Digital Subtraction Angiography Research Articles

Use of dual intraventricular vasodilators for refractory cerebral vasospasm in a pediatric patient with traumatic subarachnoid hemorrhage: A case report.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Subarachnoid hemorrhage (SAH) is a rare but life-threatening clinical event for pediatric patients. Cerebral vasospasm is a common complication of SAH that often leads to poor outcomes. This case report describes the use of dual intraventricular (IVT) vasodilators in a pediatric patient. An 11-year-old male presented with traumatic diffuse SAH and cranial vasospasm. Despite treatment with IVT nicardipine, intravenous (IV) milrinone by continuous infusion, enteral nimodipine, and intraarterial verapamil and milrinone given during digital subtraction angiography, transcranial Doppler (TCD) mean velocities continued to rise. IVT milrinone was then added to IVT nicardipine and IV milrinone. The combination of IVT nicardipine, IV milrinone, and rescue therapy with IVT milrinone was continued for a total of 7 days. TCD mean velocities decreased into the mild to moderate range within 2 days of the patient receiving this combined regimen and remained globally low thereafter. This case illustrates the potential benefit of using dual IVT vasodilators to improve outcomes for pediatric patients with refractory cerebral vasospasm.

"Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis".

Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes. In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models. 459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p < 0.001). Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.

A retrospective observation study for the diagnostic effect of dual-source CT angiography on traumatic subarachnoid hemorrhage patients

Identification of potential cerebrovascular disorder in the patient with traumatic subarachnoid hemorrhage (tSAH) is a key element to decrease the complication occurrence and mortality rate. In this study, we aim to compare the diagnostic values between dual-source computed tomography angiography (DSCTA) and traditional tomography angiography (CTA) in identification of potential cerebrovascular disorder among tSAH patients. A total of 113 tSAH patients with the hemorrhage involving more than 2 cisterns were recruited. Among that, 42 patients received DSCTA scans, and another 71 patients received traditional CTA scans. Subsequently, all patients received digital subtraction angiography (DSA) tests to confirm the presence of the cerebrovascular disorder. In DSCTA scan group, 21.4 % (9/42) patients were reported to have cerebrovascular disorders: seven patients had intracranial aneurysms; a patient had pseudoaneurysm with carotid artery cavernous sinus fistula; and a patient had Moyamoya disease. DSA tests had the same results with that with DSCTA scans. In the cohort receiving CTA scans, 19.7 % (14/71) patients were reported to had intracranial aneurysms. However, the positive results of DSA tests for this cohort were 22.5 % (16/71). Two inconsistent results between the CTA scan and DSA test were found, including an arteriovenous malformation and an arteriovenous fistula. In summary, DSCTA and CTA had similar positive rates but differ in diagnostic accuracy for identification of cerebrovascular disorders in tSAH patients.

Hemodynamics in the treatment of pseudoaneurysm caused by extreme constriction of aortic arch with coated stent.

To evaluate the changes in distal vascular morphology and hemodynamics in patients with extremely severe aortic coarctation (CoA) after covered palliative (CP) stent dilation with different surgical strategies. Perioperative computed tomography angiography and digital subtraction angiography were utilized to construct three aortic models with varying stenosis rates and one follow-up model in a patient with extremely severe CoA. The models included: an idealized non-stenosed model (A: 0%), a model post initial stent deployment (B: 28%), a model post balloon expansion (C: 39%), and a model 18 months after post-balloon expansion (D: 39%). Consistent boundary conditions were applied to all models, and hemodynamic simulation was conducted using the pure fluid method. The narrowest and distal diameter of the stent increased by 34.71% and 59.29%, respectively, from model B to C. Additionally, the distal diameter of the stent increased by -13.80% and +43.68% compared to the descending aorta diameter, respectively. Furthermore, the ellipticity of the maximum cross-section of the aneurysm region in model A to D continued to increase. The oscillatory shear index at the stenosis to the region of the aneurysm were found to be higher in Models A and B, and lower in Models C and D. At the moment of maximum flow velocity, the blood flow distribution in models A and B was more uniform in the widest section of the blood vessels at the distal end of the stenosis, whereas models C and D exhibited disturbed blood flow with more than 2 eddy currents. The time-averaged wall shear stress (TAWSS) decreased in the distal and basal aneurysms, while it significantly increased at the step position. The aneurysmal region exhibited an endothelial cell activation potential value lower than 0.4 Pa-1. In patients with extremely severe CoA, it is crucial to ensure that the expanded diameter at both ends of the CP stent does not exceed the native vascular diameter during deployment. Our simulation results demonstrate that overdilation leads to a decrease in the TAWSS above the injured vessel, creating an abnormal hemodynamic environment that may contribute to the development and enlargement of false aneurysms in the early postoperative period. ClinicalTrials.gov, (NCT02917980).

