Acute Arterial Ischemia Research Articles

Isquemia mesentérica: actualización de nuevas técnicas diagnósticas para una vieja enfermedad y revisión de signos radiológicos

Acute arterial mesenteric ischemia is a medical emergency associated with a high rate of mortality (> 60%). A diagnostic delay may lead to disease progression, thus it is important to recognize this condition as early as possible.The development of imaging techniques, such as multidetector computed tomography (MDCT) allows an early diagnosis to be made as it detects typical radiographic signs such as, the presence of a thrombus within the superior mesenteric artery (SMA), pneumatosis in bowel loops, and air in the interior of the superior mesenteric and portal veins.It is important to know of these new imaging techniques applications and the typical radiographic signs of this disease as it is an emergency which, if confirmed, could lead to performing urgent surgery to prevent progression to intestinal necrosis and a possible fatal outcome.

Low-Dose Scan Protocols in Dual-Source CT Coronary Angiography

HomeRadiologyVol. 263, No. 3 Previous CommunicationsLetters to the EditorLow-Dose Scan Protocols in Dual-Source CT Coronary AngiographyMin Li, Gang SunMin Li, Gang SunAuthor AffiliationsDepartment of Medical Imaging, Jinan Military General Hospital, 25 Shifan Rd, Jinan, Shandong, China 250031 e-mail: [email protected]Min LiGang SunPublished Online:Jun 1 2012https://doi.org/10.1148/radiol.12112369MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Neefjes LA, Dharampal AS, Rossi Aet al.. Image quality and radiation exposure using different low-dose scan protocols in dual-source CT coronary angiography: randomized study. Radiology 2011;261(3):779–786. Link, Google Scholar2 Weustink AC, Mollet NR, Pugliese Fet al.. Optimal electrocardiographic pulsing windows and heart rate: effect on image quality and radiation exposure at dual-source coronary CT angiography. Radiology 2008;248(3):792–798. Link, Google Scholar3 Hurwitz LM, Reiman RE, Yoshizumi TTet al.. Radiation dose from contemporary cardiothoracic multidetector CT protocols with an anthropomorphic female phantom: implications for cancer induction. Radiology 2007;245(3):742–750. Link, Google Scholar4 Einstein AJ, Elliston CD, Arai AEet al.. Radiation dose from single-heartbeat coronary CT angiography performed with a 320-detector row volume scanner. Radiology 2010;254(3):698–706. Link, Google Scholar5 Huda W. Computing effective doses from dose-length product in CT. Radiology 2008;248(1):321; author reply 321–322. Link, Google ScholarArticle HistoryPublished online: June 2012Published in print: June 2012 FiguresReferencesRelatedDetailsCited ByComputed Tomography in Adult Congenital Heart DiseasePraveenRanganath, SatinderSingh, SuhnyAbbara, Prachi P.Agarwal, PrabhakarRajiah2019 | Radiologic Clinics of North America, Vol. 57, No. 1Radiation dose and diagnostic accuracy of high-pitch dual-source coronary angiography in the evaluation of coronary artery stenosesM.Koplay, H.Erdogan, A.Avci, M.Sivri, K.Demir, I.Guler, L.S.Demir, Y.Paksoy2016 | Diagnostic and Interventional Imaging, Vol. 97, No. 4Questionnaire Survey of SPECT Studies after the Supply Shortage of Tc-99m and Model Analysis Concerning Earnings and Expenditure of Generator UseRyoKINOSHITA, ShigeruKOSUDA, KatsumiKOIKE, TakashiARAI2012Jan1 | RADIOISOTOPES, Vol. 61, No. 12Recommended Articles Imaging the Infant Chest without Sedation: Feasibility of Using Single Axial Rotation with 16-cm Wide-Detector CTRadiology2017Volume: 286Issue: 1pp. 279-285Advanced CT Techniques for Decreasing Radiation Dose, Reducing Sedation Requirements, and Optimizing Image Quality in ChildrenRadioGraphics2019Volume: 39Issue: 3pp. 709-726The Effect of Contrast Material on Radiation Dose at CT: Part II. A Systematic Evaluation across 58 Patient ModelsRadiology2017Volume: 283Issue: 3pp. 749-757Atrial Fibrillation: Diagnostic Accuracy of Coronary CT Angiography Performed with a Whole-Heart 230-µm Spatial Resolution CT ScannerRadiology2017Volume: 284Issue: 3pp. 676-684Next-Generation Hardware Advances in CT: Cardiac ApplicationsRadiology2020Volume: 298Issue: 1pp. 3-17See More RSNA Education Exhibits Demystifying the CT Dose Sheet and Image HeadersDigital Posters2020Spectrum of Disease in Patients Presenting with Symptoms of Acute and Chronic Arterial Limb Ischemia on CT AngiographyDigital Posters2020Can Superior Visualization CT-Angiography Replace and Overwhelm Conventional Angiography? The Pre-Operative Assessment of Endovascular Treatment with Quarter Millimeter Isotropic Data SetsDigital Posters2019 RSNA Case Collection Takayasu ArteritisRSNA Case Collection2020Cystic adventitial disease of the popliteal arteryRSNA Case Collection2020Subclavian Stenosis with Pre-StealRSNA Case Collection2021 Vol. 263, No. 3 Metrics Altmetric Score PDF download

