High quality vascular ultrasound by non-physicians is established and effective: the UK perspective

Dear Sir,

In a letter [1] replying to an editorial describing alternative ways of providing ultrasound services [2], Dr Arning has given an uncomplimentary and inaccurate account of the practice of grading carotid stenosis in the UK, stating that there are “extreme differences in the quality of British and German vascular ultrasound”.

The online NHS patient information referred to in the letter does not state that CTA and MRA are the necessary confirmatory tests for carotid stenosis and are therefore the diagnostic standards in the UK. The information merely warns the patient that; “you may need to have further tests to confirm the diagnosis, such as a CTA or MRA.” In our own practice, where vascular ultrasound is the basis for carotid intervention, there are a few cases where ultrasound is unclear or the aortic arch is involved, where a patient needs complementary imaging. We are not experts or familiar with current German practice but would believe that, on occasion, the same might be true there.

A more comprehensive and detailed account of UK practice is contained in National Stroke Strategy- an imaging guide from 2008 [3] when stroke services were overhauled in the UK. These guidelines state that ultrasound is the first line of investigation. For patients in whom intervention is contemplated, this should be confirmed by ultrasound with a different operator, or CTA.

In the UK, carotid ultrasound is performed by many disciplines. In our own hospital, vascular and clinical scientists perform these tests as part of a wide range of vascular ultrasound work within a ‘Vascular Laboratory’ in the Department of Medical Engineering and Physics. The section is led and managed by scientists, not physicians, radiologists or surgeons. We are members of the Society for Vascular Technology of Great Britain and Ireland who have contributed, with vascular surgeons, to their own standards published in 2008 [4], very similar to the DEGUM criteria.

We first audited our laboratory’s carotid ultrasound results against angiography in 1996 following which our neurologists and stroke physicians dropped angiography. We see around 2700 patients for carotid ultrasound annually out of a total 18 000 ultrasound examinations. We comply with NHS recommendations; all patients scheduled for a carotid endarterectomy have a second ultrasound scan with a different operator to confirm the findings and measure the dimensions as an aid to the surgeon. They are delighted with the quality and responsiveness of the service as are the nephrologists, neurologists, diabetologists, haematologists, paediatricians, intensivists, cardiologists and all the other specialties who find they need vascular imaging for their patients. Our hospital finance team like us too; the charge to the hospital for a carotid ultrasound is currently € 53.

There are many ways of running an ultrasound service. Vascular ultrasound is best done by those with an interest in and understanding of ultrasound imaging and measurement of vessels and the blood flow within them together with an understanding of what is required for each clinical condition. We know that the continental European model is different from our own; there are historical and cultural differences for this including the way healthcare is provided and paid for. As Dr Seitz comments in his letter [5], there are benefits in having ultrasound as an integral part of the whole examination of the patient for the physician to better understand his or her patient and to aid communication with them. The advance of small point of care machines is increasing this in the UK although the availability of scanners outpaces a framework of training and audit for new practitioners. There is, however, considerable benefit in having dedicated trained specialists in vascular ultrasound with high end equipment and the skills to use it effectively for the patient and their medical teams. This is our model, it is different from DEGUM’s but the standards of imaging are sound and are not to be denigrated with casual misinformation.

• References

• 1 Arning C. High-level carotid ultrasound must be performed by a physician. Ultraschall in Med 2017; 38: 1
• 2 Edwards HM, Sidhu PS. Who’s doing your scan? A European perspective on ultrasound services. Ultraschall in Med 2017; 38: 479-482
• 3 Implementing the National Stroke Strategy – an imaging guide. http://www.csnlc.nhs.uk/uploads/files/stroke/documents/national_documents/dh_085145.pdf
• 4 Oates CP, Naylor AR, Hartshorne T. et al. Joint recommendations for reporting carotid ultrasound investigations in the United Kingdom. Eur j Vasc. Endovasc Surg 2009; 37: 251-261
• 5 Seltz K. Who’s doing your scan? The German perspective on ultrasound services: Ultrasound is more than a technique, it’s a medical art. Ultraschall in Med 2017; 38: 1-3