one side or the other.

Evaluation by a vascular surgeon will generally be recommended if there is a renal artery narrowing of 60 percent or more. Further evaluation or treatment may be recommended. Intervention may be appropriate if renal artery narrowing is thought to be contributing to blood-pressure problems, or if severe narrowing threatens the continued function of the kidney. Renal artery stenting is the most common intervention offered when treatment is needed, but some patients may need a surgical procedure to address complex renal artery disease.

For patients found to have only mild to moderate renal artery disease, a follow-up study in the Vascular Laboratory offers a safe, non-invasive and accurate means to assess for progression of renal artery disease over time.

Venous Duplex (Deep Venous Thrombosis Examination)

Thrombosis or clot formation in the deep veins of the lower limb can lead to discomfort and swelling of the limb. Deep vein thrombosis (DVT) can be a cause of long-term leg swelling and other symptoms, and it can be serious in the short-term. If the blood-clot breaks loose and travels through the venous system (an embolism) to the lung, it will lodge in the pulmonary artery, causing a potentially fatal pulmonary embolism.

A number of factors can contribute to risk of DVT. These include prior DVT or clotting disorders; trauma; recent major surgery; medical problems, including cancer and blood diseases; immobilization; obesity and others.

Evaluation of the lower-extremity veins is indicated if there is a clinical suspicion of acute DVT. Screening blood tests (D-dimer assay) and established clinical predictors may help to determine the need for a Vascular Laboratory evaluation. A venous study by the Vascular Laboratory may be requested to evaluate outpatients, but most DVTs are detected in hospitalized patients. Tests to evaluate for DVT can be done in the Vascular Laboratory or a portable ultrasound system can be used to perform the test at the bedside.

No special preparation is required. A complete study usually takes about 30 minutes.

Evaluation by one of our endovascular specialist may be recommended. If a DVT is found and anticoagulation therapy cannot be used, a minimally invasive procedure to place an inferior vena cava (IVC) filter may be performed to provide protection from a potentially fatal pulmonary embolism. Some IVC filters have the option to be removed later, if no longer needed. Also, for some patients with large DVTs, clot-dissolving therapy, or thrombolysis, may be considered. Catheter-directed venous thrombolysis may reduce the risk of developing chronic venous insufficiency.

Venous insufficiency (Varicose Veins / Insufficiency Examination)

In the lower extremities, blood returns to the heart through a network of deep and superficial veins. Normal venous flow patterns depend on open venous channels and the function of numerous valves within the veins. Venous insufficiency may occur if veins are obstructed (from chronic thrombus, for example) or if the valves are incompetent — no longer providing for only one-way flow. Venous valvular incompetence in superficial veins or the communicating veins that connect the deep and superficial veins can result in varicose veins. Untreated chronic venous insufficiency in the deep or superficial venous system can cause a progressive syndrome involving pain, swelling, skin changes and eventual tissue breakdown.

Duplex scanning of the deep and superficial veins can detect obstruction. In addition, the function of valves in each segment of the evaluated veins can be assessed by determining the direction of blood-flow using Doppler ultrasound. The examination is often done in the upright position, as this is the best way to evaluate valve function.

Evaluation of the function of the lower extremity veins is not needed in every case, but when surgical treatment, sclerotherapy, or saphenous venous ablation (Closure) is being considered, a complete lower-extremity venous duplex scan can provide valuable information that may guide therapy. A complete study may include both lower extremities.

No special preparation is required. A complete study usually takes about 60 minutes.

In cases where an intervention or surgery are considered, the duplex scan can provide essential information about which vein segments are abnormal, whether obstruction or reflux are present (or both), and how extensive a problem exists. This information will guide the vascular specialist’s recommendations and provide information that may help predict how successful treatment might be.

Vein Mapping for Bypass or Hemodialysis Fistula Creation

When lower extremity arterial bypass surgery is required, a bypass graft using a vein often provides the best long-term result. Using the person’s own tissue reduces the risk of infection or thrombosis (clotting) of the graft. Vein grafts are also used for coronary artery bypass grafts and other purposes. The most commonly used vein is the greater saphenous vein from the lower extremity, but other superficial veins in the upper or lower extremities may be used, if needed.

It is important that the vein segments used for bypass grafts are healthy. Some vein segments may be diseased and unsuitable. In other cases, vein segments may have been removed for other operations.

Preoperative ultrasound imaging can evaluate vein segments that might be used for bypass grafts, providing the surgeon with information that may guide the planned operation.

No special preparation is required. A complete study usually takes about 45 to 60 minutes.

One or more extremities may be examined, depending on the clinical circumstances. When requested by the surgeon, the course of the vein will be marked on the skin with indelible ink.

Peripheral Arterial Duplex (Upper or Lower Artery Examination)

Peripheral artery disease (PAD) is usually diagnosed on the basis of patients’ symptoms and physical examination in the clinic, confirmed by evaluations in the Vascular Laboratory with pressure measurements and other non-invasive tests.

