Catheter-based Angiography Research Articles

Iatrogenic cervical artery dissections during endovascular interventions.

Iatrogenic cervical artery dissection (CeAD) results from various procedures including interventional angiographic procedures and diagnostic angiography. Iatrogenic CeAD is rare, resulting in limited literature on management and outcomes. This observational cohort study investigates approaches and outcomes of iatrogenic CeAD after endovascular interventions. We conducted a retrospective review for patients who underwent endovascular intervention with resulting iatrogenic CeAD at Mayo Clinic, Rochester, MN, from 1998 to 2021. Pertinent patient factors were extracted and descriptive statistics generated. Between 1998 and 2021, 21,191 patients underwent catheter-based cerebral angiography. Thirty-two had iatrogenic CeADs (23 women; median age 59 [range 40.5-92.9]). Common comorbidities included hypertension (62.5%), smoking (56.3%), and hyperlipidemia (46.9%). Nine (28.1%) had dissection with diagnostic angiograms, 6 (18.8%) endovascular thrombectomy, 15 (46.9%) intracranial aneurysm treatment/coiling, and 2 (6.3%) intracranial angioplasty with/without stenting. All dissections were diagnosed by cerebral angiography during the same session as initial interventions. Four (12.5%) underwent hyperacute stenting. Thirty (93.7%) were placed on antithrombotic therapy with aspirin alone (34.4%) or dual-antiplatelet therapy with aspirin and clopidogrel (37.5%). Median duration of acute treatment was three months. Follow-up imaging showed excellent radiological course. Iatrogenic CeAD with endovascular interventions is rare and typically benign. Most are managed medically without complications or long-term negative outcomes. Oral single or dual-antiplatelet therapies are preferred compared to previous studies which emphasize intravenous anticoagulation. The duration of acute therapy varied from three months to lifelong. Key factors influencing clinical decision-making may include occlusion rate, pseudoaneurysm formation, intracranial extension, distal collateral circulation, and resultant ischemia.

Indirect bypass surgery as a line of management of pediatric moyamoya disease

Moyamoya disease (MMD) is a chronic, rare cerebrovascular disorder of unknown cause featured by extensive narrowing of the terminal internal carotid artery (ICA) and its main branches. As a compensatory mechanism, perforators dilate forming fragile collateral vessels that appear as an abnormal vascular network resembling ‘puff of smoke drifting in the air’ observed via angiography around stenotic area in the brain.Patients and methodsThe database of the current hospital was retrospectively studied. All patients with ischemic strokes owing to MMD treated with surgical revascularization between January 2015 and December 2022 were included. MMD was identified on catheter-based digital subtraction angiography (DSA) by the presence of stenosis at the terminal portions of both internal carotid arteries and the development of abnormal collateral “moyamoya vessels” around the base of the brain. Clinical, radiological and follow-up data were retrospectively analyzed.ResultsDuring the mentioned time window, nine patients were diagnosed with moyamoya disease among all pediatric patients with established diagnosis of ischemic stroke in our institute; six of them underwent surgery. Unilateral EDMS was performed in 5 cases (83.3%), while one patient (16.67%) underwent staged bilateral surgeries with no added neurological deficit.ConclusionIndirect revascularization surgery for pediatric moyamoya-related stroke patients has high rates of reperfusion and promising outcomes.

Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review.

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

107 Conventional Catheter-based Angiography Versus Non-invasive Imaging in the Evaluation of Symptomatic Carotid Disease

INTRODUCTION: The indication for invasive treatment of symptomatic carotid disease with CEA or carotid stenting was established based on catheter digitally subtracted imaging (DSA) however operative referral for symptomatic carotid disease is still largely based on non-invasive imaging such as CTA or ultrasound. METHODS: Retrospective analysis all consecutive patients who were referred for evaluation and treatment of symptomatic carotid disease after non-invasive imaging with CTA or ultrasound showed ipsilateral carotid stenosis of >50% or occlusion. Patients were included if they had ipsilateral cerebral or ocular ischemia within two weeks of index event. RESULTS: A total of 280 patients with stenosis >50 and <100% were included. Of those, 53 (19%) were found to have stenosis <50% leading to treatment with best medical therapy instead of intervention. Out of 50 patients with total occlusion, 16 (32%) were found to have a string sign and were treated with stenting. Percent stenosis of 80 or more on non-invasive imaging was more likely to correlate with stenosis of 50% or more on DSA. CONCLUSIONS: In a cohort of two large North American institutions, 19% of patients referred for revascularization of symptomatic carotid disease based on non-invasive imaging were found to have non-significant carotid stenosis and were treated with best medical therapy and 32% of those with suspected occlusion were successfully revascularized. Our findings highlight the importance of catheter cased angiography in the evaluation of carotid disease.

