Computed Tomography Angiography Scans Research Articles

Does on-site computed tomography matter? A cross-sectional study of stroke patients' door-to-scan-time in rural hospitals.

Many rural Australian hospitals lack on-site computed tomography (CT). These hospitals often refer patients to local off-site private radiology clinics or to central hospitals, challenging the achievement of time-sensitive scans. For stroke patients, timely access to CT affects treatment options. This study questions whether on-site CT matters in rural hospitals by investigating stroke patients' door-to-scan-time (DTST) and CT scan sequence referrals. A retrospective chart audit was completed across four rural hospitals; two with on-site CT and two without. Adult emergency stroke presentations were randomly sampled. Comparisons between on-site and off-site CT hospitals were made for DTST and CT sequence referrals using Mann-Whitney U-tests and Fisher's exact tests. A total of 120 charts were audited (on-site CT, n = 60; off-site CT, n = 60). DTST was longer for off-site vs. on-site CT hospitals (median = 4.30 h vs. median = 0.70 h; U = 338, p < 0.001) regardless of whether presentations occurred in business hours or out of hours (p < 0.001). Off-site CT hospitals ordered less CT angiography or perfusion scanning (32% vs. 85%, p < 0.001). Off-site CT hospital patients had longer DTST and received less angiography or perfusion scanning. These findings suggest that on-site CT matters to rural stroke patients by improving equitable access to CT and appropriate scan referrals.

Graph neural networks for automatic extraction and labeling of the coronary artery tree in CT angiography.

Automatic comprehensive reporting of coronary artery disease (CAD) requires anatomical localization of the coronary artery pathologies. To address this, we propose a fully automatic method for extraction and anatomical labeling of the coronary artery tree using deep learning. We include coronary CT angiography (CCTA) scans of 104 patients from two hospitals. Reference annotations of coronary artery tree centerlines and labels of coronary artery segments were assigned to 10 segment classes following the American Heart Association guidelines. Our automatic method first extracts the coronary artery tree from CCTA, automatically placing a large number of seed points and simultaneous tracking of vessel-like structures from these points. Thereafter, the extracted tree is refined to retain coronary arteries only, which are subsequently labeled with a multi-resolution ensemble of graph convolutional neural networks that combine geometrical and image intensity information from adjacent segments. The method is evaluated on its ability to extract the coronary tree and to label its segments, by comparing the automatically derived and the reference labels. A separate assessment of tree extraction yielded an score of 0.85. Evaluation of our combined method leads to an average score of 0.74. The results demonstrate that our method enables fully automatic extraction and anatomical labeling of coronary artery trees from CCTA scans. Therefore, it has the potential to facilitate detailed automatic reporting of CAD.

Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated Endovascular Aortic Repair: A Multicenter, Retrospective Cohort Study.

The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic repair (FEVAR) and to determine and visualize BECS-associated complications. This multicenter retrospective study included patients who underwent FEVAR between 2018 and 2022 in 3 vascular centers participating in the VBX Expand Registry. Patients with at least one visceral artery treated with the VBX and with availability of 2 post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU] 1: 0-6 months; FU2: 9-24 months) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software. In total, 90 VBX BECS were analyzed in 43 FEVAR patients. The median CTA FU for FU1 and FU2 was 35 days (interquartile range [IQR], 29-51 days) and 14 months (IQR, 13-15 months), respectively. The mean flare-to-fenestration distance was 5.6±2.0 mm on FU1 and remained unchanged at 5.7±2.0 mm on FU2 (p=.417). The flare-to-fenestration diameter ratio was 1.19±0.17 on FU1 and remained unchanged at 1.21±0.19 (p=.206). The mean apposition length was 18.6±5.3 mm on FU1 and remained 18.6±5.3 mm (p=.550). The flare angle was 31°±15° on FU1 and changed to 33°±16° (p=.009). On FU1, the BECS-associated complication rate was 1%, and the BECS-associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3%, and the BECS-associated reintervention rate was 1%. The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up in this study. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions, but this should be confirmed in a larger study including enough patients and BECS to compare complicated and uncomplicated cases. The three-dimensional flare geometry of the Gore Viabahn VBX BECS was assessed on the first and second postoperative CTA scans, and geometrical changes during this period were identified. For BECS that were diagnosed with a type 3c endoleak or occlusion, the BECS geometry was analyzed to detect geometrical components that were related to the complication. Geometric analysis of the flare may help to better detect and identify the cause of such complications.

