Fibromuscular dysplasia (FMD), a disease well described in the renal and cerebrovascular circulations, also manifests in the lower extremity (LE) arteries. This study reports on the clinical presentation, imaging findings, and treatment of patients with LE FMD seen at a single center. Over a 7-year span, 100 of 449 patients with FMD had imaging of the LE arteries, of which 62 were found to have LE FMD (13.8% of the entire FMD cohort including patients with and without LE imaging). The majority of patients were women (96.8%), with an average age of 52 ± 11.3 years at the time of diagnosis. All patients had FMD present in another vascular bed, most commonly in the renal (80.6%) and extracranial carotid arteries (79.0%). Most patients had multifocal FMD (95.2%) and bilateral LE disease (69.4%), with the external (87.1%), common (19.4%), and internal (11.3%) iliac arteries most commonly affected. Presenting symptoms of LE involvement included claudication (22.6%), atypical leg symptoms (14.5%), and dissection (6.5%), but most patients were asymptomatic (71.0%). Nearly all patients were managed conservatively (98.4%) and only 1 patient required intervention.

Introduction Median arcuate ligament compression (MALC) may present with abdominal pain as the result of dynamic compression of the celiac artery and the superior mesenteric artery (SMA). An asymptomatic patient may also demonstrate dynamic stenosis consistent with MALC on duplex examination. Duplex examination with maneuvers may differentiate fixed stenosis attributable to atherosclerosis (ASO) from dynamic stenosis caused by MALC. In MALC, elevated velocities normalize during deep inspiration. Performance of the Doppler examination with the patient standing may lead to improved diagnosis of MALC. Methods We performed a database query for all abdominal duplex examinations performed from January 1, 2007 to December 31, 2007 in which a standing (or seated) Doppler examination was reported. Studies were performed with a curved 5–2 MHz transducer (Philips iU22, Bothell, WA) with the patient in the fasting state. A peak systolic velocity (PSV) of ≥ 250 cm/sec in the celiac artery and a PSV of ≥ 275 cm/sec in the SMA were consistent with 70–99% stenosis. Results Ten patients were identified. Mean age was 51.2 years. A total of 60% of patients were female. Four patients presented for evaluation of abdominal pain and/or weight loss; six patients for other indications. Nine patients had increased PSV in the celiac artery at rest. The abnormality resolved with maneuvers in seven out of nine patients, consistent with MALC. In two patients, celiac artery PSV normalized with inspiration while they were supine; four patients in whom celiac artery velocity did not normalize with inspiration while they were supine had normal PSV while standing; one patient had normal celiac artery velocity while seated (no supine inspiration maneuvers performed); two patients had persistent celiac artery stenosis, likely because of ASO, although one normalized partially with standing. One patient had elevated velocities in the hepatic and splenic arteries that normalized with standing. Two patients had evidence of MALC of the SMA demonstrated with standing maneuvers. Conclusion Among patients with elevated velocities in the celiac artery and the SMA, repeated Doppler examination with the patient standing may demonstrate normalized velocities, consistent with MALC. The value of incorporating standing views into the abdominal duplex protocol to avoid false positive diagnoses of ASO merits prospective evaluation.

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Introduction Brain death is the complete and irreversible loss of cerebral and brain stem function. Although transcranial Doppler may be helpful in establishing the diagnosis, conventional carotid duplex ultrasound is not typically used in this condition. Case Report We describe the case of a 43-year-old woman with a past medical history of cardiac transplantation who was transferred from an outside hospital for hemodynamic monitoring and treatment. The patient had bladder surgery 1 day previously and suffered a prolonged cardiac arrest postoperatively. On arrival, she was comatose and ventilator dependent. Clinical examination revealed no brain stem reflexes (absent pupillary, corneal and oculocephalic reflexes). Brain death was suspected, although right upper-extremity flexion movements were noted. A carotid duplex ultrasound was ordered by the neurological service and performed using an Advanced Technology Laboratory HDI 5000 (Philips, Ultrasound, Bothell, Washington) machine with a linear 7–4 MHz transducer. Abnormal pulsed Doppler signals were detected demonstrating low velocity, bidirectional flow in the common and external carotid and the vertebral arteries. The internal carotid arteries demonstrated bizarre bidirectional and high resistive signals. Computed tomography showed diffuse cerebral edema and loss of gray-white matter differentiation. An electroencephalogram performed the next day demonstrated seizure activity correlating to her right upper extremity movements and indicative of some brain function retention. The patient died soon after. Conclusion Carotid duplex ultrasonography is not usually used in the diagnosis of brain death. Findings are characterized by a lack of diastolic flow or reverberating (to-and-fro pattern) flow and small systolic peaks in early systole on transcranial Doppler. This pattern is caused by a lack of adequate arterial perfusion. Cerebral angiography may reveal nonfilling of the intracranial arteries. Other diagnostic modalities, including computed tomography and electroen-cephalography, can be used with clinical findings to confirm brain death. In our case, carotid duplex ultrasonography was useful in assessing for brain death, although the patient (as later found) did not meet all neurological criteria. Vascular technologists should be aware of these unusual duplex findings in the evaluation of the comatose patient.

Venous thoracic outlet syndrome (TOS) is a complex condition involving compression, irritation, or direct injury of the subclavian vein as it courses between the first rib, the clavicle, and the scalene muscle. Compression of the subclavian vein is a potential cause of axillosubclavian vein thrombosis. Duplex examination with color flow Doppler and appropriate abduction maneuvers can be used to identify patients with this syndrome. We describe the case of a 52 year-old female patient with a history of bilateral upper-extremity swelling and pain and a past history of bilateral subclavian deep vein thromboses (DVT). She was referred to our clinic to try and determine the cause of her upper-extremity DVTs. A venous duplex examination with abduction maneuvers was performed. Bilateral subclavian veins were studied in varying degrees of abduction to assess for the presence of venous TOS. The duplex examination revealed normal color flow and a respirophasic pulsed Doppler waveform in the subclavian veins bilaterally with the patient lying supine in the resting position. With abducting the arms, significant changes were noted. Occlusion of the subclavian vein was observed at its proximal segment with absent color flow and pulsed Doppler spectrum. Flow was reestablished after having the patient relax her arm to its resting position. These findings were documented in both the right and left subclavian veins. There was no evidence of residual DVT or venous reflux on either side. These findings suggested that subclavian vein compression at the thoracic outlet may have been responsible for the patient's bilateral deep vein thromboses. Duplex ultrasound examination with abduction maneuvers is an effective method that can be used to diagnose venous TOS. When a patient presents with upper-extremity swelling and/or a history of otherwise unexplained axillosubclavian DVT, the technologist should add abduction maneuvers to the venous duplex examination to help determine the cause.