Lesion Morphologic Characteristics Research Articles

Predictive performance of the perivascular fat attenuation index for interventional antegrade percutaneous coronary intervention for chronic total occlusion.

This study aimed to investigate the association between the perivascular fat attenuation index (FAI) and the success of the antegrade percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study evaluated patients with only one CTO lesion observed on conventional coronary angiography (CAG) who underwent coronary computed tomography angiography (CCTA) < 1 month before CAG, from 2018 to 2019. The clinical data, CCTA-based CTO lesion morphologic characteristics, and perivascular FAI of CTO lesions were recorded and analysed. In total, 156 patients with CTOs were enrolled in this study. Successful antegrade PCI (A-PCI) was achieved in 105 CTO lesions (67.3%). The perivascular FAI of the failed A-PCI group was significantly lower than the successful A-PCI group (-84.76 ± 10.44 Hounsfield unit (HU) vs. -67.54 ± 9.94 HU; p < 0.001), and the cut-off value determined by the receiver operating characteristic (ROC) curve was -77.50 HU. Multivariable analysis revealed no statistical significance in the clinical data, FAI ≤ -77.50 HU (odds ratio (OR): 33.96), negative remodeling (OR: 4.36), severe calcification degree (OR: 4.43) and occlusion length ≥ 20.25 mm (OR: 3.89) were independent predictors of A-PCI failure. The prediction performance of combining the three morphologic characteristics (severe calcification, occlusion length ≥ 20.25 mm, and negative remodeling) with FAI ≤ -77.50 HU was better than that of the three morphologic characteristics alone (0.93 versus 0.77, p < 0.001). As a non-invasive index for detecting coronary inflammation, FAI complements indicators based on coronary CTA well and may be helpful for choosing appropriate interventional strategies. • Perivascular FAI of CTO was significantly higher in the failed A-PCI group. • The combination of FAI with other morphological predictors showed higher predictive performance of failed A-PCI for CTOs. • FAI is a good complement to indicators based on coronary CTA.

Suggestions for a New Clinical Classification Approach to Panniculitis Based on a Mayo Clinic Experience of 207 Cases.

Panniculitis, or inflammation of adipose tissue, includes a heterogeneous group of disorders with similar morphologic presentations. Currently, panniculitides are classified based on histopathologic findings only. In this retrospective study of 207 cases of biopsy-proven panniculitis over 20 years at Mayo Clinic, we aimed to propose a new classification that integrates the clinical morphologic features with the histopathology of panniculitis. We collected patient demographic and lesion morphologic characteristics using lesion photographs and physician notes for each of our 207 cases, including location, ulceration, scale, pattern(unilateral versus circumferential), atrophy/sclerosis (cicatricial), redness, and swelling. The panniculitides most likely to ulcerate were calciphylaxis (85.7% ulcerating), pancreatic panniculitis (66.6%), and α1-antitrypsin deficiency-associated panniculitis (100%). The panniculitides least likely to ulcerate were erythema nodosum and medication-inducedand granulomatous panniculitis. This retrospective study used only descriptions in clinical notes and available medical photographs. We present an updated classification schema of panniculitides based on clinical findings. The primary distinctions are based on ulceration, location, and number of lesions. Although complete distinction of all panniculitides based on clinical examination alone is not possible, we hope the proposed schema allows clinicians to tailordifferential diagnoses.

Angiographic classification of patterns of restenosis following femoropopliteal artery intervention: A proposed scoring system.

