S P E C I A L V A S C U L A R E D I T I O N

Photograph supplied by Peter Kennelly, Cardiff Imaging Manager

AUTUMN EDITION 2010

ISSUE 16

1 IMAGING UPDATE - SPECIAL VASCULAR EDITION 2010, ISSUE 16

Muswellbrook, which we anticipate will be of great benefit to Upper Hunter referrers.

CT in Scone

Our new premises in Scone are almost complete and CT services will commence shortly after taking occupancy of the premises. The new premises are co-located with the Scone Medical Practice. The building and facilities are of a very high standard and we are looking forward to providing this new service.

Additional MRI at Cardiff

In Issue 15 of Imaging Update I forecast the installation of an additional state-of-the-art MRI at Cardiff. The installation was extremely well project managed and came in on schedule with first patients being scanned in December. It is now fully operational and has been instrumental in significantly reducing waiting times for MRI. The new scanner has breast MRI capability and in the coming months we will be announcing more about breast MRI and its role with Hunter Women’s Imaging.

PACS (Picture Archiving and Communications System)In late December we also began the rollout of a fully integrated RIS/PACS system in all of our practices from Belmont to Tamworth. While we have had soft copy reporting for almost 10 years, we are now moving to a totally integrated system. Until now this has been limited by the bandwidth available to the many different locations of Hunter Imaging. This is a major undertaking but we expect the

Welcome to Issue 16 of Imaging Update.

4/28 Portside CresentMaryville NSW 2293Phone: 02 4925 5451 Fax: 02 4925 5452Email: DoctorDirect@pacmedica.comWeb: http://www.hunterimaging.com.au/

FRONT COVER: Nobby’s Beach

Hunter Imaging Group

Carotid Scanningand InterventionsPAGE 2

Staff Profile:Paul MyersPAGE 5

Downloading Referrers Guide to Vascular UltrasoundPAGE 5

Cardio Vascular CentreMuswellbrookPAGE 6

Brook St

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Ordering Request Forms Online for CVCPAGE 6

Maitland Receives Digital Radiography Unit UpgradePAGE 7

Attention All ReferrersPAGE 7

To M

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Molly M

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Mr Peter SchultzChief Executive, Hunter Imaging Group

whole project to be completed before the end of June 2010. On completion this will mean faster turnaround of reports for you our valued referrers. It also facilitates subspecialist reporting and faster second opinions.

Peer Review

For many years we have run a successful internal peer review system. However with the advent of integrated PACS we are taking the opportunity to enhance our Peer Review Protocol and over the coming months will be looking at the process of inviting your participation as a referring doctor to enhance our ability to deliver optimal patient care on your behalf.

CT Coronary Angiography (CTCA)

Our congratulations to Dr Stuart Slater who has become the first doctor in the Hunter to be recognised as a CTCA Specialist. In order to be recognised as a CTCA Specialist, Cardiologists, Nuclear Medicine Physicians and Radiologists need to demonstrate that they have completed the requisite training criteria. The requisite training criteria are quite demanding and I’d like to thank Stuart for the big effort he put in to achieve CTCA Specialist recognition.

Thank you for your continued support.

Welcome to this special edition of imaging update focusing on Carotid Scanning and Interventions. Our thanks to Dr Paul Myers for his work and contribution to this edition. We are proud of the quality work our highly skilled sonographers perform at the Cardio Vascular

Centre in consultation with our consultant vascular surgeons and I am sure you will find the content of Paul’s article practical and useful.

2HUNTER IMAGING GROUP NEWSLETTER

For this reason imaging of the extra-

cranial carotid and vertebral circulation

is extremely important.

There are a number of modalities for

imaging the carotid and vertebral circulation,

including duplex scanning, digital subtraction

angiography, CT angiography, and magnetic

Carotid artery disease is involved in approximately 30% of all acute cerebral neurological events, mainly cerebrovascular accidents (CVA). CVA’s due to carotid disease are, in the main, preventable if the carotid changes are diagnosed prior to symptoms occurring.

CONTINUES PG 3.

Carotid Scanningand InterventionsBy Dr Paul Myers

resonance angiography. The least invasive of

these is duplex scanning.

Duplex scanning involves pulsed Doppler

systems with real-time spectral analysis and

fast-fourier transformation in association with

B-mode ultrasound, thus “duplex scanning”.

As always, these examinations remain highly

operator and reporter dependent.

As the reliability and technical capability

of scanners has increased, so too has the

reliability of scanning of these vessels using

duplex ultrasound. Most disease of the

carotids is atherosclerotic stenosis which

mostly occurs at the origins of the internal and

external carotid arteries.

For technical reasons the degree of stenosis

cannot be specified as a specific percentage.

Rather, classifications may be reported as

follows:

1. Normal

2. < 15% diameter reduction

3. 10-20% diameter reduction

4. 20-40% diameter reduction

5. 30-50% diameter reduction

6. 50-60% diameter reduction

7. 60-80% diameter reduction

8. 80-99% diameter reduction

9. Occluded

These classifications are assigned using

a number of criteria including systolic and

diastolic velocities, waveforms, internal carotid

artery (ICA), external carotid artery (ECA), and

common carotid artery (CCA) ratios.

