Identifying the artery of Adamkiewicz (AoA) is essential for minimizing the risk of spinal cord ischemia that can result from injury or displacement during aortopexy. A pre-operative CT angiogram (CTA) is commonly requested; however, locating the artery can be challenging due to its small size and variable course. To enhance the visualization of the artery of Adamkiewicz, it is effective to increase the tube current while maintaining a low kV of 70 and raising the Hounsfield unit (HU) trigger threshold. This method adheres to the As Low As Reasonably Achievable (ALARA) principle, ensuring a reliably diagnostic study.

Optimizing Abdominal Aortic Aneurysm Imaging to Improve Access, Clinical Utility, and Value-Based Medicine.

Microsurgical treatment of ethmoidal dural arteriovenous fistula.

Purpose: To compare the performance of two FDA-cleared artificial intelligence (AI) solutions, Vendor A (Aidoc, Tel Aviv, Israel) and Vendor B (Viz.ai, San Francisco, USA) in detecting vessel occlusions (VOs) on CT head angiograms within a large academic healthcare environment. Materials and Methods: This retrospective study included cases processed by both Vendor A and Vendor B over an 18-week period (June 1–September 27, 2024). A natural language processing (NLP) algorithm classified radiology reports. When NLP, vendor A, and vendor B outputs were concordant, this was assumed as ground truth; cases with any discordance underwent review and adjudication to establish ground truth. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: A total of 1,557 consecutive CT angiogram cases were reviewed. NLP algorithm identified 113 true positive reports, corresponding to a prevalence of 7.3% (113/1,557). With 402 cases exhibiting discordance. Vendor A demonstrated a sensitivity of 92.4%, specificity of 97.6%, PPV of 76.8%, and NPV of 99.3%. Vendor B demonstrated a sensitivity of 35.4%, specificity of 98.1%, PPV of 62.2%, and NPV of 94.5% as seen in Table 1. Vendor A detected 92.6% of Large Vessel Occlusions (LVO) and 92.3% of Medium Vessel Occlusions (MeVO). Vendor B detected 70.4% of LVOs and only 17.3% of MeVOs, highlighting notable performance differences in MeVO detection as seen in Table 2. Conclusion: In this real-world clinical comparison, Vendor A demonstrated higher sensitivity and stronger agreement with ground truth compared to Vendor B in detection of VO. Vendor A detected 92.6% of LVOs compared to 70% for Vendor B, with the overall performance gap attributable to Vendor A’s greater accuracy in identifying MeVOs.These findings provide valuable comparative data and underscore the importance of evaluating both diagnostic accuracy and statistical agreement when selecting AI solutions for stroke triage workflows. Clinical Relevance Statement: AI algorithms designed for VO detection may vary significantly in diagnostic performance and clinical integration. This study emphasizes the importance of critical vendor assessment, particularly regarding detection sensitivity and agreement with expert adjudication, to guide optimal AI adoption in acute stroke care environments.

