Vascular Testing

What is Vascular Disease?

The two main types of vascular disease are aneurysmal disease and obstructive disease. In aneurysmal vascular disease, the wall of a weakened blood vessel balloons out. This can lead to the formation of blood clots or even rupture. Obstructive vascular disease is the disruption of the normal flow of blood through the blood vessels usually as a result of atherosclerosis, the accumulation of fatty plaque in the walls of arteries. Patients with atherosclerosis are at increased risk for stroke and heart attack as well as claudication (painful cramping in the legs with walking).

Why are You Being Sent for a Specific Vascular Imaging Test?

Non-invasive tests: Only requiring office visit for ultrasound testing.

• Carotid Doppler: There are several reasons your doctor may have ordered a Carotid Doppler, including but not limited to: dizziness, fainting, strokes, mini-strokes (TIA's), previous carotid artery surgery (carotid endarterectomy) or stenting, or he or she may have heard an extra sound in the artery of the neck called a carotid bruit. It is important to identify significant obstruction in these arteries early, since blockages in these arteries can lead to stroke.

• Abdominal Aortic Ultrasound: Abdominal Aortic Aneurysm screening is recommended for men between the age of 65 and 75 years with a smoking history or for patients with first degree relatives with a history of an abdominal aortic aneurysm. The test can be used both for original identification as well as to follow aortic aneurysms/dilatations.

• Peripheral Arterial Doppler and ABI:  Reduced blood supply to the legs may cause pain/cramping with walking, early muscle fatigue, as well as buttock discomfort. Patients that are diabetic or have smoked are at particularly increased risk for this problem. If you have symptoms or findings on physical exam, you may be referred for an ankle-brachial index or ABI.  If your ABI is abnormal, you will likely be referred for the Peripheral Arterial Doppler.  A Peripheral Arterial Doppler study may also be ordered for those patients who have already been treated for peripheral arterial disease with a graft or stent. Ultrasound evaluation of the treated area is part of the follow-up procedure. This is done to ensure that the graft or stent remains open and to try to identify any potential problems before they occur.

Invasive tests: Requires same day procedure in hospital.

• Carotid angiogram:  As described by the Carotid Doppler section, it may be necessary to look to see if the arteries supplying your brain have blocks or significant cholesterol plaquing.  Generally after non-invasive tests have already noted a significant block in these arteries may this test that directly (by injecting contrast dye into the vessel) looks inside the vessel be ordered.  This may be ordered prior to going for surgery for a carotid endarterectomy (CEA) to correct these blocks.

•  Abdominal Aortogram & Renal Artery Angiogram: In a number of situations, direct visualization of the abdominal aorta is needed after non-invasive testing or sometimes during a cardiac catheterization procedure.  A directed view can be taken of the renal arteries that supply the kidneys.  In some situations such as difficult to control high blood pressure or high blood pressure in younger patients (age less than 35 years old) can result from tight blocks in these vessels.  Conclusive imaging by angiogram is required after the diagnosis has been suggested by non-invasive testing (Doppler ultrasound or MRI/MRA). While the diagnosis is important, this condition can sometimes be effectively treated by opening up the vessels by angioplasty or stenting and a conclusive imaging study is required prior to moving on with an intervention.

• Peripheral Arterial Angiography: After non-invasive tests suggest a significant block in the arteries to the arms or legs, direct visualization is required.  This is accomplished by a peripheral angiogram.  Once the block or blocks in the arteries have been clearly and conclusively visualized, the next important decision of how to treat you and potentially open these vessels can be made.

What Happens During these Tests and What Do They Show?

Vascular Ultrasound Testing.
You will lie on your back on a comfortable examination table.  To improve the quality of the pictures, gel is applied to the area of the body where the transducer will be placed.  A sonographer moves the transducer over the area of interest to obtain different views of the arteries. He or she may ask you to change positions. You may also be asked to breathe slowly or hold your breath in order to maximize the image quality.  This noninvasive procedure uses ultrasound to produce images of blood vessels and to provide information on the speed with which blood travels through the vessel. This information allows the detection of plaque or narrowing of the vessel.