Long-term Outcomes of Endovascular Repair for Blunt Thoracic Aortic Injury: A 10 Year Multi-center Experience.

This study aimed to assess the long-term outcomes in patients treated by thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injuries (BTAI). From January 2010 to December 2019, this retrospective observational study was conducted at 3 centers, involving 62 consecutive BTAI patients who underwent TEVAR. Computed tomography angiography scans were planned to be conducted at 6 months post-procedure, and annually thereafter. Technical success was achieved in all 62 procedures (100%), which included cases of dissection (n=35, 56.45%), pseudoaneurysm (n=20, 32.26%), and rupture (n=7, 11.29%). Mean injury severity score was 31.66±8.30. A total of 21 supra-arch branches were revascularized by chimney technique, with 12 cases involving the left subclavian artery (LSA) and 9 cases involving the left common carotid artery. In addition, 11 LSAs were covered during the procedure. The in-hospital mortality rate was 1.61% (n=1). The mean follow-up time was 86.82±30.58 months. The all-cause follow-up mortality rate was 3.28% (n=2). Stenosis or occlusion of 3 supra-arch branches (4.92%) was identified at follow-up, with 2 cases (3.28%) requiring re-intervention. No spinal cord ischemia, endoleak, or migration was observed. Despite only including patients with long-term follow-up, this study confirms the long-term safety and effectiveness of TEVAR for BTAI. For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. This study confirms the long-term safety and effectiveness of endovascular treatment for blunt thoracic aortic injury (BTAI). For young BTAI patients, as the thoracic aorta increases with age, longer follow-up is needed to observe the potential mismatch between the endograft and the aorta. Through a remarkably extended follow-up period (86.82±30.58 months) conducted at multiple centers in China, this study confirms the long-term safety and effectiveness of endovascular treatment for BTAI.

The role of 3D technology in the practical education of congenital coarctation and its treatment—a feasibility pilot study

BackgroundCoarctation of the aorta (CoA) is a congenital disease with an incidence of 4 out of 10,000 live births, therefore proper education of its treatment is essential. Understanding the disease and the wide array of treatment options is often difficult. Additive manufacturing technology can be used to produce 3D printed hands-on surgical training tools (HOSTT), which can be used for the education and practical training of CoA. This study aimed to investigate the effectiveness of a 3D printable HOSTT for the simulation of coarctation surgery, and it’ possible role in practical education.MethodsParticipants were medical students of Semmelweis University between the second and sixth academic year. A virtual 3D model of an aorta with CoA was generated from a computed tomography angiography scan. Each participant received a 3D-printed aorta phantom and performed either one of four surgical treatment modalities. The simulated surgeries included end-to-end anastomosis, end-to-side anastomosis, prosthetic patch, and subclavian flap aortoplasty. Participants provided feedback, evaluating their understanding of the disease and its treatment by the four surgical reconstruction modalities on a seven-point Likert scale before and after the sessions.Results21 medical students participated in this study. Participants’ average rating of their understanding of CoA disease and it treatment options before practical training was 4.62 ± 1.07. After training, their average rating increased to 6.19 ± 1.08, showing statistically significant difference.ConclusionsWithin this study’s limitations, the applied HOSTT, manufactured using 3D printing, was effective for the practical training of CoA’s surgical treatment methods for medical students.

Exploring the anatomical configurations of the cerebral arteries in a cohort of South African patients

The cerebral arteries, specifically the anterior cerebral artery (ACA) and posterior cerebral artery (PCA), work together with the smaller calibre arteries to provide effective communication between the anterior and posterior circuits of the brain via the circle of Willis (CoW). Morphologic variations of the cerebral arteries and the CoW may alter blood flow to the brain, resulting in intracranial vascular disorders associated with stroke, and aneurysms. This study aimed to document the morphology of the cerebral arteries and the CoW in the South African population. Two hundred and thirty-nine computed tomography angiography scans were assessed. Cerebral arteries and CoW normal morphology and variations were classified as complete, absent, or hypoplastic. The ACA A1 was absent in 4.91%, hypoplastic in 30.40%, fenestrated in 1.06%, and typical in 63.6%. The ACA A2 was absent in 0.42%, hypoplastic in 26.28%, and typical in 69.44%. We found triple ACA A2 in 2.98%, azygos in 1.28% and fenestrated in 1.28%. The middle cerebral artery (MCA) was hypoplastic in 7.35% and typical in 92.64%. The PCA was hypoplastic in 28.74% and typical in 71.25%. Knowledge of the configuration of the CoW plays a significant role in guiding therapeutic decision-making in treating various neurovascular pathologies.

