Catheter-directed Angiography Research Articles

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography.

To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures. Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators. In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4mm, RGA 1.6 ± 0.5mm, and GEA 1.7 ± 0.4mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans. In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

Reversal of Cerebral Arteriopathy Post-Hematopoietic Stem Cell Transplant for Sickle Cell Disease.

Sickle cell disease (SCD) is a chronic hematologic disorder which causes progressive cerebral arteriopathy beginning in childhood. As a result, arterial ischemic stroke is a major cause of morbidity and mortality in SCD, and SCD is a leading cause of childhood stroke worldwide. Allogenic hematopoietic stem cell transplant (HSCT) may be curative for individuals with SCD. Long-term outcomes and effects are currently being studied. In this report, we describe a child with SCD who presented with arterial ischemic stroke at 6 years of age and was found to have a severe form of cerebral large vessel arteriopathy by catheter-directed angiography. The patient initially underwent revascularization surgery by indirect superficial temporal artery to middle cerebral artery bypass, and 1 year later, he underwent curative HSCT. Approximately 3 years after HSCT, repeat catheter-directed angiography revealed a striking reversal of cerebral large vessel arteriopathy. This article reveals a previously unrecognized and potentially beneficial effect of HSCT that may ameliorate cerebral large vessel arteriopathy and improve cerebrovascular health for children with SCD.

Acute pulmonary embolism immediately after cesarean section despite dilatation of the left ventricle: a case report and literature review

Abstract Introduction Pulmonary embolism is a lethal complication during pregnancy and the puerperium. Compared with vaginal delivery, the risk of pulmonary disease is almost twice as high with cesarean section. However, diagnosing a pulmonary embolism can be challenging. Case presentation A 31-year-old nulliparous woman underwent cesarean section. Postoperatively, the patient suddenly developed dyspnea and dull pain in the left back region and cardiopulmonary function deteriorated rapidly. Venous ultrasonography confirmed thrombosis of the left common iliac vein. Transthoracic echocardiography revealed a normal right heart and a dilated left ventricle with a patent foramen ovale. An acute pulmonary embolism was confirmed by pulmonary angiography. Catheter-directed thrombus fragmentation and thrombolysis were then performed. Conclusion Dilated left ventricular echocardiography does not exclude postpartum acute pulmonary embolism. In extreme emergencies, when acute pulmonary embolism is the most likely diagnosis and life-threatening, catheter-directed angiography may be preferred over other approaches.

Frameless Co-Registration of Biplane 2D Digital Subtraction Angiography Whole Frames and 3D Rotational Angiography-Based Cone-Beam Computed Tomography Angiogram on Dedicated Software for Stereotactic Radiosurgery of Cranial Vascular Malformations.

Purpose: Given its high spatial resolution and vasculature selectivity, the cone-beam computed tomography (CT) angiography (CBCTA) image acquired by selective 3D rotational angiography (3DRA) is the most suitable 3D image for the target definition of stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs). Furthermore, the relatively low temporal resolution of 3DRA-based CBCTA can be complemented by the stereotactic co-registration of orthogonally paired 2D dynamic digital subtraction angiography (2D-DSA). The integration of 2D-DSA, which is usually limited to one or a few frames for each projection, into CBCTA and/or planning CT can be achieved only by catheter-directed angiography on the day of SRS via a dedicated image localizer under rigid frame fixation to the skull, which imposes substantial burdens on patients. This study aimed to demonstrate a novel, convenient, and significantly less invasive method for the frameless co-registration of biplane 2D-DSA whole frames and CBCTA on commercially available dedicated software, namely, Brainlab® Elements (Brainlab AG, Munich, Germany), and present its prerequisite for successful image fusion.Technical Report: Elements have afforded the following functionality: A 3D vasculature image is automatically extracted as a floating image from any 3D image series containing vascular details and then subsequently co-registered manually and automatically to a selected frame pair of 2D-DSA with a six-degree-of-freedom rigid registration. As a preclinical feasibility study, two anonymous image datasets from patients harboring cerebral AVM and transverse-sigmoid (TS) DAVF were used to verify the accuracy and practicality of Elements for the frameless co-registration of 2D/3D vascular images, particularly on the assumption of clinical workflow for the target delineation of SRS planning. The use of ordinary unsubtracted CBCTA resulted in the insufficient extraction of abutting vessels or vessels that are in close proximity to bony structures, particularly in the case of TS-DAVF, where the fistulous pouch and the affected venous sinuses were adjacent to the cranial bone. By contrast, the amount and selectivity of vasculatures and the accuracy of subsequent image fusion were significantly improved from the subtracted CBCTA. The integration of CBCTA into dynamic 2D-DSA allowed the simultaneous review of both image information by sharing any concerning point and 2D or 3D structures under a common 3D coordinate.Conclusions: Elements enable the clinically useful frameless co-registration of biplane 2D-DSA whole frames into CBCTA, for which the routine acquisition of both subtracted and unsubtracted CBCTA axial images for ordinary diagnostic purposes is an indispensable prerequisite for successful image fusion and further widespread application. This frameless integration of the 2D/3D angiogram would dramatically enhance both the frame-based and frameless SRS workflow and circumstances by allowing users to forward SRS planning well in advance before SRS, along with the omission of invasive angiography on the day of SRS, and would broaden the implementation of frameless SRS. Furthermore, the comprehensive alternating interactive review of the 2D/3D integrated angiogram leads to a more in-depth quasi-4D understanding of the affected angioarchitectures compared with the separate viewing of each image.

