Computed Tomography Angiography Reports Research Articles

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk

BackgroundPrehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. Materials and MethodsWe performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. Results251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 – 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. ConclusionsArterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Importance of Incidental Findings in Preoperative Computed Tomography Angiography for Abdominally Based Free Flap Breast Reconstruction: A Multi-Institutional Study

Background: In addition to its intended purpose of perforator mapping, computed tomography angiography can also identify incidental findings that may require further evaluation. In this multi-institutional study, the authors evaluated the frequency of incidental findings and their significance and effects on treatment course and aimed to identify risk factors for detecting such findings. Methods: A retrospective review of patients who underwent perforator mapping with computed tomography angiography was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information, computed tomography angiography reports, follow-up visits, and treatment outcomes were reviewed. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. Results: From January of 2015 to July of 2020, a total of 656 patients were identified who met inclusion criteria. Overall, 342 incidental findings were found, 76 of which required additional imaging or consultation. Ultimately, 10 patients (1.5 percent) had findings that altered reconstructive management, including five patients (0.8 percent) having severe disease that resulted in the cancellation of their reconstruction. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. Conclusions: Incidental findings are commonly identified on preoperative computed tomography angiography for deep inferior epigastric perforator flap breast reconstruction. Suspicious findings should be investigated thoroughly because they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Which mode of color Doppler ultrasound is most suitable for detecting endoleaks in surveillance after endovascular aneurysm repair?

Objectives: The aim of this study was to evaluate the best mode of Doppler ultrasound, blood flow imaging (BFI) versus color Doppler ultrasound (CDUS), in detecting endoleaks diagnosed using computed tomography angiography (CTA). Patients and methods: A total of 70 consecutive patients (60 males, 10 females; mean age: 68.5±7.8 years; range, 48 to 82 years) undergoing standard EVAR procedure were retrospectively evaluated in the outpatient clinic following CTA between January 2018 and December 2019. Ten (13.9%) patients in which endoleaks were detected were also evaluated using CDUS which was performed by two radiologists specializing in Doppler ultrasound. The radiologists were blind to CTA reports. A reporting protocol was developed for endoleak detection using different modes of CDUS (BFI vs. CDUS). Results: Of all cases, 10 (13.9%) endoleaks were detected using CTA. All five type I and III endoleaks requiring an intervention were detected by both modes of CDUS, while four of the five type II endoleaks were not. The single case of type II endoleak was suspected following the visualization of fresh thrombus formation. There was an inadequacy in detecting low flow endoleaks both using BFI and standard color Doppler mode. There was a strong correlation between the aneurysmal sac diameters measured using CTA and CDUS. Conclusion: The CDU and BFI are capable of detecting type I and III endoleaks with similar sensitivity and specificity. These modes should be used in combination as confirmatory tests. For surveillance, CDUS promises accurate results without missing any potential complication requiring an intervention. Lack of detecting type II endoleaks may be negligible, as sac enlargement is the key for reintervention in this case.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction.

BackgroundPreoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan.MethodsWe conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.ResultsTwo hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were “miscellaneous.” In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation.ConclusionsCTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

CTA in preoperative planning for DIEP breast reconstruction: what the reconstructive surgeon wants to know. A modified Delphi study

To gather expert reconstructive surgical opinion to define and rank the surgically most important anatomy and provide guidance for report content to radiologists when reading a preoperative computed tomography angiography (CTA). A modified Delphi approach was used, involving a panel of 13 microsurgery experts across North America. Data from three consecutive online surveys were collected and returned to the respondents in the subsequent survey, allowing each respondent to see the range of opinions from other field experts. Response rates were 62%, 77%, and 69% for each of the three survey rounds, respectively. The panel identified that the most important perforator characteristics in selecting the optimal perforator are diameter of the vein, perforator location within the flap, and diameter of the artery, respectively. The stated preference was for perforators located below the umbilicus. If no suitable perforator was located below the umbilicus, the panel would consider perforators up to 2 cm above the umbilicus. The most important considerations for the preoperative radiology planning report are: the size of the perforator vein, perforator location relative to landmarks, and the size of the perforator artery. Based on the panel of expert reconstructive microsurgeons, the most surgically important anatomical considerations to be assessed and included in preoperative CTA reports for DIEP flap breast reconstruction were determined. The recommendations for reporting of preoperative DIEP breast reconstructions are presented, which, in consultation with local surgeons, can be used to form a template for reporting.