Fungal endocarditis with central and peripheral embolization: Case report

A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation, cerebral infarcts and right common iliac artery pseudoaneurysm. While awaiting transfer to the cardiothoracic surgery department, the patient presented acute arterial ischemia of the left leg, and distal left patellofemoral embolectomy was successfully performed. The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve. After 14 days he was referred for vascular surgery, where the four-month hospitalization was complicated by left leg amputation. Four months after discharge, the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization. He was transferred to the cardiothoracic surgery department, but suffered cardiac arrest before surgical intervention.

Endocardite fúngica com embolização central e periférica: um caso clínico

A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation, cerebral infarcts and right common iliac artery pseudoaneurysm. While awaiting transfer to the cardiothoracic surgery department, the patient presented acute arterial ischemia of the left leg, and distal left patellofemoral embolectomy was successfully performed. The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve. After fourteen days he was referred for vascular surgery, where the four-month hospitalization was complicated by left leg amputation. Four months after discharge, the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization. He was transferred to the cardiothoracic surgery department, but suffered cardiac arrest before surgical intervention.

Percutaneous isolated pharmaco‐mechanical thrombolysis‐thrombectomy system for the management of acute arterial limb ischemia: 30‐day results from a single‐center experience

To study the efficacy of isolated pharmaco-mechanical thrombolysis-thrombectomy (IPMT) by Trellis device (Covidien, Mansfield, MA) in managing acute limb ischemic (ALI). ALI is both life and limb threatening disease with a reported 9-15% mortality and 15-25% limb loss in the first month after presentation. Pitfalls of current endovascular techniques include major bleeding, distal embolism, and prolonged thrombolytic infusion. IPMT isolates the thrombus between two balloons and utilizes wire oscillation to increase the thombus-lytic exposure surface area followed by aspiration. It decreases systemic lytic exposure, procedure time, and distal embolism. Technical aspects, success, and bleeding complications in 24 consecutive patients with ALI treated with IPMT between October 2009 and September 2010 were analyzed. In-hospital and 30-day mortality, amputation rates and treatment success rates were determined. 24 patients constituted 32 arteries; 18 (56.25%) were suprainguinal including 3 grafts (9.4%) and 14 (43.75%) were infrainguinal native arteries. Substantial or complete response was seen in >90% vessels with 87.5% patients revealing TIMI three flow while none demonstrated TIMI 2 or 3 pretreatment. Only three patients required adjunctive post-IPMT thrombolysis. In-hospital and 30-day all cause mortality was 4.16%. One patient died in-hospital and no patient underwent amputation. Besides being the largest series of ALI patients treated with IPMT, this is the first and largest series including 14 native infrainguinal arteries. These results suggest IPMT to be a promising and safer therapeutic option in ALI, likely due to its site-specific nature and limited thrombolysis exposure time.

