Human factors as a source of error in peak Doppler velocity measurement

Accuracy and Precision of a Plane Wave Vector Flow Imaging Method in the Healthy Carotid Artery

The objective of the study described here was to investigate the accuracy and precision of a plane wave 2-D vector flow imaging (VFI) method in laminar and complex blood flow conditions in the healthy carotid artery. The approach was to study (i) the accuracy for complex flow by comparing the velocity field from a computational fluid dynamics (CFD) simulation to VFI estimates obtained from the scan of an anthropomorphic flow phantom and from an in vivo scan; (ii) the accuracy for laminar unidirectional flow in vivo by comparing peak systolic velocities from VFI with magnetic resonance angiography (MRA); (iii) the precision of VFI estimation in vivo at several evaluation points in the vessels. The carotid artery at the bifurcation was scanned using both fast plane wave ultrasound and MRA in 10 healthy volunteers. The MRA geometry acquired from one of the volunteers was used to fabricate an anthropomorphic flow phantom, which was also scanned using the fast plane wave sequence. The same geometry was used in a CFD simulation to calculate the velocity field. Results indicated that similar flow patterns and vortices were estimated with CFD and VFI in the phantom for the carotid bifurcation. The root-mean-square difference between CFD and VFI was within 0.12 m/s for velocity estimates in the common carotid artery and the internal branch. The root-mean-square difference was 0.17 m/s in the external branch. For the 10 volunteers, the mean difference between VFI and MRA was -0.17 m/s for peak systolic velocities of laminar flow in vivo. The precision in vivo was calculated as the mean standard deviation (SD) of estimates aligned to the heart cycle and was highest in the center of the common carotid artery (SD = 3.6% for velocity magnitudes and 4.5° for angles) and lowest in the external branch and for vortices (SD = 10.2% for velocity magnitudes and 39° for angles). The results indicate that plane wave VFI measures flow precisely and that estimates are in good agreement with a CFD simulation and MRA.

Levels of agreement in the measurements of carotid artery ultrasound across a regional vascular network

INTRODUCTION

Duplex ultrasound is often the sole imaging modality used in diagnosing carotid artery disease. However, the reproducibility and repeatability of scientists in determining the peak systolic velocity and end diastolic velocity of the internal carotid artery and common carotid artery (CCA) is widely debated.

STUDY AIM

To investigate intra- and inter-operator variability in diagnostic ultrasound of the carotid arteries across a centralised vascular network using a healthy test subject. To identify potential causes of variability and highlight areas for improvement.

METHODS

Fifteen vascular scientists across four hospital Trusts in the Bristol, Bath and Weston vascular network measured the peak systolic velocity and end diastolic velocity of the internal carotid artery and common carotid artery in a subject using a single portable ultrasound machine. A double blind assessment of spectral Doppler images was performed by two vascular clinical scientists for optimal caliper placement, spectral gain and angle correction. Results were compared for intra- and inter-operator variability.

RESULTS

Initial quality assessment of the Doppler images revealed that three out of 15 scientists produced suboptimal results. Box plot analysis of the common carotid artery and internal carotid artery for each scientist revealed significant variance (ANOVA p < 0.05). However, a Levene's test revealed no single operator who consistently produced highly variable results (p = 0.569).

CONCLUSION

This study highlights the difficulty in obtaining consistent velocity measurements from a subject. Despite the variability in absolute peak systolic velocity and end diastolic velocity, scientists were generally consistent in obtaining an optimal spectral Doppler trace. Some issues with consistency were, however, identified which were subsequently addressed.

Pulmonary Flow as an Improved Method for Determining Cardiac Output in Mice after Myocardial Infarction

BACKGROUND

Echocardiography is a valuable noninvasive technique to estimate cardiac output (CO) from the left ventricle (LV) not only in clinical practice but also in small-animal experiments. CO is used to grade cardiac function and is especially important when investigating cardiac injury (e.g., myocardial infarction [MI]). Critically, MI deforms the LV, invalidating the assumptions fundamental to calculating of cardiac volumes directly from the LV. Thus, the purpose of this study was to determine if Doppler-derived blood flow through the pulmonary trunk (pulmonary flow [PF]) was an improved method over conventional LV-dependent echocardiography to accurately determine CO after MI.

METHODS

Variations in CO were induced either by transverse aortic constriction or MI. Echocardiography was performed in healthy (n = 27), transverse aortic constriction (n = 25), and MI (n = 41) mice. CO calculated from PF (pulsed-wave Doppler) was internally compared with CO calculated from left ventricular images using M-mode (Teichholz formula) and the single-plane ellipsoid two-dimensional (2D) formula and externally compared with the gold standard, flow probe CO.

RESULTS

In healthy mice, all three echocardiographic methods (M-mode, 2D, and PF) correlated well with flow probe-derived CO. In MI mice, only PF CO values correlated well with flow probe values. Bland-Altman analysis confirmed that PF was improved over M-mode and 2D echocardiography. Inter- and intrauser variability of PF CO was reduced, and both inter- and intraclass correlation coefficients were improved compared with either M-mode or 2D CO calculations.

CONCLUSIONS

PF CO calculated from pulsed-wave Doppler through the pulmonary trunk was an improved method of estimating CO over LV-dependent formulas after MI.

Vector Flow Imaging Compared with Pulse Wave Doppler for Estimation of Peak Velocity in the Portal Vein

The study described here investigated whether angle-independent vector flow imaging (VFI) technique estimates peak velocities in the portal vein comparably to pulsed wave Doppler (PWD). Furthermore, intra- and inter-observer agreement was assessed in a substudy. VFI and PWD peak velocities were estimated with from intercostal and subcostal views for 32 healthy volunteers, and precision analyses were conducted. Blinded to estimates, three physicians rescanned 10 volunteers for intra- and inter-observer agreement analyses. The precision of VFI and PWD was 18% and 28% from an intercostal view and 23% and 77% from a subcostal view, respectively. Bias between VFI and PWD was 0.57 cm/s (p = 0.38) with an intercostal view and 9.89 cm/s (p <0.001) with a subcostal view. Intra- and inter-observer agreement was highest for VFI (inter-observer intra-class correlation coefficient: VFI 0.80, PWD 0.3; intra-observer intra-class correlation coefficient: VFI 0.90, PWD 0.69). Regardless of scan view, VFI was more precise than PWD.