To propose a classification system for characterizing angiographic femoropopliteal artery restenosis patterns associated with common endovascular modalities. Peripheral artery disease is a worldwide issue affecting millions of people. Despite a myriad of endovascular technologies available to treat peripheral artery disease of the femoropopliteal arteries, restenosis remains a common failure mode. Characterizing common patterns of restenosis is important to discern the potential impact of baseline patient, lesion, and procedural characteristics, as well as treatment modalities on either the primary success or the failure patterns associated with restenosis. Studies included in the analysis were from previous core laboratory-adjudicated femoropopliteal artery disease trials and registries reflecting a wide array of treatment modalities. From the subjects enrolled and analyzed, there were 403 total angiograms for analysis and adjudication. Target lesion revascularization images of the 32 validation cases were evaluated for index treated length, diameter stenosis, and lesion morphology characteristics. The following lesion types are proposed: Type 1 "Focal" pattern, which may be "Edge Proximal" or "Edge Distal" depending on location; a Type 2 "Multifocal" pattern which may also exhibit edge restenosis, but may also be "Edge Bilateral"; a Type 3 "Moderate" pattern and a Type 4 "Diffuse" pattern; and finally, a Type 5 "Occlusion". A classification system that enables healthcare professionals to anticipate and describe failures following the index procedure, thereby impacting the choice of options for retreatment, may facilitate consistency and standardization within the heterogeneous field of endovascular device treatments for the femoropopliteal artery.

Relation Between Angiographic Lesion Severity, Vulnerable Plaque Morphology and Future Adverse Cardiac Events (from the Providing Regional Observations to Study Predictors of Events in the Coronary Tree Study)

Previous angiographic studies have suggested that the future risk for major adverse cardiovascular events (MACEs) is related to coronary stenosis severity. The aim of this study was to use the grayscale and virtual histology (VH)-intravascular ultrasound (IVUS) data from the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study to identify underlying lesion morphologic characteristics that might explain these findings. In PROSPECT, patients presenting with acute coronary syndromes in whom percutaneous coronary intervention was successful underwent 3-vessel grayscale and VH-IVUS and were followed for a median of 3.4 years for the incidence of MACEs. Overall, 3,115 nonculprit lesions detected by IVUS were divided into quartiles according to baseline angiographic diameter stenosis. From the first to fourth quartiles, there were increases in the prevalence of lesions with IVUS minimum luminal areas ≤ 4 mm(2), IVUS plaque burden ≥ 70%, and VH-IVUS thin-cap fibroatheroma (13.4%, 22.0%, 24.2%, and 30.3%, respectively, p <0.001), along with an increased frequency of plaque ruptures and greater necrotic core volumes. The incidence of lesions with plaque burden ≥ 70%, minimum luminal area ≤ 4 mm(2), and VH thin-cap fibroatheroma was highest in the fourth quartile (0%, 0.4%, 0.4%, and 2.8% in the first through fourth quartiles, respectively, p <0.001). Three-year MACE rates were also highest in the fourth quartile (0.3%, 0.7%, 1.3%, and 5.1%, respectively, p <0.001). In conclusion, increasing angiographic diameter stenosis was associated with an increased frequency of grayscale and VH-IVUS lesion morphologic features that have been associated with adverse events and that may, in part, explain why future MACEs were related to baseline lesion severity.

Comparison of gadobenate dimeglumine (Gd-BOPTA) with gadopentetate dimeglumine (Gd-DTPA) for enhanced MR imaging of brain and spine tumours in children

