Invasive Imaging Research Articles

Preoperative assessment of peripheral vascular invasion of pancreatic ductal adenocarcinoma based on high-resolution MRI

ObjectivesPreoperative imaging of vascular invasion is important for surgical resection of pancreatic ductal adenocarcinoma (PDAC). However, whether MRI and CT share the same evaluation criteria remains unclear. This study aimed to compare the diagnostic accuracy of high-resolution MRI (HR-MRI), conventional MRI (non-HR-MRI) and CT for PDAC vascular invasion.MethodsPathologically proven PDAC with preoperative HR-MRI (79 cases, 58 with CT) and non-HR-MRI (77 cases, 59 with CT) were retrospectively collected. Vascular invasion was confirmed surgically or pathologically. The degree of tumour-vascular contact, vessel narrowing and contour irregularity were reviewed respectively. Diagnostic criteria 1 (C1) was the presence of all three characteristics, and criteria 2 (C2) was the presence of any one of them. The diagnostic efficacies of different examination methods and criteria were evaluated and compared.ResultsHR-MRI showed satisfactory performance in assessing vascular invasion (AUC: 0.87–0.92), especially better sensitivity (0.79–0.86 vs. 0.40–0.79) than that with non-HR-MRI and CT. HR-MRI was superior to non-HR-MRI. C2 was superior to C1 on CT evaluation (0.85 vs. 0.79, P = 0.03). C1 was superior to C2 in the venous assessment using HR-MRI (0.90 vs. 0.87, P = 0.04) and in the arterial assessment using non-HR-MRI (0.69 vs. 0.68, P = 0.04). The combination of C1-assessed HR-MRI and C2-assessed CT was significantly better than that of CT alone (0.96 vs. 0.86, P = 0.04).ConclusionsHR-MRI more accurately assessed PDAC vascular invasion than conventional MRI and may contribute to operative decision-making. C1 was more applicable to MRI scans, and C2 to CT scans. The combination of C1-assessed HR-MRI and C2-assessed CT outperformed CT alone and showed the best efficacy in preoperative examination of PDAC.

Heterogeneity of plaque burden natural history within individual human coronary atherosclerotic plaques is based on local endothelial shear stress: insights for culprit areas and clinical events

Abstract Background Patterns of local endothelial shear stress (ESS) are heterogeneous along the course of individual coronary artery plaques. It is unknown how this heterogeneity affects the local natural history of plaque burden (PB) over time. Objectives To determine the effect of local ESS patterns along the course of coronary plaques at baseline on the heterogeneity of subsequent PB progression, regression, and quiescence in human coronary arteries and its link to clinical events. Methods 302 patients from the PREDICTION study were included in the study. The PREDICTION study was an anatomic natural history followup study of patients treated for an acute coronary syndrome (ACS) performed in 15 Japanese clinical sites, as previously published [1]. Invasive imaging was performed at baseline and, per protocol, at 6-10 months follow-up. Arterial geometry and ESS were derived from angiography/intravascular ultrasound-based vascular profiling. Plaques were identified as regions with plaque thickness > 0.5 mm in at least 3 consecutive 3-mm segments. Plaque progression was defined as change in PB (plaque area/total vessel area*100%) PB >+5% increase, regression as <-5% decrease, and quiescence as no change. The location of each sequential 3-mm segment along the plaque was related to the minimum lumen area (MLA). Performance of PCI in followup was assessed relative to the magnitude of PB change over time. Results 661 plaques (5,658 3-mm segments) from 591 coronary arteries were identified. 56% of 3-mm segments per plaque manifested PB progression, 60% PB regression, and 96% quiescence, and the presence and number of these PB changes were significantly related to plaque length (p<0.002). PB change >20% was associated with low ESS (0.75±0.31 Pa) and marked regression (PB change <-20%) with high ESS (3.94±0.04 Pa) (p<0.001, Figure 1 right panel). 3-mm segments exhibiting substantial PB progression were located along the full length of the plaque, and seldom at the MLA (p=0.874, (Figure 1 left panel), while substantial PB regression was significantly located at the MLA (p<0.001). With increasing ∆PB progression in individual 3-mm segments, a significant increase in performance of PCI was observed (p=0.012, Figure 2). Conclusions PB natural history of 3-mm segments within an individual plaque is heterogeneous, driven by local ESS, with substantial plaque progression/luminal encroachment developing along the entire course of the plaque, and typically not near the MLA. PCI was associated with the magnitude of PB progression/luminal encroachment, regardless of where the progression occurred.Figure 1Figure 2

Risk factor burden in familial hypercholesterolaemia with early onset coronary artery disease