Real-Time Blood Velocity Vector Measurement Over a 2-D Region

Quantitative blood velocity measurements, as currently implemented in commercial ultrasound scanners, are based on pulsed-wave (PW) spectral Doppler and are limited to detect the axial component of the velocity in a single sample volume. On the other hand, vector Doppler methods produce angle-independent estimates by, e.g., combining the frequency shifts measured from different directions. Moreover, thanks to the transmission of plane waves, the investigation of a 2-D region is possible with high temporal resolution, but, unfortunately, the clinical use of these methods is hampered by the massive calculation power required for their real-time execution. In this paper, we present a novel approach based on the transmission of plane waves and the simultaneous reception of echoes from 16 distinct subapertures of a linear array probe, which produces eight lines distributed over a 2-D region. The method was implemented on the ULAO-OP 256 research scanner and tested both in phantom and in vivo. A continuous real-time refresh rate of 36 Hz was achieved in duplex combination with a standard B-mode at pulse repetition frequency of 8 kHz. Accuracies of -11% on velocity and of 2°on angle measurements have been obtained in phantom experiments. Accompanying movies show how the method improves the quantitative measurements of blood velocities and details the flow configurations in the carotid artery of a volunteer.

Tissue Doppler velocity imaging and event timings in neonates: a guide to image acquisition, measurement, interpretation, and reference values

Neonatologists can use echocardiography for real-time assessment of the hemodynamic state of neonates to support clinical decision-making. There is a large body of evidence showing the shortcomings of conventional echocardiographic indices in neonates. Newer imaging modalities have evolved. Tissue Doppler imaging is a new technique that can provide measurements of myocardial movement and timing of myocardial events and may overcome some of the shortcomings of conventional techniques. The high time resolution and its ability to assess left and right cardiac function make tissue Doppler a favorable technique for assessing heart function in neonates. The aim of this review is to provide an up-to-date overview of tissue Doppler techniques for the assessment of cardiac function in the neonatal context, with focus on measurements from the atrioventricular (AV) plane. We discuss basic concepts, protocol for assessment, feasibility, and limitations, and we report reference values and give examples of its use in neonates.

Combined 2-D Vector Velocity Imaging and Tracking Doppler for Improved Vascular Blood Velocity Quantification

Measurement of the maximum blood flow velocity is the primary means for determining the degree of carotid stenosis using ultrasound. The current standard for estimating the maximum velocity is pulsed-wave Doppler with manual angle correction, which is prone to error and interobserver variability. In addition, spectral broadening in the velocity spectra leads to overestimation of maximal velocities. In this paper, we propose to combine two velocity estimation methods to reduce the bias and variability in maximum velocity measurements. First, the direction of the blood flow is estimated using an aliasing-resistant least squares vector Doppler technique. Then, tracking Doppler is performed on the same data, using the direction of the vector Doppler estimate as the tracking direction. Simulations show that the method can estimate a maximum velocity of 2 m/s with accuracy 5% for beam-to-flow angles between 20° and 75°, and that the primary source of error is inaccuracy in the flow direction estimate from vector Doppler. Simulations of complex flow in a carotid bifurcation demonstrated that the combined technique provided spectral velocity profiles corresponding well with the true maximum velocity trace, and that the bias originating from the directional estimate was within 5% for all spatial points. A healthy volunteer and a volunteer with carotid artery stenosis were imaged, showing in vivo feasibility of the method, for high velocities and with beam-to-flow angles varying throughout the cardiac cycle.

Vector and Doppler Ultrasound Velocities Evaluated in a Flow Phantom and the Femoropopliteal Vein

Ultrasound is used for evaluating the veins of the lower extremities. Operator and angle dependency limit spectral Doppler ultrasound (SDUS). The aim of the study was to compare peak velocity measurements in a flow phantom and the femoropopliteal vein of 20 volunteers with the angle-independent vector velocity technique vector flow imaging (VFI) and SDUS. In the flow phantom, VFI underestimated velocity (p = 0.01), with a lower accuracy of 5.5% (p = 0.01) and with no difference in precision, that is, error factor, compared with SDUS (VFI: 1.02 vs. SDUS: 1.02, p = 0.58). In vivo, VFI estimated lower velocities (femoral: p = 0.001; popliteal: p = 0.001) with no difference in precision compared with SDUS (femoral: VFI 1.09 vs. SDUS 1.14, p = 0.37; popliteal: VFI 1.13 vs. SDUS 1.06, p = 0.09). In conclusion, the precise VFI technique can be used to characterize venous hemodynamics of the lower extremities despite its underestimation of velocities.

Sonography of Arteriovenous Fistulas and Grafts

Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are the vascular accesses of choice for long-term hemodialysis. Strategies to establish and maintain functioning AVFs and AVGs are essential. In addition to clinical evaluation, ultrasound plays a critical role in the evaluation and maintenance of AVFs and AVGs. AVFs have a high rate of failure to mature which can be reliably diagnosed with ultrasound. Treatable etiologies of the failure to mature can often be diagnosed with ultrasound. Causes of secondary AVG failure can also be diagnosed with ultrasound and treated. AVGs have a relatively short functional life expectancy due to a high rate of AVG thrombosis. Ultrasound is a safe, noninvasive way to diagnose vascular stenosis in both AVFs and AVGs prior to thrombosis, potentially saving the access. Routine surveillance ultrasound of asymptomatic AVFs and AVGs is controversial with conflicting studies on its benefit. Routine surveillance ultrasound of AVFs and AVGs is not common practice.

Test-Retest Reliability of Measuring the Vertebral Arterial Blood Flow Velocity in People With Cervicogenic Dizziness

OBJECTIVES

The purpose of this study was to determine the within-session and between-sessions reliability of measuring the vertebral artery blood flow velocities in people with cervicogenic dizziness using Doppler ultrasound at both upper and lower cervical levels.