Ankle-Brachial Artery Index.  This test combines a traditional blood pressure cuff and Doppler ultrasound (without imaging) to compare the blood pressure in a person's arms to the blood pressure in the legs. A blood pressure cuff is inflated around a person's upper arm or lower leg to temporally cut off blood flowing through the artery, while the transducer is placed below the cuff on the artery. The cuff is deflated, and the reading on the blood pressure gauge is recorded at the moment the Doppler picks up a sustained signal, indicating normal blood flow through the artery. This procedure is done for both arms and legs. The higher of the two arm systolic pressures is compared to each foot systolic pressure to get an ABI for both the right and left leg.  Ideally, the pressures in a person's arm and ankles will be roughly the same.  A value of 1.0 is normal and values below 0.9 may indicate that vessels in your lower extremity are blocked.

Carotid, Abdominal, Renal, and Peripheral Angiography: Your procedure will take place at the Inova Fairfax Heart and Vascular Institute on the ground floor.  After registering, you will be asked to change into a hospital gown, evaluated by a nurse, and asked to sign a consent form by your cardiologist.  You will then be taken to a procedure room and asked to lie on your back on a comfortable examination table.  You will be given intravenous medication (similar to Valium) to make you comfortable and relaxed during the procedure. The area where the catheter will be inserted is anesthetized. A small puncture is made in the artery and a small tube or introducer sheath is placed in the artery. A catheter passes through the sheath and is guided up into the major leg or arm artery, abdominal aorta, renal artery, or carotid artery. X-ray dye is injected through the catheter and x-rays of the arteries are taken.  After the diagnostic angiogram, you may go on to have a balloon angioplasty or stent and then will have the catheter removed.  A small seal may be inserted to help close the hole made in the artery or direct, firm pressure may also be applied to the puncture site. You will be watched for bleeding and discharged home the same day. You may notice a bruise or small lump in the groin or arm area where the puncture was made. This is normal unless the area increases in size or you experience progressive discomfort. 

How should I prepare for each test?

• Carotid Doppler, ABI & Lower extremity Arterial Doppler: No preparation is required.
  
  
• Evaluation of Iliac stent: This is a special situation if you have had an iliac artery stent as to best see it, one should not eat or drink after 12:00 midnight.
  
  
• Abdominal Aortic Ultrasound: 
  
  
  • Do not eat or drink after 12:00 midnight prior to the test, except water with prescribed medications. 
  • Diabetic patients:  If on insulin: Take ½ dose of your prescribed dose the night before and morning of the test.
    
    
• Carotid, Abdominal, Renal, and Peripheral Angiography:
  
  
  • We ask that you consume nothing by mouth (NPO) after midnight prior to the procedure other than prescribed medication with a small quantity of water. 
  • Diabetic patients:  If on insulin: Take ½ dose of prescribed dose night before and morning of the test. If taking oral (by mouth) diabetic medications: No oral diabetic medications on the day of the procedure.  After the completion of the procedure, you will be able to eat and drink, and at that point diabetic patients can return to normal doses of your diabetic medications except Metformin (Glucophage) or combination medication that includes Metformin, as this medication must be restarted 2 days later. 
  • We ask that you come with someone that can drive you home or at least have someone prepared to pick you up without planning on driving yourself home because of the effect of sedative medication that you will receive. 
  • Report all allergies to your doctor before you come. Since contrast contains iodine it is important to report any allergies to x-ray dye or shellfish. If you are allergic, the catheterization can be safely performed but additional medications may need to be given prior to the test to decrease the chance of any reaction.
  • Standard blood tests will be sent prior to the test.
  • Please remind us if you have any kidney problems that we should know about.
  • The test is performed on the ground floor of the Inova Fairfax Hospital Heart and Vascular Institute.

IF YOU EXPERIENCE ANY OF THE FOLLOWING AFTER THE ANGIOGRAM CALL IMMEDIATELY:

• Numbness or pain in the arm or leg where the procedure was done
• Difficulty breathing
• Chest or back pain
• Palpitations or irregular heart beat
• Bleeding at the insertion site
• A fever with temperature > 101.5 F
• Warmth, tenderness or redness around the incision

How Long Does It Take?

A thorough examination usually takes 30 minutes for a Carotid Doppler, 10-15 minutes for an Abdominal Aortic Ultrasound, 30-45 minutes for a Peripheral Arterial Study, and 5-10 minutes for an ABI.   For the angiograms that require a hospital visit, the diagnostic or imaging portion takes at maximum 30 minutes as long as no intervention occurs.  The entire procedure from registering to discharge can take up to 4-5 hours.

Is the ultrasound Safe?

The echocardiogram is very safe and painless.

The Results?

Our cardiologists read the studies and the results are conveyed both to you as well as your referring physician.