Gadobenate dimeglumine (Gd-BOPTA) demonstrates superior enhancement of brain tumours in adult patients than Gd-DTPA. To determine whether Gd-BOPTA has advantages over Gd-DTPA for enhanced MR imaging of paediatric brain and spine tumours. Sixty-three subjects, aged 6 months to 16 years, who were enrolled in a prospective, fully blinded, randomized parallel-group phase III clinical trial, received 0.1 mmol/kg doses of either Gd-BOPTA (n=29) or Gd-DTPA (n=34). The MR images were acquired before and within 10 min of contrast agent injection. The primary objective was to compare the difference from pre-dose to post-dose lesion visualization between Gd-BOPTA and Gd-DTPA. Lesion visualization was determined as the sum of individual scores for three criteria of lesion morphological characteristics (lesion border delineation, internal morphology, and contrast enhancement), each assessed qualitatively using 4-point scales. Quantitative evaluation compared changes in lesion-to-background (LBR) and contrast-to-noise (CNR) ratios and per cent enhancement. Monitoring for adverse events and evaluation of vital signs and laboratory values was performed. Pre-dose to post-dose changes in lesion visualization were significantly better for Gd-BOPTA for both lesion level (2.68+/-2.17 vs. 1.05+/-1.90, P=0.0106) and patient level (2.55+/-2.18 vs. 1.14+/-1.68, P=0.0079) comparisons. The mean pre-dose to post-dose change in CNR was greater for Gd-BOPTA (9.13+/-15.36) than Gd-DTPA (2.18+/-9.90), but the difference was only marginally significant (P=0.0779; 95% CI: -0.553, 14.454) because of wide variations of signal intensity between lesions. Similar findings were obtained for LBR and per cent enhancement. No differences between the agents were noted in terms of safety parameters. At an equivalent dose Gd-BOPTA is significantly better than Gd-DTPA for visualization of enhancing CNS tumours in paediatric patients.

Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis.

Medically refractory symptomatic vertebrobasilar atherosclerotic disease has a poor prognosis. Studies have shown that longer (> or = 10 mm), eccentric, high-grade (> 70%) stenoses portend increased procedure-related morbidity. The authors reviewed their experience to determine whether a staged procedure consisting of angioplasty followed by delayed (> or = 1 month later) repeated angioplasty and stent placement reduces the morbidity associated with endovascular treatment of symptomatic basilar and/or intracranial vertebral artery (VA) stenoses. The authors retrospectively reviewed the medical records in a consecutive series of eight patients who underwent planned stent-assisted angioplasty for medically refractory, symptomatic atherosclerotic disease of the intracranial posterior circulation between February 1999 and January 2002. Staged stent-assisted angioplasty was planned for these patients because the extent and degree of stenosis of the VA and/or basilar artery (BA) lesion portended an excessive procedure-related risk. The degree of stenosis, recent onset of symptoms (unstable plaque), vessel tortuosity, and lesion length and morphological feaures were contributing factors in determining procedure-related risk. Patient records were analyzed for location and degree of stenosis, preprocedural regimen of antiplatelet and/or anticoagulation agents, devices used, procedure-related complications, and clinical and radiographic outcomes. Among the patients in whom staged stent-assisted angioplasty was planned, vessel dissection, which necessitated immediate stent placement, occurred during passage of the balloon in one of them. In a second patient, the stent could not be maneuvered through the tortuous VA. In a third patient, the VA and BAs remained widely patent after angioplasty alone, and therefore stent placement was not required. Significant complications among the eight patients included transient aphasia and hemiparesis in one and a groin hematoma that necessitated surgical intervention in another; there was no permanent neurological morbidity. The mean stenosis before treatment was 78%, which fell to 54% after angioplasty, and the mean residual stenosis after stent placement was 30%. At the last follow-up examination, none of the treated patients had further symptoms attributable to the treated stenosis. The novel combination of initial angioplasty followed by delayed endoluminal stent placement may reduce the neurological morbidity associated with endovascular treatment of long, high-grade stenotic lesions. Attempting to cross high-grade stenoses with higher-profile devices such as stents may result in an embolic shower. Furthermore, neointimal proliferation and scar formation after angioplasty result in a thickened fibrous layer, which may be protective during delayed stent deployment. Larger-scale studies involving multiple centers are needed to elucidate further the lesion morphological characteristics and patient population most likely to benefit from staged procedures.

Langerhans cell histiocytosis presenting in the neonatal period: a retrospective case series.