Vascular Myelopathies.

Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.

Real-time multi-contrast magnetic particle imaging for the detection of gastrointestinal bleeding

Gastrointestinal bleeding, as a potentially life-threatening condition, is typically diagnosed by radiation-based imaging modalities like computed tomography or more invasively catheter-based angiography. Endoscopy enables examination of the upper gastrointestinal tract and the colon but not of the entire small bowel. Magnetic Particle Imaging (MPI) enables non-invasive, volumetric imaging without ionizing radiation. The aim of this study was to evaluate the feasibility of detecting gastrointestinal bleeding by single- and multi-contrast MPI using human-sized organs. A 3D-printed small bowel phantom and porcine small bowel specimens were prepared with a defect within the bowel wall as the source of a bleeding. For multi-contrast MPI, the bowel lumen was filled with an intestinal tracer representing an orally administered tracer. MPI was performed to evaluate the fluid exchange between the vascular compartment of the bowel wall and the lumen while a blood pool tracer was applied. Leakage of the blood pool tracer was observed to the bowel lumen. Multi-contrast MPI enabled co-registration of both tracers at the same location within the bowel lumen indicating gastrointestinal bleeding. Single- and multi-contrast MPI are feasible to visualize gastrointestinal bleeding. Therefore, MPI might emerge as a useful tool for radiation-free detection of bleeding within the entire gastrointestinal tract.

The renal outcome post contrast exposure in patient with diabetes and SGLT2 inhibitor

Abstract Introduction Contrast-induced nephropathy (CIN) is increasingly prevalent as the increased age and comorbidities. Though most CIN can be reversible, some may progress to acute kidney disease (AKD) and subsequent chronic kidney disease (CKD)1-3. Sodium–glucose cotransporter-2 (2SGLT) inhibitor has been known to bring better renal outcomes 4-7. However, whether it affect contrast-induced kidney injury is not known well. we Purpose We aimed to investigate the renal outcomes post-contrast exposure in patients with diabetes and SGLT2 inhibitor. Materials and methods We used the Taipei Medical University Clinical Research Database (TMUCRD), composed of clinical data from 3 teaching hospitals. which stores electronic health data of 3 million patients. Patients with diabetes and exposure to contrast in CT-imaging studies or catheter-based angiography from 2016 to 2020 were included. The primary outcome was major kidney adverse event (MAKE), which included acute kidney disease (AKD), chronic kidney disease (CKD), renal replacement therapy (RRT), new onset of urinary albumin-creatinine ratio (uACR), eGFR decline ≥ 40% and all-cause mortality. We used overlap weighting to reduce confounding factors, as in observational studies. Results A total of 12,421 patients were included in this study, of them, 920 and 11501 patients were categorized to SGLT2 inhibitor users and non SGLT2 inhibitor users, respectively. SGLT2 inhibitor user had lower MAKE risk as compared with non-SGLT2 inhibitor i user (incidence rate: 37.9 v.s. 53.4 per 1,000 person months, P value = 0.0002) after exposure to contrast media. The incidence rate of AKD, CKD, and eGFR decline ≥ 40% were significantly lower in SGLT2 inhibitor user. However, there were no significantly different in the risk of RRT, new onset of uACR or all-cause mortality. Conclusions In this retrospective cohort study, we found that SGLT2 inhibitor user was associated with lower MAKE comparing with non-SGLT2 inhibitor user after contrast exposure in patients with diabetes.Outcomes of DM patients with PCI or contKaplan-Meier plot of major adverse kidne

High-resolution computed tomography angiography of the orbit using a photon-counting computed tomography scanner.