Crossed Cerebellar Diaschisis and Cerebral Infarction After Cerebral Hyperperfusion Syndrome Following Carotid Artery Stenting: A Case Report

Crossed cerebellar diaschisis (CCD) often occurs after ischemic or hemorrhagic stroke that does great damage to the cortico-ponto-cerebellar pathway (CPCP). Nevertheless, as far as we know, CCD due to cerebral hyperperfusion syndrome (CHS) following carotid artery stenting (CAS) is rare. We report a case where CCD and new cerebral infarction after CHS following CAS was effectively treated by intravenous use of edaravone and mannitol. The patient was a 74-year-old female. She developed dizziness and vomiting accompanied with weakness of the right limb for 8 days and was admitted to our hospital. Computed tomography angiography scan revealed severe stenosis at the beginning of the left internal carotid artery. Further digital subtraction angiography (DSA) revealed severe stenosis at the beginning of the left internal carotid artery, with a stenosis rate of approximately 90%. Therefore, she underwent left CAS implantation. After the operation, the patient developed disturbance of consciousness and decreased muscle strength in the right limb. Intravenous infusion of edaravone and mannitol were then started. After 10 days of medical treatment, the condition of patient improved to mild hemiparesis. The findings in this present case strongly suggest that CHS after CAS for carotid artery stenosis may cause transient CCD.

Mid-term Results of Endovascular Reconstruction of Aortic Bifurcation Using COVERA Stent Graft.

This article aims to evaluate the short-term and mid-term performance of a self-expanding covered stent (COVERA Plus, Bard Tempe, Arizona) during the treatment of Trans-Atlantic Inter-Society Consensus (TASC) C/D aortoiliac obstructive lesions involving the aortic bifurcation. A single-center retrospective review of all patients who underwent endovascular reconstruction of the aortoiliac bifurcation for obstructive disease, with the use of Covera, from January 2018 to March 2023. All patients received a postoperative CTA (computed tomography angiography) scan within 1 month from the intervention. Precision of deployment, stent conformation, and stent symmetry were evaluated at the arterial phase of the CTA. Early outcomes were technical success and freedom from open aortic reintervention and/or mortality. Late outcomes were primary and assisted primary patency rates and freedom from reintervention. During the study period, 35 patients underwent primary endovascular treatment of obstructive lesions involving the aortic bifurcation with parallel COVERA stents. Aortoiliac lesions were classified as TASC-IIC in 23 (65.7%) patients and TASC D in 12 (34.2%). Median follow-up was 49 months (interquartile [IQR]: 18-60). Overall survival was 97.1% (95% confidence interval [CI]=91-100) at 60 months. During follow-up, there were one early stent stenosis, treated with an angioplasty and stent relining with an estimated primary patency at 60 months of 97.1% (95% CI=94-100) and a primary-assisted patency of 100%. Estimated freedom from all types of reinterventions at 60 months was 94.3% (95% CI=89-99.3). The new self-expanding covered Bard COVERA Plus stent used for endovascular treatment of TASC C/D aorto iliac disease proved to be safe and feasible with high technical procedural success rates. Comparison with other types of stents is necessary to further assess the role of the COVERA Plus stent in aortic bifurcation repair. This study investigates the safety and feasibility of the new self-expanding covered Bard Covera Plus stent used for endovascular treatment of TASC C/D aorto iliac disease. The retrospective analysis of 35 patients highlights high technical success and primary patency rate at 60 months. The geometric analysis also helped to underline how this stent can be used precisely in particular conditions. These findings suggest the need for further research to compare COVERA with other types of stents in aortic bifurcation repair.

Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience.

The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients. We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality. A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality. The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.