Abstract Background Spontaneous coronary artery dissection (SCAD) is an uncommon cause of myocardial infarction and can be challenging to diagnose; treatment is often supportive. Post-SCAD chest pain (PSCP_ is common raises concern of extension or recurrence. Non-invasive imaging techniques are often preferred during re-evaluation given the risk of catheter-induced dissection. Coronary CT Angiogram (CCTA) is emerging modality for SCAD evaluation and has been recommended for use by consensus documents despite its limitation.. We review the utility of CCTA in evaluating our patients experiencing PSCP. Methods Patients enrolled in our SCAD registry (N=11) from 2019 to 2024 who experienced post-SCAD chest pain (N=5, 45%) that underwent CCTA (N=4) in our institution were included in series. All cases were female, presented with myocardial infarction and had single vessel SCAD diagnosed on invasive coronary angiogram. The cases this series had at least one subsequent emergency department visit for chest pain prior to CCTA without ECG changes or elevated cardiac biomarkers. No patients had any other CCTA for comparison imaging. Further baseline characteristics are outlined in table 1. Patients were imaged using the 384-detector Siemens Somatom Force dual-source CT system, a preliminary scout study was obtained, followed by coronary artery calcium protocol. Following administration of Omnipaque 350 intravenous contrast 0.6 mm collimated images were obtained through the coronary arteries via Turboflash protocol. Data were transferred off-line for 3D reconstructions including curved MPR and multi-planar imaging. All patients were on regular betablockers and in sinus rhythm. Sublingual nitroglycerine was given just prior to scanning. Results All patients had a coronary artery calcium score of 0. Case 3 was reported to also have minimal diffuse disease in the right posterior descending artery on CCTA (non-culprit vessel); no other cases demonstrated evidence of CAD in any other coronary territory. CCTA findings were supportive both of the initial diagnosis of SCAD and absence of re-infarction or extension of SCAD in all of the cases. In keeping with previous reports and known limitations of CCTA distal-SCAD correlated to less specific findings on CCTA. "Time to CCTA" from index event varied greatly (49-293 days) and some patients may have demonstrated vessel healing resulting in the absence of more specific findings of SCAD. There were no repeat visits to the emergency department or hospitalizations for chest pain after CCTA was performed and resulted. There were no other pertinent clinical findings of CCTA imaging to account for chest pain in any of the cases. Conclusion PSCP remains a significant complication of SCAD and source of distress to affected individuals. CCTA can be a useful modality in ruling out re-infarction of extension of dissection, providing reassurance to patients on vessel healing and guiding clinical monitoring.Table 1

Incidental carotid webs in trauma patients.

The impact of endovascular thrombectomy-mediated reperfusion on malignant cerebral edema (MCE) in large-core infarction remains unclear. We assessed the reperfusion-MCE relationship and MCE's mediating role in poor outcomes. This retrospective analysis used data from the national MAGIC (Prospective Multicenter Registry on Early Management of Acute Ischemic Stroke) registry (750 patients with large-core infarction, 38 Chinese centers, 2021-2023). MCE was defined as a midline shift of ≥5 mm on follow-up imaging within 72 hours after stroke onset. Recanalization was confirmed by computed tomography angiogram or magnetic resonance angiogram during hospitalization in the overall cohorts. Successful reperfusion was defined using the modified Treatment in Cerebral Ischemia classification 2b-3 in the endovascular thrombectomy arm. Functional outcome was 90-day modified Rankin scale score. Mediation analysis used reperfusion status as the independent variable and MCE as the mediator. Among 698 patients, (306 women [43.8%]; median age, 70 [interquartile range, 61-78] years; median, Alberta Stroke Program Early Computed Tomography] Scores, 4 [interquartile range, 2-5]), successful recanalization (adjusted odds ratio [aOR], 0.68 [95% CI, 0.47-0.99]; P=0.042) and reperfusion (aOR, 0.34 [95% CI, 0.18-0.67]; P=0.002) reduced MCE likelihood. MCE was partially responsible for worse modified Rankin Scale scores in patients without recanalization or reperfusion (MCE changed the logistic regression coefficients by 15.0% and 32.5%, respectively). Recanalization improved functional outcomes partly by mitigating MCE formation (indirect effect β=-0.10, 11.5% mediation proportion, P=0.028) in those with Alberta Stroke Program Early Computed Tomography Scores 3 to 5 but not in those with 0 to 2 (β=-0.26, P=0.140). Successful reperfusion attenuates MCE formation and improves clinical outcomes in patients with large-core infarction.