Recent introduction of photon counting detector (PCD) computed tomography (CT) scanners into clinical practice further improve CT angiography (CTA) depiction of orbital arterial vasculature compared to conventional energy integrating detector (EID) CT scanners. PCD-CTA of the orbit can provide a detailed arterial roadmap of the orbit which can de diagnostic on its own or serve as a helpful planning adjunct for both diagnostic and therapeutic catheter-based angiography of the orbit. For this review, EID and PCD-CT imaging was obtained in 28 volunteers. The volume CT dose index was closely matched. A dual-energy scanning protocol was used on EID-CT. An ultra-high-resolution (UHR) scan mode was used on PCD-CT. Images were reconstructed at 0.6 mm slice thickness using a closely matched medium-sharp standard resolution (SR) kernel. High-resolution (HR) images with the sharpest quantitative kernel were also reconstructed on PCD-CT at the thinnest slice thickness of 0.2 mm. A denoising algorithm was applied to the HR image series. The imaging description of the orbital vascular anatomy presented in this work was derived from these patients' PCD-CTA images in combination with review of the literature. We found that orbital arterial anatomy is much better depicted with PCD-CTA, and this work can serve primarily as an imaging atlas of the normal orbital vascular anatomy. With recent advances in technology, arterial anatomy of the orbit is much better depicted with PCD-CTA as opposed to EID-CTA. Current orbital PCD-CTA technology approaches the necessary resolution threshold for reliable evaluation of central retinal artery occlusion.

Complication Rates Following Cerebral and Coronary Angiography: Nationwide Analysis 2008-2014.

Catheter-based angiography is an essential procedure for the diagnosis and treatment of vascular complications in patients. Since cerebral and coronary angiography are similar techniques that utilize the same access sites and general principles, the associated risks overlap and should be identified to help direct patient care. The purpose of this study was to determine complication rates in a combined cohort of cerebral and coronary angiography patients, as well as conduct a comparative analysis of coronary and cerebral angiography complications. The National Inpatient Sample was queried from 2008 to 2014 to identify patients who underwent coronary or cerebral angiography. After assessment of baseline characteristics, complication rates, and disposition in the combined cohort, propensity matching was utilized to create sub-cohorts of coronary and cerebral angiography patients based on demographics and comorbidities. Comparative analysis of procedural complications and disposition was then performed. A total of 3,763,651 hospitalizations were included in our study cohort (3,505,715 coronary angiographies and 257,936 cerebral angiographies). The median age was 62.9 years, with females being 46.42%. The most prevalent comorbidities in the overall cohort were hypertension (69.92%), coronary artery disease (69.48%), smoking (35.64%), and diabetes mellitus (35.13%). Propensity matching demonstrated that the cerebral angiography cohort had lower rates of acute and unspecified renal failure (5.4% vs 9.2%, OR 0.57, 95% CI, 0.53-0.61, P < 0.001), hemorrhage/hematoma formation (0.8% vs 1.3%, OR 0.63, 95% CI, 0.54-0.73, P < 0.001), and equivalent rates of retroperitoneum hematoma formation (0.03% vs 0.04%, OR 1.49, 95% CI, 0.76-2.90, P = 0.247) and arterial embolism/thrombus formation (0.3% vs 0.3%, OR 1.01, 95% CI, 0.81-1.27, P = 0.900). Our study showed both cerebral and coronary angiography have generally low rates of procedural complications. Matched cohort analysis demonstrated that cerebral angiography patients are at no greater risk for complications than coronary angiography patients.

Head and neck angiography in the pediatric population: single-center experience with indications, safety, feasibility, and technical differences among infants, childhood, and adolescents.

Pediatric patients are candidates for head and neck endovascular procedures less frequently than adults. Data on utilization, feasibility, safety, and technical details of head and neck angiography in the pediatric population are scarce. The authors performed a retrospective review of their center's endovascular database to identify all patients ≤ 18 years of age who underwent diagnostic or interventional catheter-based angiography of the head and neck. Procedure-related variables for identified patients were compared across infancy (birth to 2 years), childhood (> 2-11 years), and adolescence (> 11-18 years). One hundred twenty-one pediatric patients who underwent 274 angiogram procedures were included in this study. Of these angiograms, 197 were diagnostic and 118 were interventional (including 41 of the diagnostic angiogram procedures that were performed concurrently with the intervention). The most common indications for diagnostic angiograms were suspected vascular malformations in 52 cases (26.4%) and aneurysms in 23 (11.7%). The rate of positive findings on diagnostic angiograms ranged from 27.3% to 80% according to the indication. Access site-related complications were observed after 2 punctures (0.7%). Procedure-related complications occurred in 3 patients (1.1%). In adolescents, the rates of general anesthesia use and sheathless access were significantly lower (each p < 0.001), and the rates of radial artery access (p < 0.001); 5-French (5F) (p = 0.01), 6F (p < 0.001), and 8F (p = 0.03) access; and closure device usage (p < 0.001) were significantly higher. In infants, the rates of ultrasound guidance, 4F access, and failure of the primary puncture site were significantly higher (each p < 0.001). Head and neck angiograms in the pediatric population were feasible and safe in the authors' overall experience. Technical differences were observed across the infant, childhood, and adolescent groups, but safe outcomes were similar throughout these age ranges.