Additional cardiac investigation prior to the introduction of the CAD-RADS classification in coronary computed tomography angiography reports

Additional cardiac investigation prior to the introduction of the CAD-RADS classification in coronary computed tomography angiography reports

Preoperative Computed Tomography Angiography in Autologous Breast Reconstruction-Incidence and Impact of Incidentalomas.

Background:Incidentalomas are lesions found coincidentally during examination, imaging, or surgical procedures. Preoperative computed tomography angiography (CTA) before abdominal flap harvest for breast reconstruction can lead to identification of incidentalomas leading to the need for further investigations. The aim of this study was to examine the prevalence of incidental findings on preoperative CTA and to determine their impact on management.Methods:A retrospective chart review was performed at a single tertiary institution. CTA reports were analyzed for the presence of incidental findings and details of follow-up were studied. Logistic regression was used to identify factors associated with incidental findings.Results:One hundred eighteen patients with a mean age of 49 years were included in the study. The majority of patients underwent bilateral reconstruction (65%, n = 77) in the immediate setting (70%, n = 83). Fifty-six percentage had an incidental finding on CTA, with hepatic (20%), renal (14%), and osseous (11%) abnormalities being most common. Additional imaging including ultrasound, CT, and magnetic resonance imaging were recommended in 19 cases (16%). Additional consultations were sought for 3 patients before reconstruction (with suspicion of bone metastases, an intraabdominal mass, and suspicion of colonic malignancy, respectively). No significant surgical delay secondary to CT findings was noted.Conclusions:Incidentalomas following preoperative CTA of the abdomen/pelvis are common (56%). However, unlike previous reports, we did not observe a change in reconstructive plan following incidentaloma discovery. We recommend that all patients are counseled pre-CTA regarding the possibilities of incidentaloma detection and need for additional imaging.

The Role of CT Angiography in Assessing Deep Inferior Epigastric Perforator Flap Patency in Patients With Pre-existing Abdominal Scars

BackgroundAbdominal scars can affect the patency of deep inferior epigastric artery (DIEA) perforators and are a concern when planning free flap breast reconstruction (FFBR). Computed tomography angiography (CTA) is routinely used for preoperative DIEA flap imaging. We investigated CTA utility in predicting the most clinically useful DIEA perforators in scarred abdomens. MethodsA single surgeon's CTA FFBR patients were studied. All were imaged by one radiologist. CTA reports, abdominal scars, and flap intraoperative details were analyzed. The operative findings were then correlated with the CTA “predictions.” ResultsA hundred and six patients with preoperative CTAs underwent 132 FFBRs, 44% (58) from scarred and 56% (74) from virgin abdomens. All flap transfers were successful. Concordance between perforators identified by CTA preoperatively and those selected by the surgeon intraoperatively was 95% (scarred 93%; non-scarred 96%, P = 0.470). There was a significant difference in the proportion of single-perforator flaps between the two groups (scarred 46%; non-scarred 28%, P = 0.041). “Scarred” flaps were heavier (789 vs 676 g, P = 0.0244) than those harvested from virgin abdomens. ConclusionsCTA accurately predicted perforator choice in flaps from scarred and virgin abdomens. “Scarred” flaps are more likely to be heavier and based on one perforator suggesting that scarring may have an effect on intraflap vascular anatomy. Further investigations are needed to delineate the mechanism by which this occurs.

Preoperative Computed Tomography Angiography for Evaluation of Feasibility of Free Flaps in Difficult Reconstruction of Head and Neck.