Lipid on stroke in intracranial artery atherosclerotic stenosis: a mediation role of glucose.

Expanding on previous investigations, this study aims to elucidate the role of lipid metabolism disorders in the development of intracranial atherosclerotic stenosis (ICAS) and the determination of stroke risk. The primary objective is to explore the connections between lipid parameters and acute ischemic stroke (AIS), while also examining the potential mediating influence of fasting glucose levels. Retrospectively, we collected data from symptomatic ICAS patients at the First Affiliated Hospital of Soochow University, including their baseline information such as medical histories and admission blood biochemical parameters. Stenotic conditions were evaluated using magnetic resonance imaging, computed tomography angiography, or digital subtraction angiography. The associations between lipid parameters and AIS risks were investigated via multivariate logistic regression analysis. A total of 1103 patients with symptomatic ICAS were recruited, among whom 441 (40.0%) suffered new ischemic events during hospitalization. After adjusting for confounding factors, the RCS curves exhibited a dose-response relationship between the atherogenic index of plasma (AIP), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and AIS. Further multivariate analysis revealed significant associations between these parameters and AIS. Furthermore, mediation analysis indicated that fasting blood glucose (FBG) acted as a mediator in the association between lipid parameters (AIP, TC, and TG) and AIS. Higher lipid parameters in ICAS patients, particularly AIP, TC, and TG, were associated with an increased AIS risk. Additionally, FBG may mediate stroke risk in ICAS patients, highlighting the need for further exploration of underlying mechanisms.

Value of hepatic artery digital subtraction angiography in the detection of small hepatocellular carcinoma lesions.

To compare the detection rates of hepatic artery digital subtraction angiography (HA-DSA) and magnetic resonance imaging (MRI) gadolinium diethylenetriaminepentaacetic acid (MRI-Gd-DTPA) and MRI gadolinium diethylenetriaminepentaacetic acid (MRI-Gd-EOB-DTPA) for small (diameter ≤2 cm) hepatocellular carcinoma (HCC) lesions. A prospective analysis of patients admitted to the Tumor Hospital of Guangxi Medical University between January 1, 2015, and December 30, 2016, was conducted. The detection rates of the three methods were analyzed. The diameter of small HCC lesions detected using HA-DSA and MRI-Gd-EOB-DTPA were evaluated. The diagnostic value of HCC Barcelona staging for HA-DSA was analyzed. For 107 small lesions detected in 57 patients, the detection rates of HA-DSA and MRI-Gd-DTPA were 86.0% (92/107) and 71.0% (76/107), respectively (p < .05). Of 77 small lesions detected in 42 patients using MRI-Gd-EOB-DTPA and HA-DSA, 67 were detected using HA-DSA, all of which had a rich blood supply, and 72 were detected using MRI-Gd-EOB-DTPA. The minimum diameter of lesions detected using MRI-Gd-EOB-DTPA was approximately 0.4 cm, whereas that of lesions detected using HA-DSA was approximately 0.5 cm. After HA-DSA, a change in the Barcelona staging occurred in 33.3% (62/186) of cases but not after MRI-Gd-DTPA; HA-DSA was significantly better than MRI-Gd-DTPA for staging (p = .03). HA-DSA and MRI-Gd-EOB-DTPA have high diagnostic values for the detection of small HCC lesions, which is helpful for accurate staging of HCC and provides the most valuable information for patient treatment and prognosis.