Colour Doppler waveform, Internal Carotid Artery with 80% stenosis

3 IMAGING UPDATE - SPECIAL VASCULAR EDITION 2010, ISSUE 16

CONTINUED FROM PAGE 2

Although the exact parameters and the way

they are expressed vary, the meaning of

the features is constant and is in line with

haemodynamic concepts.

Colour Doppler represents the signal as a

vector. Thus, objects moving towards the

transducer will appear in red, and objects

moving away from the transducer will appear

in blue.

The faster the velocity, the brighter the colour

and the lower the velocity, the darker the colour.

Thus, colour duplex allows greater definition of

the lesion.

It has now been established in numerous trials

that duplex scanning is safe, non-invasive,

reliable and can be reproduced in appropriate

operator and reporter hands.

What To Do With The Results?

This has been conclusively established by

the North American Symptomatic Carotid

Endarterectomy Trial (NASCET), and the

European Carotid Surgery Trial (ECST), both

large, randomised Class I studies.

These found that, for symptomatic patients

with a 70% or more stenosis, an intervention

was required to prevent stroke. This

recommendation has not changed.

There are a number of studies done also

looking at asymptomatic patients, particularly

the European Asymptomatic Carotid Surgery

Carotid Scanning and Interventions

Colour Doppler, Internal Carotid Artery with 80% stenosis

Trial (ACST). Here, the recommendations are

that those with a stenosis of > 80% should

have an intervention.

There is also evidence that symptomatic

patients with less severe carotid occlusions

(50-60%) show a benefit from intervention,

albeit less so. Additionally, patients who are

asymptomatic but have a stenosis > 60% also

benefit from intervention, but only if their co-

morbidities and anatomy put them in a very

low-risk group.

For maximum benefit symptomatic patients

should be operated on soon after a TIA or

stroke, preferably within the first month.

The standard procedure for many years was

carotid thrombo-endarterectomy (CTEA).

This procedure has well defined mortality and

morbidity figures in good hands. But many

complications, such as up to 10% local nerve

dysfunction, can also be quite significant.

Recent years have seen the development of

carotid artery stenting (CAS) as an alternative

to CTEA.

CAS has seen numerous registries and trials

compiled and performed.

The Stent-Protected Angioplasty Versus

Carotid Endarterectomy (SPACE) trial was

stopped because the numbers needed to

reach statistical significance were not able to

be achieved because the recruitment was too

slow and the trial funding ceased. It did not

show that CTEA was superior to CAS or the

reverse.

The Endarterectomy versus Angioplasty in

patients with severe Carotid Stenosis (EVA -

3S) trial, a French trial, purported to show that

CAS was inferior to CTEA. However, there

have been serious doubts raised about the

methodology of this trial and hence the validity

of the results.

The International Carotid Stenting Study (ICSS)

trial has very recently released preliminary

results.

Whilst these appear to indicate that CAS

may not be as good as CTEA, there are also

significant issues with this trial.

4HUNTER IMAGING GROUP NEWSLETTER

The jury “remains out” on the best treatment.

The Carotid Revascularisation Endorterectomy

versus Stenting Trial (CREST) in the USA,

has released its preliminary results. The trial

has shown that CAS and CTEA are, overall,

equivalent. Patients aged less than 70 years

did marginally better with CAS, while patients

aged over 70 years did marginally better with

CTEA. The rates for stroke and death for both

procedures were the lowest reported in any

trial to date.

Regardless, all the trials and the data confirm

that those patients who are symptomatic,

particularly those who have amaurosis fugax,

transient ischaemic attack or stroke and who

have an appropriate carotid lesion, should

have an intervention.

Medical ManagementThe use of statins over the last 10-15 years,

in addition to the availability of more effective

anti-platelet agents such as clopidogrel, has

Carotid Endarterectomy ICA Stent

almost certainly improved the outcomes of

medical management. This improvement has

not been quantified.

However, there are no trials which supercede

the definitive trials for symptomatic and

asymptomatic patients.

All patients who have had a specific

neurological event should have their risk

factors assessed, should have their lipids

modified where appropriate, and should be on

an anti-platelet agent, regardless of whether

there are indications for an intervention.

Indications for InvestigationThe indications to perform carotid duplex

scanning have not changed.

Those patients who have had a neurological

event such as amaurosis fugax, transient

ischaemic attack (TIA), a reversible ischaemic

neurological disease (RIND) or a stroke, should

be investigated.

There are numerous other patient subsets in

whom investigation with carotid and vertebral

duplex scanning is warranted. These include

patients with a neck bruit, with non-localising

or lateralising signs such as syncopal attacks

or dizzy spells, and obviously patients with

a suggestion of any local lesion, such as the

possibility of aneurysm.

Indications For ReferralThe indications for referral for an intervention

have not changed.

Patients with a 50% or greater stenosis, who

are symptomatic, should be referred for an

opinion on treatment.

Asymptomatic patients, with a stenosis > 60%

should be referred for an opinion.

Whether that treatment is CTEA or CAS should

be tailored to the individual patient.