Abstract Background Familial hypercholesterolaemia (FH) is considered a causal risk factor for premature coronary artery disease (CAD) with a priority placed on identifying index cases and their relatives for preventative interventions. However recent population sequencing studies have identified that not all FH mutation carriers develop CAD. We hypothesised that a significant burden of traditional risk factors is required in addition to genetic risk to develop CAD. Methods We interrogated the clinical registry of patients attending the CVD risk and Lipids clinic at St Bartholomew’s Hospital in London which serves a large multi-ethnic population. Patients were prioritized for genetic testing based on Simon Broome and Dutch Lipid criteria. A second cohort of patients from the clinic consisted of premature CAD patients without phenotypic FH. CAD was defined as > 50% stenosis in an epicardial vessel by invasive or non-invasive imaging. Results We identified 40 patients with genetically confirmed FH and CAD (FH+/CAD+) and 116 people with FH and without CAD (FH+/CAD-). Of 10 traditional risk factors evaluated, prevalence of each was higher in FH +/CAD+ compared to FH+/CAD- patients. Collectively, FH+/ CAD+ patients had a median number of risk factors of 5(4,6) compared to 4(3,5) for FH+/CAD- patients, (P<0.001). In non-FH patients, risk factors burden was higher in those with CAD (FH-/CAD+), compared to those without CAD: 5(4,6) V. 4(3,5) risk factors, respectively(P<0.001). Importantly, in patients who developed CAD, the traditional risk factor burden was greater in FH- patients than that of FH+ patients whereas, the genetic risk burden was greater in FH+ patients (Figure-1). The mean age of onset of CAD in both FH+ and FH- patients was comparable: 43± 10 V. 43± 12years. Patients with FH+/CAD+ were older (53± 11 V 49± 13 years, P=0.276) but had an earlier onset of CAD, when risk burden was greater (43± 8 years if ≥ 5 risk factors v 49± 15 years if < 5 risk factors, P=0.192). Conclusion In a selected population from a large specialist lipid clinic, we demonstrate that traditional risk factor burden is additive to genetic risk for the development and age of onset of CAD, supporting a disease liability threshold model in FH.Figure-1.Risk Burden in FH with CAD

Cost-effectiveness of sequential CAC-first imaging approach for detection of coronary artery disease in comparison to SPECT-first imaging

Abstract Background Prior guidelines recommended a functional first-line test as in patients with suspected CAD. More recently the high NPV of a coronary artery calcium score (CACS) of zero has put focus on CACS-first strategy in selected patients. However, it is unknown if a CACS-first strategy followed by additional Coronary CT angiography (CCTA) or PET MPI if CACS > 0 is a cost-effective alternative. Purpose Our aim was to retrospectively compare the costs-effectiveness of sequential CACS-first imaging to SPECT-first imaging. Methods 2152 patients with CACS-first strategy were retrospectively 1:1 propensity matched with a cohort of SPECT-first strategy resulting in a total of 4304 patients. Referral to invasive coronary angiography (ICA), percentage of patients with diagnosed obstructive CAD, revascularization or all-cause death during 1 year follow-up were compared between both groups. In addition, the non-invasive and invasive diagnostic costs within the first year to detect obstructive CAD were also compared. Results 30.0% (N=646) in the CACS-first group had CAC zero and 51.% (N=1086) had normal stress-SPECY only. Downstream referral to ICA <90 days was lower in the CAC group ( 8.4% vs 11.5%, p=0.001), while obstructive CAD on ICA within 90 days was comparable (60.2% vs 62.5%, p=0.705) between the CACS-first and SPECT-first. Number of revascularizations (6.3% vs 7.9%, p=0.044) was lower in the CACS-first group, while death (0.5% vs 0.3%, p=0.331) was comparable between the CACS-first and SPECT-first group within the first year, respectively. The average costs spent on both non-invasive (€407 vs. €674, p<0.001) and invasive diagnostic imaging (€587 vs. €888, p<0.001) was lower when offering CACS-first instead of a MPI SPECT first protocol, respectively. Conclusion Sequential CAC-first protocol is a more cost-effective than a SPECT-first protocol in patients suspected of having CAD and reduces the referral for ICA while more patients underwent revascularization in the SPECT-first group without impact on prognosis. We therefore recommend the use of a CAC-first CT protocol in these patients.