METHODS

Outcome measures were taken on 2 occasions 3 weeks apart with no active treatment provided in between the assessments on 12 participants. Pulsed-wave Doppler ultrasound was used to quantify time-averaged mean velocities through the vertebral artery at upper cervical (C0-1) and lower cervical vertebrae (C5-6). The clinical outcome measures were also recorded in people with cervicogenic dizziness. The intraclass correlation coefficient (ICC) was used to determine the within-session and between-session repeatability. Paired t test was used to determine the differences in the time-averaged mean velocities of blood flow at the same site of the vertebral artery and the clinical outcome measures in 2 sessions 3 weeks apart.

RESULTS

In people with cervicogenic dizziness, there was no significant change in both clinical outcome measures and the time-averaged mean velocities when the patients were measured 3 weeks apart (P > .05). This study identified good within-session (ICC: 0.903-0.967) and between-session (ICC: 0.922-0.984) repeatability in measuring the vertical blood flow velocities in patients with cervicogenic dizziness when the clinical outcome measures were unchanged.

CONCLUSIONS

This study supports the use of Doppler ultrasound to identify changes in mean vertebral arterial blood flow velocities before and after intervention in people with cervicogenic dizziness in future studies.

Open-source, vendor-independent, automated multi-beat tissue Doppler echocardiography analysis

Current guidelines for measuring cardiac function by tissue Doppler recommend using multiple beats, but this has a time cost for human operators. We present an open-source, vendor-independent, drag-and-drop software capable of automating the measurement process. A database of ~8000 tissue Doppler beats (48 patients) from the septal and lateral annuli were analyzed by three expert echocardiographers. We developed an intensity- and gradient-based automated algorithm to measure tissue Doppler velocities. We tested its performance against manual measurements from the expert human operators. Our algorithm showed strong agreement with expert human operators. Performance was indistinguishable from a human operator: for algorithm, mean difference and SDD from the mean of human operators’ estimates 0.48 ± 1.12 cm/s (R² = 0.82); for the humans individually this was 0.43 ± 1.11 cm/s (R² = 0.84), −0.88 ± 1.12 cm/s (R² = 0.84) and 0.41 ± 1.30 cm/s (R² = 0.78). Agreement between operators and the automated algorithm was preserved when measuring at either the edge or middle of the trace. The algorithm was 10-fold quicker than manual measurements (p < 0.001). This open-source, vendor-independent, drag-and-drop software can make peak velocity measurements from pulsed wave tissue Doppler traces as accurately as human experts. This automation permits rapid, bias-resistant multi-beat analysis from spectral tissue Doppler images.

Ultrasound imaging velocimetry with interleaved images for improved pulsatile arterial flow measurements: a new correction method, experimental and in vivo validation

Blood velocity measurements are important in physiological science and clinical diagnosis. Doppler ultrasound is the most commonly used method but can only measure one velocity component. Ultrasound imaging velocimetry (UIV) is a promising technique capable of measuring two velocity components; however, there is a limit on the maximum velocity that can be measured with conventional hardware which results from the way images are acquired by sweeping the ultrasound beam across the field of view. Interleaved UIV is an extension of UIV in which two image frames are acquired concurrently, allowing the effective interframe separation time to be reduced and therefore increasing the maximum velocity that can be measured. The sweeping of the ultrasound beam across the image results in a systematic error which must be corrected: in this work, we derived and implemented a new velocity correction method which accounts for acceleration of the scatterers. We then, for the first time, assessed the performance of interleaved UIV for measuring pulsatile arterial velocities by measuring flows in phantoms and in vivo and comparing the results with spectral Doppler ultrasound and transit-time flow probe data. The velocity and flow rate in the phantom agreed within 5-10% of peak velocity, and 2-9% of peak flow, respectively, and in vivo the velocity difference was 9% of peak velocity. The maximum velocity measured was 1.8 m s^-1, the highest velocity reported with UIV. This will allow flows in diseased arteries to be investigated and so has the potential to increase diagnostic accuracy and enable new vascular research.

Least-Squares Multi-Angle Doppler Estimators for Plane-Wave Vector Flow Imaging

Designing robust Doppler vector estimation strategies for use in plane-wave imaging schemes based on unfocused transmissions is a topic that has yet to be studied in depth. One potential solution is to use a multi-angle Doppler estimation approach that computes flow vectors via least-squares fitting, but its performance has not been established. Here, we investigated the efficacy of multi-angle Doppler vector estimators by: 1) comparing its performance with respect to the classical dual-angle (cross-beam) Doppler vector estimator and 2) examining the working effects of multi-angle Doppler vector estimators on flow visualization quality in the context of dynamic flow path rendering. Implementing Doppler vector estimators that use different combinations of transmit (Tx) and receive (Rx) steering angles, our analysis has compared the classical dual-angle Doppler method, a 5-Tx version of dual-angle Doppler, and various multi-angle Doppler configurations based on 3 Tx and 5 Tx. Two angle spans (10°, 20°) were examined in forming the steering angles. In imaging scenarios with known flow profiles (rotating disk and straight-tube parabolic flow), the 3-Tx, 3-Rx and 5-Tx, 5-Rx multi-angle configurations produced vector estimates with smaller variability compared with the dual-angle method, and the estimation results were more consistent with the use of a 20° angle span. Flow vectors derived from multi-angle Doppler estimators were also found to be effective in rendering the expected flow paths in both rotating disk and straight-tube imaging scenarios, while the ones derived from the dual-angle estimator yielded flow paths that deviated from the expected course. These results serve to attest that using multi-angle least-squares Doppler vector estimators, flow visualization can be consistently achieved.