Localized Nicardipine Release Implants for Prevention of Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Cerebral vasospasm largely contributes to a devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH), with limited therapeutic options. To investigate the safety and efficacy of localized nicardipine release implants positioned around the basal cerebral vasculature at risk for developing proximal vasospasm after aSAH. This single-masked randomized clinical trial with a 52-week follow-up was performed between April 5, 2020, and January 23, 2023, at 6 academic neurovascular centers in Germany and Austria. Consecutive patients with World Federation of Neurological Surgeons grade 3 or 4 aSAH due to a ruptured anterior circulation aneurysm requiring microsurgical aneurysm repair participated. During aneurysm repair, patients were randomized 1:1 to intraoperatively receive 10 implants at 4 mg of nicardipine each plus standard of care (implant group) or aneurysm repair alone plus standard of care (control group). The primary end point was the incidence of moderate to severe cerebral angiographic vasospasm (aVS) between days 7 and 9 after aneurysm rupture as determined by digital subtraction angiography. Of 41 patients, 20 were randomized to the control group (mean [SD] age, 54.9 [9.1] years; 17 female [85%]) and 21 to the implant group (mean [SD] age, 53.6 [11.9] years; 14 female [67%]). A total of 39 patients were included in the primary efficacy analysis. In the control group, 11 of 19 patients (58%) developed moderate or severe aVS compared with 4 of 20 patients (20%) in the implant group (P = .02). This outcome was paralleled by a lower clinical need for vasospasm rescue therapy in the implant group (2 of 20 patients [10%]) compared with the control group (11 of 19 patients [58%]; P = .002). Between days 13 and 15 after aneurysm rupture, new cerebral infarcts were noted in 6 of 19 patients (32%) in the control group and in 2 of 20 patients (10%) in the implant group (P = .13). At 52 weeks, favorable outcomes were noted in 12 of 18 patients (67%) in the control group and 16 of 19 patients (84%) in the implant group (P = .27). The adverse event rate did not differ between groups. These findings show that placing nicardipine release implants during microsurgical aneurysm repair can provide safe and effective prevention of moderate to severe aVS after aSAH. A phase 3 clinical trial to investigate the effect of nicardipine implants on clinical outcome may be warranted. ClinicalTrials.gov Identifier: NCT04269408.

Super-Selective Intra-arterial Thrombolytic Therapy for Peripheral Facial Paralysis After Postauricular Hyaluronic Acid Injection for the Esthetic Correction of Lying Ears.

Hyaluronic acid (HA) injection in the auricular base is one of the most popular and non-surgical cosmetic procedures for correcting lying ears and optimizing the facial profile because of its minimal invasiveness, immediate effect and safety (Li et al. in Aesthet Surg J 44: 746-75, 2024). But we have recently discovered that this treatment may lead to a new and rare complication called peripheral facial paralysis that has never been reported before. Until now, the etiology, clinical traits, treatment strategies, outcomes and possible reversibility have not been characterized. In the present study, we enrolled 4 patients with peripheral facial paralysis after subcutaneous postauricular HA filler injection. Preoperative digital subtraction angiography revealed a vascular embolism. Then, the patients underwent super-selective facial arterial thrombolytic therapy via hyaluronidase and papaverine injections. Simultaneously, general symptomatic treatment and nutritional therapy were performed. The patients were relieved of their clinical symptoms and the significant improvement was observed in terms of motor function in her left facial areas after treatment. The auricular skin necrosis of all patients was restored to near normal appearance. Our results indicate that super-selective facial arterial thrombolytic therapy is feasible for patients with peripheral facial paralysis induced by HA embolism. It was also beneficial in the recovery from skin necrosis. The therapy was shown to be worthy of clinical application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complete removal of a cavernous malformation in the dorsal pons, in contact with the expanded transpontine vein: illustrative case.

