Calcification Grade Research Articles

Failure of aneurysm sac shrinkage after endovascular repair; the effect of mural calcification

To evaluate the effect of abdominal aortic aneurysm wall calcification on subsequent sac shrinkage after endovascular repair. Seventy-three patients underwent endovascular aneurysm repair. The degree of sac wall calcification on pre-procedural computed tomography (CT) examination was graded from 1 to 4 according to the degree of circumferential involvement. On follow-up CT imaging, the maximum transverse diameter (MTD) of the sac was recorded, as well as the presence or absence of endoleak. In those patients with a non-shrinking aneurysm, but no CT evidence of endoleak, contrast-enhanced ultrasound (USS) was performed. Any patient with an endoleak, however diagnosed, was excluded from the study. Kruskal-Wallis and Spearman's rank correlation coefficient testing was applied to compare the degree of calcification and change in MTD. Sixty-three pre-procedural CT images were available for calcification grading. Six of this group had endoleaks resulting in 57 sets of data being available for the study. A reduction in MTD occurred in 68.25% of these patients by 1 year post-procedure. Our figures show aortic calcification is inversely associated with MTD reduction at 6 months (p = 0.01), 1 year (p = 0.05) and 2 years (p = 0.05). This study indicates that the degree of aortic wall calcification is significant in predicting MTD reduction post-endovascular repair. The possible mechanisms and implications of this are discussed.

Nephrogenic Fibrosing Dermopathy: A Review of the Massachusetts General Hospital Experience

We have undertaken a review of the Massachusetts General Hospital experience of nephrogenic fibrosing dermopathy (NFD). Twelve cases were identified, and the dermatopathologic features of lesional skin biopsies were examined. We looked systematically at nine parameters and graded each on a scale of 0 (minimal or none) to 3 (highest or most): 1) extent of fibrocytic proliferation, 2) extent of collagen thickening, 3) extent of vascularity, 4) extent of pannicular involvement, 5) extent of elastolysis, 6) presence of mucin, 7) presence of calcification, 8) presence of giant cells, and 9) presence of inflammation. Results demonstrate that fibrocytic proliferation, collagen thickening, inflammation, and vascularity most commonly were classified as grade 1–2; mucin deposition and elastolysis varied from 0–2; pannicular involvement ranged from 1–3; nearly all had calcification grade of 0, and there were no giant cells detected in any of the twelve cases. Comparing our results to published reports suggests that there are some interesting observations. Our cases tended to be less fibrocellular, have less mucin, and have more vascularity than the initial 14 cases described by Cowper et al (2001). The implications of the dermatopathologic findings for clinical course and prognosis are currently being evaluated.

Oral anticoagulant treatment: friend or foe in cardiovascular disease?

AbstractCalcification is a common complication in cardiovascular disease and may affect both arteries and heart valves. Matrix γ-carboxyglutamic acid (Gla) protein (MGP) is a potent inhibitor of vascular calcification, the activity of which is regulated by vitamin K. In animal models, vitamin K antagonists (oral anticoagulants [OACs]) were shown to induce arterial calcification. To investigate whether long-term OAC treatment may induce calcification in humans also, we have measured the grade of aortic valve calcification in patients with and without preoperative OAC treatment. OAC-treated subjects were matched with nontreated ones for age, sex, and disease. Calcifications in patients receiving preoperative OAC treatment were significantly (2-fold) larger than in nontreated patients. These observations suggest that OACs, which are widely used for antithrombotic therapy, may induce cardiovascular calcifications as an adverse side effect.

Association of pelvic arterial calcification with arteriovenous thigh graft failure in haemodialysis patients.