Investigation of Crossbeam Multi-receiver Configurations for Accurate 3-D Vector Doppler Velocity Estimation

An accurate estimation of low blood velocities whose Doppler shifts span the wall filter cutoff, such as near the wall in recirculation or disturbed flow regions, is important for accurate mapping of velocities to achieve improved estimations of wall shear stress and turbulence, which are known risk factors for atherosclerosis and stroke. This paper presents the comparative benefit of increasing the number of receiver beams above three for an improved estimation of low 3-D velocities. The 3-D crossbeam vector Doppler ultrasound configurations were studied in terms of the number of receiver beams, interbeam angle, and beam selection method (criterion for discriminating between tissue and blood Doppler signals) for a range of velocity orientations, which may prove useful in the design of a future 2-D array for vascular imaging. For maximum velocity resolution, a shallow gradient of low flow velocities up to 5 cm/s was generated across a large-diameter (2.46 cm) straight vessel. Data were acquired using a linear array rotated around the central transmit beam axis to generate three- to eight-receiver (3R-8R) configurations;the rotation of each configuration relative to the flow axis was used to mimic a broad range of velocity vector orientations. Accuracy and precision for ≥5 receivers were consistently better over all velocity orientations and for all selection methods. For a velocity magnitude of 2 cm/s, the best accuracy and precision in both magnitude and direction (~21% ± 13%, <1° ± 9°, respectively) were seen with a 5R configuration using a weighted least-squares selection method. Asymmetry in the 5R configuration led to an improved accuracy and precision compared with that in symmetrical 6R and 8R configurations. The results demonstrated relatively little to no benefit from more than five receiver beams.

Assessment of Spectral Doppler for an Array-Based Preclinical Ultrasound Scanner Using a Rotating Phantom

Velocity measurement errors were investigated for an array-based preclinical ultrasound scanner (Vevo 2100, FUJIFILM VisualSonics, Toronto, ON, Canada). Using a small-size rotating phantom made from a tissue-mimicking material, errors in pulse-wave Doppler maximum velocity measurements were observed. The extent of these errors was dependent on the Doppler angle, gate length, gate depth, gate horizontal placement and phantom velocity. Errors were observed to be up to 172% at high beam-target angles. It was found that small gate lengths resulted in larger velocity errors than large gate lengths, a phenomenon that has not previously been reported (e.g., for a beam-target angle of 0°, the error was 27.8% with a 0.2-mm gate length and 5.4% with a 0.98-mm gate length). The error in the velocity measurement with sample volume depth changed depending on the operating frequency of the probe. Some edge effects were observed in the horizontal placement of the sample volume, indicating a change in the array aperture size. The error in the velocity measurements increased with increased phantom velocity, from 22% at 2.4 cm/s to 30% at 26.6 cm/s. To minimise the impact of these errors, an angle-dependent correction factor was derived based on a simple ray model of geometric spectral broadening. Use of this angle-dependent correction factor reduces the maximum velocity measurement errors to <25% in all instances, significantly improving the current estimation of maximum velocity from pulse-wave Doppler ultrasound.

Comparison of carotid artery blood velocity measurements by vector and standard Doppler approaches

Although severely affected by the angle dependency, carotid artery peak systolic velocity measurements are widely used for assessment of stenosis. In this study, blood peak systolic velocities in the common and internal carotid arteries of both healthy volunteers and patients with internal carotid artery stenosis were measured by two vector Doppler (VD) methods and compared with measurements obtained with the conventional spectral Doppler approach. Although the two VD techniques were completely different (using the transmission of focused beams and plane waves, respectively), the measurement results indicate that these techniques are nearly equivalent. The peak systolic velocities measured in 22 healthy common carotid arteries by the two VD techniques were very close (according to Bland-Altman analysis, the average difference was 3.2%, with limits of agreement of ± 8.6%). Application of Bland-Altman analysis to comparison of either VD technique with the spectral Doppler method provided a 21%-25% average difference with ± 13%-15% limits of agreement. Analysis of the results obtained from 15 internal carotid arteries led to similar conclusions, indicating significant overestimation of peak systolic velocity with the spectral Doppler method. Inter- and intra-operator repeatability measurements performed in a group of 8 healthy volunteers provided equivalent results for all of the methods (coefficients of variability in the range 2.7%-6.9%), even though the sonographers were not familiar with the VD methods. The results of this study suggest that the introduction of vector Doppler methods in commercial machines may finally be considered mature and capable of overcoming the angle-dependent overestimation typical of the standard spectral Doppler approach.

Accurate blood peak velocity estimation using spectral models and vector doppler

Ultrasound blood peak velocity estimates are routinely used for diagnostics, such as the grading of a stenosis. The peak velocity is typically assessed from the Doppler spectrum by locating the highest frequency detectable from noise. The selected frequency is then converted to velocity by the Doppler equation. This procedure contains several potential sources of error: the frequency selection is noise dependent and sensitive to the spectral broadening, which, in turn, is affected by the Doppler angle uncertainty. The result is, often, an inaccurate estimate. In this work we propose a new method that removes the aforementioned errors. The frequency is selected by exploiting a mathematical model of the Doppler spectrum that has recently been introduced. When a very large sample volume is used, which includes all the vessel section, the model is capable of predicting the exact threshold to be used without the need of broadening compensation. The angle ambiguity is solved by applying the threshold to the Doppler spectra measured from two different directions, according to the vector Doppler technique. The proposed approach has here been validated through Field II simulations, phantom experiments, and tests on volunteers by using defocused waves to insonify a large region from a linear array probe. A mean error lower than 1% and a mean coefficient of variability lower than 5% were measured in a variety of experimental conditions.

Volume flow in arteriovenous fistulas using vector velocity ultrasound

Volume flow in arteriovenous fistulas for hemodialysis was measured using the angle-independent ultrasound technique Vector Flow Imaging and compared with flow measurements using the ultrasound dilution technique during dialysis. Using an UltraView 800 ultrasound scanner (BK Medical, Herlev, Denmark) with a linear transducer, 20 arteriovenous fistulas were scanned directly on the most superficial part of the fistula just before dialysis. Vector Flow Imaging volume flow was estimated with two different approaches, using the maximum and the average flow velocities detected in the fistula. Flow was estimated to be 242 mL/min and 404 mL/min lower than the ultrasound dilution technique estimate, depending on the approach. The standard deviations of the two Vector Flow Imaging approaches were 175.9 mL/min and 164.8 mL/min compared with a standard deviation of 136.9 mL/min using the ultrasound dilution technique. The study supports that Vector Flow Imaging is applicable for volume flow measurements.