A novel deep learning model for a coronary computed tomography angiography diagnosis of plaque erosion

Abstract Background Plaque erosion is the underlying pathology in up to 50% of patients with non-ST-segment elevation acute coronary syndromes (ACS). Previous studies suggest that patients with erosion might be treated conservatively without stenting. Currently, a diagnosis of plaque erosion requires invasive intracoronary imaging. Purpose We sought to develop a deep learning (DL) model that enables an accurate diagnosis of plaque erosion using coronary computed tomography angiography (CTA). Methods A total of 532 coronary CTA scans (143 coronary CTA scans with plaque rupture, 113 with plaque erosion, and 276 with reference segment) from 395 patients were included to develop a model: 426 coronary CTA scans from 316 patients for training and internal validation, and 106 separate scans from 79 patients for test set validation. Among ACS patients, the diagnosis of plaque rupture or erosion identified by OCT was used as the ground truth, and the corresponding site on the CTA image matched with OCT image was determined to be the culprit lesion. A novel DL, Momentum Distillation Composite Transformer Attention (MD-CTA) model, was developed that can effectively process the whole CTA scans to diagnose plaque erosion. Results The novel DL model showed diagnostic performance in the five-fold cross-validation with an area under the receiver-operating characteristic curve (AUC) of 0.901 (0.873-0.930), a sensitivity of 81.2 (72.8-88.0), and a specificity of 86.6 (82.4-90.2), all of which were significantly higher than those of convolutional neural network (CNN) model with an AUC of 0.621 (0.567-0.675), the sensitivity of 59.8 (50.1-69.0), and specificity of 60.2 (54.5-65.7) in training validation. Similarly, in the test set validation, the AUC, sensitivity, and specificity of the MD-CTA model were 0.899 (0.841-0.957), 87.1 (70.2-96.4), and 85.3 (75.3-92.4), respectively, higher than those of 0.724 (0.622-0.826), 71.0 (52.0-85.8), and 68.0 (56.2-78.3) of the CNN model. At the slice level, the MD-CTA model was also superior in the five-fold cross-validation and the test set validation compared to the CCN model. This model significantly outperformed experienced cardiologists, especially for sensitivity. Conclusions The newly developed DL model enables an accurate CTA diagnosis of plaque erosion, which might enable the cardiologist to provide tailored therapy without invasive procedures. This algorithm might lead to a major shift in managing millions of patients with plaque erosion each year.Table 1Figure 1

First in human study BIOMAG-I: 12 months results of the sirolimus eluting resorbable coronary magnesium scaffold system (DREAMS 3G) in the treatment of subjects with de novo coronary artery lesions

Abstract Background/Introduction Bioresorbable scaffolds have emerged as an attractive alternative to polymeric scaffolds. A 3rd generation drug-eluting resorbable magnesium scaffold (DREAMS 3G) was developed to enhance the performance of previous scaffold generations and achieve angiographic outcomes comparable to those of contemporary drug-eluting stents. Purpose The aim of the BIOMAG-I first-in-human (FIM) study was to assess the angiographic, clinical and safety performance of DREAMS 3G in patients with de novo coronary artery lesions. We assessed the 12-month safety and performance of this novel device as well intravascular imaging data at baseline, 6- and 12-month follow-up. Methods In this prospective, multicentre, non-randomized, first-in-human study 116 subjects with 117 coronary artery lesions were enrolled at 14 centers in Europe. Clinical follow-up was scheduled at 1, 6 and 12-months and annually thereafter until 5 years. Invasive imaging assessments were scheduled 6 and 12-months post-procedure. Vasomotion was assessed in a subgroup of subjects during the 12-months follow-up. The primary endpoint was in-scaffold LLL at six months. Secondary endpoints include in-segment LLL, TLF, clinically driven target lesion revascularization (TLR), cardiac death, target-vessel myocardial infarction (TV-MI) and scaffold thrombosis. Results Preliminary in-scaffold LLL (n=89 subjects) remained stable from 6 months (0.20 ± 0.28 mm) to 12 months (0.24 ± 0.35 mm). Interim intravascular ultrasound assessments and optical coherence tomography findings corroborated the QCA results with a preservation of the lumen area from 6 (IVUS: 7.0 ± 2.5 mm2; OCT: 8.1 ± 2.7 mm2) to 12 months (IVUS: 7.2 ± 2.6 mm2; OCT: 7.8 ± 2.6 mm2). Vasomotion assessment in a subgroup of subjects confirmed the motility of the scaffolded segment at 12 months follow up: after Acetylcholine administration: 12.5% ± 7.5 (n=27); after nitro administration: 10.7% ± 9.2 (n=22). Up to 12-months follow up, 3 clinically driven TLR were reported (3.4%). No cardiac death, no TV-MI and no scaffold thrombosis were reported up to 12 months. Full data set of the 116 subjects will be available upon presentation. Conclusions The novel third-generation drug-eluting magnesium scaffold, DREAMS 3G, showed a continuous favorable safety and efficacy profile up to 12 months and stable angiographic parameters between 6 and 12 months. Intravascular imaging assessment showed a preservation of the lumen area between 6 and 12 months.