Arterial calcification is a common problem in patients with chronic kidney disease, and has been associated with adverse clinical outcomes. The goal of the present study was to evaluate whether pelvic artery calcifications are associated with technical failure of arteriovenous thigh grafts in haemodialysis patients. From 1 January 1999 to 30 June 2002, thigh grafts were placed in 54 haemodialysis patients who had exhausted all options for permanent vascular access in the upper extremities. Perioperative computed tomography (CT) of the abdomen and pelvis was obtained in 32 of the patients for diagnostic purposes unrelated to vascular access planning. Two radiologists, who were blinded to the graft outcomes, scored the vascular calcifications on CT of the distal aorta, common iliac, external iliac and common femoral arteries on a semi-quantitative 5-point scale. The association between technical graft failure (inability to complete the anastomosis) and the vascular calcification score was analysed. There was a high inter-observer agreement in scoring vascular calcification (kappa = 0.801). Among 26 patients with absent or mild pelvic arterial calcifications (grade 1-2) on CT, none (0%) experienced technical graft failure. In contrast, three of six patients (50%) with moderate to severe calcification (grade 3-5) had technical graft failures (P = 0.004 by Fisher's exact test). The cumulative 1 year graft patency was lower in the group with grade 3-5 calcification (33 vs 81%, P = 0.09). The two groups were similar in age, gender, race, diabetes, duration of dialysis, serum calcium, serum phosphorus and serum parathyroid hormone. There is a strong association between pelvic artery calcifications and technical failure of thigh grafts. The presence of moderate to severe vascular calcification is predictive of poor cumulative 1 year graft patency.

Carotid Artery Calcium: Accuracy of a Calcium Score by Computed Tomography—An In vitro Study with Comparison to Sonography and Histology

Objectives. The aim of this study was to compare methods of quantifying calcification of the internal carotid artery. Materials and methods. We examined 92 internal carotid artery endarterectomy specimens. Grey scale median (GSM) values were calculated from optimized B-mode scans. The degree of calcification was assessed using radiographic calcification grading. Plaques were processed histologically, and classified into: (1) calcium-rich hard plaques, (2) lipid-rich soft plaques, and (3) combined plaques. The specimens were scanned in CT-scanner. The calcium score was determined as described by Agatston. Results. Histopathology and GSM results concurred in 39 out of 92 cases (κ=0.088). There was no significant correlation between the calcium score and the median GSM value ( R=0.005; P=0.959). Histology and CT morphology showed a significant concordance ( P<0.001). Also CT and radiomorphological classification showed close agreement ( R=0.628, P<0.001). Conclusions. Calcium scores calculated using CT morphology enable precise in vitro evaluation of the calcium content of plaques in the internal carotid. In contrast, grey scale median values do not adequately reflect calcification of plaques.

Preoperative high-frequency duplex scanning of potential pedal target vessels.

The aim of this prospective study conducted at a tertiary referral center was to evaluate the efficacy of high-frequency duplex scanning in the preoperative evaluation of potential pedal target vessels. Material and methods The study population consisted of thirty-three consecutive diabetics suffering critical limb ischemia, with indications of infra-popliteal occlusive disease. Duplex ultrasound was performed by an angiologist unaware of any prior imaging procedures. The pedal vessels were divided into four segments. The inner diameter-, the grade of calcification (on a scale from 1-to-3), the maximal systolic velocity, and the resistance index ([V.max syst-V min syst]/V max syst), were assessed by using a 13-MHz probe, and the pedal target vessel best suited for surgery was identified. Results of duplex scanning were compared to (1) the results of selective digital subtraction angiography (DSA) and contrast-enhanced magnetic resonance angiography (CE-MRA) studies interpreted by two radiologists, (2) the site of distal anastomosis predicted by a vascular surgeon according to DSA and CE-MRA studies, (3) the definitive site of distal anastomosis, and (4) early postoperative results (patency at three months). Duplex scanning depicted significantly more pedal vascular segments than selective DSA- (P =.004, McNemar test). Agreement in predicting the site of distal anastomosis expressed as kappa value as follows: duplex versus DSA/CE-MRA, kappa 0.71;-DSA/CE-MRA versus definitive anastomosis, kappa 0.67; -and duplex versus definitive anastomosis kappa 0.82. Two patients were excluded from surgery as all three imaging modalities failed to demonstrate a pedal target vessel. Two patients had exploratory dissection of a pedal vessel (according to CE-MRA findings) that turned out to be occluded (as predicted by duplex scanning). In one patient the operation had to be terminated due to lack of autologous bypass material. In 31 patients who underwent pedal artery bypass, the resistance index could not be correlated to the run-off as assessed by intra-operative angiography. High-frequency duplex focusing on the vacular-morphology is a worthwhile diagnostic tool to evaluate-potential pedal target vessels and extremely helpful when contrast-related methods (selective DSA, CE-MRA) do not sufficiently depict the pedal vasculature.

