Kathleen M. Garcia, BS, FASE, RDCS, RVT

Susana Perese, BS, RVT, APS, FASE

Holding the power of ultrasound in the palm of your hand promises simplicity in form and function for ultrasound imaging. Compacting computing power into ever smaller handheld devices has been the norm for several years. Handheld devices are challenging traditional usages of many devices, indeed even shaping entertainment, communication, and social behavior. This past spring, the ASE co-sponsored echocardiography screenings for over 1,000 symptomatic individuals all from an remote location outside of New Delhi, India. ASE member volunteer echocardiographers provided cardiac screening using a powerful handheld ultrasound scanner (Vscan; GE Healthcare, Little Chalfont, UK). This enabling technology, plus cloud-based telemedicine, allowed cardiologists to diagnose a host of heart diseases. Indeed, the size and portability can make common medical technology available in areas where medical imaging in any form is uncommon. Transforming an entire ultrasound cart into a five-inch palm-sized device may be considered disruptive technology, challenging customary settings for clinical medical imaging.

Handheld ultrasound are a perfect fit for point-of-care ultrasound; a tool intended for a physician to “take a look”. Consider the focused exam in an emergency dedicine (ED) setting; a handheld device fits perfectly in this scenario. ED physicians use focused echocardiography to aid in recognizing cardiac arrest, volume assessment, pericardial fluid and other emergent cardiac situations. The technique also recognizes a set of standards for appropriateness, clinical competence and skill. The handheld device may empower the user to perform focused point-of-care ultrasound. Similarly a stethoscope empowers the user to perform a clinical exam but requires competency and is operator dependent. A common hammer is also operator dependent and requires skill; every tool requires some knowledge and proficiency level to make a good impact. Handheld ultrasound has proven the potential of handheld integration into cardiovascular imaging. Limitations in probe imaging make the current handhelds ineffective in performing focused vascular imaging in the ED environment. Making the use of handheld devices practical in a vascular imaging setting will require assurance, considering the imaging challenges specific to the vascular laboratory standards and practices. The handheld device is perfect for a “touch and go” scenario, but is it scalable enough for a vascular lab environment? One probe may work well when all you need to do is take a look, but vascular imaging needs are notoriously multipurpose. A hammer will work to set or pull out a nail, but it will not serve to set a screw or chop wood. What vascular-centric factors are necessary for a handheld device to find acceptance and make a good impact in the vascular laboratory?

The success of handheld devices in vessel imaging demands ease of use. The human factor element in ultrasound systems is huge. Standard systems work well the lab setting, but when you have to perform studies at the bedside, a handheld system has size advantages. Venous Doppler exam requirements are the same whether it is done in the laboratory or at the bedside: a multiplex imaging system and a sonographer. Can you practically perform a venous exam while holding the system in one hand, the probe in the other hand and augment Doppler signals, punch through the system menu to change color Doppler scale, and save the image with the third? No, a third arm is not practical; setting the little unit on the bed or a table is an option. However, if you must set the handheld down on a surface to perform the scan, does it defeat a handheld fundamental? Improved portability with a lightweight imaging device would revolutionize portable vascular studies. There are cumulative and repetitive physical demands involved in vascular imaging. Reducing system weight and simplifying system function would reduce many inconvenient aspects of portable studies. Take away all the pushing, pulling, and dragging of gear and patient’s fixtures and there will likely be a reduction in sonographer musculoskeletal injury, Improved lightweight transducer design, smart system software, and perhaps even improved morale.

Modifications to a handheld unit just to improve workflow in the vascular lab may seem relevant and worthwhile. However, as end users, we must recognize the doctrine that vendors use when leveraging worthiness and refinement in a platform. Simply, vendors need a marketable unit based on previous investments in research and development. The vascular lab end user needs a handheld device scalable to his lab and patient population. It is unlikely that one broadband probe is capable of the workflow demands in the vascular laboratory. Handheld devices for vascular imaging need to be robust, yet sensitive enough to resolve upper and lower extremity veins throughout, image dialysis access graphs, duplex renal assessment, and accurately document Doppler angle dynamics involved with a carotid duplex exam. The handheld should possess sensitive color Doppler settings to mine out the level of a peripheral vascular arterial obstruction. In this sense, a handheld device may save hauling two systems to the intensive care unit or emergency department for duplex and physiologic assessment.

Challenges to reimbursement may affect further refinements in handheld functionality for use in the vascular laboratory. The end user and vendor may consider adapting the handheld functionality to fit in a vascular laboratory environment. Instead of a hands on system, perhaps smart software, a ‘protocol driven’ algorithm with optional heads-up virtual reality glasses to expand the handheld’s small display, would work. Wireless video streaming, cineloop, and store forward formats in a DICOM standard are necessary to communicate to picture archiving and communication software. Smart tools that expand functionality and improve workflow, such as modality work lists and structured reporting, would reduce manual documentation. Expanded study software capabilities after the scan could be incorporated for advanced analysis, carotid intima media thickness, and possibly stitch panoramic or three-dimensional imaging.

What are your thoughts on handheld imaging for the vascular laboratory? Sound out your perfect handheld system at ASE Connect under Communities. Choose the Vascular Ultrasound Council community to network, share and collaborate on handheld ultrasound for a vascular laboratory workflow.