Multicentric clinical evaluation of a computed tomography-based fully automated deep neural network for aortic maximum diameter and volumetric measurements

ObjectiveThis study aims to evaluate a fully automatic deep learning-based method (augmented radiology for vascular aneurysm [ARVA]) for aortic segmentation and simultaneous diameter and volume measurements. MethodsA clinical validation dataset was constructed from preoperative and postoperative aortic computed tomography angiography (CTA) scans for assessing these functions. The dataset totaled 350 computed tomography angiography scans from 216 patients treated at two different hospitals. ARVA's ability to segment the aorta into seven morphologically based aortic segments and measure maximum outer-to-outer wall transverse diameters and compute volumes for each was compared with the measurements of six experts (ground truth) and thirteen clinicians. ResultsGround truth (experts') measurements of diameters and volumes were manually performed for all aortic segments. The median absolute diameter difference between ground truth and ARVA was 1.6 mm (95% confidence interval [CI], 1.5-1.7; and 1.6 mm [95% CI, 1.6-1.7]) between ground truth and clinicians. ARVA produced measurements within the clinical acceptable range with a proportion of 85.5% (95% CI, 83.5-86.3) compared with the clinicians' 86.0% (95% CI, 83.9-86.0). The median volume similarity error ranged from 0.93 to 0.95 in the main trunk and achieved 0.88 in the iliac arteries. ConclusionsThis study demonstrates the reliability of a fully automated artificial intelligence-driven solution capable of quick aortic segmentation and analysis of both diameter and volume for each segment.

Abstract TP10: Artificial Intelligence Algorithm as a Diagnostic Tool for Aneurysms

Viz Aneurysm is an artificial intelligence engine created to detect aneurysms from CT-Angiography (CTA) scans. As with any new technology, it should be measured against the current standard of care. Here, we compared Viz.ai ‘flagging’ of an aneurysm against interpretation reports by faculty radiologists in order to understand accuracy and precision of the technology as a diagnostic tool. In this study, CTA scans were analyzed by Viz Aneurysm from October 2022 to June 2023 at a single Comprehensive Stroke Center. Information regarding each subject was collected through Epic, and the presence of an aneurysm was verified by a radiologist. Although Viz.ai states that the algorithm is limited to detecting aneurysms that are 4 mm in diameter or greater, we have included all aneurysms discovered by radiologists. These ranged in diameter from 0.8 to 22 mm. A total of 963 scans were analyzed, with 70 aneurysms detected total. Approximately 51.10% scans were performed on male patients, and our population ranged in age from 23 to 94 years. The algorithm performed well in flagging scans containing definite aneurysms, with a specificity of 96.78% (95% CI 0.95-0.98) and a negative predictive value of 97.23% (95% CI 0.96-0.98). It was less accurate in excluding scans without aneurysms, showing a sensitivity of 63.64% (95% CI 0.51-0.75) and a positive predictive value of 60.00% (95% CI 0.50-0.69). When aneurysms smaller than 4 mm were excluded, the sensitivity and specificity increased to 81.25% (95% CI 0.64-0.93) and 96.90% (95% CI 0.96-0.98), respectively. The algorithm was successful in identifying all cases (n = 5) of ruptured aneurysms. In several cases (n = 27), radiologists were unable to definitively diagnose an aneurysm, frequently citing the possibility of an infundibulum. It should be noted that there was one case where the algorithm detected an aneurysm, but the patient was diagnosed with a 23-mm pituitary macroadenoma. This suggests that the algorithm may be susceptible to neuroanatomical mimics. We have shown that Viz Aneurysm is a highly specific diagnostic tool that may help medical professionals to identify definite aneurysms. More studies of this nature should be conducted in a variety of populations to confirm these results.

Pre-TAVI imaging: an Italian survey by the CT PRotocol optimization (CT-PRO) group

PurposeThe purpose of this survey was to evaluate the current state-of-art of pre-TAVI imaging in a large radiological professional community.MethodsBetween December 2022 and January 2023 all members of the Italian Society of Medical and Interventional Radiology (SIRM) were invited by the CT PRotocol Optimization group (CT-PRO group) to complete an online 24-item questionnaire about pre-TAVI imaging.Results557 SIRM members participated in the survey. The greatest part of respondents were consultant radiologists employed in public hospitals and 84% claimed to routinely perform pre-TAVI imaging at their institutions. The most widespread acquisition protocol consisted of an ECG-gated CT angiography (CTA) scan of the aortic root and heart followed by a non-ECG-synchronized CTA of the thorax, abdomen, and pelvis. Contrast agent administration was generally tailored on the patient’s body weight with a preference for using high concentration contrast media. The reports were commonly written by radiologists with expertise in cardiovascular imaging, and included all the measurements suggested by current guidelines for adequate pre-procedural planning. About 60% of the subjects affirmed that the Heart Team is present at their institutions, however only 7% of the respondents regularly attended the multidisciplinary meetings.ConclusionsThis survey defines the current pre-TAVI imaging practice in a large radiological professional community. Interestingly, despite the majority of radiologists follow the current guidelines regarding acquisition and reporting of pre-TAVI imaging studies, there is still a noteworthy absence from multidisciplinary meetings and from the Heart Team.