Influence of commissural calcification on the immediate outcomes of percutaneous balloon mitral valvuloplasty

Objectives — To evaluate the impact of mild to moderate commissural calcification on the immediate outcomes of percutaneous balloon mitral valvuloplasty (PBMV).Methods and results — We analysed the results of 223 consecutive patients (mean age 37.6±8.7 years) who underwent PBMV for rheumatic mitral stenosis. Commissural calcification was identified with a two-dimensional echocardiography (echo) in 65 (29.1%) patients with the severity of calcification being graded from 0-3.The anatomy and function of the mitral valve were assessed by Wilkins echo score. In patients with no commissural calcification the increase in mitral valve area after PBMV was 0.90±0.42 cm2, which was greater than the increase in those with calcification grade 1 (0.83± 0.42 cm2, p<0.05), grade 2 (0.72±0.38 cm2, p<0.05) and grade 3 (0.63±0.13 cm2, p<0.05). In patients with an echo score of ≤8, the presence of commissural calcification was associated with a smaller increase in mitral valve area (p<0.05) and a smaller reduction in New York Heart Association (NYHA) function class after PBMV (p<0.05). In patients with an echo score of more than 8, commissural calcification had no significant effect on the valve area increase and NYHA function class reduction (p>0.05).Conclusions — Commissural calcification has an adverse effect on the clinical results of PBMV. Detailed pre-procedural assessment of commissural calcification with echocardiography must be performed to provide background information on the immediate outcomes of PBMV.

Extracoronary atherosclerotic plaque at multiple sites and total coronary calcification deposit in asymptomatic men. Association with coronary risk profile.

Recent studies have suggested that knowledge of the extent of subclinical atherosclerosis may improve prognostic information in subjects at risk of cardiovascular disease. Therefore, we tested the value of extracoronary plaque detected with echography at multiple sites and that of total coronary calcification deposit evaluated with ultrafast computed tomography for predicting the risk of coronary events estimated on the basis of traditional risk factors. We analyzed in 618 asymptomatic at-risk men the extent of extracoronary atherosclerosis, as assessed with ultrasound imaging of carotid, aortic, and femoral sites and coded as number of disease sites (none, one, two, or three) on the basis of the presence of plaque at each site, and the amount of total coronary calcification deposit, as evaluated with ultrafast computed tomography and coded as grade 0, 1, 2, or 3 on the basis of the determination of a total coronary calcium score. Concomitantly, age, systolic pressure, total and HDL cholesterol levels, current smoking, presence of diabetes, and presence of ECG left ventricular hypertrophy (ECG-LVH) were evaluated with the goal of estimating coronary risk with the use of the Framingham Study risk algorithm. The prevalence rates of at least one extracoronary disease site and coronary calcification (any grade) were high (72% and 63%). There was a strong association between the number of extracoronary disease sites and the grade of coronary calcification (P < .001). As the number of extracoronary disease sites increased, age, systolic pressure, smoking frequency, and number of risk factors increased (P < .001). As the grade of coronary calcification increased, age and systolic pressure increased (P < .001), as did the number of risk factors (P < .01). The estimated coronary risk increased with the number of extracoronary disease sites and the grade of coronary calcification (P < .001). The odds ratio of coronary risk between three and no extracoronary disease site was 2.37 (95% confidence interval [CI], 1.08 to 5.21), whereas that between grade 3 and grade 0 of coronary calcification was 1.79 (95% CI, 0.94 to 3.40). In an apparently healthy population, the extracoronary atherosclerotic burden as measured with multiple-site echography appears to be more powerful than the ultrafast computed tomography-detected coronary calcium burden in reflecting the multifactorial coronary risk profile. However, only men were included in the present study, and the present findings cannot be extrapolated to women.