Abstract 18320: Vessel-Specific Coronary Inflammation Quantified Using Perivascular Fat Attenuation Index Score on CCTA Detects the Vulnerable Coronary Artery and Predicts Acute Plaque Events

Background: Coronary artery inflammation can be detected non-invasively on routinely performed coronary computed tomography angiograms (CCTA) by measuring the 3D changes of perivascular adipose tissue attenuation. Fat attenuation index (FAI) Score is the corrected metric of coronary inflammation measured in any of the 3 coronary arteries, and predicts acute myocardial infarction (AMI). Although FAI score is able to detect the vulnerable patient, it is unclear whether it can be used to detect the vulnerable artery in advance of an acute event. Aim: To evaluate the ability of FAI Score to detect the vulnerable coronary artery in patients undergoing CCTA for investigation of chest pain. Methods: Consecutive patients (n = 3,393, mean age 61±15, 57% male) from two UK hospitals in the Oxford Risk Factors and Non Invasive Imaging (ORFAN) study underwent CCTA between 2010-2018 for suspected coronary artery disease (CAD), and were followed up prospectively for a median of 7.7 years. AMI events were recorded via nationwide screening and the culprit vessel was identified based on the target lesion in percutaneous coronary intervention (PCI). FAI score was generated with CaRi-Heart® device. Results: A total of 296 AMI events occurred during the follow up period and 176 patients underwent PCI (59 attributed to the right coronary artery (RCA), and 93 to left anterior descending artery (LAD)). Patients with high FAI score in the LAD had 2 times higher risk for AMI in the LAD (Fig. A), but not in the RCA (HR 1.73 95% CI 0.96-3.08, p=0.07). Similarly, patients with high FAI score in the RCA had 1.9 times higher risk for AMI in the RCA (Fig. B), and modestly elevated risk for an AMI from the LAD. (HR 1.62, 95% CI 1.02-2.59, p=0.04) Conclusion: Vessel-specific FAI score predicts AMI caused by a culprit lesion in the corresponding coronary artery. The ability of FAI score to identify the vulnerable artery before it gives a plaque rupture event may be useful in planning targeted therapeutic interventions.

Abstract 17209: Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance versus Invasive Coronary Angiography: A Meta-Analysis on Diagnostic Accuracy for Cardiovascular Ischemia

Introduction: Invasive Coronary Angiography (ICA) has been the gold standard for diagnosing cardiovascular ischemia, however, it carries an inherent risk due to its invasive nature. Late Gadolinium Enhancement (LGE) by Cardiovascular Magnetic Resonance (CMR) is a promising non-invasive alternative. This necessitates determining its diagnostic accuracy to inform clinical decision-making. Hypothesis: This study aims to assess the diagnostic accuracy of LGE by CMR and ICA in detecting cardiovascular ischemia. Methods: We performed a systematic review of studies until January 2023 across multiple databases, including PubMed, Embase, and the Cochrane Library, that compared the diagnostic accuracy of LGE by CMR and ICA for cardiovascular ischemia. Diagnostic performance measures, including sensitivity, specificity, false-positive rate estimates, diagnostic odds ratio, and positive and negative Likelihood Ratios (LR), were pooled using a random-effects model and presented with a 95% Confidence Interval (CI). R software (version 4.0.3) with the mada package was utilized for statistical analyses. Results: Our meta-analysis collected data from 8 studies encompassing 1,020 patients, of which 395 had confirmed ischemic imaging and 625 had confirmed non-ischemic heart imaging. The results revealed that LGE by CMR had high diagnostic accuracy for detecting cardiovascular ischemia. The sensitivity was 90.9% (95% CI: 80.2%-96.1%, I2=50.4%), the specificity was 89.3% (95% CI: 79.2%-94.8%, I2=90.5%), and the false-positive rate was 10.7% (95% CI: 5.2%-20.8%). The diagnostic odds ratio for LGE by CMR was 82.82 (95% CI: 25.2-272.5), and the positive and negative Likelihood Ratios were 8.46 (95% CI: 4.19-17.06) and 0.10 (95% CI: 0.05-0.23), respectively. Conclusions: This study demonstrates the high diagnostic accuracy of LGE by CMR for cardiovascular ischemia, as indicated by its high sensitivity, specificity, and substantial diagnostic odds ratio. These findings suggest that LGE by CMR could be a reliable non-invasive alternative to ICA, potentially improving clinical decision-making and reducing risks associated with invasive imaging. Further studies and policy reviews are needed to optimize the use of this promising diagnostic modality.

