Inteleos Blog: The Carotid Study

Photo of Kristi BantyBy: Kristi Bandy

Early in my career as a Registered Vascular Technologist I was faced with a sonography study that informed how I would perform ultrasound studies for the rest of my career.

I was a year and half into my career, and I thought I had seen nearly everything. The study is one I’ll never forget – it was a carotid study that proved to be the most challenging I had encountered to that point, and it took more time and patience than almost any other study I had performed, even surpassing the complexity of renal vascular examinations.

At the time, I worked at a Cardiologist’s office as the sole Vascular Technologist. I was responsible for conducting cardiac studies, in addition to various vascular studies. This carotid study, in particular, was a significant test of my skills.

The study began with the right side of the patient’s neck. I carefully activated color doppler to sample the common carotid artery, a fundamental part of the examination. To my surprise, no color flow was detected. No matter how I adjusted my angle or the color scale, the elusive color flow remained absent. For the next 20 minutes, I persisted in scanning the right side, hoping to detect any signs of blood flow to the right common carotid artery, but to no avail.

In an effort to salvage the study, I switched to the left side. There, I found the normal carotid artery flow that I expected. Returning to the right common carotid artery, I struggled to identify the completely occluded artery, hindered by the slight variations in grayscale on the images.

After a meticulous comparison of the left and right sides, I concluded that the right common carotid artery was occluded all the way to the bulb. Continuing my examination, I moved to the external carotid artery, where I discovered a reversal of flow. While I had read about such scenarios in case studies, it was my first time witnessing it in a real patient. The grayscale throughout the common carotid artery was so hypoechoic that identifying the occlusion was challenging.

As I progressed with the study, I frequently verified my findings by scanning back over the segments on the patient’s right side. Once I identified the etiology, the study made total sense. I was determined to ensure the accuracy of my findings before presenting the results to the referring physician. I developed the habit of performing the temporal tap on every carotid study to avoid any confusion or questions regarding the vessels under evaluation.

I completed the study and felt confident that I thoroughly assessed all the patient’s vessels required for the study. My images were of the highest quality, with proper color fill and appropriate Doppler angles and scales. I couldn’t help but apologize to the patient for the lengthy duration and constant adjustments, but she was understanding and kind, putting me at ease.

To this day, I vividly remember that study as if I had just performed it. I recounted this experience numerous times, especially when I was new as an RVT, and it remains etched in my memory. 

My advice to fellow sonographers, especially those starting out, is to conduct an optimal number of “normal” studies so that when you do encounter an abnormal case, you’re well-prepared to get it right. Mastery in sonography often comes from these challenging, unforgettable cases and experiences.