An improved Doppler model for obtaining accurate maximum blood velocities

Maximum blood velocity estimates are frequently required in diagnostic applications, including carotid stenosis evaluation, arteriovenous fistula inspection, and maternal-fetal examinations. However, the currently used methods for ultrasound measurements are inaccurate and often rely on applying heuristic thresholds to a Doppler power spectrum. A new method that uses a mathematical model to predict the correct threshold that should be used for maximum velocity measurements has recently been introduced. Although it is a valuable and deterministic tool, this method is limited to parabolic flows insonated by uniform pressure fields. In this work, a more generalized technique that overcomes such limitations is presented. The new approach, which uses an extended Doppler spectrum model, has been implemented in an experimental set-up based on a linear array probe that transmits defocused steered waves. The improved model has been validated by Field II simulations and phantom experiments on tubes with diameters between 2mm and 8mm. Using the spectral threshold suggested by the new model significantly higher accuracy estimates of the peak velocity can be achieved than are now clinically attained, including for narrow beams and non-parabolic velocity profiles. In particular, an accuracy of +1.2±2.5 cm/s has been obtained in phantom measurements for velocities ranging from 20 to 80 cm/s. This result represents an improvement that can significantly affect the way maximum blood velocity is investigated today.

Combined vector velocity and spectral Doppler imaging for improved imaging of complex blood flow in the carotid arteries

Color flow imaging and pulsed wave (PW) Doppler are important diagnostic tools in the examination of patients with carotid artery disease. However, measurement of the true peak systolic velocity is dependent on sample volume placement and the operator's ability to provide an educated guess of the flow direction. Using plane wave transmissions and a duplex imaging scheme, we present an all-in-one modality that provides both vector velocity and spectral Doppler imaging from one acquisition, in addition to separate B-mode images of sufficient quality. The vector Doppler information was used to provide automatically calibrated (angle-corrected) PW Doppler spectra at every image point. It was demonstrated that the combined information can be used to generate spatial maps of the peak systolic velocity, highlighting regions of high velocity and the extent of the stenotic region, which could be used to automate work flow as well as improve the accuracy of measurement of true peak systolic velocity. The modality was tested in a small group (N = 12) of patients with carotid artery disease. PW Doppler, vector velocity and B-mode images could successfully be obtained from a single recording for all patients with a body mass index ranging from 21 to 31 and a carotid depth ranging from 16 to 28 mm.

Improving the reliability of venous Doppler flow measurements: relevance of combined ECG, training and repeated measures

The nature of venous Doppler waves is highly variable. An additional electrocardiogram (ECG) improves the interpretation of venous Doppler wave characteristics and allows measurement of venous pulse transit time. The purpose of this study was to assess the reproducibility of ECG-guided repeated measurements of venous Doppler flow characteristics before and after sonographer training and the inter- and intra-observer variability. In four groups of 25 healthy women, venous Doppler flow measurements were performed at the level of the kidneys and liver according to a standardized protocol. Intra-observer Pearson correlation coefficients of the renal interlobar vein Doppler indices were ≥ 0.80 with the addition of the ECG, which are higher than the results of a former study. The inter-observer correlation between an experienced ultrasonographer and an inexperienced ultrasonographer improved from ≥ 0.71 to ≥ 0.91 after training. The correlation range of all parameters between two independent observers improved when values were based on repeated measures. The addition of an ECG to the Doppler image, training and repeated measurements are helpful in improving venous Doppler wave interpretation.

Automated aortic Doppler flow tracing for reproducible research and clinical measurements

In clinical practice, echocardiographers are often unkeen to make the significant time investment to make additional multiple measurements of Doppler velocity. Main hurdle to obtaining multiple measurements is the time required to manually trace a series of Doppler traces. To make it easier to analyze more beats, we present the description of an application system for automated aortic Doppler envelope quantification, compatible with a range of hardware platforms. It analyses long Doppler strips, spanning many heartbeats, and does not require electrocardiogram to separate individual beats. We tested its measurement of velocity-time-integral and peak-velocity against the reference standard defined as the average of three experts who each made three separate measurements. The automated measurements of velocity-time-integral showed strong correspondence (R(2) = 0.94) and good Bland-Altman agreement (SD = 1.39 cm) with the reference consensus expert values, and indeed performed as well as the individual experts ( R(2) = 0.90 to 0.96, SD = 1.05 to 1.53 cm). The same performance was observed for peak-velocities; ( R(2) = 0.98, SD = 3.07 cm/s) and ( R(2) = 0.93 to 0.98, SD = 2.96 to 5.18 cm/s). This automated technology allows > 10 times as many beats to be analyzed compared to the conventional manual approach. This would make clinical and research protocols more precise for the same operator effort.

Accuracy and reproducibility of a novel dynamic volume flow measurement method

In clinical practice, blood volume flow (BVF) is typically calculated assuming a perfect parabolic and axisymmetric velocity distribution. This simple approach cannot account for the complex flow configurations that are produced by vessel curvatures, pulsatility and diameter changes and, therefore, results in a poor estimation. Application of the Womersley model allows compensation for the flow distortion caused by pulsatility and, with some adjustment, the effects of slight curvatures, but several problems remain unanswered. Two- and three-dimensional approaches can acquire the actual velocity field over the whole vessel section, but are typically affected by a limited temporal resolution. The multigate technique allows acquisition of the actual velocity profile over a line intersecting the vessel lumen and, when coupled with a suitable wall-tracking method, can offer the ideal trade-off among attainable accuracy, temporal resolution and required calculation power. In this article, we describe a BVF measurement method based on the multigate spectral Doppler and a B-mode edge detector algorithm for wall-position tracking. The method has been extensively tested on the research platform ULA-OP, with more than 1700 phantom measurements at flow rates between 60 and 750 mL/min, steering angles between 10 ° and 22 ° and constant, sinusoidal or pulsed flow trends. In the averaged BVF measurement, we found an underestimation of about -5% and a coefficient of variability (CV) less than 6%. In instantaneous measurements (e.g., systolic peak) the CV was in the range 2%-8.5%. These results were confirmed by a preliminary test on the common carotid artery of 10 volunteers (CV = 2%-11%).