Abstract 14630: Young Female Presenting With Chest Pain Due to Left Main Aneurysm

Background: Incidence of ACS is increasing in young patients. While atherosclerosis needs to be ruled out, there should be high suspicion for alternate causes. Case: A 36-year-old African American woman with obesity, prediabetes and tobacco use, presented to the ED with chest pain. Initial cardiac investigations unremarkable. CTA chest ruled out pulmonary embolism and aortic dissection. Her pain had resolved and she was discharged home. Within hours, the pain recurred and became progressively worse. She returned to the ED and was found to have an anterior STEMI with a troponin I 0.72 ng/ml. Cardiology was consulted, left heart cath revealed a large left main aneurysm (LMA) with large thrombus burden, with mildly aneurysmal LAD, RCA and LCx, moderate decrease in systolic function and no significant arch or main vessel aneurysms. Case was discussed with cardiothoracic surgery, who recommended medical management. Her symptoms resolved while on anticoagulation. Discussion: Coronary artery aneurysms (CAA) are a rare cause of ACS. The reported incidence of CAA ranges from 0.3% to 5%, most often affecting men. The RCA is the most commonly affected artery followed by the LAD, with the LM being the least common. Risk factors include hypertension, dyslipidemia, smoking, diabetes, and a family history of coronary artery disease. Known etiologies include atherosclerosis, Kawasaki disease, inflammatory, congenital, and degenerative conditions. Transient myocardial ischemia may result from aneurysm-related blood stasis that may predispose to thromboembolic events, coronary spasm, and microvascular dysfunction. Conclusion: Although considered extremely rare, the number of LMA reported has increased in the last decades and may continue to grow with the widespread use of invasive and noninvasive coronary imaging. Considering the rarity of CAA and absence of dedicated studies, both the interventional and the pharmacological management of patients with LMA are challenging.

Abstract 033: Trends in Cerebral Angiogram Utilization for Patients with Infective Endocarditis: A Nationwide Analysis

Introduction Infectious intracranial aneurysms (IIA) represent one of several cerebrovascular pathologies associated with infective endocarditis (IE). Neuroimaging in patients with IE, especially in those undergoing cardiac procedures, have scarcely been examined in the literature. Digital subtraction angiography (DSA), or cerebral angiogram, remains the gold standard for the detection of IIA, yet the utility of this invasive imaging modality is uncertain. Herein, we aim to better understand current national trends in the use of neuroimaging in this group of patients, and its impact on patient outcomes. Methods Hospitalizations for IE with concurrent procedures for left‐sided cardiac valve surgery (VS) were identified in the National Inpatient Sample (NIS) registry during the period of 2015‐2020 using weighted approximations and validated International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) diagnosis and procedural coding. The primary exposure was DSA and the trend of its use was evaluated during the study period. Multivariable logistic regression analysis was performed to evaluate the adjusted association of angiography with in‐hospital mortality, the primary study endpoint, while accounting for age and illness severity [quantified by All Patient Refined Diagnostic Related Groups (APR‐DRG) illness severity subclass]. Effect size was reported as adjusted odds ratio (aOR) with 95% confidence interval (CI) and a stringent statistical significance threshold of p < 0.001. Results This analysis identified 31,550 hospitalizations for IE treated with VS, of which 1,160 (3.7%) underwent DSA. Utilization of angiography significantly increased during the study period (trend p < 0.001; Kendall’s tau‐b = 0.002), with the rate of the final year of the study nearly doubling that of the first (2020 4.9% vs. 2015 2.5%, p < 0.001). IE VS patients undergoing angiography experienced significantly decreased mortality rates in comparison to those not receiving an angiogram (4.3% vs. 7.5%; p < 0.001). Following multivariable logistic regression analysis, angiography was significantly associated with decreased mortality, independent of age and illness severity (aOR 0.49, 95% CI 0.37, 0.66; p < 0.001). Conclusion The current literature on neurological complications of IE includes limited data on the defined role of neuroimaging in dictating management. The theoretical risk in IE patients undergoing cardiac procedures involving heparinization includes the risk of intracerebral hemorrhage, especially in those with IIA. While less invasive neuroimaging is thought to suffice in detecting bleeds, DSAs remain more sensitive for IIA detection. In our study, not only did the number of IE patients undergoing DSA increase over time, but they had better mortality rates. Future directions should focus on understanding the appropriate timing of imaging in relation to the patient’s disease course to optimize inpatient care.