Craniotomy is required for the removal of brainstem cavernous malformations (CMs) with repeated hemorrhage, and this condition is often complicated by an accompanying developmental venous anomaly (DVA). However, a DVA of the brainstem or cerebellum with drainage penetrating the pons is an exceptional finding. A 57-year-old man presented with double vision. Computed tomography revealed progressive enlargement of the hemorrhage in the dorsal pons. Contrast-enhanced magnetic resonance angiography revealed an expanded transverse vessel penetrating the center of the pons in contact with the CM. Digital subtraction angiography revealed that the DVA, comprising the expanded transpontine vein and some cerebellar medullary veins acting as normal venous drainage, coexisted with the CM. By utilizing the angioarchitecture and intraoperative neuronavigation system data, electrophysiological mapping, and indocyanine green videoangiography, complete removal of the CM was accomplished while preserving the DVA and brain function. This study presents the intraoperative images of an expanded transpontine vein as a DVA, which has never been depicted in a live patient before, accompanied by a CM in the dorsal portion of the pons. https://thejns.org/doi/10.3171/CASE24314.

Optical Coherence Tomography-Guided Stenting for Common Carotid Free-Floating Thrombus.

Digital subtraction angiography (DSA) has traditionally been considered an effective method for visualizing carotid free-floating thrombus (CFFT), but it falls short in providing detailed structures of the lumen and the composition of thrombi, making it challenging to determine the etiology. Intravascular optical coherence tomography (OCT) is a valuable adjunct to DSA that can precisely evaluate the characteristics of the intrinsic vessel wall and accurately distinguish between red and white thrombus, providing clues to the etiology of CFFTs. Moreover, OCT not only precisely determined the scope of a floating thrombus but also provided guidance for decision-making in endovascular treatment.

A novel intrasaccular aneurysm device with high complete occlusion rate: initial results in a rabbit model

BackgroundIntrasaccular flow-disrupting devices are a safe and effective treatment strategy for intracranial aneurysms. We utilized high-frequency optical coherence tomography (HF-OCT) and digital subtraction angiography (DSA) to evaluate SEAL Arc, a...

Endovascular transvenous treatment of carotid–cavernous fistula

Carotid–cavernous fistulas represent abnormal communication between the carotid circulation and the cavernous sinus. They can be classified as direct or indirect. The Barrow classification is the most widely used system that categorizes the carotid–cavernous fistulas based on their arterial supply (type A–D). The mainstay of therapy for carotid–cavernous fistulas consists of transarterial or transvenous embolization, while other treatment options such as open surgery or radiosurgery are still utilized as second-line or adjuvant therapeutic options. We present the case of a 72-year-old female patient with conjunctival chemosis and exophthalmos. Computed tomography angiography detected a carotid–cavernous fistula that was confirmed with catheter angiography (Barrow type C). Through right femoral vein catheterization, detachable coils were deployed in the right cavernous sinus, adjacent to the fistula shunt point. The procedure was completed with N-butyl cyanoacrylate injection (dilution 1:2). At post-procedural digital subtraction angiography, the fistula was excluded. Endovascular transvenous treatment is a valid therapeutic option for indirect carotid–cavernous fistulas.

Transvenous embolization of a carotid-cavernous fistula via the inferior ophthalmic vein: illustrative case.