Design of anthropomorphic flow phantoms based on rapid prototyping of compliant vessel geometries

Anatomically realistic flow phantoms are essential experimental tools for vascular ultrasound. Here we describe how these flow phantoms can be efficiently developed via a rapid prototyping (RP) framework that involves direct fabrication of compliant vessel geometries. In this framework, anthropomorphic vessel models were drafted in computer-aided design software, and they were fabricated using stereolithography (one type of RP). To produce elastic vessels, a compliant photopolymer was used for stereolithography. We fabricated a series of compliant, diseased carotid bifurcation models with eccentric stenosis (50%) and plaque ulceration (types I and III), and they were used to form thin-walled flow phantoms by coupling the vessels to an agar-based tissue-mimicking material. These phantoms were found to yield Doppler spectrograms with significant spectral broadening and color flow images with mosaic patterns, as typical of disturbed flow under stenosed and ulcerated disease conditions. Also, their wall distension behavior was found to be similar to that observed in vivo, and this corresponded with the vessel wall's average elastic modulus (391 kPa), which was within the nominal range for human arteries. The vessel material's acoustic properties were found to be sub-optimal: the estimated average acoustic speed was 1801 m/s, and the attenuation coefficient was 1.58 dB/(mm·MHz(n)) with a power-law coefficient of 0.97. Such an acoustic mismatch nevertheless did not notably affect our Doppler spectrograms and color flow image results. These findings suggest that phantoms produced from our design framework have the potential to serve as ultrasound-compatible test beds that can simulate complex flow dynamics similar to those observed in real vasculature.

Duplex ultrasound evaluation of hemodialysis access: a detailed protocol

A detailed protocol for the performance and interpretation of duplex ultrasound evaluation of hemodialysis access is described.

Role of dysfunctional maternal venous hemodynamics in the pathophysiology of pre-eclampsia: a review

The venous compartment has an important function in regulation and control of cardiac output. Abnormalities of cardiac output have been found in early gestational stages of both early- and late-onset pre-eclampsia. The venous compartment also maintains the balance between circulating and non-circulating blood volumes and regulates the amount of reserve blood stored in the splanchnic venous bed. It is well known that adaptive regulation of maternal blood volume is disturbed in pre-eclampsia. Abnormal venous hemodynamics and venous congestion are responsible for secondary dysfunction of several organs, such as the kidneys in cardiorenal syndrome and the liver in cardiac cirrhosis. Renal and liver dysfunctions are among the most relevant clinical features of pre-eclampsia. Doppler sonography studies have shown that the maternal venous compartment is subject to gestational adaptation, and that blood flow characteristics at the level of renal interlobar and hepatic veins are different in pre-eclampsia compared with uncomplicated pregnancy. In comparison to late-onset pre-eclampsia, in early-onset pre-eclampsia venous Doppler flow abnormalities are more prominent and present up to weeks before clinical symptoms. This paper reviews the growing evidence that dysfunction of maternal venous hemodynamics is part of the pathophysiology of pre-eclampsia and may perhaps be more important than is currently considered. Doppler sonography is a safe and easily performed method with which to study maternal venous hemodynamics. Therefore, exploring the role of maternal venous hemodynamics using Doppler sonography is an exciting new research topic for those who are interested in cardiovascular background mechanisms, as well as prediction and clinical work-up of pre-eclampsia.

Blood Flow Measurements during Hemodialysis Vascular Access Interventions - Catheter-Based Thermodilution or Doppler Ultrasound?

Purpose

To test the clinical performance of catheter-based thermodilution and Doppler ultrasound of the feeding brachial artery for blood flow measurements during hemodialysis vascular access interventions.

Methods

Thirty patients with arteriovenous fistulas who underwent 46 interventions had access blood flow measured before and after every procedure. Two methods, catheter-based thermodilution and Doppler ultrasound, were compared to the reference method of ultrasound dilution. Catheter-based thermodilution and Doppler ultrasound were performed during the endovascular procedures while flow by ultrasound dilution was determined within three days of the procedure. The methods were compared using regression analysis and tested for systematic bias.

Results

Failure to position the thermodilutional catheter correctly was observed in 8 out of 46 (17%) pre-intervention measurements. Post-intervention measurements and ultrasound measurements were feasible in all patients. The average level of agreement was good when comparing catheter-based thermodilution to ultrasound dilution. However, blood flow by ultrasound dilution may differ by ±130 mL/min (±22%) at a flow level of 600 mL/min by thermodilution. Results from Doppler ultrasound displayed a moderate level of agreement on average when compared to ultrasound dilution. Blood flow by ultrasound dilution may differ by ±160 mL/min (±27%) at a flow level of 600 mL/min by Doppler ultrasound. No systematic bias was detected by either method.

Conclusions

On average, results from catheter-based thermodilution were more in agreement with results from the ultrasound dilution technique compared to Doppler ultrasound. However, considering the cost and the high technical failure rate of the thermodilutional system, we recommend the use of ultrasound.

Estimation of blood velocity, volumetric flow and wall shear rate using Doppler ultrasound

Commercial ultrasound systems can make a number of measurements related to haemodynamics which are relevant to clinical practice and to clinical research. These include maximum velocity, volumetric flow and wall shear rate. Using appropriate protocols, measurements can be made averaged over the cardiac cycle, or as a function of time through the cardiac cycle. Maximum velocity underpins most of these measurements. Maximum velocity is overestimated as a result of geometric spectral broadening, by typically up to 30%, but by much larger amounts as the angle approaches 90°. Though not used in clinical practice, a simple correction technique using a string phantom can substantially reduce these errors. For volumetric flow and wall shear rate, methods such as specialist multi-gate ultrasound systems, magnetic resonance imaging and image guided modelling are available. Before resorting to these more complex methods users might consider that, with care and attention to procedure, high quality information may be obtained using commercial ultrasound systems. Manufacturers could make more use of the colour flow image for quantification of velocity, and adopt vector Doppler techniques.