Tissue Loss Secondary to Extrinsic Compression of Common Iliac Artery From Uterine Leiomyoma

Uterine leiomyomas are commonly reported to cause deep venous thrombosis and rarely arterial compression. A 48-year-old woman was transferred to our institution with acute right lower limb ischemia and tissue loss. She underwent urgent iliac thrombectomy and was subsequently found to have right common iliac artery compression by a large uterine leiomyoma. She underwent successful resection of the tumor followed by endovascular iliac stent placement. This case emphasizes the importance of preoperative imaging when possible in the setting of acute arterial ischemia to evaluate for sources of extrinsic compression. Management requires correction of the etiology of extrinsic compression.

Acute Limb Ischemia in Cancer Patients: Should We Surgically Intervene?

Cancer patients have an increased risk of venous thromboembolic events. Certain chemotherapeutic agents have also been associated with the development of thrombosis. Reported cases of acute arterial ischemic episodes in cancer patients are rare. Patients who underwent surgery for acute limb ischemia associated with malignancy in a university teaching hospital over a 10-year period were identified. Patient demographics, cancer type, chemotherapy use, site of thromboembolism, treatment and outcome were recorded. Four hundred nineteen patients underwent surgical intervention for acute arterial ischemia, 16 of these patients (3.8%) had associated cancer. Commonest cancer sites were the urogenital tract (n = 5) and the lungs (n = 5). Eight patients (50%) had been recently diagnosed with cancer, and four (25%) of these cancers were incidental findings after presentation with acute limb ischemia. Four patients (25%) developed acute ischemia during chemotherapy. The superficial femoral artery was the most frequent site of occlusion (50%), followed by the brachial (18%) and popliteal (12%) arteries. All patients underwent thromboembolectomy, but two (12%) patients subsequently required a bypass procedure. Six patients (37%) had limb loss, and in-patient mortality was 12%. Histology revealed that all occlusions were due to thromboembolism, with no tumor cells identified. At follow-up, 44% of patients were found to be alive after 1 year. Cancer and chemotherapy can predispose patients to acute arterial ischemia. Unlike other reports that view this finding as a preterminal event most appropriately treated by palliative measures, in this series, early diagnosis and surgical intervention enabled limb salvage and patient survival.

Outcomes of Revascularized Acute Mesenteric Ischemia in the American College of Surgeons National Surgical Quality Improvement Program Database

This report examines outcomes of revascularization for acute arterial mesenteric ischemia (AAMI) using the American College of Surgeons National Surgical Quality Improvement Program database. Patients with International Classification of Diseases, 9th Revision and Current Procedural Terminology codes indicating AAMI with concomitant mesenteric revascularization were identified. Demographic, risk factor, procedural, morbidity, and mortality data were examined. Associations with morbidity and mortality were analyzed by logistic regression. One hundred forty-two cases of AAMI were identified. Seventy-one cases were thrombotic and 71 were embolic according to revascularization codes. Mean age was 66 years, 84 per cent of patients were white, and 54 per cent were female. Unadjusted major morbidity and mortality rates were 69 and 30 per cent, respectively. Patients with thrombotic AAMI were more likely to have a lower body mass index, greater than 10 per cent weight loss in the past 6 months, and a history of smoking. Patients with embolic AAMI were more likely to present emergently with sepsis. Unadjusted morbidity and mortality rates were 78 and 38 per cent for embolic and 61 and 23 per cent for thrombotic AAMI, respectively. Multivariable predictors of morbidity included bowel resection at the time of revascularization, transfer admission, and involvement of a surgical resident. Multivariable predictors of mortality included impaired functional status, increased age, and postoperative sepsis. Cause of AAMI was not a significant predictor of morbidity or mortality. In a large sample of AAMI cases, AAMI remained a highly lethal and morbid condition. Predictors of morbidity and mortality included indicators of advanced presentation, treatment delay, and patient-related factors specific to AAMI, including debility and advanced age. Efforts directed at prevention and increasing the speed of diagnosis and definitive treatment appear to be necessary to improve outcomes.

