I have included 2 articles :
Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke
Paola Palazzo,
1 , 2 Pierre Ingrand, 3 Pierre Agius, 4 Rafik Belhadj Chaidi, 5 and Jean‐Philippe Neau 1
1 , 2 Pierre Ingrand, 3 Pierre Agius, 4 Rafik Belhadj Chaidi, 5 and Jean‐Philippe Neau 1
I include this for your review because it is 2019, because all the patients were done brachial, and because the references are very well done. It does not address the femoral route
Sensitivity of brachial versus femoral vein injection of agitated saline to detect right‐to‐left shunts with Transcranial Doppler
Conflict of interest: Nothing to report.
Abstract
Background
Transcranial Doppler (TCD) can detect a right‐to‐left shunt (RLS) with high sensitivity but has a 5% chance of a false negative study. TCD is usually performed with injection of agitated saline into an arm vein. We compared the sensitivity of TCD performed from the brachial versus femoral veins.
Methods
Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power M‐mode Transcranial Doppler (Terumo 150 PMD) was conducted. After injection of a mixture of 8 cc of agitated saline, 0.5 cc of air, and 1 cc of blood into the brachial vein, embolic tracks were counted over the middle cerebral arteries. The degree of RLS was evaluated by TCD at rest, and with Valsalva at 40 mmHg aided by visual feedback with a manometer device. The test was repeated using femoral venous injections.
Results
Sixty five patients were enrolled, mean age 52, 43% male. TCD grades were significantly higher with femoral injections compared to brachial injections at rest (p<0.0001), and with the Valsalva maneuver (p<0.0001). The presence of a RLS was confirmed by intracardiac echocardiography (ICE) during cardiac catheterization in 62 (95.4%) patients.
Conclusion
The sensitivity of TCD for detection of RLS is increased when agitated saline injections are performed through the femoral vein. In patients with a high clinical suspicion for RLS, low TCD grades obtained with traditional brachial venous access should be interpreted with caution. When possible, a repeat study using femoral venous access may be considered. © 2014 Wiley Periodicals, Inc.
I have included this second article from 2014 as responsive to your note.
cTCD by brachial injection has a 93% sensitivity and a 97% specificity. I am not sure how much better "2X as good" is. The introduction of a 1.5%-8% complication rate with a femoral catheter and the added cost may be justified under some circumstances.
The assumption is that the TIA or CVA is, in fact, cryptogenic,( that it has has been fully evaluated with Holter monitor, coag studies etc) In this circumstance, negative TEE in which satisfactory valsalva has been noted along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic.
The benefit of transcutanious PFO closure has always been clear to me, but the proof of benefit over ASA does require some statistical yoga. This leaves the clear option of treating a truly cryptogenic group with ASA. The number of spots on the MRI might help decide
I wonder if those relatively rare circumstances might be best resolved with a cardiac cath. ( especially if events are recurrent on ASA) PVL can certainly participate in a f/u cTCD with femoral catheter. We are not set up to do it in the PVL
-----Original Message-----
From: djacobs272 <djacobs272@aol.com>
To: adam.waldman <adam.waldman@orlandohealth.com>; mmenkin <mmenkin@aol.com>; ca.rosado <ca.rosado@gmail.com>; dhj1.strokenotes <dhj1.strokenotes@blogger.com>
Sent: Wed, Apr 24, 2019 9:39 am
Subject: pfo Studies
From: djacobs272 <djacobs272@aol.com>
To: adam.waldman <adam.waldman@orlandohealth.com>; mmenkin <mmenkin@aol.com>; ca.rosado <ca.rosado@gmail.com>; dhj1.strokenotes <dhj1.strokenotes@blogger.com>
Sent: Wed, Apr 24, 2019 9:39 am
Subject: pfo Studies
from Thaler DE and Cramer SC Paradoxical embolism in stroke in Caplan LR, Biller J. Uncommon Causes of Stroke
"The choice of vein used to introduce echocardiographic contrast influences the sensitivity for PFO detection. Blood entering the right atrium via the inferior vena cava is directed towards the interatrial septum where PFOs are located whereas blood from the superior vena cava tends to be directed towards the tricuspid valve. Studies have been consistent in finding a 2.5-fold increase in diagnostic sensitivity when the contrast medium is injected via the femoral rather than the antecubital vein (Gin et al., 1993; Hamann et al., 1998).
Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition.
full citations for above:
Gin, K., Huckell, V., and Pollick, C. 1993. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol, 22, 1994– 2000.
Hamann, G., Schatzer-Klotz, D., Frohlig, G., et al. 1998. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology, 50, 1423– 8.
ALL MY TAKE
I ASSUME ONE HUNDRED PERCENT OF OUR STUDIES BOTH TCD AND TEE BUBBLE ARE DONE THROUGH ARM VEIN BUT RHEOLOGY SHOWS FEMORAL VEIN IS 2.5 X AS GOOD. PERHAPS WE COULD CONSIDER DOING THESE STUDIES FEMORRALLY SECOND LINE IN CHALLENGING PATIENTS SUCH AS WE HAVE HAD LATELY? LOOK FORWARD TO EVERYONE'S THOUGHTS
DJ
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