Invasive imaging modalities in a spontaneous coronary artery dissection: when "believing is seeing".

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome (ACS) with recent advancements in cardiac imaging facilitating its identification. However, SCAD is still often misdiagnosed due to the absence of angiographic hallmarks in a significant number of cases, highlighting the importance of meticulous interpretation of angiographic findings and, when necessary, additional usage of intravascular imaging to verify changes in arterial wall integrity and identify specific pathoanatomical features associated with SCAD. Accurate diagnosis of SCAD is crucial, as the optimal management strategies for patients with SCAD differ from those with atherosclerotic coronary disease. Current treatment strategies favor a conservative approach, wherein intervention is reserved for cases with persistent ischemia, patients with high-risk coronary anatomy, or patients with hemodynamic instability. In this paper, we provide a preview of invasive imaging modalities and classical angiographic and intravascular imaging hallmarks that may facilitate proper SCAD diagnosis.

An In Vitro Brain Tumour Model in Organotypic Slice Cultures Displaying Epileptiform Activity.

Brain tumours have significant impacts on patients' quality of life, and current treatments have limited effectiveness. To improve understanding of tumour development and explore new therapies, researchers rely on experimental models. However, reproducing tumour-associated epilepsy (TAE) in these models has been challenging. Existing models vary from cell lines to in vivo studies, but in vivo models are resource-intensive and often fail to mimic crucial features like seizures. In this study, we developed a technique in which normal rat organotypic brain tissue is implanted with an aggressive brain tumour. This method produces a focal invasive lesion that preserves neural responsiveness and exhibits epileptiform hyperexcitability. It allows for real-time imaging of tumour growth and invasion for up to four weeks and microvolume fluid sampling analysis of different regions, including the tumour, brain parenchyma, and peritumoral areas. The tumour cells expand and infiltrate the organotypic slice, resembling in vivo behaviour. Spontaneous seizure-like events occur in the tumour slice preparation and can be induced with stimulation or high extracellular potassium. Furthermore, we assess extracellular fluid composition in various regions of interest. This technique enables live cell confocal microscopy to record real-time tumour invasion properties, whilst maintaining neural excitability, generating field potentials, and epileptiform discharges, and provides a versatile preparation for the study of major clinical problems of tumour-associated epilepsy.

Case Report: A rare story of dysmenorrhea and hematuria in a young female with a case of nutcracker syndrome

Nutcracker syndrome (NCS) is a sporadic syndrome due to the compression of the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery (SMA). This condition may present with unexplainable pain, hematuria, orthostatic hypotension, proteinuria, or dysfunction of the kidneys. These symptoms would be explained by the fact that if a chronically standing venous congestion is there then there could be the development of gonadal vein and pelvic vein collateral drainage pathways. Doppler USG (ultrasound), cross-sectional and invasive imaging modalities are frequently used for the purpose of diagnosis. Here, in this report, there's a female patient in her mid- 20's. She was asymptomatic since birth and presented with a history of abdominal pain and blood in the urine. USG is not the best modality for describing the findings hence a further contrast-enhanced computed tomography was done which reported an NCS. In all cases of unexplained hematuria, after excluding all differential diagnoses, NCS must be taken into account.

FRI606 Changes In The Pedal Microcirculation Of Diabetic Patients With Poor Glycemic Control Detected Using Non Invasive Optical Imaging