Seven-Tesla micro-MRI in early detection of acute arterial ischaemia: evolution of findings in an in vivo rat model

Acute mesenteric ischaemia (AMI) is a life-threatening vascular emergency with a high mortality rate. Early diagnosis is the key to reducing its mortality rate and improving the quality of life. Although computed tomography (CT) is still the gold standard for acute intestinal disorders, over the last few years, magnetic resonance imaging (MRI) has become a useful alternative tool. An animal model of AMI was developed in order to study the effectiveness of MRI in early detection of this condition and to observe lesion evolution. Thirty Sprague Dawley rats were randomly divided into two groups (n=15): in the first group, after laparotomy, the animals underwent ligation of the superior mesenteric artery (SMA), followed by macroscopic monitoring and histological evaluation; in the second, ischaemia was induced by squeezing a loop around the SMA 3 days before evaluation with 7-T micro-MRI. Macroscopically, a reflex spastic ileus followed by reflex hypotonic ileus and colour changes in some of the loops were detected. MRI evidenced luminal dilatation with air-fluid levels, free intraperitoneal fluid and bowelwall oedema. Histological analysis confirmed ischaemia and earlier damage involving the central portion of the ileum. This model shows the correct sequence of events during arterial AMI and demonstrates that MRI can be recommended for early diagnosis of these lesions.

Susceptibility-weighted imaging (SWI): A potential non-invasive imaging tool for characterizing ischemic brain injury?

Susceptibility-weighted imaging (SWI) is a new high-resolution magnetic resonance imaging (MRI) tool that uses the paramagnetic susceptibility effects of deoxygenated blood to study the intracranial venous vasculature. We present SWI imaging findings in two children who suffered from acute arterial ischemia. Various patterns of normal/altered venous drainage could be identified. Our case study suggests that SWI assisted mapping of the regional changes of the cerebral venous drainage and correlation with diffusion weighted MRI may identify critically perfused brain at risk for infarct progression. Prospective studies are mandatory to further validate the value of SWI.

Results of Catheter-directed Endovascular Thrombolytic Treatment of Acute Ischaemia of the Leg

Objectives To observe immediate and late results of catheter-directed endovascular thrombolytic treatment of acute ischaemia of the leg. Design, material and methods A total of 212 patients treated with Actilyse ® at the University Hospital of North Norway because of acute arterial ischaemia of the leg during the period 01 January 2000–30 June 2006 were analysed retrospectively. Results The radiologic outcome was judged to be successful in 101 (48%), adequate in 80 (38%) and failed in 31 (14%). At 1-year follow-up, 158 (75%) were alive without amputation, 14 (7%) were alive with amputation, 20 (9%) were dead without amputation and 20 (9%) were dead with amputation. Altogether, 34 (16%) were amputated and 40 (19%) were dead after 1 year. After an average observation period of 3.25 years, 111 (52%) were alive without amputation, 16 (8%) were alive with amputation, 60 (28%) were dead without amputation and 25 (12%) were dead with amputation. A total of 41 (19%) were amputated and 85 (40%) were dead. Fifty complications were registered; 30 (14%) patients had a compartment syndrome, eight (4%) had cerebral stroke and 12 (6%) had a myocardial infarction. Conclusions The results are at least as good as historic controls and similar to international series. Especially, it appears as though the long-term results are somewhat better. The complication rate and morbidity are less than in surgery alone.

Should Steroids be Offered to Patients With Nonarteritic Anterior Ischemic Optic Neuropathy?

