The reliability of color duplex ultrasound in diagnosing total carotid artery occlusion.

BACKGROUND AND PURPOSE: Color duplex ultrasound has been advocated as an alternative to arteriography before carotid endarterectomy. However, one limitation of color duplex ultrasound is that it sometimes fails to differentiate high-grade stenosis from total carotid occlusion. This study was done to determine (1) the accuracy of carotid duplex ultrasound in diagnosing total carotid occlusion, and (2) when angiography is necessary. PATIENT POPULATION AND METHODS: Carotid duplex ultrasound and angiography results were compared for 520 carotid arteries, and 103 of these had a duplex diagnosis of total carotid occlusion or suspected almost total-to-total occlusion. The diagnosis of total carotid occlusion was primarily based on the absence of flow in the internal carotid artery as visualized on B-mode imaging for at least 1 inch beyond the bifurcation (optimal study). If the internal carotid artery was not optimally seen beyond the bifurcation, but secondary criteria were present, such as dampening of the common carotid signal and internalization of the external carotid artery, a diagnosis of suspected subtotal to total occlusion was made (limited study). RESULTS: In the optimal studies, 91 arteries had total carotid occlusions and of these, 87 were confirmed by angiography. The accuracy of carotid duplex ultrasound in diagnosing total carotid occlusion was 97% with a positive predictive value of 96%, negative predictive value of 98%, sensitivity of 91%, and specificity of 99%. Twelve arteries were diagnosed as suspected subtotal to total occlusion (limited studies), and of these, three were occluded on angiography, eight had stenoses ranging from 90% to 99%, and one had 80% stenosis. CONCLUSIONS: A carotid duplex ultrasound study is an acceptable method for predicting total carotid occlusion when the study is optimal, and angiography is unnecessary in asymptomatic patients. Angiography is recommended for patients who are surgical candidates with a limited duplex study.

Alterations in atrial natriuretic peptide (ANP) secretion and renal effects in aging.

Aging is associated with hypertension and electrolyte disturbances. The purpose of this study was to determine the effect of aging upon secretion and renal actions of atrial natriuretic peptide (ANP). Rats were anesthetized and received tracheal, jugular vein, carotid artery, and bilateral uretheral catheterization. One set of young (2-3 mo) rats (Group 2, n = 9) and one set of old (18-21 mo) rats (Group 4, n = 7) received bilateral atrial appendectomies. Control young (Group 1, n = 8) and old (Group 3, n = 8) rats received a sham appendectomy. All rats were infused (iv) with 6% albumin in Krebs buffer, sufficient to increase blood volume by 15%. Finally, each rat was injected with ANP (1 microgram/kg). Sodium excretion rate (U(Na+)V) in response to volume expansion was significantly decreased in all groups compared to Group 1 (young control, p < .05). All groups demonstrated a striking increase in U(Na+)V with the ANP injection, but the response was greatest in young control rats when factored by body weight (p < .05). There were no significant differences in MAP between the groups, suggesting that the differences in U(Na+)V observed were not the result of hemodynamic factors. Isolated perfused atria from young (n = 9) and old (n = 8) rats were subjected to stretch and endothelin stimulation (50 nM). Atria from young rats showed a dramatic increase in ANP secretion in response to atrial stretch and a further marked increase in secretion in response to endothelin, whereas both of these responses were markedly attenuated in old rats (p < .05). These results suggested that the secretion and renal effects of ANP are impaired in aging. Changes in secretion and actions of ANP in aging could contribute to the development of hypertension or heart failure.

Effect of contralateral severe stenosis or carotid occlusion on duplex criteria of ipsilateral stenoses: comparative study of various duplex parameters.

PURPOSE: This study compares the accuracy of various duplex parameters in grading ipsilateral carotid stenoses in patients with contralateral severe stenoses or occlusion. METHODS: Four duplex criteria were correlated to arteriography in 356 carotid arteries in blind fashion: (1) standard criteria: a peak systolic frequency (PSF) of the internal carotid artery (ICA) of > or = 4 kHz was used to diagnose > or = 50% stenosis; (2) new criteria: a PSF of the ICA of > or = 4.5 kHz was used; (3) Fujitani criteria: a PSF of the ICA of > 4.5 kHz and an end-diastolic frequency of < 5.0 kHz was used; (4) internal carotid/common carotid artery (ICA/CCA) PSF ratio of > or = 1.5 was used. RESULTS: The standard method overestimated 56 (16%) of 356 stenoses in contrast to 3% for the new method (p < 0.001), and this effect was most evident in the 50% to < 80% stenosis category (30%). The Fujitani method underestimated 97 (27%) of 356 stenoses, and the ICA/CCA ratio overestimated stenoses in 77 (22%) of 356. The overall exact correlation was 94%, 82%, 70%, and 75% for the new, standard, Fujitani, and ICA/CCA ratio, respectively. The kappa statistic and corresponding confidence intervals for the new method (kappa = 0.923, +/- 0.016) are significantly higher (p < 0.001) than those for the standard method (kappa = 0.760, +/- 0.027), the Fujitani method (kappa = 0.608, +/- 0.031), and the ICA/CCA ratio method (kappa = 0.642, +/- 0.051). The overall accuracy in diagnosing > or = 50% ipsilateral stenosis in the whole series was 85% for the standard method, 97% for the new method, 95% for the Fujitani method, and 81% for the ICA/CCA ratio. The new method was superior to the standard and ICA/CCA ratio methods (p < 0.001) and the Fujitani method (p = 0.024). CONCLUSIONS: The presence of significant contralateral stenosis (> or = 50%) can lead to overestimation of ipsilateral stenosis if the standard criteria are used; however, this problem can be avoided by using a PSF of the ICA of > or = 4.5 kHz for the diagnosis of > or = 50% stenosis.