Carotid ultrasound for pulmonary arteriovenous malformation screening

Anita Yanna-Schulze 1 , Günther Schneider 2 , 3 , Alexander Maßmann 3 , Stefan Gräber 4 , and Urban W. Geisthoff 5
  • 1 Department of Cardiology, Städtisches Krankenhaus Pirmasens gGmbH, Pettenkoferstr. 22, 66955 Pirmasens, Germany
  • 2 Medical Faculty of the Saarland University, 66421 Homburg/Saar, Germany
  • 3 Department of Diagnostic and Interventional Radiology, Saarland University Hospital, 66421 Homburg/Saar, Germany
  • 4 Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, 66421 Homburg/ Saar, Germany
  • 5 Department of Otorhinolaryngology, Essen University Hospital, 45147 Essen, Germany

Abstract

Objective: In patients with hereditary hemorrhagic telangiectasia (HHT), pulmonary arteriovenous malformations (PAVMs) can cause serious neurological complications. Our aim was to evaluate the potential of contrast-enhanced Doppler ultrasound (CE-US) of the common carotid artery as a screening test for detection of PAVMs. Methods: A total of 124 consecutive patients with HHT or a positive family history underwent screening for PAVMs with CE-US and thoracic contrast-enhanced magnetic resonance angiography (CE-MRA). CE-US was performed after receiving (D)-galactose microparticulate, and CE-MRA with gadobenate dimeglumine. Twenty-five patients with confirmed PAVMs were referred to conventional pulmonary catheter angiography (PA). Findings on CE-US and CE-MRA were evaluated using contingency tables and McNemar’s test. Results: Using CE-MRA as the reference test, CE-US had a sensitivity of 100%, a specificity of 87%, and a negative predictive value of 100%. In 25 patients who underwent PA, PAVMs that had been diagnosed on CE-US and CE-MRA were confirmed. Of the PAVMs detected by CE-MRA, 24% were not identified on PA. Conclusion: CE-US is a simple, minimally invasive screening method that can easily be performed in different settings. CE-US can predict PAVMs with high probability of success. CE-US may be a simple alternative to transthoracic echocardiography in the assessment of PAVMs in certain HHT-patients.

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  • [1] Faughnan M.E., Palda V.A., Garcia-Tsao G., Geisthoff U.W., McDonald J, Proctor D.D., et al., International guidelines for the diagnosis and the management of hereditary hemorrhagic telangiectasia, J. Med. Genet., 2011, 48, 73-87

  • [2] Gossage J.R., Kanj G., Pulmonary arteriovenous malformations: a state of the art review, Am. J. Respir. Crit. Care Med. 1998, 158, 643-661

  • [3] White R.I., Pollak J.S., Wirth J.A., Pulmonary arteriovenous malformations: diagnosis and transcatheter embolotherapy, J. Vasc. Interv. Radiol., 1996, 7, 787-804

  • [4] Iqbal M., Rossoff L.J., Steinberg H.N., Marzouk K.A., Siegel D.N., Pulmonary arteriovenous malformations: a clinical review, Postgrad. Med. J., 2000, 76, 390-394

  • [5] Pollak J.S., Saluja S., Thabet A., Henderson K.J., Denbow N., White R.I., Clinical and anatomical outcomes of pulmonary AVM Embolotherapy, J. Vasc. Interv. Radiol., 2006, 17, 35-45

  • [6] Begbie M.E., Wallace G.M.F., Shovlin C.L., Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): a view from the 21st century, Postgrad. Med. J., 2003, 79, 18-24

  • [7] Shovlin C.L., Winstock A.R., Peters A.M., Jackson J.E., Hughes J.M., Medical complications of pregnancy in hereditary haemorrhagic telangiectasia. QJM, 1995, 88, 879-887

  • [8] Gershon A.S., Faughnan M.E., Chon K.S., Pugash R.A., Clark J.A., Bohan M.J., Henderson K.J., et al., Transcatheter embolotherapy of maternal pulmonary arteriovenous malformations during pregnancy, Chest, 2001, 119, 470-477

  • [9] Moussouttas M., Fayad P., Rosenblatt M., Hashimoto M., Pollak J., Henderson K., et al., Pulmonary arteriovenous malformations: Cerebral ischemia and neurological manifestations, Neurology, 2000, 55, 959-964

  • [10] Shovlin C.L., Jackson J.E., Bamford K.B., Jenkins I.H., Benjamin A.R., Ramadan H., et al., Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia, Thorax, 2008, 63, 259-266

  • [11] Nanthakumar K., Graham A.T., Robinson T.I., Grande P., Pugash R.A., Clarke J.A., et al., Contrast echocardiography for detection of pulmonary arteriovenous malformations, Am. Heart J., 2001, 141, 243-246

  • [12] Cottin V., Plauchu H., Bayle J.-Y., Barthelet M., Revel D., Cordier J.-F., Pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia, Am. J. Respir. Crit. Care Med., 2004, 169, 994-1000

  • [13] Kjeldsen A.D., Oxhoj H., Andersen P.E., Elle B., Jacobsen J.P., Vase P., Pulmonary arteriovenous malformations: screening procedures and pulmonary angiography in patients with hereditary hemorrhagic telangiectasia, Chest, 1999, 116, 432-439

  • [14] van Gent M.W., Post M.C., Luermans J.G., Snijder R.J., Westermann C.J., Plokker H.W. , et al., Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study, Eur. Resp. J., 2009, 33, 85-91