Clinical and haemodynamic features in relation to severity of aortic stenosis in adults

The main symptoms of aortic stenosis (AS), angina pectoris, dyspnoea, and syncope/effort dizziness, are thought to reflect the severity of AS. This assumption is based on studies in relatively young patients, and may not apply to older age groups. Thus, in 100 consecutive adults (age 41-79 years) referred to cardiac catheterization with suspected AS, clinical and haemodynamic variables were assessed in relation to significant (less than or equal to 0.50 cm2 m-2) (n = 70) and nonsignificant AS (n = 30), and to symptoms. Prevalence of symptoms, functional class, and systolic murmur grade greater than or equal to 3, was similar in the groups. However, patients with significant AS more often had an abnormal second heart sound, electrocardiographic left ventricular (LV) hypertrophy with strain, severe echocardiographic aortic valve calcification, and increased LV wall thickness. Multivariate analysis identified an abnormal second heart sound, and aortic calcification grade, as independent predictors of significant AS. When the Doppler mean gradient was added to the analysis, it became the best predictor. Angina pectoris (n = 74) was related to coronary artery disease, but not to severity of AS. However, 31% of patients without angina also had coronary artery disease. Dyspnoea (n = 69) was only related to age, and syncope/effort dizziness (n = 26) was more frequent in women. Functional class grade was not related to severity of AS. Thus, in adults with assumed symptomatic AS, clinical symptoms do not predict severity of AS. Therefore, the decision for valve replacement should rely on Doppler assessment of the severity of AS. Furthermore, in adults with AS, coronary artery disease cannot be excluded without selective coronary angiography.

A comparative study of atherosclerosis and osteopenia in elderly and young hemodialysis patients

The effects of aging on atherosclerosis and osteopenia in hemodialysis patients were investigated. Eighty patients on maintenance hemodialysis were subdivided according to age into old (greater than or equal to 65 years old, N = 40) and young (less than 65 years old, N = 40). Biochemical, radiologic, and biophysical studies were performed in each patient to assess the degree of atherosclerosis and osteopenia. Compared to age-matched controls, patients in the old group exhibited a significantly higher aortic pulse wave velocity (PWV), and old female patients had a significantly lower bone mineral content/bone width (BMC/W). Elderly patients also had a significantly higher aortic PWV and higher grade of aortic calcification as assessed radiologically; in contrast, the BMC/W was lower. Concerning sex differences, elderly male patients had the highest average grade of aortic calcification, the lowest serum Pi, [Ca] x [Pi], and immunoreactive parathyroid hormone concentrations, while elderly female patients had the lowest BMC/W and highest incidence of osteopenia. These observations suggest that elderly male hemodialysis patients are more prone to develop atherosclerosis and elderly female hemodialysis patients to develop advanced osteopenia.

Mitral balloon valvuloplasty for mitral restenosis after surgical commissurotomy

Mitral balloon valvuloplast was performed in 14 patients with recurrent mitral stenosis 16.9 ± 1.8 years (range 6 to 30) after surgical commissurotomy. There were 13 women and 1 man with a mean age of 55 ± 4 years (range 23 to 73). Mitral balloon valvuloplasty resulted in an increase in mitral valve area from 0.8 ± 0.1 to 1.7 ± 0.2 cm2(p = 0.001), a decrease in mean mitral diastolic pressure gradient from 15 ± 2 to 7 ± 1 mm Hg (p = 0.001) and an increase in cardiac output from 3.4 ± 0.3 to 3.9 ± 0.3 liters/min (p = 0.03). No deaths, strokes, vascular complications or conduction abnormalities were observed. Mitral regurgitation developed or increased in severity in seven patients (50%). There was no evidence of significant left to right shunt through the atrial septal puncture site after mitral balloon valvuloplasty.A good result (defined as a mitral valve area >1.0 cm2, an increase in mitral valve area >25% and a mean gradient <10 mm Hg) was achieved in 9 (64%) of the 14 patients. A subgroup of four patients who had a superior result (increase in mitral valve area of 1.7 ± 0.2 versus 0.5 ± 0.1 cm2in the other 10 patients, p = 0.004) was identified. These patients had less echocardiographic evidence of rheumatic mitral valve damage and were the only patients who had sinus rhythm. They were also younger1, less debilitated and had a lower grade of fluoroscopic valve calcification compared with the other patients.Thus, mitral balloon valvuloplasty is a safe and effective procedure for patients with recurrent mitral stenosis after surgical commissurotomy. A subgroup of younger patients, who have sinus rhythm and less echocardiographic evidence of rheumatic mitral valve damage, has the best outcome with mitral balloon valvuloplasty.

