Andreas Hjelm Brandt

Surveillance for hemodialysis access stenosis: usefulness of ultrasound vector volume flow.

Purpose To investigate if ultrasound vector-flow imaging (VFI) is equal to the reference method ultrasound dilution technique (UDT) in estimating volume flow and changes over time in arteriovenous fistulas (AVFs) for hemodialysis. Materials and methods From January 2014 to January 2015, patients with end-stage renal disease and matured functional AVFs were consecutively solicited to participate in this prospective study. All patients were included after written informed consent and approval by the National Committee on Biomedical Research Ethics and the local Ethics Committee (journal no. H-4-2014-FSP). VFI and UDT measurements were performed monthly over a six-month period. Nineteen patients were included in the study. VFI measurements were performed before dialysis, and UDT measurements after. Statistical analyses were performed with Bland-Altman plot, Students t-test, four-quadrant plot, and regression analysis. Repeated measurements and precision analysis were used for reproducibility determination. Results Precision measurements for UDT and VFI were 32% and 20%, respectively (p = 0.33). Average volume flow measured with UDT and VFI were 1161 mL/min (±778 mL/min) and 1213 mL/min (±980 mL/(min), respectively (p = 0.3). The mean difference was -51 mL/min (CI: -150 mL/min to 46 mL/min) with limits of agreement from -35% to 54%, with a strong correlation (r2 = 0.87). A large change in volume flow between dialysis sessions detected by UDT was confirmed by VFI (p = 0.0001), but the concordance rate was poor (0.72). Conclusions VFI is an acceptable method for volume flow estimation and volume flow changes over time in AVFs.

Velocity estimation of the main portal vein with Transverse Oscillation

This study evaluates if Transverse Oscillation (TO) can provide reliable and accurate peak velocity estimates of blood flow the main portal vein. TO was evaluated against the recommended and most widely used technique for portal flow estimation, Spectral Doppler Ultrasound (SDU). The main portal vein delivers blood from the bowls to the liver, and patients with certain liver diseases have decreased flow in the portal vein. Errors in velocity estimation with SDU are well described, when the beam-to-flow angle is >70 degrees. TO estimates the flow angle independently and is not limited by the beam-to-flow angle. It is less operators depended, as no angle correction is necessary. TO measurements were performed with a 3 MHz convex probe (BK medical 8820e, Herlev, Denmark) connected to the experimental ultrasound scanner SARUS (Synthetic Aperture Real-time Ultrasound Scanner). SDU velocity measurements were performed with a commercial ultrasound scanner (BK 3000, BK Ultrasound, Herlev Denmark) and a convex probe (BK ultrasound 6C2, Herlev, Denmark). Ten healthy volunteers were scanned, and recordings of the portal flow during 3-5 heartbeats were conducted with an intercostal and subcostal view. Intercostal TO peak velocities were not significantly different from SDU peak velocities (TO=0.203m/s, SDU=0.202m/s, p=0.94). Subcostal and Intercostal obtained TO values were not significantly different (intercostal mean TO=0.203m/s, subcostal mean TO=0.180m/s, p=0.26). SDU values obtained intercostal and subcostal were significantly different (intercostal mean SDU=0.202m/s, subcostal mean SDU=0.320m/s, p<;0.001). Standard deviation for TO beam-to-flow angle was 10.3°-91.5°, indicating a large beam-to-flow angle variability in the portal vein. This can affect the peak velocity estimation, and is not addressed in SDU. The TO convex array implementation provides the first vector velocity measurements below 60mm (mean 89mm), and is a useful alternative for flow estimation in abdominal ultrasound. It may provide new information of abdominal fluid dynamics and yield both velocity and angle estimates for a more realistic flow characterization.

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.