5 IMAGING UPDATE - SPECIAL VASCULAR EDITION 2010, ISSUE 16

Step 1Go online and access

the website at:

www.hunterimaging.com.au/cvc

Step 2Once on the Cardio Vascular

Centre home page select

“Information for Our

Referrers” at the top of the

page. When the drop down

menu is visualised click on

“Publications”

By accessing the Cardio Vascular Centre’s website you or your staff can download or print

a copy of Referrers Guide to Vascular Ultrasound. It’s quick and easy. See the instructions

below to see how this can be done.

Step 3Double click to open file and

from there you can download

onto your desktop or print a

copy.

rofilePaul Myers is a Vascular and Endovascular

Surgeon based in Newcastle.

He has been a consultant to the Cardio

Vascular Centre, now part of the Hunter

Imaging Group, since 1988.

He trained initially in general surgery and

subsequently vascular surgery in Australia and

England.

He finds the new techniques in vascular surgery

extremely exciting especially for endovascular

procedures for aortic aneurysm, carotid artery

disease, peripheral and visceral artery disease

and those being introduced for below knee

arterial disease.

He is in private practice with rooms at

Newcastle Private Hospital (NPH) Medical

Suites. He also consults in Maitland, Singleton

and Tamworth.

He is a Conjoint Associate Professor at the

University of Newcastle.

He is a Member of the Executive of the ANZ

Society of Vascular Surgery.

He is a Member of the Executive of the Hunter

Post Graduate Medical Institute.

He is a Councillor of the NSW AMA,

representing the Hunter and Central Coast

regions.

He remains active in the Army Reserve in the

rank of Colonel, having served overseas on

numerous deployments

profileprofile

M.B.B.S.(Syd), F.R.C.S. (Eng), F.R.A.C.S., AIMM

Paul Myers

Contact Details:Suite 2.1, NPH Medical Suites

24 Lookout Road, New Lambton Heights

NSW 2305

Phone: 02 4953 9615

Fax: 02 4953 9618

Downloading Referrers Guideto Vascular Ultrasound Did you know that you can download a Referrers Guide to Vascular Ultrasound from the Cardio Vascular Centre’s website to your desktop?

6HUNTER IMAGING GROUP NEWSLETTER

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This new location at 55 Brook

Street Muswellbrook will assist you

and your patients in providing the

imaging service required for diagnosis of

vascular disease.

Our sonographer, Helen Charlwood,

already scans for general ultrasound

with Hunter Imaging Group and has

had inhouse training with senior CVC

sonograpghers to gain competency with:

Arterial Leg scans •

Carotid Artery scans•

AAA scans•

DVT scans•

Over the coming months she will attend

more training to be proficient with:

Renal Artery scans•

Endoluminal graft scans•

She is enjoying the challenge of new

examinations and looks forward to being

able to perform more examinations in the

future to help provide a great service to

patients in the area.

Ordering RequestForms Online for CVC

Step 1Go online and access

the website at:

www.hunterimaging.com.au/cvc

Did you know that you can order Cardio Vascular Centre request forms online?

By accessing the Cardio Vascular Centre’s website you or your staff can order a range of

request forms. It’s quick and easy. See the instructions below to see how this can be

done.

Step 2Once on the Cardio Vascular

Centre home page select

“Information for Our Referrers”

at the top of the page. When the

drop down menu is visualised

click “Request Pads Order”

Step 3Fill in data.

Scroll further down the screen

and make your selection and

click on “Submit”

Cardio Vascular Centre

MuswellbrookCardio Vascular Centre is pleased to announce that we have opened a branch in the Upper Hunter Valley.

If you would like to know more or wish to speak to our signing doctors or sonographers about a specific case please contact our referrer services team on 49255 430.

7 IMAGING UPDATE - SPECIAL VASCULAR EDITION 2010, ISSUE 16

The upgrade of equipment means shorter, more

comfortable examinations for patients.

With high performance attributes such as:

Increased field of exposure, to cover more anatomy in 1.

one exposure;

Increased number of exposure chambers to read 2.

exposures more accurately, this will reduce patient dose;

Excellent image quality with scintillator that has high 3.

resolution ratio;

Fixed detector with excellent pixel ratio, which leads to 4.

reduction in exposure level to patient; and

High projection ability, equipment can be moved around 5.

patient instead of patient being placed in awkward

positions during examinations.

Maitland Receives Digital Radiography Unit Upgrade Hunter Imaging Group has recently installed a new Philips Digital Radiography unit at its Maitland rooms.

We are no longer at Mitchell Drive, moving to our new location

two years ago. Some of you would still have old request forms

with the Mitchell Drive address and map on it (confusing

some patients), so if you would like updated request forms please contact

Referrer Services 49255430 or e-mail ReferrerServices@pacmedica.com

or order online at website; www.hunterimaging.com.au/cvc (see page 6

for detailed instructions)

Attention All ReferrersCardio Vascular Centre has rooms at East Maitland.

Cardio Vascular Centre, East Maitland

Level 1, Suite 7

Maitland Specialist Medical Centre - Maitland Private Hospital

Corner Chisholm Road and New England Highway, East Maitland

New Address To M

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