Ultrasound duplex scanning can provide additional information that may guide therapeutic decisions. The location and severity of arterial narrowing  and occlusions can be identified. The vascular technologist can map disease in lower-extremity segments with great accuracy.

The additional information from duplex scanning can help determine if arterial disease might be appropriately treated with an endovascular intervention. The type of treatment and the technical approach can be guided by the duplex scan findings. Information from the duplex scan can help patients be better informed about their options. Duplex scanning after intervention can provide objective information about the success of the procedure and serial follow-up examinations can identify recurrent problems at an early stage, sometimes prompting follow-up interventions.

Pseudoaneurysm Evaluation and Treatment

A pseudoaneurysm, also termed a false aneurysm, is a leakage of arterial blood from an artery into the surrounding tissue with a persistent communication between the originating artery and the resultant adjacent cavity. This may occur after arterial puncture for a diagnostic cardiac catheterization or an arteriogram, but is more common after an arterial intervention. Catheter-directed interventions more commonly require larger arterial sheaths to be used, and the anticoagulation or antiplatelet agents that are administered can interfere with normal sealing of the puncture site.

Some pseudoaneurysms resolve themselves, though others require treatment to prevent hemorrhage, an uncontrolled leak or other complications.

An ultrasound study in the Vascular Laboratory may be requested to evaluate a puncture site if swelling, pain or extensive bruising suggests a pseudoaneurysm may have developed.

Surgery is sometimes required, but most pseudoaneurysms at arterial puncture sites can be treated with a brief, minimally-invasive procedure performed under local anesthesia. Preparation takes a few minutes. The procedure will be explained and informed consent obtained. Ultrasound imaging guides placement of a needle into the pseudoaneurysm and then thrombin is injected. Thrombin is an enzyme that promotes rapid clot formation, immediately obliterating the pseudoaneurysm cavity when injected. There are some risks of an adverse reaction or clot formation in a major artery or vein (which might require urgent surgery), but the procedure is usually uncomplicated.

No special preparation is required. A complete diagnostic study usually takes about 30 minutes. Treatment, if required, takes less than 30 minutes. A brief period of observation in the recovery area may follow.

A follow-up duplex scan is generally performed three to seven days after successful treatment. Further evaluation or treatment may be recommended if thrombin injection does not completely eliminate the pseudoaneurysm.

Lower Extremity Physiological Testing (Upper and Lower Extremities)

Peripheral artery disease (PAD) is common, and the prevalence increases with age. Symptoms may include intermittent claudication (muscle pain, aching or fatigue with walking) or in severe cases critical limb ischemia, which may lead to chronic pain, non-healing wounds on the feet, or gangrene.

Evaluation of the arterial supply to the lower limbs is done by measuring blood pressures at various levels and by evaluation of the arterial-pulse characteristics. Blood flow is evaluated with an ultrasound Doppler flow detector. Arterial pressures in the lower extremities are compared to the pressures measured in the arms. These tests are usually referred to as segmental pressure measurements and pulse volume recording (PVR).

When the pressures are measured at only a single level in the lower extremities — the ankle — they may be reported as the ratio of the ankle pressure to the arm pressure. The ankle/brachial index (ABI) is a very useful general measure of PAD severity.

A lower extremity arterial physiologic study may be requested to determine whether peripheral artery disease is present, what vessels are affected, and how severely the blood flow is impaired. A study may be ordered prior to an initial consultation with a vascular specialist for patients referred for evaluation of PAD.

No special preparation is required. A complete non-invasive study usually takes about 60 minutes. Inflatable cuffs are applied to the thighs, legs and toes to take measurements at different levels. People with diabetes may have calcification of their lower extremity arteries. Some of the cuff measurements may not accurate in such cases, but arterial waveforms and pressures from the level of the toes may still be useful.

In some cases, additional Vascular Laboratory evaluations may include treadmill exercise testing or peripheral arterial duplex scanning.

PAD treatments offered by specialists in the Vascular Center include medical management, catheter-based interventions (angioplasty or stent placement) and surgical therapies. Vascular Laboratory testing may identify PAD that does not require immediate intervention, but may need follow-up. People with diabetes and PAD may be at particular risk for developing foot problems, and Vascular Laboratory testing may be useful in assessing the likelihood of future problems and this information may be considered in determining what follow-up is optimal.

Abdominal Aortic Duplex (Abdominal Aorta Examination)

An aneurysm is a dilation of a segment of an artery. The aorta, the main artery through the trunk, can develop an aneurysm that can grow to the point of rupture of the aortic wall. The most common site for an aneurysm of the aorta is in the abdomen, below the level of the arteries to the kidneys (renal arteries). An abdominal aortic aneurysm (AAA) may not be detected on routine examinations, but ultrasound imaging provides an accurate, safe and non-invasive means to measure the aortic size.