To describe the morphologic characteristics of skin lesions, extent of extracutaneous disease, and outcomes in patients with neonatal presentation of Langerhans cell histiocytosis (LCH), and to examine clinical predictors of disease prognosis. Retrospective validation cohort study. Maximum duration of follow-up was 10 years. A tertiary care children's hospital in Chicago, Ill. Nineteen children with cutaneous findings in the first 4 weeks of life and subsequently diagnosed with LCH based on compatible tissue histologic analysis, confirmed by electron microscopy and/or immunohistochemical analysis. Cutaneous lesion morphologic characteristics, extracutaneous manifestations, treatments, and outcomes were tabulated and compared. The most common initial skin lesion was erythematous, often crusted, vesiculopustules. Skin lesion morphologic traits did not correlate with extent of extracutaneous disease. One third of patients had disease limited to the skin and/or mucous membranes. All of these patients are alive and well, and 1 has developed diabetes insipidus. Twelve of the 19 patients had multisystem disease, and 2 died of disease. The results of a multiorgan workup performed at the time of diagnosis were predictive of which patients in this cohort manifested multisystem disease. The overall incidence of diabetes insipidus was 21%. Vesiculopustular lesions are common in congenital/neonatal LCH, but the morphologic characteristics of lesions are not helpful in predicting the extent of disease. A multiorgan evaluation at the time of diagnosis may be predictive of the probability of multisystem involvement with LCH.

Clinical risk factors for ischemic complications after percutaneous coronary interventions: Results from the EPIC trial

Background Most analyses of complications after percutaneous coronary intervention have been limited to angiographic predictors of abrupt closure. We sought to determine the relation between baseline clinical and angiographic characteristics and clinical ischemic events and whether treatment with the platelet glycoprotein IIb/IIIa receptor antagonist c7E3 reduced ischemic events differentially in patients with distinct lesion morphologic characteristics. In the EPIC trial, a bolus and infusion of c7E3 decreased the 30-day incidence of death, myocardial infarction, and need for revascularization by 35% in 2099 high-risk patients. Methods We used logistic regression modeling to determine the relations between these patients’ baseline clinical and angiographic characteristics and the composite primary end point. We also constructed multivariable models with interaction terms to assess treatment effect on prespecified, core laboratory–assessed, coronary morphologic characteristics. Results The most important predictors of a poor outcome were low weight (chi-square = 10.5, P =.001) and preprocedural percent stenosis (chi-square = 15.0, P <.001). History of hypertension, nonwhite race, and peripheral vascular disease were also associated with an increased risk, as were all measures of lesion complexity except calcification and presence of a side branch. The treatment benefit with abciximab was significantly greater with less complex than with more complex lesion morphologic characteristics. Conclusions Future risk models should include these baseline characteristics to define the risk for ischemic complications in individual patients, and treatment with abciximab should not be predicated on lesion morphologic findings alone. (Am Heart J 1999;137:264-73.)

Effectiveness of heparin in preventing thrombin generation and thrombin activity in patients undergoing coronary intervention

Background Thrombus is important in the pathophysiology of several complications of angioplasty, including abrupt closure and restenosis. Levels of prothrombin fragment F1.2 and fibrinopeptide A reflect thrombin generation and activity. The effect of angioplasty on levels of these markers is unclear. Methods Patients undergoing either balloon angioplasty (n = 30) or directional atherectomy (n = 9) were treated with heparin to maintain an activated clotting time of >300 seconds. Levels of F1.2, fibrinopeptide A, and thrombin-antithrombin complex were measured in the coronary sinus and coronary artery before and after intervention. Angiograms were reviewed for lesion morphologic characteristics and dissection. Results There was no evidence for thrombin generation or increased thrombin activity after angioplasty regardless of lesion morphologic characteristics, dissection, type of intervention, or blood sampling site. In fact, coronary sinus concentrations of F1.2 decreased after intervention (median 0.31 nmol/L; 25th percentile 0.26 nmol/L, 75th percentile 0.37 nmol/L) before intervention to 0.23 nmol/L (25th percentile 0.19 nmol/L, 75th percentile 0.34 nmol/L) after intervention (P =.002). Conclusions Angioplasty performed in the presence of adequate heparin inhibited thrombin even when there was complex lesion morphology or dissection. These data suggest that heparin provides satisfactory thrombin inhibition during routine angioplasty. (Am Heart J 1999;137:250-7.)