Arterioectatic Spinal Angiopathy of Childhood: Clinical, Imaging, Laboratory, Histologic, and Genetic Description of a Novel CNS Vascular Pathology.

Pediatric patients with myelopathy expressing intradural spinal vascular ectasia without arteriovenous shunting were studied at four tertiary referral neuropediatric centers. Patients were identified by retrospective review of institutional records and excluded if spinal vascular pathology could be classified into a previously described category of spinal vascular malformation. Four patients meeting the study criteria were enrolled in the study. Clinical, magnetic resonance imaging, catheter-directed angiography, laboratory, histological and genetic data were analyzed to characterize the disease process and elucidate underlying pathomechanisms. Our study revealed a highly lethal, progressive multi-segmental myelopathy associated with a unique form of non-inflammatory spinal angiopathy featuring diffuse enlargement and tortuosity of spinal cord arteries, spinal cord hyperemia, and spinal cord edema (Arterioectatic Spinal Angiopathy of Childhood). The condition was shown to mimic venous congestive myelopathy associated with pediatric spinal cord arteriovenous shunts on MRI but to have distinct pathognomonic findings on catheter-directed angiography. Clinicopathological, genetic, and neuroimaging features, which are described in detail, closely overlap with those of mitochondrial disease.

Automated Angiographic Labeling Pipeline

Background & Hypothesis: Treatment decisions for medical management, endovascular therapy, open surgery, and hybrid approaches for peripheral artery disease (PAD) are largely driven by imaging. While catheter-directed angiography remains the gold-standard for endoluminal vessel analysis, currently, there is not widespread clinical use of machine learning to provide automated segmentation. This project aims to develop an active learning pipeline to automate the labeling of vascular structures in angiographic images. 
 Methods: We queried the picture archiving and communication system (PACS) database for Indiana University Health and Eskenazi Health to identify studies with catheter-directed angiograms of the extremities. From this dataset we randomly selected an initial convenience sample of 50 angiograms to manually label using the 3D Slicer software. We compared three workflow approaches for labeling this training data - (1) human-only single-pass labelling whereby one person labels each image; (2) human-only multi-pass labelling whereby three humans label a vessel with increasing precision; (3) “human-in-the-middle” approach using NVIDIA’s AI-Assisted Annotation client whereby the image is auto-segmented and then manually checked for accuracy. 
 Results: We are currently evaluating speed and accuracy for each of these approaches. However, our preliminary data suggests that human-only multi-pass labeling is most efficientappreac We will be validating the following three-step process. First, thresholding tool was used to leverage differences in contrast gradations to approximate the location of vascular structure. Second, the eraser tool was utilized to refine the vessel boundaries. Finally, major blood vessels contributing to axial flow to the foot were manually labeled. These labeled angiograms will be used to develop an active learning algorithm to automate future labeling of the remaining dataset. 
 Conclusion: A machine learning approach to interpreting lower extremity images can dramatically improve the efficiency of triaging patients with PAD. Further work is underway to develop and implement this program clinically.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries.

Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Endovascular embolization for pulmonary artery pseudoaneurysms with massive hemoptysis

Objective: To investigate the efficacy and safety of transcatheter embolization for the treatment of pulmonary artery pseudoaneurysms (PAPs) with massive hemoptysis via both arterial and venous access. Methods: The clinical data of 15 patients of pulmonary tuberculosis presenting with massive hemoptysis, who were confirmed by CTA/DSA with PAPs at the Second Affiliated Hospital of Hainan Medical University from January 2016 to February 2018, were retrospectively analyzed. The imaging presentation, technical and clinical success of endovascular treatment, and recurrence of hemoptysis within 1 year was recorded. Results: A total of 15 PAPs were involved. Fourteen PAPs were confirmed by pulmonary CTA and one by angiography. Six PAPs were visualized during bronchial artery angiography, 4 PAPs during pulmonary artery angiography, and 4 PAPs both. One PAP was not shown during catheter-directed angiography. Except for one patient who died of asphyxia due to severe hemoptysis undergoing embolization, hemoptysis relapse was achieved in 14 patients after endovascular treatment. During 12 months follow-up, one patient underwent surgical resection because of recurrent hemoptysis 2 weeks after embolization, and another patient with recurrence hemoptysis 3 months after embolization received repeated intervention and hemoptysis relapsed. Conclusion: Transcatheter embolization via dual access is effective and feasible for the treatment of PAPs with massive hemoptysis in patients with pulmonary tuberculosis, but still some risks.

Abstract No. 387 Evaluation of renal function and contrast-induced nephropathy in patients with clinical concern for lower gastrointestinal bleed: comparison of patients with negative initial computed tomography angiography and positive computed tomography angiography with subsequent catheter-directed angiography

Abstract No. 387 Evaluation of renal function and contrast-induced nephropathy in patients with clinical concern for lower gastrointestinal bleed: comparison of patients with negative initial computed tomography angiography and positive computed tomography angiography with subsequent catheter-directed angiography

04:03 PM Abstract No. 342 Utility of second look imaging in patients with persistent clinical concern for lower gastrointestinal bleed after initial negative CTA

Patients with lower gastrointestinal bleed (LGIB) primarily receive computed tomography angiography (CTA) as their initial diagnostic test. A negative initial CTA can be challenging for the clinical team as these patients can become acutely unstable without a source of bleeding. This study aims to evaluate the utility of second look imaging in patients with persistent clinical concern for LGIB after initial negative CTA. This is a retrospective study of 278 patients who presented with LGIB and received an initial CTA. All patients presented to the ER or as inpatients with the following clinical signs or symptoms for LGIB: 90 of 278 (32%) nonspecific symptoms, 57 of 278 (21%) postoperative, 52 of 278 (19%) bright red blood per rectum, 34 of 278 (12%) pain, 16 of 278 (6%) melena, 8 of 278 (3%) mass, 7 of 278 (3%) hematochezia, 5 of 278 (2%) diverticulitis, 2 of 278 (1%) IBD, 1 of 278 (<1%) AVM. For patients with multiple scan during a single admission, the first CTA performed with concern for LGIB was used in the dataset. Our imaging protocol includes non-contrast, arterial, and portal venous phases. After an negative initial CTA, 28 of 278 (10%) patients received second look imaging with CTA, NM bleeding scan, or catheter-directed angiography during a single hospital admission for persistent concern for LGIB. The results of the second look imaging is as follows: 22 of 28 (79%) patients with negative CTA, 3 of 28 (11%) patients with negative NM bleeding scan, 2 of 28 (7%) patients had negative catheter-directed angiography, and 1 of 28 (4%) patients with positive NM bleeding scan. Overall, 27 of 28 (96%) of patients with negative initial CTA demonstrated a negative second look imaging. 7 of 33 patients with positive or negative initial CTA proceeded to catheter-directed angiography. Three of these patients received second look CTA, with 100% negative for active hemorrhage. The utility of second look imaging is limited in patients with persistent clinical concern for LGIB after initial negative CTA.

3:00 PM Abstract No. 23 Axial measurements of acute gastrointestinal bleeding size on CTA predicts subsequent positive catheter-directed angiography

3:00 PM Abstract No. 23 Axial measurements of acute gastrointestinal bleeding size on CTA predicts subsequent positive catheter-directed angiography

Endovascular Management of Severe Arterial Haemorrhage After Radical Prostatectomy: A Case Series.