Background: Type B Aortic Dissection (TBAD) management relies on risk stratification, yet evidence-based tool adoption remains inconsistent in National Health Services (NHSs). Bridging the gap between Emergency Medicine (EM) and Vascular Surgery remains essential for timely diagnosis, optimal risk stratification, and appropriate intervention to improve outcomes and reduce mortality. Methods: A cross-sectional survey of EM consultants yielded n = 173 valid responses from n = 33 units across the UK. Subgroup analyses were conducted using a Chi-square test (p < 0.05) alongside descriptive analysis. A pooled prevalence analysis of the literature, utilizing a random-effects model at a 95% confidence interval (CI), served as a benchmark for perception analysis. Agreement was evaluated using Bland–Altman analysis, incorporating upper, lower, and overall bias of agreeability. Results: Access to a rapid Computed Tomography Angiogram (CTA) was 70% (95% CI: 63.3–76.8%, p < 0.001), while 32% had standard operating procedures (SOPs) for TBAD (95% CI: 25.3–39.1%), and 26% were aware of any decision tool (95% CI: 20.6–33.6%). Labetalol as a first-line antihypertensive was more common amongst least experience (p < 0.05). TBAD diagnosis increased 1.6-fold with every 4 years of additional experience (p < 0.05). Perception analysis showed strong agreement for pain (characteristics and location), hypertension, gender, and age with moderate-to-low agreement for other factors with a reported bias of 23.58% (−38.20% to 85.36%) (p = 0.02). Conclusions: The survey suggests a degree of misperception and inconsistency in recognition of most and least prevalence factors for TBAD suspicion and management. This outcome advocates targeted strategies to enhance diagnostic accuracy using tools aligned with NHS resources and QALY frameworks. Furthermore, upon recognition of the most prevalent factors, CTA and specialist referral is advocated.

Introduction: Hemoglobin SC sickle cell disease in the setting of pregnancy with pre-eclampsia or HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) is a challenging clinical scenario that greatly increases maternal and fetal risks during pregnancy. Hemoglobin SC sickle cell disease is a variant of sickle cell disease characterized by the presence of both hemoglobin S and C. This can exacerbate pregnancy complications through its vaso-occlusive properties, which can impair placental function, lead to fetal growth restriction, and increase the risk of pre-eclampsia, preterm birth, stillbirth, and maternal morbidity and mortality. Pre-eclampsia is a hypertensive disorder of pregnancy paired with proteinuria that occurs after 20 weeks gestational age. It can lead to HELLP syndrome, a severe form of pre-eclampsia characterized by hemolysis, elevated liver enzymes, and thrombocytopenia. The pathophysiology of HELLP syndrome involves endothelial dysfunction and microangiopathic hemolytic anemia, which can be particularly severe in the setting of Hemoglobin SC sickle cell disease due to an underlying hemolytic state. Management of Hemoglobin SC sickle cell disease in the setting of pregnancy with pre-eclampsia or HELLP syndrome requires a multidisciplinary approach, involving OB/GYNs, hematologists, and sometimes even gastroenterologists, to optimize maternal and fetal outcomes and provide patient-centered care. Methods: Case report. Case Description: Patient is a 27-year-old G1 with a history of Hemoglobin SC sickle cell disease (managed with hydrocodone outpatient), asthma, retinopathy, and avascular hip necrosis. She was admitted at 37+0 weeks for a sickle cell pain crisis characterized by 10/10 lower back pain with radiation to her bilateral hips and legs. Her pain was unrelieved with hydromorphone, and she declined increases to her medications due to her concern for fetal harm after her biophysical profile (BPP) showed a score of 6/10- likely secondary to the effects of narcotics. She ruled into pre-eclampsia without severe features based on proteinuria and mildly elevated blood pressures. As a result, she was induced at 37+3 weeks with a spontaneous vaginal delivery complicated by postpartum hemorrhage (PPH) of 882 mL. After delivery, she developed tachycardia of 147. Her hemoglobin dropped from 10.7 g/dL to 8.6 g/dL a few hours prior to delivery, then to 5.6 g/dL at 4 hours after delivery. Her alanine aminotransferase (ALT) was 444 units/L and her aspartate aminotransferase (AST) was 865 units/L. She experienced reactive leukocytosis with up trending white blood cell count of 25.37 x 103/mcL, but was asymptomatic with negative urine and blood cultures. She was started on cefepime, vancomycin, and metronidazole for prophylaxis. Her platelets had been down trending throughout her hospitalization. Her thrombocytopenia in combination with pre-eclampsia led to the diagnosis of pre-eclampsia with severe features. A coagulation panel was obtained and trended after the PPH, and it showed worsening levels with lactate dehydrogenase of 990 units/L, an international normalized ratio increase to 1.37, and a fibrinogen drop from 316 to 280 mg/dL. Due to her anemia, she was transfused with 2 units of packed red blood cells (pRBCs). Her tachycardia and sickle cell pain continued despite escalating hydromorphone doses, and there was concern for HELLP syndrome versus acute worsening of sickle cell crisis. Due to her hemodynamic instability and worsening of her labs, she was transferred to the MICU. An electrocardiogram showed sinus tachycardia. Splenic ultrasound showed stable splenomegaly. A computed tomography angiogram (CTA) was negative for acute pulmonary embolism but showed bilateral small pleural effusions with atelectasis. Her right lower extremity doppler ultrasound was negative. In the MICU, she was treated with magnesium for seizure prophylaxis, and she remained stable without seizure activity. Her pain regimen was escalated per sickle cell protocols, and her pain improved. She received an additional 2 units of pRBCs for hemoglobin of 6.4 g/dL, and her hemoglobin stabilized at 9.9 g/dL. Additionally, her platelets stabilized at 146x103/mcL, and her ALT and AST down trended. Additional imaging showed grade 1 hepatic steatosis. A CT brain without contrast was unremarkable. Once she was stabilized, she continued to meet postpartum milestones and remained hemodynamically stable. She also continued to deny symptoms of pre-eclampsia. Her reactive leukocytosis improved, and antibiotics were discontinued. Discussion: In the case of this patient, several discussions and many multidisciplinary decisions were made to optimize maternal and fetal outcomes and manage postpartum complications with the goal of minimizing long term negative effects and organ damage to the mother. Hydromorphone can be a mainstay of treatment for sickle cell pain crises, but in the setting of pregnancy, some women may be reluctant to take the medication due to potential risks of poor fetal growth, stillbirth, preterm delivery, neonatal abstinence syndrome, and the need for cesarean delivery. In this patient’s case, her BPP score was 6/10, suspected to be secondary to hydromorphone use. Due to patient concern about this, the increased doses were held prior to delivery, and other management routes were taken, which demonstrated patient-centered care.