Free tissue transfer has been advocated for anatomic and functional reconstruction of soft tissue defects after surgical removal of an extensive recurrent tumor and/or arising from previous irradiation in the head and neck. We report a case series of difficult reconstruction in the head and neck in which preoperative computed tomography (CT) angiography was utilized to evaluate the feasibility of free flap reconstruction. The preoperative radiological evaluation was performed to determine the availability of reliable vessels for anastomosis in free flap reconstruction. If none was found, regional pedicle flap or palliative treatment was applied instead. The use of CT angiography allows the clinical surgeon to perform precise surgical planning with greater confidence. This may improve surgical results, thereby potentially reducing perioperative morbidity. Twenty CT angiograms were obtained from 20 patients. All patients were men with a mean age of 57.2 years (range, 42-72 years) and were scheduled to undergo difficult reconstruction in the head and neck. All patients (20/20 [100%]) suffered from oral squamous cell carcinoma. They had all received extensive operations and radiation therapy. Eighteen patients (18/20 [90%]) had completed a course of perioperative irradiation. The CT angiography reports were used to perform detailed preoperative surgical planning accordingly. The findings of CT angiography were classified into 3 groups: group I: normal CT angiography (patent recipient arteries) (Fig. 3); group II: abnormal CT angiography (recipient vessels were present but stenosis or atherosclerotic lesions were noted) (Fig. 4); group III: abnormal CT angiography with no patent recipient arteries in bilateral sides of the neck (Fig. 5); CT angiography results were correlated to the operative findings. The patients were classified into 3 groups based on the angiographic findings. Six patients (6/20 [30%]) were assigned to group I, 8 patients (8/20 [40%]) to group II, and 6 patients (6/20 [30%]) to group III. In groups I and III, all patients (12/12 [100%]) underwent the treatment according to the original preoperative detailed planning. No flap failure was noted in these 2 groups. In group II, 4 patients' recipient vessels (4/8 [50%]) possessed adequate blood flow intraoperatively; hence, microvascular free flaps were transplanted. Venous congestion in 1 case (1/4 [25%]) was noted. The remaining patients in this group (4/8 [50%]) underwent reconstruction with pedicle flaps rather than free flaps because of the lack of suitable target vessels intraoperatively. All flaps (4/4 [100%]) survived. Among the patients who were treated surgically, intraoperative findings were in accordance with those predicted by CT angiography. The total abnormality rate of CT angiography was 70%. Vascular abnormalities detected as a result of preoperative CT angiography led to changes in the operative plan in 50% (10/20) of the patients. The use of CT angiography should be considered for difficult microsurgical reconstructions in the head and neck. When an abnormality in vascular anatomy is detected by CT angiography, the surgeon is advised to consider altering the operative plan accordingly. This allows precise operation, thereby maximizing the possibility of an optimal outcome. Changing the operative plan based on results of CT angiography may also help to avoid the difficult situation in which the surgeon finds that there are no suitable recipient vessels for free flap reconstruction during the operation. In addition, CT angiography enables surgeons to conduct the preoperative surgical planning with greater confidence, thereby potentially enhancing the success rate of difficult reconstructions in the head and neck, which in turn would tend to improve the perioperative course for the patient and consequently to improve results by decreasing vascular complication rates.

Incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism.

To investigate how often computed tomography (CT) pulmonary angiography contributes to establishing a diagnosis in patients presenting to the emergency department and how it performs compared to chest radiograph. The objective of this study was to measure the ability to identify a diagnosis and to investigate the prevalence and significance of incidental findings in patients evaluated with computed tomography pulmonary angiography in the emergency department. All adult patients evaluated with CT angiography over a 2-year period (January 1, 2011 to December 31, 2012) were included in the analysis. A total of 641 records were identified. Chest radiographs and CT angiography reports were reviewed to determine whether they could provide a diagnosis in patients without pulmonary embolism (PE). Studies negative for PE were stratified into three categories according to significance: type I prompted immediate action, type II required follow up, and type III had findings of limited significance. CT angiography identified a diagnosis in 22.46% of the patient population and in 14.31% of patients without PE. In patients who had CT angiography with chest radiograph, diagnoses were provided in 14.01 and 9.86% of patients, respectively. When analysis was isolated to patients with low probability for PE, CT angiography provided a diagnosis in 20% and chest radiography in 10.23% of patients. The majority of missed cases represented infiltrates too small to be detected by radiography and were believed to represent lung infections by the interpreting radiologist. Among studies negative for PE, 15% were type I, 17.07% were type II, 48.1% were type III, and the rest were normal. CT angiography is superior to chest radiography at providing a diagnosis in patients investigated for PE, even when no PE is present. However, in patients at low risk for PE, the clinical benefit of the additional diagnoses is questionable.