Abstract Disclosure: I.K. Bolakale-Rufai: None. S. French: None. J.C. Arias: None. K. Concha-Moore: None. T. Tan: None. D.G. Armstrong: None. A. Mazhar: Employee; Self; Modulim. C.C. Weinkauf: None. Background: Microvascular disease (MVD) describes systemic changes in the small vessels (∼100 υm diameter) that impair tissue oxygenation and perfusion. Emerging evidence has shown that MVD (which is prevalent in diabetics) is clinically relevant as it synergistically acts with peripheral arterial disease to increase the risk of limb loss by 22.7-fold. Poor glycemic control has been linked to clinical microvascular disease (nephropathy and retinopathy) However, the direct impact of poor glycemic control on the microcirculation of the feet is unknown as there are currently no standardized non-invasive methods used clinically to assess and quantify MVD of the lower limbs. Spatial frequency domain imaging (SFDI) is a novel non-invasive optical technology that can detect and quantify microvascular disease of the foot by measuring the amount of hemoglobin(HbT1) in the capillaries of the superficial dermis up to 1-2mm deep and oxygenation (StO2) in the dermal micro-circulation. We hypothesize that poor glycemic control in DM affects pedal microcirculation and the changes can be detected using the SFDI technology. Methods: 307 patients (600 lower extremity limbs) were prospectively enrolled at a single institution, Banner University Medicine, Tucson, AZ from 2016- 2023. Diabetic patients were stratified into three groups based on their HbA1c level: ≤6.7%, 6.8-9.9%, and ≥10%. Mann U Whitney test and Spearman rank correlation were used in testing the association between HbA1C and SFDI-metrics with p<.05 considered as statistical significance. Results: We included 230 lower limbs belonging to diabetic patients. The mean age of the patients was 61.7 years. Clinical neuropathy and retinopathy were found in 79% and 30.7% of patients, respectively. SFDI-derived biomarkers of microcirculation were compared among diabetics categorized by HbA1C levels. We observed a significant reduction in papillary dermal perfusion (HbT1) as the glycemic control (HbA1C) of the patients worsened (p<0.001). Although tissue oxygenation (StO2) was not statistically different across diabetic groups, the St02/HbT1 ratio which represents the ratio of tissue oxygenation to perfusion, increased with elevated HbA1C levels. This indicated that poorly controlled diabetics had less oxygen being extracted from their poorly perfused micro-circulation. Conclusions: This study suggests that poor glycemic control directly affects the microcirculation of the feet in diabetic patients. The SFDI technology is a promising noninvasive tool to evaluate microvascular disease of the feet and potentially may be utilized clinically to stratify diabetic patients at risk for foot ulceration or limb loss based on glycemic control over time. Presentation: Friday, June 16, 2023

Noninvasive and invasive imaging of lower-extremity acute and chronic venous thrombotic disease.

The spectrum of venous thromboembolic (VTE) disease encompasses both acute deep venous thrombosis (DVT) and chronic postthrombotic changes (CPC). A large percentage of acute DVT patients experience recurrent VTE despite adequate anticoagulation, and may progress to CPC. Further, the role of iliocaval venous obstruction (ICVO) in lower-extremity VTE has been increasingly recognized in recent years. Imaging continues to play an important role in both acute and chronic venous disease. Venous duplex ultrasound remains the gold standard for diagnosing acute VTE. However, imaging of CPC is more complex and may involve computed tomography, magnetic resonance, contrast-enhanced ultrasound, or intravascular ultrasound. In this narrative review, we aim to discuss the full spectrum of venous disease imaging for both acute and chronic venous thrombotic disease.

Management of myocardial infarction and ischemia without obstructive coronary arteries: insights from a case series

Acute coronary syndromes typically result from the formation of atherosclerotic lesions in a large epicardial vessel, which restrict blood flow either partially or completely. These lesions can be identified through angiography, an invasive imaging technique that enables visualization of the coronary arteries. However, a small percentage of patients, usually ranging from 5% to 10%, experience symptoms and/or signs of myocardial ischemia, either acute or chronic, without significant obstructive coronary lesions visible on angiography. This condition is particularly prevalent in young women and is characterized by two distinct forms: myocardial infarction with no obstructive coronary arteries (MINOCA) and myocardial ischemia with no obstructive coronary arteries (INOCA). MINOCA can be caused by a variety of heterogeneous mechanisms, including coronary vascular spasm, microvascular disease, spontaneous coronary dissection, and plaque rupture or erosion. Conversely, coronary vasospasm and microvascular dysfunction account for the majority of patients with INOCA. We here present three cases of MINOCA/INOCA that were evaluated using optical coherence tomography, coronary flow reserve, index of microcirculatory resistance, and acetylcholine provocative test. These diagnostic tests allowed us to identify a specific condition and adopt a targeted treatment for each patient.

Non invasive subsurface imaging to investigate the site evolution of Machu Picchu

The construction history of a site is partially preserved underground and can be revealed through archaeological investigations, including excavations, integrated with earth observation (EO) methods and technologies that make it possible to overcome some operational limits regarding the areal dimensions and the investigation depths along with the invasiveness of the excavations themselves. An integrated approach based on EO and archaeological records has been applied to improve the knowledge of Machu Picchu. The attention has been focused on the first construction phase of Machu Picchu, and for this reason the investigations were directed to the imaging and characterization of the subsoil of the Plaza principal, considered the core of the whole archaeological area. Archaeological records and multiscale remote sensing (including satellite, UAS, and geophysical surveys) enabled the identification and characterization of the first construction phase of the site, including the preparation phases before building Machu Picchu. The interpretative hypothesis on the constructive history of Machu Picchu started from the identification and use of the quarry, followed by the planification and set of the drainage systems and by the next steps based on diverse reshaping phases of what would be the central plaza.