Blood flow velocity in the popliteal vein using transverse oscillation ultrasound

Chronic venous disease is a common condition leading to varicose veins, leg edema, post-thrombotic syndrome and venous ulcerations. Ultrasound (US) is the main modality for examination of venous disease. Color Doppler and occasionally spectral Doppler US (SDUS) are used for evaluation of the venous flow. Peak velocities measured by SDUS are rarely used in a clinical setting for evaluating chronic venous disease due to inadequate reproducibility mainly caused by the angle dependency of the estimate. However, estimations of blood velocities are of importance in characterizing venous disease. Transverse Oscillation US (TOUS), a non-invasive angle independent method, has been implemented on a commercial scanner. TOUSs advantage compared to SDUS is a more elaborate visualization of complex flow. The aim of this study was to evaluate, whether TOUS perform equal to SDUS for recording velocities in the veins of the lower limbs. Four volunteers were recruited for the study. A standardized flow was provoked with a cuff compression-decompression system placed around the lower leg. The average peak velocity in the popliteal vein of the four volunteers was 151.5 cm/s for SDUS and 105.9 cm/s for TOUS (p <0.001). The average of the peak velocity standard deviations (SD) were 17.0 cm/s for SDUS and 13.1 cm/s for TOUS (p <0.005). The study indicates that TOUS estimates lower peak velocity with improved SD when compared to SDUS. TOUS may be a tool for evaluation of venous disease providing quantitative measures for the evaluation of venous blood flow.

In-vivo synthetic aperture and plane wave high frame rate cardiac imaging

A comparison of synthetic aperture imaging using spherical and plane waves with low number of emission events is presented. For both wave types, a 90 degree sector is insonified using 15 emission events giving a frame rate of 200 frames per second. Field II simulations of point targets show similar resolution of approximately one wavelength radially and one degree angularly for both wave types. The use of spherical waves is found to have higher signal strength and better cystic resolution than plane waves. Measurements on wires in water yield similar results to simulations with similar resolution between the two wave types but better cystic resolution for spherical waves. Measurements on tissue mimicking phantoms show that both wave types penetrate down to 11 cm. Intensity measurements show an Ispta.3 of 18.4 mW/cm2 for spherical waves and 22.7 mW/cm2 for plane waves. The derated MI is 0.43 for spherical and 0.70 for plane waves. All measures are well within FDA limits for cardiac imaging. In-vivo images of the heart of a healthy 28-year old volunteer are shown.

A Methodology for Anatomic Ultrasound Image Diagnostic Quality Assessment

This paper discusses the methods for the assessment of ultrasound image quality based on our experiences with evaluating new methods for anatomic imaging. It presents a methodology to ensure a fair assessment between competing imaging methods using clinically relevant evaluations. The methodology is valuable in the continuing process of method optimization and guided development of new imaging methods. It includes a three phased study plan covering from initial prototype development to clinical assessment. Recommendations to the clinical assessment protocol, software, and statistical analysis are presented. Earlier uses of the methodology has shown that it ensures validity of the assessment, as it separates the influences between developer, investigator, and assessor once a research protocol has been established. This separation reduces confounding influences on the result from the developer to properly reveal the clinical value. This paper exemplifies the methodology using recent studies of synthetic aperture sequential beamforming tissue harmonic imaging.

Advanced automated gain adjustments for in-vivo ultrasound imaging

Automatic gain adjustments are necessary on the state-of-the-art ultrasound scanners to obtain optimal scan quality, while reducing the unnecessary user interactions with the scanner. However, when large anechoic regions exist in the scan plane, the sudden and drastic variation of attenuations in the scanned media complicates the gain compensation. This paper presents an advanced and automated gain adjustment method that precisely compensate for the gains on scans and dynamically adapts to the drastic attenuation variations between different media. The proposed algorithm makes use of several ultrasonic physical estimates such as scattering strength, focus gain, acoustic attenuation, and noise level to gain a more quantitative understanding of the scanned media and to provide an intuitive adjustment of gains on the scan. The proposed algorithm was applied to a set of 45 in-vivo movie sequences each containing 50 frames. The scans are acquired using a recently commercialized BK3000 ultrasound scanner (BK Ultrasound, Denmark). Matching pairs of in-vivo sequences, unprocessed and processed with the proposed method were visualized side by side and evaluated by 4 radiologists for image quality. Wilcoxon signed-rank test was then applied to the ratings provided by radiologists. The average VAS score was highly positive 12.16 (p-value: 2.09×10-23) favoring the gain-adjusted scans with the proposed algorithm.