New method to measure coronary velocity and coronary flow reserve

Coronary flow reserve (CFR) is an important index of coronary microcirculatory function. The objective of this study was to validate the reproducibility and accuracy of intravascular conductance catheter-based method for measurements of baseline and hyperemic coronary flow velocity (and hence CFR). The absolute coronary blood velocity was determined by measuring the time of transit of a saline injection between two pairs of electrodes (known distance) on a conductance catheter during a routine saline injection without the need for reference flow. In vitro validation was made in the velocity range of 5 to 70 cm/s in reference to the volume collection method. In 10 swine, velocity measurements were compared with those from a flow probe in coronary arteries at different CFR attained by microsphere embolization. In vitro, the mean difference between the proposed method and volume collection was 0.7 ± 1.34 cm/s for steady flow and −0.77 ± 2.22 cm/s for pulsatile flow. The mean difference between duplicate measurements was 0 ± 1.4 cm/s. In in vivo experiments, the flow (product of velocity and lumen cross-sectional area that is also measured by the conductance catheter) was determined in both normal and stenotic vessels and the mean difference between the proposed method and flow probe was −1 ± 12 ml/min (flow ranged from 10 to 130 ml/min). For CFR, the mean difference between the two methods was 0.06 ± 0.28 (range of 1 to 3). Our results demonstrate the reproducibility and accuracy of velocity and CFR measurements with a conductance catheter by use of a standard saline injection. The ability of the combined measurement of coronary lumen area (as previously validated) and current velocity and CFR measurements provides an integrative diagnostic tool for interventional cardiology.

Doppler angle correction in the measurement of intrarenal parameters

Background:

The aim of this study was to assess differences in intrarenal artery Doppler parameters measured without and with Doppler angle correction.

Methods:

We retrospectively reviewed color duplex sonography in 30 normally functioning kidneys (20 native kidneys in 10 subjects and 10 transplanted kidneys in 10 subjects) performed between January 26, 2010 and July 26, 2010. There were 10 age-matched men and 10 age-matched women (mean 39.8 ± 12.2, range 21–60 years) in this study. Depending on whether the Doppler angle was corrected in the spectral Doppler measurement, Doppler parameters including peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) measured at the interlobar artery of the kidney were divided into two groups, ie, initial Doppler parameters measured without Doppler angle correction (Group 1) and remeasured Doppler parameters with Doppler angle correction (Group 2). Values for PSV, EDV, and RI measured without Doppler angle correction were compared with those measured with Doppler angle correction, and were analyzed statistically with a paired-samples t-test.

Results:

There were statistical differences in PSV and EDV at the interlobar artery in the upper, mid, and lower poles of the kidney between Group 1 and Group 2 (all P < 0.001). PSV and EDV in Group 1 were significantly lower than in Group 2. RI in Group 1 was the same as that in Group 2 in the upper, mid, and lower poles of the kidneys.

Conclusion:

Doppler angle correction plays an important role in the accurate measurement of intrarenal blood flow velocity. The true flow velocity converted from the maximum Doppler velocity shift is produced only when the Doppler angle is 0°, so that the emission sound beam is parallel to the direction of blood flow at the sampled artery. Therefore, the Doppler angle correction should be routinely applied and displayed on renal color duplex sonography.

An automatic angle tracking procedure for feasible vector Doppler blood velocity measurements

Two-dimensional angle-independent blood velocity estimates typically combine the Doppler frequencies independently measured by two ultrasound beams with known interbeam angle. A different dual-beam approach was recently introduced in which one (reference) beam is used to identify the flow direction, and the second (measuring) beam directly estimates the true flow velocity at known beam-flow angle. In this paper, we present a procedure to automatically steer the two beams along optimal orientations so that the velocity magnitude can be measured. The operator only takes care of locating the Doppler sample volume in the region of interest and, through the extraction of appropriate parameters from the Doppler spectrum, the reference beam is automatically steered toward right orientation to the flow. The velocity magnitude is thus estimated by the measuring beam, which is automatically oriented with respect to the (known) flow direction at a suitable Doppler angle. The implementation of the new angle tracking method in the ULtrasound Advanced Open Platform (ULA-OP), connected to a linear array transducer, is reported. A series of experiments shows that the proposed method rapidly locks the flow direction and measures the velocity magnitude with low variability for a large range of initial probe orientations. In vitro tests conducted in both steady and pulsatile flow conditions produced coefficients of variability (CV) below 2.3% and 8.3%, respectively. The peak systolic velocities have also been measured in the common carotid arteries of 13 volunteers, with mean CV of 7%.

Maternal hepatic vein Doppler velocimetry during uncomplicated pregnancy and pre-eclampsia

Changes of Doppler velocity measurements of distinct hepatic vein (HV) Doppler wave components were evaluated during uncomplicated pregnancy (UP) as a reference to measurements in pre-eclampsia (PE). Women with UP (n = 13) were submitted to standardised duplex scanning of HV at 11 stages of pregnancy between 10 and 38 weeks. For each stage, mean +/- SD was calculated for HV A-, X-, V- and Y-peaks. Women with PE (n = 30) were evaluated once, and mean +/- SD was calculated for pregnancies <32 weeks, 32-34(+6) weeks and > or =35 weeks. PE and UP values at corresponding gestational age were compared statistically using t-test. HV A-velocity measurements changed markedly from negative values in early uncomplicated pregnancy, converting around 22-24 weeks to positive values until term. Changes throughout gestation were less prominent for HV X-, V- and Y-velocities. HV A-velocity measurements were significantly lower in PE than in UP, the difference being more pronounced at 30 weeks (-3.59 +/- 3.41 vs. 6.12 +/- 3.43, p = 0.0001) than at 37 weeks (2.35 +/- 4.54 vs. 5.32 +/- 1.92, p = 0.04). From our results, we conclude that HV Doppler velocimetry shows a gradual shift from central venous reversed flow during atrial contraction in uncomplicated early pregnancy to constantly forward moving flow until term. HV A-velocities are significantly lower in PE than in UP, the differences being more pronounced in late second trimester than near term.

Measurements of left ventricular myocardial longitudinal systolic displacement using spectral and colour tissue Doppler: time for a reassessment?

BACKGROUND

Echocardiographic measurements of left ventricular (LV) myocardial displacement may produce different results depending on the choice of employed modality and subjective adjustments during data acquisition and analysis.

METHODS

In this study, left ventricular longitudinal systolic displacement was quantified in 57 patients (31 women and 26 men, 50 +/- 16 years) using colour (colour TD) and spectral tissue Doppler (spectral TD) before and after temporal filtering (30 to 70 milliseconds in 20-millisecond steps) and changed offline gain saturation (0%, 50% and 100%), respectively. The results were compared with those obtained with anatomic M-mode.