Rationale and design of the INVICTUS Registry: (Multicenter Registry of Invasive and Non-Invasive imaging modalities to compare Coronary Computed Tomography Angiography, Intravascular Ultrasound and Optical Coherence Tomography for the determination of Severity, Volume and Type of coronary atherosclerosiS)

BackgroundCoronary CT angiography (CCTA) is a first-line noninvasive imaging modality for evaluating coronary artery disease (CAD). Recent advances in CCTA technology enabled semi-automated detection of coronary arteries and atherosclerosis. However, there have been to date no large-scale validation studies of automated assessment of coronary atherosclerosis phenotype and coronary artery dimensions by artificial intelligence (AI) compared to current standard invasive imaging. MethodsINVICTUS registry is a multicenter, retrospective, and prospective study designed to evaluate the dimensions of coronary arteries, as well as the characteristic, volume, and phenotype of coronary atherosclerosis by CCTA, compared with the invasive imaging modalities including intravascular ultrasound (IVUS), near-infrared spectroscopy (NIRS)-IVUS and optical coherence tomography (OCT). All patients clinically underwent both CCTA and invasive imaging modalities within three months. ResultsPatients data are sent to the core-laboratories to analyze for stenosis severity, plaque characteristics and volume. The variables for CCTA are measured using an AI-based automated software and assessed independently with the variables measured at the imaging core laboratories for IVUS, NIRS-IVUS, and OCT in a blind fashion. ConclusionThe INVICTUS registry will provide new insights into the diagnostic value of CCTA for determining coronary atherosclerosis phenotype and coronary artery dimensions compared to IVUS, NIRS-IVUS, and OCT. Our findings will potentially shed new light on precision medicine informed by an AI-based coronary CTA assessment of coronary atherosclerosis burden, composition, and severity. (ClinicalTrials.gov: NCT04066062).

Lymph node metastasis and its risk factors in T1 lung adenocarcinoma.

In this study, the focus was primarily on examining the occurrence of lymph node metastasis in T1 lung adenocarcinoma, while also analyzing the relationship between clinical variables such as imaging characteristics, pathological classifications, and lymph node metastasis. We retrospectively analyzed data from patients with T1 lung adenocarcinoma who underwent lobectomy and lymph node dissection between January 2016 and December 2019. Utilizing univariate and multivariate analyses, we assessed the associations between lymph node metastasis and various clinical factors, including imaging characteristics, lesion location and depth, and pathological subtypes. Of the 433 patients with T1 lung adenocarcinoma, 139 had lymph node metastasis. Moreover, the incidence of node 1 (N1) lymph node, sequential, and node 2 (N2) skip metastases were 12.2%, 12.7%, and 7.2%, respectively. Univariate analysis revealed that tumor diameter, depth ratio, sex, invasive imaging features, and pathological subtype were significantly associated with lymph node metastasis. Multivariate analysis revealed that the tumor depth ratio, tumor diameter, pleural indentation or traction sign, nonvascular penetration sign, solid component, nonadherence, and micropapillary pathological subtype were risk factors for lymph node metastasis. In the multivariate analysis, the micropapillary pathological subtype was an independent risk factor for N2 skip metastasis. In patients with clinical stage T1 lung adenocarcinoma, the risk of lymph node metastasis is higher for tumors located deep within the lung tissue with solid components, invasive preoperative imaging features, and larger diameters. For N2 skip lymph node metastasis, the micropapillary pathological subtype represents a significant high-risk factor.

Spiral dissection of the left coronary artery as a rare and serious complication of coronary angiography: a case report

Background: Iatrogenic spiral dissection of the coronary artery is a rare but serious complication of Coronary angiography (CA). CA is a standard imaging method, which is considered as a safe and commonly used.Aim of the study: To demonstrate a rare complication of CA that significantly changed the patient’s outcome.Material and methods: A retrospective review of the procedure and the patient’s follow-up has been performed.Case report: A 56-year-old woman with type two atrial septal defect complicated by heart failure (HF), complaining of a gradual HF worsening and two episodes of syncope was admitted for preoperative assessment. Prior to cardiac surgery an elective CA revealed no stenoses in coronary arteries, however it was complicated by the spiral dissection of the left main coronary artery continuing towards the left anterior descending artery. Immediate percutaneous coronary angioplasty was performed with a good acute angiographic and clinical result. Subsequently, the patient developed a periprocedural inferolateral myocardial infarction and cardiac arrest due to pulseless electrical activity. Cardiopulmonary resuscitation was ineffective.Conclusion: The take home message of the case presented is that even a relatively safe procedure may be complicated and that less invasive imaging modalities should be considered prior to CA.