Aging techniques for deep vein thrombosis: a systematic review.

Deep vein thrombosis is common with an incidence of 1 in 1000. Acute thrombus removal for extensive proximal deep vein thrombosis using catheter-directed techniques highlights the need for accurate assessment of thrombus age. This systematic review summarises experimental and clinical evidence of imaging techniques for aging deep vein thrombosis. Ultrasound elastography and magnetic resonance imaging were highlighted as the most studied imaging modalities. Elastography was shown to distinguish between acute and chronic clots, despite demonstrating difficulty in accurate aging of clots older than 10 days in rat models. Elastography is noted as a feasible adjunct to current first-line imaging for deep vein thrombosis using duplex ultrasonography. Combinations of magnetic resonance imaging techniques can identify acute, sub-acute and chronic thrombi using endogenous contrast agents and provide objective standardisation of the diagnostic process, with reduced onus upon operator dependency. Further validation is required of these novel imaging techniques prior to clinical implementation for deep vein thrombosis aging.

Impact of risk scoring on decision-making in symptomatic moderate carotid atherosclerosis.

BACKGROUND: Benefit from carotid endarterectomy (CEA) in symptomatic moderate (50-69 per cent) carotid stenosis remains marginal. The Fourth National Clinical Guideline for Stroke recommends use of the risk score from the European Carotid Surgery Trial (ECST) to aid decision-making in symptomatic carotid disease. It is not known whether clinicians are, in fact, influenced by it. METHODS: Using the ECST risk prediction model, three scenarios of patients with a low (less than 10 per cent), moderate (20-25 per cent) and high (40-45 per cent) 5-year risk of stroke were devised and validated. Invitations to complete an online survey were sent by e-mail to vascular surgeons and stroke physicians, with responses gathered. The questionnaire was then repeated with the addition of the ECST risk score. RESULTS: Two hundred and one completed surveys were analysed (21·5 per cent response rate): 107 by stroke physicians and 94 by vascular surgeons. The high-risk scenario after the introduction of the ECST risk score showed an increased use of CEA (66·7 versus 80·1 per cent; P = 0·009). The low-risk scenario after risk score analysis demonstrated a swing towards best medical therapy (23·4 versus 57·2 per cent; P < 0·001). CEA was preferred in the moderate-risk scenario and this was not altered significantly by introduction of the risk score (71·6 versus 75·6 per cent; P = 0·609). Vascular surgeons exhibited a preference towards CEA compared with stroke physicians in both low- and moderate-risk scenarios (P < 0·001 and P = 0·003 respectively). CONCLUSION: The addition of a risk score appeared to influence clinicians in their decision-making towards CEA in high-risk patients and towards best medical therapy in low-risk patients.

Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS.

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

The use of contrast enhanced ultrasound in carotid arterial disease.

Traditionally, stroke risk stratification has centred on the degree of internal carotid artery stenosis, and the presence of focal neurological symptoms. However, degree of stenosis alone is a relatively poor predictor of future stroke in asymptomatic patients; the Asymptomatic Carotid Surgery Trial highlighting the need to identify a subgroup of asymptomatics that may benefit from intervention. Attempting to define this subgroup has inspired imaging research to identify, in vivo, high-risk plaques. In addition to pre-operative risk stratification of carotid stenosis, contrast enhanced ultrasound (CEUS) may be employed in monitoring response to plaque-stabilising therapies. Unlike most contrast agents used for computed tomography and magnetic resonance imaging, microbubbles used in CEUS remain within the vascular space and can hence be used to study the vasculature. In addition to improving current carotid structural scans, CEUS has potential to add extra information on plaque characteristics. Furthermore, by targeting microbubbles to specific ligands expressed on vascular endothelium, CEUS may have the ability to probe plaque biology. This review describes the current carotid ultrasound examination and the need to improve it, rationale for imaging neovascularisation, use of CEUS to image neovascularisation, microbubbles in improving the structural imaging of plaque, potential problems with CEUS, and future directions.