The treatment of nonarteritic anterior optic neuropathy remains very limited and disappointing. Recent publications have suggested that oral steroids as well as intravitreal injections of steroids might be helpful to accelerate resolution of disc edema and improve visual outcome. However, the use of steroids to treat acute NAION remains largely debated.

Case report: acute thrombotic occlusion and pseudoaneurysm of the brachial artery diagnosed by Doppler ultrasound after nondiagnostic angiography

The swift and accurate diagnosis of acute arterial occlusion and limb ischemia is critical to prevent morbidity from this vascular emergency as reported by Bettman et al. (Radiology 215:101-105, 2000). There are a number of imaging modalities available to the diagnosing physician. However, the most appropriate modality may vary according to the clinical presentation. We present an atypical case of acute thrombosis of the brachial artery, which could not be diagnosed by conventional angiography, but was identified successfully with Doppler ultrasound. We also briefly discuss the issues surrounding vascular imaging in this case and overview the strengths and weaknesses of available imaging modalities.

Acute Mesenteric Ischemia: Diagnostic Approach and Surgical Treatment

Mortality related to acute mesenteric arterial occlusion remains very high. Patient survival is dependent on prompt recognition and revascularization before ischemia progresses to intestinal gangrene. Biphasic computed tomography angiography has surpassed angiography as the diagnostic test of choice due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia. Unlike chronic mesenteric ischemia, the treatment of acute arterial mesenteric ischemia, either embolic or thrombotic, remains largely surgical. This is due to the emergent need for revascularization combined with a careful evaluation of the intestines. Endovascular techniques remain useful, however, and can save precious time in the treatment of these challenging patients if integrated into a treatment pathway combined with definitive surgical treatment. A new hybrid endovascular-surgical treatment for the treatment of acute mesenteric thrombosis is described.

Endovascular Techniques in Acute Arterial Mesenteric Ischemia

Rapid developments in preoperative noninvasive imaging as well as advanced endovascular techniques have made endovascular treatment of acute arterial mesenteric ischemia a feasible treatment option in many patients. Multidetector computed tomographic angiography will provide the diagnosis and guide treatment in most cases. The use of mechanical and aspiration embolectomy, sometimes in combination with thrombolytic therapy, is often successful in offering these very sick patients a good treatment option to open surgical revascularization. Underlying occlusive lesions can be treated in the same setting. Hybrid techniques using open abdominal exploration in combination with endovascular tools have the possibility of offering minimally invasive treatment to even more patients. Access to a hybrid operating room is very advantageous when performing these operations because it allows for performing both open and endovascular interventions in the same setting. A fixed angiographic system also minimizes radiation exposure and improves the imaging capabilities compared to a conventional, mobile C-arm. These tools must be used in conjunction with wise, careful clinical evaluation of the patient.

Successful infrainguinal revascularization with autologous vein for inadvertent stripping of superficial femoral artery: a case report

A referral patient who had previously undergone varicose vein surgery was admitted as an emergency case. On admission, the patient complained of intolerable pain, paralysis and paresthesia of the affected limb, which was characterized by acute arterial ischemia symptoms. Color Doppler of the artery of the affected limb indicated that no blood flow signal existed in the superficial femoral artery. During exploratory operation, we found that the right superficial femoral artery instead of the great saphenous vein of the affected limb had been stripped and ligated. Therefore, the intact right great saphenous vein was taken for auto-transplantation by inverse end-to-end anastomosis to the proximal and distal residual superficial femoral artery, which resulted in gradual recovery. Except for ischemic reperfusion injury, no other post-operative complications occurred after a 10 month follow-up; however, the long-term curative effect needs further observation. Here we report our treatment experience.