Symptomatic nonstenotic (<50% stenosis) carotid disease in the presence of high-risk plaque features is a potential cause of ischemic stroke. We assessed stroke risk associated with symptomatic nonstenotic carotid disease. This cross-sectional secondary analysis of the AcT (Alteplase Compared to Tenecteplase) randomized controlled trial evaluated baseline computed tomography angiograms for degree of internal carotid artery stenosis, plaque features and the presence of intraluminal thrombi, webs, dissection, and rim sign. Stroke location was evaluated on 24-hour follow-up imaging. At a carotid level, mixed-effects logistic regression models adjusted for age and sex, with patient identity as a random effect, examined associations between "concordant stroke" (ipsilateral acute stroke in the internal carotid artery territory) and symptomatic nonstenotic carotid disease. Of 1577 patients enrolled, 1407 (89.2%) with interpretable imaging were included: 329 (23.4%) had no carotid disease, 869 (61.8%) had nonstenotic carotid disease, and 209 (14.9%) had stenotic (≥50%) carotid disease in either the left or right internal carotid artery. Median age was 73 years (interquartile range, 63-83), with 48% female patients. Among 2519 (89.5%) internal carotid arteries with nonstenotic disease, 689 (27.4%) concordant strokes were identified. Intraluminal thrombi, carotid webs, carotid dissections, and carotid rim sign were significantly associated with concordant stroke (adjusted odds ratio, 8.11 [95% CI, 1.60-41.08]; adjusted odds ratio, 3.58 [95% CI, 1.53-8.35]; adjusted odds ratio, 6.77 [95% CI, 1.72-26.75]; and adjusted odds ratio, 3.17 [95% CI, 1.39-7.23], respectively). Results remained unchanged after excluding patients with atrial fibrillation and lacunar infarctions. Features other than the degree of stenosis should be considered when evaluating patients with carotid disease.

