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Innominate artery occlusion: a case study

Mohamed Nashnoush
Mohamed Nashnoush
, 
Hosna Sahak
Hosna Sahak
, 
Yoojin Shin
Yoojin Shin
, 
Roja Ahimsadasan
Roja Ahimsadasan
, 
Yanuga Raveendran
Yanuga Raveendran
, 
John Hanna
John Hanna
 e 
Khulud Nurani
Khulud Nurani
   | 27 feb 2024
Journal of Ultrasonography's Cover Image
INFORMAZIONI SU QUESTO ARTICOLO
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Article Category: Case study
Pubblicato online: 27 feb 2024
Pagine: -
Ricevuto: 18 apr 2023
Accettato: 19 gen 2024
DOI: https://doi.org/10.15557/jou.2024.0008
Parole chiave
© 2024 Mohamed Nashnoush et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

Comparison between the dampened waveform in the proximal RCCA and the normal waveform of the proximal LCCA
Comparison between the dampened waveform in the proximal RCCA and the normal waveform of the proximal LCCA

Fig. 2.

Dampened right external carotid artery (RECA) waveform with a PSV of 45 cm/s and end-diastolic velocity (EDV) of 28 cm/s compared to the high-resistance left external carotid artery (LECA) waveform
Dampened right external carotid artery (RECA) waveform with a PSV of 45 cm/s and end-diastolic velocity (EDV) of 28 cm/s compared to the high-resistance left external carotid artery (LECA) waveform

Fig. 3.

Evidence of transient end-diastolic flow reversal and dampening of the waveforms in the distal RICA. The PSV in the RICA does not exceed 23 cm/s in all segments. The proximal left internal carotid artery (LICA) waveform was added for comparison. When imaging the distal ICA, it is important to visualize the parotid gland and to follow the distal ICA, as it dives posteriorly. Increasing the color gain and decreasing the color pulse repetition frequency (PRF) may help visualize the distal ICA
Evidence of transient end-diastolic flow reversal and dampening of the waveforms in the distal RICA. The PSV in the RICA does not exceed 23 cm/s in all segments. The proximal left internal carotid artery (LICA) waveform was added for comparison. When imaging the distal ICA, it is important to visualize the parotid gland and to follow the distal ICA, as it dives posteriorly. Increasing the color gain and decreasing the color pulse repetition frequency (PRF) may help visualize the distal ICA

Fig. 4.

Retrograde flow noted in the right vertebral artery with a PSV of 94 cm/s and EDV of 40 cm/s. The left vertebral artery demonstrates antegrade flow with a PSV of 105 cm/s and EDV of 35 cm/s. When the direction of flow is not clear in the vertebral artery, it is advised to document the CCA in split screen, with red representing blood flow towards the brain, and then angling and sliding the probe laterally and posteriorly to image the vertebral artery without changing any of the Doppler parameters. The vertebral vein will be seen anterior to the vertebral artery and may appear pulsatile. It is important not to confuse the two vessels. Both will pass through the transverse foramina of the cervical spine, and it may be easier to distinguish the two by looking for the origin of the vertebral artery off the subclavian artery
Retrograde flow noted in the right vertebral artery with a PSV of 94 cm/s and EDV of 40 cm/s. The left vertebral artery demonstrates antegrade flow with a PSV of 105 cm/s and EDV of 35 cm/s. When the direction of flow is not clear in the vertebral artery, it is advised to document the CCA in split screen, with red representing blood flow towards the brain, and then angling and sliding the probe laterally and posteriorly to image the vertebral artery without changing any of the Doppler parameters. The vertebral vein will be seen anterior to the vertebral artery and may appear pulsatile. It is important not to confuse the two vessels. Both will pass through the transverse foramina of the cervical spine, and it may be easier to distinguish the two by looking for the origin of the vertebral artery off the subclavian artery

Fig. 5.

Occlusion of the innominate artery is demonstrated proximal to the origin of the RCCA and subclavian artery. Lack of enhancement in the innominate artery is demonstrated in all three planes
Occlusion of the innominate artery is demonstrated proximal to the origin of the RCCA and subclavian artery. Lack of enhancement in the innominate artery is demonstrated in all three planes

Fig. 6.

Evident left vertebral dominance alluding to contralateral compensatory flow
Evident left vertebral dominance alluding to contralateral compensatory flow

Fig. 7.

Moderate stenosis of the supraclinoid RICA is illustrated by the purple arrow, and calcified plaque (blue arrow) is demonstrated at the origin of the RICA (red arrow), causing a 30% diameter lumen reduction
Moderate stenosis of the supraclinoid RICA is illustrated by the purple arrow, and calcified plaque (blue arrow) is demonstrated at the origin of the RICA (red arrow), causing a 30% diameter lumen reduction

Fig. 8.

Tardus parvus waveform seen in the proximal RCCA
Tardus parvus waveform seen in the proximal RCCA

Fig. 9.

Rapid systolic upstroke with a sharp deceleration and diminished forward flow in diastole is characteristic of flow in the LECA. This is in contrast to the prolonged systolic acceleration and rounding of the systolic peak demonstrated in the RECA, consistent with a tardus parvus waveform. Temporal tap was applied on the right side to help distinguish between the RICA and RECA. Reflected waves indicated by the green arrow demonstrate a ‘saw-tooth’ pattern confirming the identification of the ECA
Rapid systolic upstroke with a sharp deceleration and diminished forward flow in diastole is characteristic of flow in the LECA. This is in contrast to the prolonged systolic acceleration and rounding of the systolic peak demonstrated in the RECA, consistent with a tardus parvus waveform. Temporal tap was applied on the right side to help distinguish between the RICA and RECA. Reflected waves indicated by the green arrow demonstrate a ‘saw-tooth’ pattern confirming the identification of the ECA

Fig. 10.

Tardus parvus waveform seen in the proximal RICA with spectral broadening. Diminished diastolic flow is seen in all segments of the RICA, signaling a change to high-resistance flow compared to the tardus parvus waveforms visualized in the RECA and RCCA. This may be caused by a moderate stenosis in the intracranial RICA. In the proximal LICA there is a PSV of 255 cm/s indicative of a 50–69% stenosis.
Tardus parvus waveform seen in the proximal RICA with spectral broadening. Diminished diastolic flow is seen in all segments of the RICA, signaling a change to high-resistance flow compared to the tardus parvus waveforms visualized in the RECA and RCCA. This may be caused by a moderate stenosis in the intracranial RICA. In the proximal LICA there is a PSV of 255 cm/s indicative of a 50–69% stenosis.

Fig. 11.

Right brachial, radial and ulnar artery waveforms display a rounded peak with a pronounced decrease in amplitude compared to the triphasic left upper extremity waveforms. The difference in brachial pressures across the arms, along with the CW Doppler findings, suggest moderate disease in the right arm. Ankle-brachial indices are in the normal range bilaterally, with multiphasic CW Doppler waveforms.
Right brachial, radial and ulnar artery waveforms display a rounded peak with a pronounced decrease in amplitude compared to the triphasic left upper extremity waveforms. The difference in brachial pressures across the arms, along with the CW Doppler findings, suggest moderate disease in the right arm. Ankle-brachial indices are in the normal range bilaterally, with multiphasic CW Doppler waveforms.
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Medicine, Basic Medical Science, other
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