Intravascular ultrasonography allows accurate assessment of abdominal aortic aneurysm: An in vitro validation study

Objective: The objective of this study was to acquire insight into the interpretation of intravascular ultrasound images of the abdominal aorta and to assess to what extent this technique can provide useful parameters for the endovascular treatment of patients with abdominal aortic aneurysm. Study Design: This was a descriptive study. Methods: Fifteen abdominal aortic specimens (normal, atherosclerotic, or aneurysmal) were studied. Ultrasonic images and corresponding histologic sections were compared for vessel wall characteristics, lesion morphologic characteristics, and lumen diameter. The length of the aneurysm and the length of the proximal and distal neck were measured and compared with external measurements. Tomographic images were reconstructed to a three-dimensional format. Results: Normal aortic wall was seen as a two- or three-layered structure corresponding with intima, media, and adventitia. A distinction could be made among fibrous lesion, calcified lesion, and thrombus and between normal and aneurysmal aorta. Correlation between the histologic specimens and intravascular ultrasonography for lumen diameter measurements was high ( r = 0.93; p < 0.001). In a similar fashion, correlation between external measurements and intravascular ultrasound measurements on the length of the aneurysm and its proximal and distal neck was high ( r = 0.99; p < 0.001). Three-dimensional analysis enhanced interpretation of the tomographic images by visualizing the spatial position of anatomic structures and contributed to understanding the shape and dimensions of the aneurysm. Conclusions: Intravascular ultrasonography provides accurate information on the vessel wall, lesion morphologic characteristics, and quantitative parameters of the abdominal aorta. Spatial information supplied by three-dimensional analysis contributes to a more realistic interpretation of the tomographic images. (J Vasc Surg 1998;27:347-53.)

Clinical and lesion morphologic determinants of coronary angioplasty success and complications: Current experience

This study evaluated the validity of the American College of Cardiology/American Heart Association ABC lesion classification scheme and its modifications. With the continued refinement in angioplasty technique and equipment evolution, the lesion morphologic determinants of immediate angioplasty outcome have changed significantly. Hence, the validity of the classification scheme has been questioned. We assessed the lesion morphologic determinants of immediate angioplasty outcome in 729 consecutive patients who underwent coronary angioplasty of 994 vessels and 1,248 lesions. Angioplasty success was achieved in 91% of lesions, and abrupt closure occurred in 3%. Success was achieved in 96%, 93% and 80% of type A, B and C lesions, respectively (A vs. B, p = NS; B vs. C, p < 0.001; A vs. C, p < 0.001; A vs. B1, p = NS; A vs. B2, p = 0.03; B1 vs. B2, p = 0.02; B2 vs. C, p < 0.001; C1 vs. C2, p = NS). Abrupt closure occurred in 2.1%, 2.6% and 5% of type A, B and C lesions, respectively (A vs. B, B vs. C, A vs. C and A vs. B1, all p = NS; B1 vs. B2, p = 0.01; B2 vs. C1, p = NS; C1 vs. C2, p = 0.04). Type B characteristics had a success rate ranging from 74% to 95% and an abrupt closure rate ranging from 2.2% to 14%. Type C characteristics had a success rate ranging from 57% to 88% and an abrupt closure rate ranging from 0% to 16%. Longer lesions, calcified lesions, diameter stenosis of 80% to 99% and presence of thrombus were predictive of a lower success rate. Longer lesions, angulated lesions, diameter stenosis of 80% to 99% and calcified lesions were predictive of an abrupt closure. The previously proposed classification schemes are outdated and need to be changed for application in current angioplasty practice. Analyzing specific lesion morphologic characteristics rather than applying a simple lesion classification score when evaluating angioplasty outcome may be more useful because it provides a more precise profile of the lesion and allows better patient stratification and selection.