Bile duct injuries during cholecystectomy are most frequently attributed to misidentification of surgical anatomy. Initial management following a major bile duct injury is time-sensitive and critical to the patient's clinical course and overall outcome. We present a 63-year-old male patient who sustained a common bile duct transection during laparoscopic cholecystectomy at a resource-limited rural surgery center. Upon recognition of the injury, an intraoperative video consultation was made to hepatobiliary surgery at our academic referral institution, providing a real-time explanation of the dissection with direct visualization of surgical anatomy. This expedited sequence facilitated acquisition of diagnostic studies, including an intraoperative cholangiogram, confirming common bile duct transection, and a CT angiogram, demonstrating intact arterial anatomy. Direct to OR transfer to the tertiary facility was therefore prioritized, circumventing a prolonged bed wait the patient would have otherwise required while awaiting injury diagnosis and characterization. He underwent definitive repair with robotic-assisted Roux-en-Y hepaticojejunostomy on the same day that the injury occurred. This paper provides an operative video with a concise and adoptable method for performing a definitive hepaticojejunostomy following bile duct transection intended for fellowship-trained hepatobiliary surgeons.

The Role of Open Abdominal Aortic Aneurysm Repair in the Era of Fenestrated Endovascular Repair.

High Risk Predictors for Thoracic Aortic Injury in Pediatric Blunt Chest Trauma.

There is emerging evidence that plaque features may play a critical role in future acute coronary syndrome. In this study, we analyzed plaque features using an artificial intelligence-enabled algorithm in a clinical cohort who developed non-ST-elevation myocardial infarction (NSTEMI) following coronary CT angiogram (CCTA). We performed a case-control study selected from 13 751 consecutive cases in a single center referred for outpatient CCTA. After a follow-up of 4.3 ± 4 years, 48 patients without preexisting coronary disease developed NSTEMI. Controls (N = 187) were matched to the cases on age, gender, BMI, and kilovoltage for CTA acquisition. Quantitative plaque analysis was performed using artificial intelligence-enabled Autoplaque software (Autoplaque version 3.0; Cedars-Sinai Medical Center, Los Angeles, California, USA). Multivariable Cox proportional hazards models were performed to identify the predictors of NSTEMI. The mean age was 64 ± 11 years. Both case and control groups had mild stenosis at baseline (26 vs 17%, P = 0.01). The total calcified plaque and fibrous plaque volume were not different (P = 0.10 and P = 0.13, respectively). Necrotic core plaque volume and fibrous fatty plaque volume were higher in the NSTEMI group (28 ± 29 vs 9 ± 13 mm3, 169 ± 157 vs 84 ± 105 mm3, respectively, both P < 0.01). In multivariable Cox regression, necrotic core volume portended the greatest risk of NSTEMI, a seven-fold higher than that of total plaque volume. Using artificial intelligence-enabled plaque analysis, noncalcified plaque volume, especially necrotic core and fibrous fatty plaque volume are important precursors for future NSTEMI events.

Abstract Background The aberrant right hepatic artery (ARHA) is a significant anatomical variation in hepatic vasculature, found in approximately 10-20% of the population. Laparoscopic Cholecystectomy is one of the indexed procedures required for certification in General Surgery, here we present 4 cases of laparoscopic cholecystectomy where we encountered ARHA to signify the awareness that it is not uncommon to encounter these variations intra operatively. Case There were 4 cases over 3 months operated by ST3 trainees under direct supervision, anomalies were detected intraoperatively after high suspicions of abnormally large, dilated vessel crossing cystic duct were made. Careful dissection of ARHA till liver insertion were done along with clipping of high origin of cystic artery. The rest of surgery and recovery was uneventful. Post-surgery CT Angiogram were organized to delineate anatomy of vessel for future reference. Discussion This arterial anomaly originates from the superior mesenteric artery rather than the common hepatic artery, deviating from the typical arterial supply of the liver. We encountered 2 cases where the artery was having its course medially and 2 cases from inferior aspect of the hilum. Clinically, the presence of an ARHA holds considerable importance, especially in hepatobiliary and pancreatic surgeries, liver transplantations, and interventional radiology procedures, where unrecognized variants can lead to complications such as ischemia, haemorrhage, and postoperative liver dysfunction. Conclusions ARHA represents a vital anatomical variant with implications interventional outcomes. Recognition of ARHA through imaging and meticulous operative planning is essential for minimizing intraoperative complications and ensuring optimal patient outcomes in hepatobiliary care.