High diagnostic performance of time-resolved MR angiography in spinal arteriovenous shunts

Background and purposeIn comparison with the limited efficacy of conventional MR imaging and the invasiveness of catheter-based digital subtraction angiography (DSA), time-resolved MR angiography (TR-MRA) has been proposed as a promising examination for early diagnosis of spinal arteriovenous shunts (SAVSs). This paper aims to investigate the diagnostic performance of TR-MRA with scan parameters optimized for SAVSs evaluation in a large number of patients. MethodsOne hundred patients with suspected SAVSs were enrolled. Each patient underwent preoperative TR-MRA with optimized scan parameters followed by DSA. The presence or absence of SAVS, the types and the angioarchitecture of SAVSs in the TR-MRA images were diagnostically analyzed. ResultsAmong the final 97 patients, 80 cases (82.5 %) were diagnosed and classified by TR-MRA as spinal cord arteriovenous shunts (SCAVSs; n = 22), spinal dural arteriovenous shunts (SDAVSs; n = 48), and spinal extradural arteriovenous shunts (SEDAVSs; n = 10). The agreement for classifying SAVSs between TR-MRA and DSA was excellent (κ = 0.91). The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA for the diagnosis of SAVSs were 100 % (95 % CI, 94.3–100.0 %), 76.5 % (95 % CI, 49.8–92.2 %), 95.2 % (95 % CI, 87.6–98.5 %), 100 % (95 % CI, 71.7–100.0 %), and 95.9 % (95 % CI, 89.9–98.4 %). The accuracy rates of TR-MRA for the detection of feeding arteries were 75.9 %, 91.7 %, and 80.0 % for SCAVSs, SDAVSs, and SEDAVSs respectively. ConclusionTime-resolved MR angiography showed excellent diagnostic performance for SAVSs screening. Additionally, this method can classify SAVSs and identify feeding arteries in SDAVSs with high diagnostic accuracy.

Prevalence and clinical characteristics of renovascular hypertension associated with fibromuscular dysplasia in China.

The aim of this study was to investigate the clinical characteristics of renal artery fibromuscular dysplasia (FMD) in patients in China and identify the cure rate of hypertension after angioplasty. Consecutive hypertensive patients with renal artery stenosis caused by FMD who underwent catheter-based angiography, and were followed at two Chinese referral centres, were retrospectively analysed. All patients underwent a detailed investigation, including demographic characteristics, clinical characteristics, biochemical sampling, Doppler ultrasonography of carotid arteries, magnetic resonance angiography (MRA) of the intracranial artery, and CTA or MRA of the abdominal artery and catheter-based renal angiography. Patients were routinely followed up at 1 month, 6 months and every year after the procedure. Among 245 study participants, with a mean diagnosed age of 26.9 ± 9.9 years, 137 (55.9%) were women, and 38 (15.5%) were children. All patients were diagnosed with hypertension at a mean age of 23.4 ± 8.4 years. There were 73.5% focal and 15.2% multivessel cases. Aneurysms, arterial dissections and total occlusions were found in 21.6, 4.1 and 12.2% of patients, respectively. Patients with multifocal FMD were older (26.0 vs. 23.7 years, P = 0.021) and more often female (70.8 vs. 50.6%, P = 0.004). Among children with renal FMD, 55.2% were men, and 86.8% were focal. After a median follow-up of 7.0 years, multifocal FMD had a higher cure rate of hypertension than focal FMD after revascularization (71.7 vs. 55.8%, P = 0.032). In a cohort of mostly young Chinese patients, the prevalence of hypertension associated with renal FMD is similar in both sexes. Focal FMDs were more frequent than the multifocal ones and, after angioplasty, were associated with a worse blood pressure outcome.