Experimental evaluation of porcine-valved conduits processed with a calcium-retarding agent (T6)

The effectiveness of a water-soluble C-12 alkyl sulfate (T6) (U.S. Patent No. 4,323,358) in retarding bioprosthetic calcification was evaluated in 23 porcine-valved conduits (13 T6-treated conduits and 10 controls) implanted in young sheep between the right ventricle and the pulmonary trunk. The grafts were divided into three groups according to the period of function: Group I, less than 2 months; Group II, 2 to 4 months; and Group III, 5 to 7 months. In Group I (four T6 and four controls), endocarditis occurred in five cases. In Group II (three T6 and three controls), four conduits showed severe fibrous peel ingrowth. In Group III (six T6 and three controls), fibrous peel was the main feature in four conduits and calcium deposits occurred in the porcine aortic wall in all cases, with cusp involvement in two; in both T6-treated and control conduits, chemical analysis showed a much lower calcium content of the cusps (8.45 +/- 80 versus 2.95 +/- 1.52 mg/gm dry weight, respectively) than that reported in other animal or human explants. The grade of calcification in control and T6-treated conduits was equal on x-ray analysis, and no differences in calcification patterns were noted on electron microscopy. This experimental model shows a low degree of cusp calcification and no significant differences between T6-treated and control conduits. Peel formation markedly interferes with performance of the porcine-valved conduit. The results of this analysis indicate that valved conduits are not the optimum model for evaluating calcium-retardant agents in biological valves.

CALCIFICATION IN BREAST ARTERIES

94 breast specimens without malignant changes, from women 30-89 years of age, were investigated for arterial calcification, graded in three degrees. In 40 specimens calcification of the vessels was found. The frequency of calcified vessels and the three grades of calcification varied with age, grade I predominating in the medium age-groups and grade III dominating in the oldest age-groups. It is concluded that calcification of breast arteries is a frequent degenerative age-related change, most severe in the oldest age-groups.

"Hormone receptor diseases" in Japan: A nation-wide survey for testicular feminization syndrome, pseudohypoparathyroidism, nephrogenic diabetes insipidus, Bartter's syndrome and congenital adrenocortical unresponsiveness to ACTH (author's transl)

A nation-wide survey for five "hormone receptor diseases" was carried out. For the first survey, an inquiry was sent to all hospitals in Japan having more than 200 beds, in order to determine how many patients there were between 1968-1977. A further detailed survey was carried out on patients who were reported in the first survey. The approximate numbers of patients in Japan estimated from these surveys are the following: testicular feminization syndrome (TFS), 390; pseudohypoparathyroidism (PHP), 220, nephrogenic diabetes insipidus (NDI), 280; Bartter's syndrome, 90; congenital adrenocortical unresponsiveness to ACTH (CAUA), 18. In 73 cases of TFS, partial virilization was observed in 23% (the incomplete form). Testes were found in all cases and the epididymis in 84%, whereas none of the patients had seminal vesicles. PHP consisted of 38 Type-I cases, 6 Type-II cases and 25 unclassified cases. There were 27 males and 42 females. Skeletal anomalies were found in two-thirds of the patients. Grades of hypocalcemia and soft tissue calcification were more prominent in Type I. After treatment, none of the Type-I patients showed normal urinary cyclic AMP response to parathormone, although urinary phosphate response was normalized in one and markedly improved in 4. In 78 patients with NDI, there were 67 males and 11 females. The age of the onset of NDI ranged from 0 to over 50, but 22 out of 29 cases of hereditary NDI had the onset at age 0. There seemed to be at least two subtypes; one beginning in the neonatal period or early childhood, and the other having the onset in late childhood or adult. The important initial symptoms were fever and anorexia in the early onset type. Growth retardation was remarkable in early childhood. Diuretics were effective in most of the cases. There were 22 male and 12 female patients with Bartter's syndrome. Indomethacin was effective in 9 out of 10 patients studied.