Abstract Introduction Bleeding from a Zenker's diverticulum is a rare occurrence, and currently no formal guidelines exist for its management. It is a potentially life-threatening condition and an important consideration in the differential diagnosis of haemoptysis or haematemesis. Presentation of case A 63-year-old man presented with haemoptysis and haematemesis while on dual antiplatelet therapy for a recent NSTEMI. After resuscitation he underwent a CT angiogram which demonstrated an active contrast blush and pooling of contrast in a pharyngeal diverticulum. At endoscopy a large Zenker's diverticulum was encountered which contained an ulcerated area with general oozing of blood from multiple points and a single brisk bleeding point. Haemostasis was achieved with two syringes of a topical haemostatic agent. Discussion Less than 15 case reports exist in the literature of this clinical entity, and fewer still have been managed successfully via endoscopic methods. The pathophysiology is unclear however may be related to antiplatelet agents exerting a topical effect after lodging in the diverticulum, causing ulceration, diverticulitis and bleeding. Early diagnosis can be challenging as patients may seem to present with haemoptysis, and delay to prompt diagnosis may further delay management. Conclusions This is the first Australian case report of bleeding from a Zenker's diverticulum who underwent successful endoscopic management. It highlights the diagnostic dilemma presented by this clinical entity and the subsequent impacts on management. Endoscopic haemostasis is an ideal intervention either as a definitive procedure in elderly patients unfit for surgery, or initial management as a bridge to surgery.

Decisions to perform abdominal aortic aneurysm (AAA) repair are dependent on aneurysm size, but variation in size measurement leads to inconsistency in management. AI-assisted systems have potential to improve repeatability of measuring aortic dimensions. This study compared the repeatability and agreement in clinical decision-making between using artificial intelligence (AI)-automated and traditional semi-automated methods for measuring abdominal aortic aneurysm (AAA) size. Computed tomography angiogram scans from 142 patients who had scans at baseline (n = 142), 1 year (n = 100), 2 years (n = 56) and 3 years (n = 4) were analysed using semi-automated and AI-assisted automated systems. Three observers measured maximal AAA diameter and volume twice with each method. Intra- and inter-observer repeatability were assessed using reproducibility coefficients (RC). Measurements were used to decide if AAA repair was required according to clinical guidelines, and agreement was evaluated using Kappa coefficients (K). The ability of AI-assisted measurements to predict actual requirement for AAA repair was assessed using Cox proportional hazard analysis. AI-assisted measurements had perfect intra- and inter-observer repeatability (RC = 0) which were significantly superior to traditional measurements (RC for diameter: 1.9-5.6mm; volume: 7.8-22.6cm³, p < 0.001). Agreement about AAA repair was superior using AI-assisted (K = 1) than traditional (K = 0.55-0.70) measurements. Baseline AI-assisted measurements predicted actual requirement for AAA repair (Hazard ratio, HR, per mm diameter increase 1.12, 95% confidence intervals, CI, 1.03-1.22, HR per cm³ volume increase 1.02, 95% CI 1.01-1.02, p < 0.001). The findings suggest AI-assisted measurement of AAA size would enhance the consistency of decisions about AAA repair.

This study examines the most common causes of pulsatile tinnitus (PT) found with a modified CTA (mCTA) protocol and analyzes the protocol's diagnostic success rate. Retrospective cohort. A single academic institution. Adult patients presenting for evaluation of PT from 2011 to 2021 who underwent mCTA were included. mCTA is a bone-windowed CT angiogram with delayed postcontrast image acquisition permitting both arterial and venous imaging. Demographics, audiometric data, imaging, and final diagnoses were analyzed. The patients were divided into 2 groups: no prior imaging (NPI) and prior imaging (PI). Top diagnoses were determined and rates of efficacy and failure of the mCTA protocol were compared. One hundred nine patients were recommended to obtain mCTA, of which 22 were lost to follow-up before obtaining imaging. The remaining 87 patients were included in data analysis, 42 in the NPI group and 45 in the PI group. The most common etiology of PT was transverse sinus stenosis with sigmoid sinus wall anomalies, affecting 22 patients (25.3%). The mCTA protocol efficacy rate was 96.5% and failed to capture an important imaging diagnosis at a rate of 3.5%. There was no significant difference in efficacy between the NPI and PI groups. mCTA was found to be an effective initial diagnostic tool for all patients, regardless of prior imaging status. The most common etiology of PT was transverse sinus stenosis with sigmoid sinus wall anomalies.