PS-C34-12: MAJOR CLINICAL CHARACTERISTICS OF RENAL ARTERY FIBROMUSCULAR DYSPLASIA IN CHINESE HYPERTENSIVE PATIENTS

Background: Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease that most commonly affects renal arteries. There is growing awareness of this disease entity. However, most of the previous studies have been from US or European populations. Methods: Consecutive hypertensive patients with renal artery stenosis caused by FMD underwent catheter-based angiography, followed at two Chinese referral centers in China between January 2000 and December 2021. Results: Of 245 study participants, with a mean diagnosed age of 26.9 ± 9.9 years, 137 (55.9%) were female, 38 (15.5%) were children. All patients had diagnosed hypertension at a mean age of 23.4 ± 8.4 years. 73.5% were focal and 15.2% were multivessel. Aneurysms, arterial dissections, and total occlusions were found in 21.6%, 4.1% and 12.2% of patients, respectively. Patients with multifocal FMD, compared to those with focal FMD, were older (26.0 vs.23.7 years, P = 0.021) and more often female (70.8% vs. 50.6%, P = 0.004), had a higher proportion of renal artery dissection (9.2% vs. 2.2%, P = 0.014), lower proportion of kidney atrophy (18.5% vs.31.1%, P = 0.013), and had fewer antihypertensive drugs (1.7 vs. 2.1, P = 0.002). After a median of 6.9 years follow-up, multifocal FMD had a higher cure rate of hypertension than focal FMD after revascularization (71.2% vs.55.2%, P = 0.033). Conclusions: Chinese patients with renal artery FMD had different characteristics from Caucasians, especially in adults. In Chinese, renal artery FMD occurred primarily in the young hypertensive patients with little sex predilection, and was frequently focal, which showed a worse blood pressure outcome than multifocal.

Quantitative magnetic resonance angiography as an alternative imaging technique in the assessment of cerebral vasospasm after subarachnoid hemorrhage.

The major mechanism of morbidity of delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is considered to be severe vasospasm. Quantitative MRA (QMRA) provides direct measurements of vessel-specific volumetric blood flow and may permit a clinically relevant assessment of the risk of ischemia secondary to cerebral vasospasm. To evaluate the utility of QMRA as an alternative imaging technique for the assessment of cerebral vasospasm after SAH. QMRA volumetric flow rates of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were compared with vessel diameters on catheter-based angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of QMRA for detecting cerebral vasospasm was determined by receiver-operating characteristic curves. Spearman correlation coefficients were calculated for QMRA flow versus angiographic vessel diameter. Sixty-six vessels (10 patients) were evaluated with QMRA and catheter-based angiography. The median percent QMRA flow of all vessels with angiographic vasospasm (55.0%, IQR 34.3-71.6%) was significantly lower than the median percent QMRA flow of vessels without vasospasm (91.4%, IQR 81.4-100.4%) (p < 0.001). Angiographic vasospasm reduced QMRA-assessed flow by 23 ± 5 (p = 0.018), 95 ± 12 (p = 0.042), and 16 ± 4 mL/min (p = 0.153) in the ACA, MCA, and PCA, respectively, compared to vessels without angiographic vasospasm. The sensitivity, specificity, PPV, and NPV of QMRA for the discrimination of cerebral vasospasm was 84%, 72%, 84%, and 72%, respectively, for angiographic vasospasm >25% and 91%, 60%, 87%, and 69%, respectively, for angiographic vasospasm >50%. The Spearman correlation indicated a significant association between QMRA flows and vessel diameters (rs = 0.71, p < 0.001). Reduction in QMRA flow correlates with angiographic vessel narrowing and may be useful as a non-invasive imaging modality for the detection of cerebral vasospasm after SAH.