A 49-year-old woman with a history of hypertension presented to the emergency department with right eye redness, proptosis, orbital fullness, and blurry vision. She had initially been diagnosed with an orbital pseudotumor, and the symptoms worsened over a course of steroids. Computed tomography angiography raised concern for a carotid-cavernous fistula (CCF), which was subsequently confirmed by digital subtraction angiography. She underwent fistula coil embolization via the internal maxillary artery and inferior ophthalmic vein (IOV). At the 2-month follow-up, she reported complete resolution of diplopia, orbital fullness, and proptosis. An ophthalmology examination revealed normal visual fields bilaterally. CCF embolization is rarely performed through the IOV, with only 5 reported cases in the literature. This case demonstrates that the procedure can be easily performed if the anatomy is favorable over the superior ophthalmic vein, with the illustration of good cosmetic outcomes. https://thejns.org/doi/10.3171/CASE24183.

Hemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow™ tool.

Hemodynamic factors significantly influence the onset, progression, and rupture of intracranial aneurysms (IAs). Current rupture risk prediction scores focus primarily on the clinical, anatomical and morphological aspects. This study aimed to investigate the hemodynamic characteristics differences between ruptured and unruptured IAs. Conducted from July 2021 to July 2022, this prospective cohort study involved patients with ruptured and unruptured IAs undergoing digital subtraction angiography (DSA). Hemodynamic characteristics were assessed using the AneurysmFlow™ tool. Hemodynamic, clinical, anatomical and morphological parameters were compared between ruptured and unruptured IA groups. The study included 127 patients with 135 aneurysms (67 ruptured, 68 unruptured). Complex flow patterns (type 3 and 4) were observed more frequently in ruptured aneurysms compared to unruptured aneurysms (odds ratio [OR], 5.57; 95% confidence interval [CI], 2.49-12.45; P < 0.001) in univariate analysis, and were also more common in unruptured aneurysms associated with daughter sacs features (P = 0.015). The mean aneurysm flow amplitude (MAFA) was lower in ruptured aneurysms, and associated with lower flow velocity in the parent artery related to vasospasm. MAFA in the aneurysmal dome or any additional daughter sacs was lowest compared to other regions inside the aneurysms. The technical failure rate of AneurysmFlow™ measurements was 8.5% (12 out of 139 patients). Additionally, hypertension (OR, 0.42; 95% CI, 0.30-0.54; P < 0.001), bifurcation location (AcomA/ACA/MCA/PcomA/posterior circulation) (OR, 0.17; 95% CI, 0.05-0.29; P = 0.005), and irregular shape (OR, 0.19; 95% CI, 0.05-0.35; P = 0.012) were identified as independently associated with rupture. Complex flow patterns identified on the AneurysmFlow™ tool are significantly more common in ruptured and unruptured aneurysms associated with daughter sac features. The lowest MAFA in the aneurysmal dome and daughter sacs likely indicates specific pathophysiological changes within the aneurysm wall associated with rupture incidence. Hypertension, bifurcation location, and an irregular shape are independently associated with the risk of rupture. Further multicenter studies with larger sample sizes are needed to validate these findings. ACA = anterior cerebral artery; AcomA = anterior communicating artery; IAs = intracranial aneurysms; ICA = internal carotid artery; MAFA = mean aneurysm flow amplitude; MCA = middle cerebral artery; PcomA = posterior communicating artery; RIAs = ruptured intracranial aneurysms; SAH = subarachnoid hemorrhage; UIAs = unruptured intracranial aneurysms.

Radiation Dose during Digital Subtraction Angiography of the Brain-The Influence of Examination Parameters and Patient Factors on the Dose.