Predicting the risk of abrupt vessel closure after angioplasty in an individual patient

Objectives. We proposed to examine the relation between angiographic morphologic characteristics and abrupt closure after coronary angioplasty and to develop an empirically based risk stratification system.Background. Certain lesion morphologic characteristics are associated with higher rates of abrupt closure after coronary angioplasty. Previous approaches have been limited by relatively small sample sizes and an inability to combine multiple characteristics to predict risk in an individual patient.Methods. Lesion morphology was determined for 779 lesions in 658 patients undergoing an elective first angioplasty. Abrupt closure occurred in 63 lesions (8.1%). Variables associated with abrupt closure were identified by univariate and stepwise multiple logistic regression analysis, and internal validity was assessed by use of bootstrapping. An empirically based scoring system was developed by assigning diferent weights to each predictive characteristic and was then validated.Results. Almost all lesion characteristics previously labeled “adverse” were associated with an increased risk of abrupt closure, but only total occlusion, location at a branch point, increasing lesion length, evidence for thrombus and right coronary artery location were statistically significant independent predictors. Despite the large sample size, the study was underpowered to detect even a 50% increase in risk with many characteristics. Using a scoring system, we assigned each lesion a specific risk of abrupt closure. The distribution of risk was broad, with 20% of patients having ≤2.5% risk and 25% having >10% risk. Internal validation techniques revealed that when 10% of patients were randomly eliminated from the sample in multiple iterations, the risk estimates varied, again pointing to the need for a larger sample.Conclusions. Empirically based weighting of lesion characteristics could quantify the risk of abrupt closure for individual patients, but a very large sample will be required to understand the interplay of complex lesion characteristics in altering expected outcomes.

Intracoronary ultrasound imaging: Correlation of plaque morphology with angiography, clinical syndrome and procedural results in patients undergoing coronary angioplasty

Objectives. This study was designed to establish the relation between ultrasound-derived atheroma morphology and the clinical, procedural and angiographie features of patients presenting for coronary angioplasty.Background. Intracoronary ultrasound imaging provides accurate dimensional information regarding arterial lumen and wall structures. Atheroma composition may also be assessed by ultrasound; however, only limited studies have been performed in patients.Methods. In 65 patients a diagnostic ultrasound imaging catheter or a combination imaging-angioplasty balloon catheter was used during coronary angioplasty to image both the lesion and the vessel segment just proximal to it (reference segment). Ultrasound images were analyzed for lumen, total vessel and plaque areas and were classified into five morphologic subtypes (soft, fibrous, calcific, mixed plaque and concentric subintimal thickening). These data were compared with angiographic morphologic features, procedural results and clinical angina pattern (stable vs. unstable).Results. Morphologic analysis of the ultrasound images obtained from the lesion correlated well with the clinical angina syndrome. Compared with patients with stable angina, patients with unstable angina had more soft lesions (74% vs. 41%), fewer calcified and mixed plaques (fibrotic, soft or calcific contponeats in one or more combinations [25% vs. 59%]) and fewer intralesional calcium deposits (16% vs. 45%) (all p < 0.01). There was no correlation between ultrasound and angiographic lesion morphologic characteristics for either the reference segment or the lesion. Ultrasound demonstrated greater sensitivity than angiography for identifying unstable lesions (74% vs. 40%). Dimensional analysis demonstrated a large plaque burden in the reference segments 145 ± 15% of total vessel area). Postangioplasty plaque burden was also high (62 ± 9%). There was a significant, but only fair correlation between lumen area determined by angiography and ultrasound for both the reference segment (r = 0.70, p < 0.001) and the postangioplasty lesion (r = 0.63, p < 0.05).Conclusions. Morphologic plaque classification by ultrasound is closely correlated to clinical angina but has little relation to established angiographie morphologic characteristics, Iatracoronary ultrasound imaging daring angioplasty identifies a large residual plaque burden in both the reference segment and the lesion. In the future, determination of plaque composition by intracoronary ultrasound may be important in selecting or modifying interventional therapeutic options.