Visceral artery aneurysms - review

Introduction: Visceral artery aneurysms remain a rare condition. A rupture is the dangerous complication, which occurs in about 10-20% of the cases, they have a high mortality rate estimated up to 70%. Rupture percentage is higher in pregnancy, up to 50%, with considerable mortality rates of 75% for the pregnant and 95% for the foetus. The most common location of abdominal aneurysm is splenic artery with prevalence of 60% out of visceral aneurysms affecting this vessel. Since they are asymptomatic in 95% of cases, they are usually a random finding of examinations performed for other indications. &#x0D; State of knowledge: Patients with a suspected visceral aneurysm are qualified for ultrasound as the first line examination, but currently computed tomography is the most favourable method. Catheter-based angiography is considered to be the gold standard. It allows precise identification of the location of aneurysm and its morphology. For the treatment of visceral artery aneurysms numerous ways are available, however the endovascular method is recommended as the first choice in most cases.&#x0D; Conclusions: Visceral artery aneurysms are a rare but potentially fatal pathology. The silent nature makes it difficult to diagnose. When recognised, aneurysms should be treated immediately, since rupture is associated with a considerable high mortality rate. Open and endovascular interventions are equally durable for elective repair of visceral artery aneurysms, but endovascular interventions are considered to be safe and effective, resulting in lower morbidity and mortality rate. There is a need for further large studies evaluating effectiveness and long-term outcome of endovascular treatment.

Pediatric magnetic resonance angiography: to contrast or not to contrast.

Magnetic resonance (MR) angiography and MR venography imaging with contrast and non-contrast techniques are widely used for pediatric vascular imaging. However, as with any MRI examination, imaging the pediatric population can be challenging because of patient motion, which sometimes requires sedation. There are multiple benefits of non-contrast MR angiographic techniques, including the ability to repeat sequences if motion is present, the decreased need for sedation, and avoidance of potential risks associated with gadolinium administration and radiation exposure. Thus, MR angiography is an attractive alternative to CT or conventional catheter-based angiography in pediatric populations. Contrast-enhanced MR angiographic techniques have the advantage of increased signal to noise. Blood pool imaging allows long imaging times that result in high-spatial-resolution imaging, and thus high-quality diagnostic images. This article outlines the technique details, indications, benefits and downsides of non-contrast-enhanced and contrast-enhanced MR angiographic techniques to assist in protocol decision-making.

Defining Duplex Ultrasound Criteria for In-Stent Restenosis of the Carotid Artery Using Computed Tomographic Angiography.

IntroductionDuplex ultrasound (DUS) velocity measurement is the preferred method for evaluating carotid artery stenosis. However, velocity criteria based upon native carotid arteries may not apply to internal carotid artery stents. Previously, catheter-based angiography was used to determine DUS velocity criteria for in-stent restenosis (ISR), but conventional angiography is invasive and can be limited. This study sought to define duplex ultrasound velocity criteria for predicting internal carotid artery in-stent restenosis by correlating in-stent velocities with computed tomographic angiography (CTA) measurements of percent stenosis.MethodsA retrospective chart review was conducted on all patients who underwent internal carotid artery (ICA) stenting within our health system between January 2013 and February 2020. Thirty-eight surveillance DUS studies from 32 patients were found to have CTA performed within 30 days. Centerline reconstructions of internal carotid artery stents were created using Aquarius iNtuition software (TeraRecon, Durham, NC, USA). Two independent observers measured percent stenosis by three built-in methods. Stenotic areas were matched to DUS-measured peak systolic velocities (PSV) and end-diastolic velocities (EDV). Internal carotid artery PSV (stent) to common carotid artery (CCA) PSV ratios (ICA/CCA) were calculated, and receiver operating characteristic (ROC) curves were generated. The optimal DUS velocity criteria in the stented ICA were determined by maximizing Youden’s index.ResultsMean vessel diameter measurement of percent stenosis resulted in the most accurate model for all DUS velocity parameters (PSV, EDV, and ICA/CCA ratio) and was used for threshold determinations (area under the receiver operating characteristics (AUROC): 0.99, 0.96, and 0.96, respectively). A PSV cutoff of 240 cm/s for ≥60% ISR resulted in the highest Youden’s index (97%) with 100% sensitivity and 97% specificity. Secondary DUS parameters included an EDV ≥50 cm/s (Youden’s index 84%) and an ICA/CCA ratio ≥ 2.2 (Youden’s index 91%).ConclusionsVelocity criteria to predict internal carotid artery ISR is needed to inform decisions for possible reintervention. Using CTA, we found that a PSV ≥240 cm/s on carotid DUS can predict ≥60% ISR with high sensitivity and specificity. This value can be used as an alternative to current velocity criteria based on native carotid arteries. However, the optimal thresholds for EDV and ICA/CCA ratio were similar to native carotid arteries.

PH Roundtable: Tailoring CTEPH Imaging for Evaluation and Postintervention Assessment—What Works and What’s New?

PH Roundtable: Tailoring CTEPH Imaging for Evaluation and Postintervention Assessment—What Works and What’s New?