  • [15] Daniëls C., Weytjens C., Cosyns B., Schoors D., De Sutter J., Paelinck B., et al., Second harmonic transthoracic echocardiography: the new reference screening method for the detection of patent foramen ovale, Eur. J. Echocardiogr., 2004, 5, 449-452

  • [16] Thompson R.D., Jackson J., Peters M., Dore C.J., Hughes J.M., Sensitivity and specificity of radioisotope right-left shunt measurements and pulse oximetry for the early detection of pulmonary arteriovenous malformation, Chest, 1999, 115, 109-113

  • [17] Shovlin C.L., Guttmacher A.E., Buscarini E., Faughnan M.E., Hyland R.H., Westermann C.J., et al., Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome), Am. J. Med. Genet., 2000, 91, 66-67

  • [18] Shovlin C.L., Letarte M., Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms, Thorax, 1999, 54, 714-729

  • [19] Droste D.W., Lakemeier S., Wichter T., Stypmann J., Dittrich R., Ritter M., et al., Optimizing the technique of contrast transcranial Doppler ultrasound in the detection of right-to-left shunts, Stroke 2002, 33, 221-226

  • [20] Cosgrove D., Eckersley R., Contrast-enhanced ultrasound: basic physics and technology overview. In Enhancing the Role of Ultrasound with Contrast Agents, pp 3-14. Ed Lencioni R., 1st ed., Springer, Milan, 2006.

  • [21] Soliman O.I., Geleijnse M.L., Meijboom F.J., Nemes A., Kamp O., Nihoyannopoulous P., Masani N., et al, The use of contrast echocardiography for the detection of cardiac shunts, Eur. J. Echocardiogr. 2007, 8, S2-12

  • [22] Freeman J.A., Woods T.D., Use of saline contrast echo timing to distinguish intracardiac and extracardiac shunts: failure of the 3- to 5-beat rule, Echocardiography, 2008, 25, 1127-1130

  • [23] Kervancioglu S., Davutoglu V., Ozkur A., Soydinc S., Adaletli I., Sirikci A., et al.; Duplex sonography of the carotid arteries in patients with pure aortic regurgitation: pulse waveform and hemodynamic changes and a new indicator of the severity of aortic regurgitation, Acta Radiol:, 2004, 45, 411-416

  • [24] Draganski B., Blersch W., Holmer S., Koch H., May A., Bogdahn U., et al., Detection of Cardiac Right-to-Left Shunts by Contrast- Enhanced Harmonic Carotid Duplex Sonography, J. Ultrasound Med. 2005, 24, 1071-1076

  • [25] Pilcher J., Blomley M., Shovlin C., Eckersley J.A.R., Hamilton G,. Harvey C., et al., Detection and quantification of pulmonary arteriovenous shunts using an ultrasound contrast agent, presented at the 4th HHT Scientific Conference, April 2001, Tenerife, Canary Islands

  • [26] Euler U.S., Liljestrand G., Observations on the pulmonary arterial blood pressure in the cat, Acta Physiol. Scand., 1946, 12, 301-320

  • [27] Schneider G., Uder M., Koehler M., Massmann A., Kirchin M.A., Bücker A., et al., Contrast enhanced MR angiography for detection of pulmonary arterio-venous malformations in patients with hereditary hemorrhagic telangiectasia (HHT), AJR, 2008, 190, 892-901

  • [28] Gazzaniga P., Buscarini E., Leandro G., Reduzzi L., Grosso M., Pongiglione G., et al. Contrast echocardiography for pulmonary arteriovenous malformations screening: does any bubble matter?, Eur. J. Echocardiogr., 2009, 10, 513-518

  • [29] Velthuis S., Buscarini E., Gossage J.R., Snijder R.J., Mager J.J., Post M.C., Clinical Implications of Pulmonary Shunting on Saline Contrast Echocardiography, J. Am. Soc. Echocardiogr., 2015, 28, 255-263

  • [30] Van Gent M.W.F., Post M.C., Snijder R.J., Swaans M.J., Plokker H.W.M., Westermann C.J.J., et al., Grading of pulmonary rightto- left shunt with transthoracic contrast echocardiography, Chest, 2009, 135, 1288-1292

  • [31] Lee W.L., Graham A.F., Pugash R.A., Hutchison S.J., Grande P., Hyland R.H., et al., Contrast echocardiography remains positive after treatment of pulmonary arteriovenous malformations, Chest, 2003, 123, 351-358

  • [32] Woods T.D., Harmann L., Purath T., Ramamurthy S., Subramanian S., Jackson S., et al., Small – and moderate-size right-to-left shunts identified by saline contrast echocardiography are normal and unrelated to migraine headache, Chest, 2010, 138, 264-269

  • [33] Vase P., Holm M., Arendrup H., Pulmonary arteriovenous fistulas in hereditary hemorrhagic telangiectasia. Acta Med. Scand. 1985, 218, 105-109

  • [34] Marriott K., Manins V., Forshaw A., Wright J., Pascoe R., Detection of right-to-left atrial communication using agitated saline contrast imaging: experience with 1162 patients and recommendations for echocardiography, J. Am. Soc. Echocardiogr., 2013, 26, 96-102

  • [35] Blackshear W.M., Phillips D.J., Chikos P.M., Harley J.D., Thiele B.L., Strandness D.E. Jr, Carotid Artery Velocity Patterns in Normal and Stenotic Vessels, Stroke, 1980, 11, 67-71

  • [36] Glišić T.M., Perišić M.D., Dimitrijevic S., Jurišić V., Doppler assessment of splanchnic arterial flow in patients with liver cirrhosis: correlation with ammonia plasma levels and MELD score, J. Clin. Ultrasound, 2014, 42, 264-269

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