Cerebral vascular angiography, or digital subtraction angiography (DSA), is essential for diagnosing neurological conditions but poses radiation risks. This study aims to analyze the impact of examination parameters and patient characteristics on the radiation dose received during DSA to optimize safety and minimize exposure. A retrospective analysis of 251 DSA procedures using the GE Innova IGS 630 dual-plane instrument was conducted. Data on dose area product (DAP) and air kerma (KERMA), along with patient and examination details, were collected. Statistical analyses, including Mann-Whitney, Kruskal-Wallis, and Spearman rank correlation tests, assessed the relationships between variables and radiation dose outcomes. Significant correlations were found between the sides examined (left, right, or both) and DAP (p < 0.0001) and KERMA (p < 0.0001) values, with bilateral studies showing the highest values. The post hoc Dunn tests showed that the 'L + P' group significantly differs from both the right group (p < 0.0001 and the left group (p < 0.0001). There is no significant difference between the 'P' group and the 'L' group (p-value = 0.53). These results suggest that the right and left (both) group have unique KERMA mGy values compared to the other two groups. A strong correlation (rS = 0.87) existed between DAP and KERMA. The number of projections significantly impacted radiation dose (rS = 0.61). Tube parameters (kV and mA) and skull size had low correlations with DAP and KERMA. Optimizing imaging protocols and individualizing parameters can significantly enhance patient safety and diagnostic efficacy while also reducing occupational exposure for medical staff.

Route patterns of the collateral venous pathway in patients with tumors invading the superior sagittal sinus: an angiographic study and clinical applications

Chronic occlusion of the superior sagittal sinus (SSS) by tumors in the midsagittal region causes the collateral venous pathway (CVP). Understanding common patterns of CVP is helpful in reducing surgical complications. This study aimed to investigate the CVP found in patients with SSS-invading tumors, and to provide information on the prevention of operative venous complications. From January 2015 to December 2022, this retrospective study collected patients with tumors that invaded the SSS and underwent digital subtraction angiography of intracranial vessels. Data collected included sex, age, tumor pathology, tumor location along the SSS, tumor side, degree of obstruction of the SSS, types and route patterns of the CVP, and the distance between the tumor and the diploic vein (DV). Twenty patients (6 males, 14 females) were recruited. The prevalence of CVP types was 90% for DV, 35% for end-to-end anastomosis of superficial cortical vein, 15% for meningeal vein, and 20% for other types of CVP. The pteriofrontoparietal and occipitoparietal diploic routes were found on the cerebral hemisphere contralateral to the tumor significantly more than in the cerebral hemisphere ipsilateral to the tumor. Of all patients with presence of collateral DV, 61% had a very close (less than 1 cm) distance between the nearest DV and tumor attachment in the SSS. DV in the cerebral hemisphere contralateral to the tumor was the most common type of CVP found in patients with tumor-induced SSS obstruction. Most of the collateral DV was located very close to the SSS tumor attachment. Neurosurgeons should realize these findings when planning a craniotomy.

Role of digital subtraction angiography in acute cervical spinal cord ischemia.

Ascertaining the etiology of cervical spinal cord dysfunction presents a challenge to clinicians, as the list of differential diagnoses is extensive. Although compressive and inflammatory disorders are common and should be considered immediately, vascular causes are similarly important and acute. The overlap of clinical, magnetic resonance imaging, and cerebrospinal fluid features among the causes of myelopathies may lead to erroneous diagnoses. Such errors may be compounded if routine vascular imaging does not reveal the underlying vasculopathy. We present here three cases in which computed tomography angiography and magnetic resonance angiogram could not clarify the nature of an acute myelopathy, whereas digital subtraction angiography established the diagnosis of spinal cord ischemia.

CO2 Angiography in the Standard and Complex Endovascular Repair of the Abdominal Aorta-A Narrative Review of the Literature.