Diagnostic Evaluation of Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a distinct form of pulmonary hypertension, uniquely characterized by pulmonary artery narrowing and occlusion from clot material. With advances in medical education and therapeutic options, awareness of CTEPH has grown significantly in recent years. The diagnostic evaluation remains complex, warranting an integrated assessment of history, physical exam, echocardiogram, chest imaging including computerized tomography with angiography, ventilation–perfusion scanning, right heart catheterization, catheter-based pulmonary angiography, and assessment for medical and mechanical CTEPH risk factors. The diagnostic evaluation of CTEPH is reviewed here.

Outcome of Claudication Patients Treated With Endovascular Intervention

Previous reports have suggested that peripheral vascular intervention (PVI) for intermittent claudication (IC) may be associated with poor outcome, progression to chronic limb-threatening ischemia (CLTI), and a higher risk of amputation. These data often arise from large database studies, which lack granularity and combine patients treated in various settings by a variety of providers. The aim of this study is to define the outcomes of claudication patients treated with PVI and specifically understand the risk of deterioration to CLTI and/or amputation. We performed a review of patients undergoing PVI for IC between 2011 and 2019 at single institution. Patients who underwent isolated aortoiliac intervention or hybrid procedures were excluded. Primary patency (PP), target vessel revascularization, limb salvage, and overall survival were analyzed using the Kaplan-Meier method and assessed with univariate analysis and multivariable Cox regression. Loss of PP (restenosis) was defined as a peak systolic velocity ratio of more than 2.0 on duplex ultrasound examination, a decrease in the ankle-brachial index of more than 0.15 or more than 20%, or imaging with a computed tomography scan or catheter-based angiography. We identified 393 patients with a mean age of 68.6 years (63% male) with multiple risk factors for atherosclerosis (Table). Mean follow-up was 44.1 ± 24.5 months. PP was 82.0% at 36 months and 74.3% at 60 months (Figure). Freedom from target vessel revascularization was 71.8%, overall survival was 71.1%, and limb salvage was 97.2% at 60 months. Univariate and multivariate analyses found that dialysis dependence was associated with restenosis. Paclitaxel use enhanced PP on univariate analysis while atherectomy did not have a detrimental effect. Multivariate analysis also demonstrated that male sex was associated with PP. Of the 67 patients who had restenosis, 23 were asymptomatic and were managed medically. Forty-four patients underwent revision—34 endovascular and 10 surgical. At 60 months, a total of 10 patients underwent amputation (2.8% by Kaplan-Meier estimate). Patients with IC can be treated with PVI with high rates of technical success and patency. Patients on dialysis fare worse. Progression to CLTI and amputation is low. Whether PVI for IC is preferential to medical therapy alone requires further study.TableVariableAll (n = 393)PP (n = 326)Restenosis (n = 67)P valueMultivariate analysis for restenosis (hazard ratio)P valueAge68.6 ± 10.769.0 ± 10.666.8 ± 9.9.1310.98.266Male sex251 (63.9)211 (64.7)40 (59.7).4360.53.039Hypertension348 (88.6)286 (87.7)62 (92.5).2601.52.413Hyperlipidemia294 (74.8)243 (76.1)51 (74.4).7861.05.879Coronary artery disease215 (54.7)177 (54.3)38 (56.7).7171.57.158Diabetes mellitus184 (46.8)153 (46.9)31 (46.3).9210.77.391Chronic pulmonary obstructive disease89 (22.7)70 (21.5)19 (28.4).2201.80.085Congestive heart failure63 (16.0)55 (16.9)8 (11.9).3160.57.226Carotid artery disease95 (24.2)177 (54.3)38 (56.7).7170.56.121Abdominal aortic aneurysm25 (6.4)21 (6.4)4 (6.0).8850.54.333Dialysis13 (3.3)6 (1.8)7 (10.45)<.0018.30.001History of smoking334 (85.0)279 (85.6)55 (82.1).4660.79.572Atherectomy103 (26.2)90 (27.6)13 (19.4).1640.93.845Uncoated balloon angioplasty156 (39.7)121 (37.1)35 (52.2).0210.76.802Paclitaxel balloon angioplasty235 (59.8)204 (62.6)31 (46.3).0130.56.593Bare metal stent123 (31.3)97 (29.75)26 (38.8).1461.56.132PP, Primary patency. Open table in a new tab