Death by midgut infarction: clinical lessons from 88 post‐mortems in Auckland, New Zealand

Mortality rates from acute arterial mesenteric ischaemia remain high. Early diagnosis is of prognostic importance; however, early features are often non-specific, necessitating a high index of suspicion and knowledge of the at-risk patient. This study reviewed three decades of fatal cases in Auckland, New Zealand, to identify risk factors and associated pathologies that might help guide early diagnosis. Diagnostic delay was also evaluated. Cases were identified through a pathology database maintained from 1977 to 2006. Autopsy reports were assessed together with available clinical detail. Eighty-eight cases were recovered. Mean age was 75.4 years, with women predominating (57%). Thromboembolic occlusion was the leading cause, followed by thrombotic occlusion. Embolic sources included atrial disease, aortic disease and myocardial infarction. Patients routinely showed extensive comorbidities, especially cardiovascular. Pain was the most constant presenting symptom, but features were often subtle and clinicians frequently misdiagnosed more minor ailments. Of operated patients, 36% received operations within 6 h of admission, 33% within 24 h, 17% at between 1 and 2 days, and the remainder between 2 and 12 days. Knowledge of risk factors defined here is important to guide early diagnosis of mesenteric ischaemia. Diagnostic delay is again shown to be significant and case experience gathered in this series may improve doctors' discernment when meeting this condition.

Gemcitabine: vascular toxicity and prothrombotic potential

Background: Gemcitabine has been associated with important thrombotic and vascular side effects. As indications for its use in oncology and hematology are expanding, comprehensive characterization of these complications becomes imperative. Objective: This article reviews the prothrombotic potential and other vascular effects of gemcitabine and experience accrued through its use in research laboratories, clinical trials and clinical practice. Methods: The most relevant publications were identified through the PubMed database and by reviewing the drug information released by the FDA. Results/conclusions: In the author's opinion, the incidence of thrombotic and vascular toxicity with gemcitabine is higher than previously estimated. Venous thromboembolism (VTE) and acute arterial events, digital ischemia and necrosis, vasculitis and thrombotic microangiopathy, potentially fatal systemic capillary leak and reversible posterior leukoencephalopathy syndromes are only a few items on the long list of vascular–toxic effects of gemcitabine. These toxicities seem to be more frequent with the use of gemcitabine–platinum doublets than with gemcitabine alone. Careful consideration of gemcitabine use should be given in the setting of pre-existing arterial vascular disease, venous thromboembolism, collagenoses, heart failure, liver damage and advanced hepatic metastases. Specific treatment requirements of individual patients, their comorbidities and the gemcitabine risk:benefit ratio should be always sought before using this agent in antineoplastic therapy.

Acute painless paraparesis due to bilateral femoral artery occlusion

Acute peripheral arterial occlusion is a medical emergency manifesting with pain, pallor, absence of pulse, paralysis, and paresthesia. Neurological deficits have occasionally been described as the presenting symptoms of acute arterial ischemia. We report a patient with acute bilateral occlusion of the femoral arteries and an underlying severe atherosclerotic aorto-iliac disease who presented with acute painless paraplegia and anesthesia in the lower extremities. The patient underwent arterial thrombectomy of the right and left femoral artery, followed by angioplasty and stent insertion of the right and left common iliac artery within 5 h from the onset of his symptoms. Subsequent physical therapy resulted in rapid improvement in the strength of his lower extremities and the patient was able to walk unaided after two weeks.

Intestinale Ischämie – Chirurgische Sicht

In mesenteric ischemia, we are still facing the problem of late diagnosis: Only early start of therapy within the first 12 hours of symptom onset can reduce mortality rates below 50 percent. Most effective diagnostic tests are catheter-angiography with the option of therapeutic intervention and multi-slice computed tomography. As for treatment strategy reasons, acute arterial thrombosis and embolic ischemia should be regared separately from venous, non-occlusive (NOMI) and chronic mesenteric ischemia. Acute arterial ischemia is treated by immediate open exploration, revascularization and bowel resection. Venous ischemia is treated best by catheter anticoagulation, while in NOMI restoration of altered hemodynamics and selective vasodilatation is the therapy of choice. Late complications in mesenteric ischemia are malabsorption, bypass graft thrombosis and the small-bowel-syndrom, that can be solved in selected cases by small bowel transplantation.