When ballooning of the aorta leads to rupture, the results are catastrophic. Many people with a ruptured AAA don’t make it to the hospital, and those who do often die of complications. Ruptured aortic aneurysm is the 13th leading cause of death in the U.S. — a cause of 15,000 deaths each year. Detection and treatment make this preventable.

The most important risk factors for abdominal aortic aneurysm development include: age over 60 years, a family history of AAA, cigarette smoking and high blood-pressure. When clinical assessment suggests an aneurysm may be present, an ultrasound evaluation in the Vascular Laboratory will be requested.

Some preparation is needed. The study examines arteries in the abdomen and pelvis. Gas in the intestinal tract can interfere with ultrasound evaluation. It is therefore best to have the examination performed after an overnight fast, and it is important to avoid tobacco and caffeine prior to the test. A complete examination may take as long as an hour.

The aorta in the abdomen is normally two centimeters or less in diameter. An aneurysm is present when the aorta is dilated to a diameter of three centimeters , but there is almost no risk of rupture until the aneurysm grows beyond this size. Evaluation of by a vascular surgeon is recommended if an AAA measures four centimeters in size or greater, though endovascular repair or surgery are usually not considered until the diameter of the aneurysm is at least 5.0 to 5.5 centimeters.

Abdominal Aortic Aneurysm Endograft Duplex

While treatment of abdominal aortic aneurysm (AAA) with an endograft — also known as an endoluminal graft or stent-graft — is a much less invasive approach to treating AAA, endografts have specific technical limitations and potential complications that must be considered. Once an endograft has been placed, there is a need for long-term surveillance to ensure that the graft remains in the correct position, that flow through the graft is normal and that the aneurysm is not expanding.

An “endoleak” is present if there is flow in the aneurysm sac outside the endograft. Some endoleaks require treatment, others can be observed.

The schedule for post-operative surveillance imaging may vary, but usually tests are ordered at three, six and 12 months after the endograft is placed, then annually thereafter. Plain X-rays are used to look at the stent positioning and a CT scan with contrast is used to evaluate for the size of the aneurysm and endoleak. A duplex scan in the Vascular Laboratory will be ordered at the first follow-up visit; and if ultrasound imaging provides a complete assessment, duplex scans will be substituted for CT scans at the time of subsequent evaluations.

Ultrasound duplex scanning is non-invasive and does not require use of X-ray contrast. The duplex scan can show the size of the aneurysm sac, the absence or presence of endoleak, and it can assess blood flow through the endograft.

Some preparation is needed. The study examines arteries in the abdomen and pelvis. Gas in the intestinal tract can interfere with ultrasound evaluation. It is therefore best to have the examination performed after an overnight fast and it is important to avoid tobacco and caffeine prior to the test. In addition to a complete duplex scan of the implanted graft, the aorta and the iliac arteries, ankle and arm blood pressures will be measured using inflatable cuffs and an ultrasound Doppler flow detector. A complete study usually takes 30-45minutes

Peripheral Stent and Bypass Graft Evaluation

An arterial stent of  bypass graft is a durable means to treat severe, peripheral, artery disease when the blockage is below the level of the groin. Angioplasty and stenting offer many minimally invasive advantages. They can be used for extensive arterial blockages, which are common with diabetes, as well as blockages involving smaller arteries below the knee. They are also resistant to infection and now with drug eluting medicines.

Ultrasound evaluation is done at the time of the procedure to ensure there is adequate flow, but in some cases narrowing can subsequently develop within the stents or arteries. When this occurs in the first two years after the operation, it is most commonly due to intimal hyperplasia, a process that is somewhat like scar formation within the stent. If this is detected before the stented segments becomes completely occluded, a procedure may be performed to repair the narrowed segment. Vascular Laboratory testing is regularly used to detect a problem at a fixable stage.

No special preparation is required for a graft surveillance examination. In addition to a complete duplex scan of the graft and the inflow and outflow arteries, ankle and arm blood pressures will be measured using inflatable cuffs and an ultrasound Doppler flow detector. A complete study usually takes 45-60 minutes.

Hemodialysis Fistula or Graft Duplex

This is a very specialized ultrasound test which directly visualizes the hemodialysis fistula or graft. This ultrasound evaluation is sensitive enough to detect impending failure of the fistulas before a complete shutdown of the fistula is suspected.  In many instances ultrasound rules out impending fistula or graft failure reserving dialysis patients from a possible fistulograms.

Ultrasound is the preferred follow up method post-procedure fistulograms with repairs. Generally, these patients are followed serially to survey the accesses for post procedural latent complications such as re-stenosis or occlusion.

No special preparation is required for a graft surveillance examination. A dialysis access study usually takes 20-30 minutes.


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