The aim of this study is to assess the safety, effectiveness and long-term outcome of endovascular management of arterial haemorrhage after radical prostatectomy (RP). Ten patients who received endovascular treatment for refractory bleeding after RP between January 2008 and December 2016 were retrospectively identified. Contrast-enhanced computed tomography (CT) was performed and followed by catheter-directed treatment by means of transarterial embolization (TAE) or stent graft placement. Follow-up included analysis of bleeding recurrence, embolization-related adverse events and tumour recurrence. Contrast-enhanced CT and catheter-directed angiography showed pelvic contrast extravasation in nine patients. Nine patients were successfully treated with TAE of the internal pudendal, superior and/or inferior vesical or (the anterior division or main branch of) the internal iliac arteries using microparticles in two patients, coils in two patients, a combination of microparticles and coils in three patients, glue in one patient and Gelfoam in one patient. The remaining patient was treated with stent graft placement in the external iliac artery, which was most likely injured during robot-assisted lymphadenectomy. One patient developed a puncture site pseudoaneurysm. No other complications related to the endovascular procedures occurred, in particular no pelvic ischaemic complications were identified. Mean follow-up period was 45months (range 22-80). The endovascular management of arterial haemorrhage after RP is safe and effective, without post-embolization ischaemic events.

Transarterial embolization of nonvariceal gastrointestinal bleeding: Our experience

Objective: To analyze the technical and clinical outcomes of transarterial embolization in patients with nonvariceal gastrointestinal (GI) bleeding in our institute. Materials and Methods: From July 2009 to June 2013, retrospective data of all patients with nonvariceal GI bleeding who underwent catheter-directed angiography with or without Transarterial Embolization (TAE) were collected and included in the study. All were inpatients at the time of the procedures, and they were followed up till discharge or demise. Results: Out of 152 patients, 127 cases (age - 12-94 years; median age - 47 years) of GI bleeding were included in the study. Male to female ratio was ~4:1. Catheter-directed angiography was tried in all 127 patients. Out of 37 patients (29%) who had a normal angiogram, 26 (70%) improved spontaneously without embolization whereas in 11 (30%) the bleeding source could not be identified even with a repeat angiogram and clinical evidence of haemorrhage requiring surgery. Out of 90 patients (71%) with angiographically visible bleeding; 88 (69.3%) had successful, catheter directed trans-arterial embolization (TAE) whereas in 2 patients (2.2%), the bleeding vessel could not be cannulated (technical failure). Complications were encountered in 11 patients (8.7%) and rebleeding occurred in 3 patients (3.4%). Angiography related mortality was 4.7% (6/127). Conclusion: Endovascular treatment can be performed safely in sick patients. It is technically demanding, and it is not always possible for anatomic reasons or because of distorted anatomy due to previous surgeries.

Challenges of Anomalous Coronary Artery Intervention: Case Series and a Review

Catheter-directed angiography remains the gold standard both for diagnosis and treatment of a coronary artery anomaly (CAA). CAA intervention continues to remains a complicated task even in the hands of experienced operators. The greatest challenges faced in the management of CAAs are delays in identification and difficulty engaging the anomalous coronary artery. Operator experience in promptly identifying the anomaly and selection of the appropriate catheter is critical for successful CAA intervention. We discuss a series of cases where CAAs were encountered during angiography and review the diverse technical difficulties faced by operators during interventions of these congenital anomalies.

Multimodality imaging of fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is an uncommon non-inflammatory and non-atherosclerotic cause of arterial disease that may result in stenosis, tortuosity, aneurysm, or dissection. The clinical presentation depends on the vascular bed involved and ranges from asymptomatic to multisystem disease and end organ ischemia. The purpose of this article is to review the role of imaging in patients with FMD with an emphasis on renal FMD. The relevant epidemiology, histopathology, imaging techniques, and interpretation of images will be discussed. Renal artery FMD requires a high index of suspicion for accurate and prompt diagnosis and implementation of appropriate therapy. The treatment will vary based on clinical presentation and distribution of involvement. Noninvasive imaging with duplex ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are reasonable alternatives for the depiction of FMD in comparison to catheter-directed angiography (CA). Patients with FMD are often treated by multispecialty practice including the interventional radiologist.