Diagnosis of intracranial aneurysms by computed tomography angiography using deep learning-based detection and segmentation

BackgroundDetecting and segmenting intracranial aneurysms (IAs) from angiographic images is a laborious task.ObjectiveTo evaluates a novel deep-learning algorithm, named vessel attention (VA)-Unet, for the efficient detection and segmentation of IAs.MethodsThis...

Alterations in Th17 Cells and Non-Classical Monocytes as a Signature of Subclinical Coronary Artery Atherosclerosis during ART-Treated HIV-1 Infection.

Cardiovascular disease (CVD) remains an important comorbidity in people living with HIV-1 (PLWH) receiving antiretroviral therapy (ART). Our previous studies performed in the Canadian HIV/Aging Cohort Study (CHACS) (>40 years-old; Framingham Risk Score (FRS) > 5%) revealed a 2-3-fold increase in non-calcified coronary artery atherosclerosis (CAA) plaque burden, measured by computed tomography angiography scan (CTAScan) as the total (TPV) and low attenuated plaque volume (LAPV), in ART-treated PLWH (HIV+) versus uninfected controls (HIV-). In an effort to identify novel correlates of subclinical CAA, markers of intestinal damage (sCD14, LBP, FABP2); cell trafficking/inflammation (CCL20, CX3CL1, MIF, CCL25); subsets of Th17-polarized and regulatory (Tregs) CD4+ T-cells, classical/intermediate/non-classical monocytes, and myeloid/plasmacytoid dendritic cells were studied in relationship with HIV and TPV/LAPV status. The TPV detection/values coincided with higher plasma sCD14, FABP2, CCL20, MIF, CX3CL1, and triglyceride levels; lower Th17/Treg ratios; and classical monocyte expansion. Among HIV+, TPV+ versus TPV- exhibited lower Th17 frequencies, reduced Th17/Treg ratios, higher frequencies of non-classical CCR9lowHLADRhigh monocytes, and increased plasma fibrinogen levels. Finally, Th17/Treg ratios and non-classical CCR9lowHLADRhigh monocyte frequencies remained associated with TPV/LAPV after adjusting for FRS and HIV/ART duration in a logistic regression model. These findings point to Th17 paucity and non-classical monocyte abundance as novel immunological correlates of subclinical CAA that may fuel the CVD risk in ART-treated PLWH.

The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction

The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection. A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared. Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7mm (DS±0.6mm) at the origin, 2.2mm (DS±0.4mm) at the adductor space midpoint, and 1.7mm (DS±0.3mm) at the deep fascia. The mean adipose tissue thickness was 3.35cm (DS±0.94) at the deep fascia and 3.59cm (DS±1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22cm (DS±0.87) from the posterior border of the gracilis muscle and 8.98cm (DS±1.44) from the inferior gluteal crease. A radiological area located 9.33cm (DS±4.81) from the y-axis and 7.48cm (DS±1.88) from the x-axis was identified. CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators.

Endovascular aortic repair with sac embolization for the prevention of type II endoleaks (the EVAR-SE study): study protocol for a randomized controlled multicentre study in Germany