Diagnostic imaging is essential in evaluating abdominal pathology, yet inappropriate imaging requests remain a concern due to potential radiation exposure, extended hospital stays, increased healthcare costs, and resource strain. However, little is known about the extent of inappropriate imaging in abdominal radiology. This study investigates the prevalence of inappropriate imaging across imaging modalities and departments in three German hospitals. We analyzed all 3393 scored abdominal imaging requests submitted by any of 13 departments from three German university hospitals over a 2.5-year period within the context of the MIDAS trial (NCT05490290). Each request was scored for appropriateness using the European Society for Radiology (ESR) iGuide and categorized as appropriate, appropriate under certain conditions, or inappropriate. Descriptive statistics were used to assess appropriateness overall, by modality, and by patient demographics. Estimated radiation exposure and cost were also calculated using standardized dose and pricing models. Of all scored imaging requests, 6.19% were deemed inappropriate (99% Confidence Interval (CI) 5.12-7.25). Ultrasound had the highest proportion of inappropriate requests (12.35%, 99% CI 8.14-16.56), followed by fluoroscopy (7.14%, 99% CI 1.23-13.05), Computed Tomography (CT) (5.47%, 99% CI 3.94-6.99), MRI (5.20%, 99% CI 3.63-6.77), and conventional radiography (1.89%, 99% CI 0-6.70). The most frequently requested exams were chest/abdominal/pelvic CTs, Magnetic Resonance Imaging (MRI) Abdomen, MRI pelvis, abdominal ultrasound and CT angiogram chest/abdomen/pelvis. The total estimated radiation exposure of requested exams was 27,954 miligray (mGy), and the total associated cost was €604,411. Inappropriate abdominal imaging requests were relatively uncommon but varied across modalities. The findings in this paper highlight areas for potential improvement in imaging practices, further training and further development of clinical decision support tools to enhance guideline adherence in real-world settings.

This study was performed to evaluate the anatomical feasibility of the off-the-shelf G-Branch device (Lifetech Scientific, Shenzhen, China) for the endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs). Digital computed tomography angiograms were analyzed in 171 consecutive patients with TAAAs who enrolled for imaging screening in a national multicentre clinical trial to evaluate the feasibility of the G-Branch system between November 12, 2021 and June 25, 2023. Anatomical feasibility was assessed based on the investigational protocols and the instructions for use (IFUs). According to the standard, conservative, and liberal IFU criteria, the overall feasibility of the G-Branch system was 74.9% (128/171), 59.1% (101/171), and 80.7% (138/171), respectively. The top 3 factors limiting feasibility by the standard IFU criteria were a stenosed or occlusive renal artery (19/171), an accessory renal artery with a diameter of ≥3 mm (15/171), and a renal artery landing zone of <15 mm (14/171). The G-Branch system demonstrates favorable feasibility for the endovascular treatment of TAAAs, particularly with the aid of other endovascular techniques. The main limitations were stenosed or occlusive renovisceral arteries and accessory renal arteries.Clinical ImpactThe G-Branch system's high anatomical feasibility, especially with the aid of other endovascular techniques, has the potential to change clinical practice in the treatment of thoracoabdominal aortic aneurysms (TAAAs). For clinicians, it offers a more viable off-the-shelf option that can be applied to a large proportion of TAAA patients, expanding the scope of endovascular treatment and providing a more convenient and efficient alternative to traditional open surgery. The innovation behind this study lies in the comprehensive evaluation of the G-Branch system's anatomical feasibility based on a large sample size from a national multicentre clinical trial, which provides valuable insights into its clinical application and helps identify the main limitations that need to be addressed in future device development and clinical practice.