Journal for Vascular Ultrasound

We recently encountered a patient who required urgent leg venous ultrasound. The patient warned us of a previous severe allergic reaction to ultrasound gel, an uncommon problem without a defined prevalence (according to our searches for literature on PubMed, Google Scholar, and uptodate.com). The reaction was so severe that he permitted ultrasound only if an alternative agent could be used. We recalled both that allergy to gel is possible and that mineral oil could be used as a coupling agent in such cases and purchased a bottle on the spot while the patient waited. The clinical flexibility of switching to an alternative coupling agent turned out to be potentially life-saving because the patient was found to have an extensive deep venous thrombosis of the common femoral, femoral, deep femoral, popliteal, and gastrocnemius veins. This case report details this patient's course; reviews the potential adverse effects of ultrasound gel, proven and theoretical; demonstrates the excellent imaging characteristics of a large number of alternative coupling agents that we tested on our patient as well as another subject; and describes strategies for prevention and management of adverse effects. Although isolated case reports were found by literature search regarding use of alternative ultrasound coupling agents, we have found no review article or study evaluating as many agents as we have.

Aneurysms involving the third portion of the axillary artery and its branches have been reported in baseball pitchers and in other overhead-throwing athletes. The abnormality can vary from intermittent compression to axillary artery thrombosis and formation of an aneurysm. Patients presenting with symptoms secondary to an axillary artery injury, like upper extremity weakness, require rapid and precise diagnosis. Moreover, accurate identification of the arterial pathology helps guide necessary surgical therapy. Previous reports have made the diagnosis from physical examination, noninvasive studies, and additional, invasive studies, such as arteriography. In this case, a young healthy major league baseball pitcher was referred for hand numbness and a suspected axillary artery aneurysm. We were able to confirm the physical examination abnormalities with arterial duplex only and make an operative plan on the basis of the ultrasound findings.

Recent changes to our Medicare broker state that either a graft duplex or segmental pressures must be performed for routine follow-up for arterial bypass grafts. We have had several cases in which the ankle brachial index (ABI) has been within normal limits, 0.9, and the graft duplex has revealed an abnormality with the graft. The Intersocietal Accreditation Commission standard says that if a graft duplex is performed, the ABI must be included; the ABI must be done within 2 weeks at the same facility with no change in the patient's symptoms. When we obtained the patient histories, each patient noted no specific vascular claudicating symptom, but more general symptoms of weakness or pain in a specific area of the leg. It is important for laboratories to perform both tests. The ABI is a good indicator of disease in the normal population, but in older patients and those with diabetes, it can yield false-positive results.

Ultrasound-guided endovenous ablation procedures have revolutionized the care of patients with venous reflux disease for more than a decade. Precise application of energy forms and substances that occlude superficial truncal veins is pivotal for technical success. Exact spatial and temporal delivery of ablative vectors to the vein is operator dependent, readily measurable, and hinges on precise timing of pullback of the various catheters and fibers that effect vein ablation. Several physical and online electronic pullback timing aids, including metronomes and other metric devices, are available to ensure precise ablation, although operators are often left to discover them. Although these are not ultrasound devices per se, they are essential adjuncts for the effective delivery of a key ultrasound-guided intervention and are used in direct proximity to ultrasound. To the authors’ knowledge, there are no publications regarding this key ablation step, which is typically dependent on operator resourcefulness.