BackgroundBeyond a certain threshold diameter, abdominal aortic aneurysms (AAA) are to be treated by open surgical or endovascular aortic aneurysm repair (EVAR). In a quarter of patients who undergo EVAR, inversion of blood flow in the inferior mesenteric artery or lumbar arteries may lead to type II endoleak (T2EL), which is associated with complications (e.g. AAA growth, secondary type I endoleak, rupture). As secondary interventions to treat T2EL often fail and may be highly invasive, prevention of T2EL is desirable. The present study aims to assess the efficacy of sac embolization (SE) with metal coils during EVAR to prevent T2EL in patients at high risk.MethodsOver a 24-month recruitment period, a total of 100 patients undergoing EVAR in four vascular centres (i.e. Klinikum rechts der Isar of the Technical University of Munich, University Hospital Augsburg, University Hospital Dresden, St. Joseph’s Hospital Wiesbaden) are to be included in the present study. Patients at high risk for T2EL (i.e. ≥ 5 efferent vessels covered by endograft or aneurysmal thrombus volume <40%) are randomized to one group receiving standard EVAR and another group receiving EVAR with SE. Follow-up assessments postoperatively, after 30 days, and 6 months involve contrast-enhanced ultrasound scans (CEUS) and after 12 months an additional computed tomography angiography (CTA) scan. The presence of T2EL detected by CEUS or CTA after 12 months is the primary endpoint. Secondary endpoints comprise quality of life (quantified by the SF-36 questionnaire), reintervention rate, occurrence of type I/III endoleak, aortic rupture, death, alteration of aneurysm volume, or diameter. Standardized evaluation of CTA scans happens through a core lab. The study will be terminated after the final follow-up visit of the ultimate patient.DiscussionAlthough preexisting studies repeatedly indicated a beneficial effect of SE on T2EL rates after EVAR, patient relevant outcomes have not been assessed until now. The present study is the first randomized controlled multicentre study to assess the impact of SE on quality of life. Further unique features include employment of easily assessable high-risk criteria, a contemporary follow-up protocol, and approval to use any commercially available coil material. Overcoming limitations of previous studies might help SE to be implemented in daily practice and to enhance patient safety.Trial registration ClinicalTrials.gov NCT05665101. Registered on 23 December 2022.

Blunt Cerebrovascular Injury: Our Experience and Review of Current Practice

Abstract Background: Blunt cerebrovascular injury (BCVI) is an injury to the carotid or vertebral artery that is nonpenetrating and results from stretching or impingement of the vessel walls due to sudden head movement. Recent studies showed that the incidence of BCVI is around 1%–9%, with stroke being the most dreaded complication. Methodology: This retrospective study was conducted after approval by the medical research ethics committee at our tertiary care center, including all consecutive neck computed tomography angiography scans for blunt trauma patients from January 2017 to December 2020. The patient demographics, symptoms, and signs at presentation and imaging were reviewed through the electronic patient records for the presence of BCVI using the modified Denver scoring and Biffl criteria. Patients younger than 18 years, those with penetrating trauma, and patients with no head-and-neck scans were excluded from the study. The treatment and outcome of the positive cases were studied. Results: There were 871 patients with blunt trauma during the study. Of this number, 16 patients were identified with BCVI (1.83%). Most of the patients were male (75%), and the mean age of the cohort was 31 years (18–45 years). Among those with BCVI, five had carotid artery injuries (31%), and 11 had vertebral artery injuries (68.8%). BCVI Grades 2 and 4 were the most prevalent injuries. Ischemic infarction was seen in three patients (18%). Five patients (31.3%) with BCVI received antiplatelet therapy. None of the patients underwent endovascular or surgical treatment. Moreover, there was no BCVI-related mortality. There was a statistically significant between the Biffl grading, type of artery injury, and the presence of neurological deficit at the time of initial presentation, which both turned to be significant with a P = 0.017 and P = 0.049, respectively. Conclusion: BCVI is a serious injury with the potential for neurological complications. The artery involved and Biffl grading influence the presentation. Initiation of therapy with antithrombotic medications for stroke prevention is essential in all patients. The patients with positive findings need follow-up imaging, and an internationally recognized guideline is essential to manage this cohort.

Dark-Blood Computed Tomography Angiography Combined With Deep Learning Reconstruction for Cervical Artery Wall Imaging in Takayasu Arteritis.