An Unusual Malformation of the Forebrain and Concomitant Destructive Encephalopathy with Calcifications

A 9-year old boy with profound mental retardation and severe neurologic deficit presented an unusual malformation of the forebrain distinguished by the following features: 1) microtelencephalon, alobulation, afissuration, and abnormal convolutional pattern; 2) persistence of hippocampal formation at its embryonic site in the dorsomedial wall of the telencephalon; 3) hypoplasia and abnormal configuration of ventricles; 4) agenesis of cerebral commissures; and 5) abnormal location and orientation of gray structures. Important concomitant findings characterized by severe destructive lesions, massive calcification, granular ependymitis, and low grade inflammation were suggestive of late sequelae of an infectious process, possibly congenital. Transplacental transmission of an unidentified pathogen with teratogenic properties was hypothesized as the probable cause. The teratogenic insult started in an early embryonic period and affected primarily the development of the neopallium in the telencephalic wall. The arrested development of the neopallium disrupted the chain of interdependent developmental events; consequently characteristic morphological modifications normally induced by the continuous growth and differentiation of the neopallium failed to occur or took an abnormal course. The name architelencephalon (Greek: arche, beginning; telencephalon, cerebral hemispheres) proposed for this particular malformation of the forebrain indicates its resemblance both to the human brain at early stages of development and also to mammalian brains on a lower level of phylogeny. Associated anomalies included an unilateral microphthalmia with cataract, severe stenosis of the aqueduct of Sylvius and macrocephaly. The microphthalmia was either a developmental anomaly or was infectious in origin. The stenosis of the aqueduct was attributed to granular ependymitis. Tearing of the thin dorsal diencephalic plate and arachnoid membrane and escape of the cerebrospinal fluid into the subdural space probably accounted for the macrocephaly.

冠状動脈硬化と年齢

Atherosclerotic change of coronary artery was examined with reference to advancing age in autopsied materials obtained at Tokyo Medical Examiner's Office (a forensic institute) and Harunaso Hospital (a geriatric hospital). Severity of atherosclerosis was evaluated by two methods. One is measurement of the surface involvement stained by Sudan 4 and the other is estimation of grade of arterial luminal narrowing.Fatty streaks mostly appeared in the third decade, but the affected area was limited and did not enlarge with age. Fibrous plaque mostly appeared in the fourth decade and increasd in area and severity with advancing age. Narrowing of the coronary arterial lumen by more than 50% was found to become prominent in the sixth decade, reaching the highest level in the seventh and eighth decade. Grade of coronary calcification detected by super-soft X ray had a good correlation with the arterial luminal stenosis. Myocardial infarction is associated with the most severe atherosclerosis.

ANGINA PECTORIS—TRUE AND FALSE.

True angina pectoris is, comparatively speaking, an uncommon condition. The mechanism involved in its pathogenesis is imperfectly understood, and the views found recorded on the subject in medical literature are, for the most part, hypothetical. Two facts, however, are generally accepted: First, that structural changes of the cardio-vascular system are present in the immense majority of cases, the chief among them being arterial sclerosis, especially of the coronaries, aortic regurgitation, aortitis (syphilitic?), hypertrophy, aortic aneurism, adherent pericardium and myocardial degeneration—fatty and fibroid. These lesions may be variously combined and the instances in which a certain grade of calcification of the coronary arteries and root of the aorta, associated with more or less myocardial degeneration, has not been found in evidence postmortem, are of rare occurrence. The second fact which passes current is that irritation or disturbance of the cardiac sensory nerves exists. Unfortunately most of the leading theories concerning the