Background/Objectives: Carbon dioxide digital-subtraction angiography (CO2-DSA) is an increasingly adopted technique in endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/B-EVAR); it is used to reduce the amount of iodinate contrast medium (ICM) and prevent postoperative renal function worsening (PO-RFW). Our aim is to report results from the literature on EVAR and F/B-EVAR procedures using CO2-DSA, together with wider applications in aortic endovascular treatment. Methods: We performed a literature review by searching electronic databases for published data on CO2-DSA during EVAR and F/B-EVAR procedures. The endpoints were postoperative renal function worsening (PO-RFW) and efficacy of intraoperative arterial visualization. Further, applications of CO2 for thoracic endovascular aortic repair (TEVAR) were described. Results: Seventeen studies reporting results on CO2-DSA in EVAR (644 patients) were retrieved. Overall, 372 (58%) procedures were performed with CO2 alone, and 272 (42%) were performed with CO2+ICM. Eight studies analyzed the effect of CO2-DSA angiography on PO-RFW; four studies showed a significantly lower rate of PO-RFW compared to ICM. Five studies (153 patients) analyzed intraoperative arterial visualization with CO2-DSA; renal and hypogastric arteries were effectively visualized in 69% and 99% of cases, respectively. The use of CO2-DSA in F/B-EVAR has not been widely investigated. The largest series reported that PO-RFW was lower in the CO2 vs. ICM group. Conclusions: Carbon dioxide is widely applied in modern aortic endovascular treatment. CO2-DSA for EVAR and F/B-EVAR is an efficient technique for reducing PO-RFW while allowing acceptable arterial intraoperative visualization.

Imaging of Carotid Stenosis: Where Are We Standing? Comparison of Multiparametric Ultrasound, CT Angiography, and MRI Angiography, with Recent Developments.

Atherosclerotic disease of the carotid arteries is a crucial risk factor in predicting the likelihood of future stroke events. In addition, emerging studies suggest that carotid stenosis may also be an indicator of plaque load on coronary arteries and thus have a correlation with the risk of acute cardiovascular events. Furthermore, although in symptomatic patients the degree of stenosis is the main morphological parameter studied, recent evidence suggests, especially in asymptomatic patients, that plaque vulnerability should also be evaluated as an emerging and significant imaging parameter. The reference diagnostic methods for the evaluation of carotid stenosis are currently ultrasonography, magnetic resonance imaging (MRI), and computed tomography angiography (CTA). In addition, other more invasive methods such as 123I-metaiodobenzylguanidine (MIBG) scintigraphy and PET-CT, as well as digital subtraction angiography, can be used. Each method has advantages and disadvantages, and there is often some confusion in their use. For example, the usefulness of MRI is often underestimated. In addition, implementations for each method have been developed over the years and are already enabling a significant increase in diagnostic accuracy. The purpose of our study is to make an in-depth analysis of all the methods in use and in particular their role in the diagnostic procedure of carotid stenosis, also discussing new technologies.

Enhancing procedural decision making with cone beam CT in renal artery embolization

Cone-beam computed tomography (CBCT) has proven to be a safe and effective adjunctive imaging tool for interventional radiology. Nevertheless, limited studies have examined the application of CBCT in renal artery embolization (RAE). The objective of this study is to evaluate the role of CBCT in intra-procedural decision-making for RAE. This multicenter retrospective study included 40 consecutive patients (age: 55.9 ± 16.5 years; male, 55%) who underwent CBCT during RAE from January 2019 to January 2023. The additional information provided by CBCT was classified into Category 1 (no additional information), Category 2 (more information without changing the treatment plan), and Category 3 (valuable information that led to a change in the treatment plan). CBCT did not add unique information for four patients (10%) classified as Category 1. CBCT clarified ambiguous angiographic findings and confirmed the existing treatment plan for 19 patients (47.5%) graded as Category 2; complex vascular anatomy was explained (n = 13), and a correlation between vascular territory and target lesion was established (n = 6). CBCT offered valuable information that was not visible on digital subtraction angiography and changed the treatment plan for 17 patients categorized as Category 3; a mismatch between the vascular territory and the target lesion led to the identification of alternative (n = 3) and additional feeders (n = 8); and the extent of embolization was reduced by using automatic feeder detection software (n = 6). CBCT is an efficient tool that aids in the decision-making process during the embolization procedure by providing supplementary imaging information. This additional information enables the confident identification of target vessels, facilitates superselective embolization, prevents non-target embolization, and helps locate missing feeders.