To evaluate the image quality of novel dark-blood computed tomography angiography (CTA) imaging combined with deep learning reconstruction (DLR) compared to delayed-phase CTA images with hybrid iterative reconstruction (HIR), to visualize the cervical artery wall in patients with Takayasu arteritis (TAK). This prospective study continuously recruited 53 patients with TAK (mean age: 33.8 ± 10.2 years; 49 females) between January and July 2022 who underwent head-neck CTA scans. The arterial- and delayed-phase images were reconstructed using HIR and DLR. Subtracted images of the arterial-phase from the delayed-phase were then added to the original delayed-phase using a denoising filter to generate the final-dark-blood images. Qualitative image quality scores and quantitative parameters were obtained and compared among the three groups of images: Delayed-HIR, Dark-blood-HIR, and Dark-blood-DLR. Compared to Delayed-HIR, Dark-blood-HIR images demonstrated higher qualitative scores in terms of vascular wall visualization and diagnostic confidence index (all P < 0.001). These qualitative scores further improved after applying DLR (Dark-blood-DLR compared to Dark-blood-HIR, all P < 0.001). Dark-blood DLR also showed higher scores for overall image noise than Dark-blood-HIR (P < 0.001). In the quantitative analysis, the contrast-to-noise ratio (CNR) values between the vessel wall and lumen for the bilateral common carotid arteries and brachiocephalic trunk were significantly higher on Dark-blood-HIR images than on Delayed-HIR images (all P < 0.05). The CNR values were significantly higher for Dark-blood-DLR than for Dark-blood-HIR in all cervical arteries (all P < 0.001). Compared with Delayed-HIR CTA, the dark-blood method combined with DLR improved CTA image quality and enhanced visualization of the cervical artery wall in patients with TAK.

Bilateral Iliac Arteries Stent Compression Following Pelvic Surgery: A Case Report and Review of Literature

Extrinsic compression of iliac arteries stents has been reported from different causes, such as uterine fibroids and orthopedic surgery. Although extrinsic compression of stents in the iliac veins has been widely studied, stent compression in the iliac arteries is less common. Here we presented a case with bilateral common iliac arteries stent compression following pelvic surgery. A patient (65-year-old woman) presented with acute critical right limb ischemia. Computed tomography angiography (CTA) showed occlusion of the right common and external iliac artery, and severe stenosis in the left common iliac artery. In addition, there was evidence of a Brenner tumor originating from the left ovary. The patient underwent endovascular recanalization of the right iliac arteries and bilateral balloon-expandable stent deployment, and the ovarian tumor was removed after three weeks. The control CTA scan showed asymmetric bilateral iliac arteries stent compression more prominent on the right side, then self-expanding stents were implanted bilaterally. In Conclusion although iatrogenic compression of the stent in the iliac artery is rare despite scarcity, it is important to maintain a high index of suspicion in selected cases and choose the proper stent accordingly.

Endograft position and endoleak detection after endovascular abdominal aortic repair with low-field tiltable MRI: a feasibility study

BackgroundAbdominal aortic endoleaks after endovascular aneurysm repair might be position-dependent, therefore undetectable using supine imaging. We aimed to determine the feasibility and benefit of using a low-field tiltable magnetic resonance imaging (MRI) scanner allowing to study patients who can be imaged in both supine and upright positions of endoleaks.MethodsTen EVAR patients suspected of endoleak based on ultrasound examination were prospectively included. MRI in upright and supine positions was compared with routine supine computed tomography angiography (CTA). Analysis was performed through (1) subjective image quality assessment by three observers, (2) landmark registration between MRI and CTA scans, (3) Euclidean distances between renal and endograft landmarks, and (4) evaluation of endoleak detection on MRI by a consensus panel. Statistical analysis was performed by one-way repeated measures analysis of variance.ResultsThe image quality of upright/supine MRI was inferior compared to CTA. Median differences in both renal and endograft landmarks were approximately 6–7 mm between upright and supine MRI and 5–6 mm between supine MRI and CTA. In the proximal sealing zone of the endograft, no differences were found among all three scan types (p = 0.264). Endoleak detection showed agreement between MRI and CTA in 50% of the cases, with potential added value in only one patient.ConclusionsThe benefit of low-field upright MRI for endoleak detection was limited. While MRI assessment was non-inferior to standard CTA in detecting endoleaks in selected cases, improved hardware and sequences are needed to explore the potential of upright MRI in patients with endoleaks.Relevance statementUpright low-field MRI has limited clinical value in detecting position-dependent endoleaks; improvements are required to fulfil its potential as a complementary modality in this clinical setting.Key points• Upright MRI shows potential for imaging endoleaks in aortic aneurysm patients in different positions.• The image quality of upright MRI is inferior to current techniques.• Upright MRI complements CTA, but lacks accurate deformation measurements for clinical use.• Advancements in hardware and imaging sequences are needed to fully utilise upright MRI capabilities.Graphical