RESULTS

Whereas only minor differences occurred between the results of colour TD and anatomic M-mode measurements, spectral TD significantly overestimated the results obtained with both these methods. However, the limits of agreement between the results produced by all three studied methods were not clinically acceptable in any of the cases. The spectral TD displacement values increased along with increasing offline gain saturation whereas the effect of temporal filtering on colour Doppler measurements was insignificant.

CONCLUSION

Measurements of LV myocardial longitudinal displacement employing spectral TD, colour TD or anatomic M-mode produce different results, thus discouraging interchangeable use of these modalities. Whereas the results of spectral TD measurements can be significantly altered by changing offline gain setting, the effect of temporal filtering on colour TD measurements is insignificant, a fact that increases clinical practicality of the latter method.

Bronchoscopy is associated with decreased mesenteric arterial flow

BACKGROUND

We hypothesized that fiberoptic bronchoscopy can contribute to mesenteric ischemia and bacterial translocation.

OBJECTIVE

To test this hypothesis we investigated in patients undergoing bronchoscopy mesenteric blood flow and markers in association with ischemia reperfusion injury.

PATIENT

Forty-seven consecutive patients requiring diagnostic fiberoptic bronchoscopy were studied.

MEASUREMENTS

Parameters evaluated were superior mesenteric artery Doppler sonography, oxidative stress mediators, arterial blood gases, blood cultures pre-fiberoptic bronchoscopy, and 1st, 4th, and 24th hr post-fiberoptic bronchoscopy.

MAIN RESULTS

After bronchoscopy; PaO2 decreased by 21.8% +/- 1.5% (range 6-40), and remained low at all time points (p = 0.0001, p = 0.0001, p = 0.008). Flow volume decreased by 38.8% +/- 14.9% (range 6-72), and remained low at 1st and 4th hr (p = 0.0001, p = 0.01). Resistive and pulsatile index increased at 1st hr (p = 0.0001, p = 0.001) and 4th hr (p = 0.018, p = 0.045). Myeloperoxidase and malondialdehyde increased at 1st hr (p = 0.0001) and 4th hr (p = 0.037, p = 0.028). Corresponding glutathione and catalase decreased at 1st hr (p = 0.0001), and glutathione remained significant at 4th and 24th hr (p = 0.0001, p = 0.003). Correlation between flow volume and PaO2 (r = .71, p = 0.0001), myeloperoxidase (r = -.39, p = 0.05), glutathione (r = .41, p = 0.03) was significant. Nine of 47 (19.1%) had fever, and 3 of 47 (6.4%) had gram-negative bacteremia.

CONCLUSION

Fiberoptic bronchoscopy is associated with decreased mesenteric blood flow, which may place the patient at risk for mesenteric ischemia and gastrointestinal bacterial translocation.

Computer vision approach for ultrasound Doppler angle estimation

Doppler ultrasound is an important noninvasive diagnostic tool for cardiovascular diseases. Modern ultrasound imaging systems utilize spectral Doppler techniques for quantitative evaluation of blood flow velocities, and these measurements play a crucial rule in the diagnosis and grading of arterial stenosis. One drawback of Doppler-based blood flow quantification is that the operator has to manually specify the angle between the Doppler ultrasound beam and the vessel orientation, which is called the Doppler angle, in order to calculate flow velocities. In this paper, we will describe a computer vision approach to automate the Doppler angle estimation. Our approach starts with the segmentation of blood vessels in ultrasound color Doppler images. The segmentation step is followed by an estimation technique for the Doppler angle based on a skeleton representation of the segmented vessel. We conducted preliminary clinical experiments to evaluate the agreement between the expert operator's angle specification and the new automated method. Statistical regression analysis showed strong agreement between the manual and automated methods. We hypothesize that the automation of the Doppler angle will enhance the workflow of the ultrasound Doppler exam and achieve more standardized clinical outcome.

Automated Doppler gate placement and velocity calculation based on a vessel angle estimate

Pulsed-wave Doppler (PWD) sonography allows the quantitative measurement of blood flow in vessels if the vessel's diameter and the angle (Doppler angle theta) between the ultrasound beam and the vessel's flow direction are known. In current clinical routine, these parameters are manually determined by the examiner. However the manual determination is time-consuming and a source of error in blood flow measurements because of inaccuracy and variability. To overcome these problems, we present methods for an automated Doppler gate placement and Doppler angle estimation based on image processing algorithms. The Doppler gate is determined by analyzing the intensity profile along the ultrasound beam. To calculate the Doppler angle, we present a multiscale approach which estimates the vessel's flow direction by principal component analysis. A first evaluation shows promising results. Our automated approach yields parameters which match the parameters determined by clinical experts very well.

Digital output volumetric pulmonary artery catheters eliminate interoperator interpretation variability and improve consistency of treatment decisions

BACKGROUND

The pulmonary artery catheter (PAC) has been fraught with controversy over issues of safety and impact on outcomes variables for many years. Multiple attempts to quantify the utility of this diagnostic instrument have failed to resolve the matter. Previous investigations have focused on either quantifying inter-rater variability of waveform output interpretation from PACs or on clinical outcomes when PACs are used in care. We tested the hypothesis that the true link between a diagnostic tool and outcomes is treatment selection, and an instrument that minimizes or eliminates the need for data interpretation would also minimize the variability of treatment selections.

STUDY DESIGN

We performed a prospective, single institutional, single blinded survey study.

RESULTS

The inter-rater variability of waveform interpretation among all raters was notable (p < 0.01); for continuous end diastolic volume index interpretation, there was no notable inter-rater variability (p=1.0). Inter-rater variability of treatment selections based on waveform interpretation was notable for all raters (p < 0.01). Continuous end diastolic volume index data presentation of hemodynamic status did not result in notable inter-rater variability in treatment selections (p=0.10). Treatment choices based on continuous end diastolic volume index among raters with 5 or more years of experience are not different from clinical practice guideline-directed choices (p > 0.05), independent of patient ventilator status.

CONCLUSIONS

Digital output volumetric PACs eliminate inter-rater variability of data interpretation, decrease inter-rater variability of data-driven treatment selections, and improve rater agreement with clinical practice guidelines when compared with traditional waveform output PACs.