Automated hierarchical time gain compensation for in-vivo ultrasound imaging

Time gain compensation (TGC) is essential to ensure the optimal image quality of the clinical ultrasound scans. When large fluid collections are present within the scan plane, the attenuation distribution is changed drastically and TGC compensation becomes challenging. This paper presents an automated hierarchical TGC (AHTGC) algorithm that accurately adapts to the large attenuation variation between different types of tissues and structures. The algorithm relies on estimates of tissue attenuation, scattering strength, and noise level to gain a more quantitative understanding of the underlying tissue and the ultrasound signal strength. The proposed algorithm was applied to a set of 44 in vivo abdominal movie sequences each containing 15 frames. Matching pairs of in vivo sequences, unprocessed and processed with the proposed AHTGC were visualized side by side and evaluated by two radiologists in terms of image quality. Wilcoxon signed-rank test was used to evaluate whether radiologists preferred the processed sequences or the unprocessed data. The results indicate that the average visual analogue scale (VAS) is positive ( p-value: 2.34 × 10-13) and estimated to be 1.01 (95% CI: 0.85; 1.16) favoring the processed data with the proposed AHTGC algorithm.

Surveillance of hemodialysis vascular access with ultrasound vector flow imaging

The aim of this study was prospectively to monitor the volume flow in patients with arteriovenous fistula (AVF) with the angle independent ultrasound technique Vector Flow Imaging (VFI). Volume flow values were compared with Ultrasound dilution technique (UDT). Hemodialysis patients need a well-functioning vascular access with as few complications as possible and preferred vascular access is an AVF. Dysfunction due to stenosis is a common complication, and regular monitoring of volume flow is recommended to preserve AVF patency. UDT is considered the gold standard for volume flow surveillance, but VFI has proven to be more precise, when performing single repeated instantaneous measurements. Three patients with AVF were monitored with UDT and VFI monthly for five months. A commercial ultrasound scanner with a 9 MHz linear array transducer with integrated VFI was used to obtain data. UDT values were obtained with Transonic HD03 Flow-QC Hemodialysis Monitor. Three independent measurements at each scan session were obtained with UDT and VFI each month. Average deviation of volume flow between UDT and VFI was 25.7 % (Cl: 16.7% to 34.7%) (p= 0.73). The standard deviation for all patients, calculated from the mean variance of each individual scan sessions, was 199.8 ml/min for UDT and 47.6 ml/min for VFI (p = 0.002). VFI volume flow values were not significantly different from the corresponding estimates obtained using UDT, and VFI measurements were more precise than UDT. The study indicates that VFI can be used for surveillance of volume flow.

The Impact of Transient Hepatic Attenuation Differences in the Diagnosis of Pseudoaneurysm and Arteriovenous Fistula on Follow-Up CT Scans after Blunt Liver Trauma

A feared complication to liver trauma is delayed vascular complication, such as pseudoaneurysm and arteriovenous fistula (PS/AF) seen as focal enhancement on contrast-enhanced computed tomography (CT) in the arterial phase. A hyperdense area termed transient hepatic attenuation difference (THAD) representing altered hepatic blood flow can be seen in the arterial phase near the liver lesion. The objective of this study was to describe THAD and PS/AF on follow-up CT after blunt liver trauma, and to evaluate if THAD influenced the evaluation of PS/AF. Three radiology residents retrospectively evaluated scans of 78 patients. The gold standard for PS/AF was an evaluation by an experienced senior radiologist, while THAD was a consensus between the residents. PS/AF was present in 14% and THAD in 54%. THAD was located in the periphery of the lesion with hazy borders and mean HU levels of 100, while PS/AF was located within the lesion with focal enhancement and mean HU levels of 170 (p < 0.05). In evaluation of PS/AF, the likelihood of agreement between the observers and the gold standard was 89% when THAD was present, and 98% when THAD was absent (p = 0.04). THAD is common and can hamper the evaluation of PS/AF.