Transjugular intrahepatic portosystemic shunt stent-graft placement: mean optimal portal venous projection view determined by three-dimensional portography

Suboptimal stent-graft placement at the lower anastomosis during transjugular intrahepatic portosystemic shunt (TIPS) may result in early shunt stenosis and occlusion owing to incomplete covering of the parenchymal tract by the covered part of the stent-graft. To determine the optimal portal venous projection view for stent-graft placement during TIPS and the potential influence of the portal vein anatomy. On 76 cirrhotic patients (48 men and 28 women) selected for TIPS, rotational, three-dimensional (3D), catheter-directed angiography of the portal vein was performed. The 3D portograms were reviewed by two independent interventional radiologists to determine the optimal angiographic projection views for stent-graft placement. Intra-observer and inter-observer reliabilities were tested and subgroups of patient portal vein anatomy were categorized. Among all patients, the optimal portal venous projection views for stent-graft placement during TIPS centered around 27° (±14°) right oblique and 3° (±7°) craniocaudal. Of these, 56% were within the standard deviations. Intra-observer reliabilities were 0.60 and 0.62 for the two radiologists, respectively. Inter-observer reliability was 0.48. Anatomical variations in the patient population were: normal portal vein (67%), trifurcation at main portal vein (16%), right posterior portal vein as the first branch of main portal vein (3%), no right posterior portal vein (1%), and other variations (13%). Anatomical subgroups did not influence the best angiographic projection view significantly (F4,295 = 0.91, P = 0.457). The mean optimal angiographic projection view for TIPS stent-graft placement was 27° right oblique and 3° craniocaudal. Patient anatomic variations do not play a significant role in determining the optimal angiographic view for TIPS stent-graft placement.

Pediatric Arterial Interventions

The spectrum of pediatric vascular pathology differs from the adult population and it varies greatly to include congenital and acquired disorders. Although catheter-directed angiography remains the gold standard, most vascular conditions in the child can be adequately diagnosed with magnetic resonance angiography, computed tomographic angiography, or duplex/Doppler ultrasonography with only a few exceptions, such as intrarenal arterial stenosis, small vessel vasculitides, and visceral vascular malformations. The advancement of catheter and wire technology has made it increasingly possible for complex arterial interventions to be performed in children, including embolization, angioplasty with stent insertion, thrombolysis, and endovascular neurological procedures. More angiographic procedures are being performed with the aim of also being therapeutic. Special considerations in children include the use of appropriate equipment and adequate dosing of contrast and of the various medications used during angiography, particularly in patients less than 15 kg in weight. This article will focus on the management of renovascular hypertension, liver transplant hepatic arterial intervention, and the use of carbon dioxide gas as a contrast agent in the child.

Peripheral Pulmonary Arterial Pseudoaneurysms: Therapeutic Implications of Endovascular Treatment and Angiographic Classifications

To classify peripheral pulmonary arterial pseudoaneurysms (PAPs) associated with infectious lung diseases according to angiographic findings and to determine treatment options for PAPs on the basis of angiographic classifications. The institutional review board approved this study. A total of 24 patients with massive hemoptysis had PAPs that were detected at pulmonary computed tomographic (CT) angiography; underlying diseases were pulmonary tuberculosis (n = 16), a fungus ball (n = 5), lung abscess (n = 2), and pneumonia (n = 1). All patients underwent bronchial and nonbronchial systemic collateral arterial angiography and pulmonary and selective pulmonary angiography. On the basis of the angiographic findings, PAPs were classified into four types: PAPs visualized at nonselective right or left pulmonary angiography were defined as type A (n = 5), PAPs visualized at selective segmental or subsegmental pulmonary angiography were defined as type B (n = 10), PAPs apparent at bronchial and nonbronchial systemic collateral arterial angiography by means of a bronchopulmonary arterial shunt but not at selective pulmonary angiography were classified as type C (n = 5), and PAPs apparent at pulmonary CT angiography alone but not at catheter-directed angiography were classified as type D (n = 4). For type A or B PAPs, bronchial and nonbronchial systemic collateral arteries and pulmonary arteries were successively embolized. Hemoptysis was controlled for all type A and type B PAPs. For type C or type D PAPs, embolization alone of bronchial and nonbronchial systemic collateral arteries and follow-up pulmonary CT angiography were performed. Hemoptysis was not controlled in three of the nine patients: In those patients, percutaneous injection therapy (n = 2) and surgical resection (n = 1) were performed. Classification of PAPs on the basis of angiographic findings and determination of treatment options according to these findings are useful for the endovascular management of PAPs associated with massive hemoptysis.