Quantification of Pulmonary Thromboembolism in CT Angiography Reports and Predicting Right Ventricular Dysfunction and Patient Mortality

: Recently, attempts have been made to quantify the clot burden on the basis of CT angiographic findings. The development of clot burden index [pulmonary arterial obstruction index (PAOI)] may have important prognostic and therapeutic implications and may provide a reproducible standard for measuring response to thrombolytic therapy. The presence of right ventricular dysfunction (RVD) is a marker for adverse clinical outcome in patients with acute pulmonary embolism (PE). The ratio of the right ventricle to left ventricle short axis diameters (RV/LV) has been proposed as an accurate sign for the presence of RVD. Other studies suggested that the quantification of a clot at pulmonary computed tomography (CT) angiography is an important predictor of right heart failure and patients' outcome in the setting of PE. In this study, we assess the measurement of PAOI and RV/LV ratio in pulmonary CT angiography and discuss the significant correlations between them. Patients and Methods: The study population comprised 42 patients (19 women, 23 men; mean age, 52 + 18 years) with the definite diagnosis of PE based on their pulmonary CT angiography. The CT angiographies of patients were reviewed, and PAOI and RV/LV ratio were measured. PAOI was calculated from the size of embolus and the location of thrombus on CT images in accordance with another study by Qanadli et al. The index was defined as the product of N x D, where N was the value of the proximal clot site, equal to the number of segmental bronchial branches, and D was the degree of obstruction, defined as 1 for partial obstruction and 2 for total obstruction. Furthermore, the scans were evaluated by measuring the minor axes of the right and left ventricles of the heart in the transverse plane at their widest points between the inner surface of the free wall and interventricular septum. By using logistic regression, PAOIs were compared with RV/LV ratio. Correlation between PAOI and RV/LV ratio was evaluated by Spearman correlation test, and receiver operating characteristic (ROC) curve was used to determine an optimal cut-off value for PAOI. : Results: In our study group, mean PAOI was 24.3 + 19.2%. Nine cases (21.4%) had a PAOI of more than 40%. The mean RV/LV ratio was 1.03 + 0.25; eighteen patients (43%) had an RV/LV ratio of more than 1; twenty-four patients (57%) had an RV/LV ratio of less than 1. There was a statistically significant correlation between PAOI and RV/LV ratio (P = 0.007; r = 0.4). The mean PAOI of patients with RV/LV ratio of >1 was significantly higher than that of patients with RV/LV ratio of ? 1 (32.6% vs. 18.1%; P = 0.02). However, based on ROC analysis, an ideal cut-off value for PAOI could not be defined. Also, there was no significant difference in PAOIs between different age (P > 0.05) and sex (P > 0.05) groups. Conclusion: Our findings were in agreement with those of Wu et al. and suggested that the quantification of a clot at CT pulmonary angiography is an important predictor of right heart failure and determines patients' outcome in the setting of PE. There was a significant correlation between PAOI and RV/LV ratio in PE. However, there was no ideal PAOI cut-off value for the diagnosis of right ventricular dysfunction (RV/LV ratio > 1). Further studies with a larger study population may be necessary to generalize our findings and to suggest a sensitive and specific cut-off point for ventricular dysfunction in patients with PE. The prognostic role of RV/LV ratio and obstruction index on spiral CT may also warrant further investigation in patients with PE.

A retrospective review of multi—slice CT and DSA reports in patients with non—traumatic subarachnoid haemorrhage and the resultant diagnostic yield of aneurysms

AbstractPurpose: To examine the diagnostic yield differences between computed tomography angiography (CTA) and digital subtraction angiography (DSA) at The Alfred Hospital, Australia in order to justify patient management that results in all subarachnoid haemorrhage (SAH) patients receiving a 4 vessel cerebral angiogram as part of their investigations despite findings on CTA. Methods: The retrospective study of radiology reports in cases of acute non traumatic SAH in which both CTA and DSA had been performed was conducted in July 2006 to December 2008. Results: Sixty‐three patients over two years were included in our study. Twenty (32%) of these patients had no aneurysm identified on CTA or DSA. A total of 68 aneurysms were found in 40 patients. Twelve (30%) of these patients had aneurysms that were only identified on DSA and not on CTA at the time of initial reporting. Three (5%) patients had false positive CTs. While our positive predictive value of CTA approached near 100%, the negative predictive value was found to be less than 70% with an overall diagnostic accuracy of our CTA reports to be 76%. Eighty one percent of the undiagnosed aneurysms on CTA were less than or equal to 3 mm in size. Conclusion: These findings demonstrate the need for a CTA to be used in combination with a formal 4 vessel subtraction angiogram in every case presenting with a SAH despite the findings of the CTA.