Patients Underwent CT Angiography Research Articles

Incidence of acute kidney injury in patients with acute ischaemic stroke undergoing CT angiography (CTA) and CT perfusion (CTP): a systematic review and meta-analysis

Background and purposeWe conducted a systematic review and meta-analysis to assess the incidence of acute kidney injury (AKI) in patients undergoing CT angiography (CTA) and CT perfusion (CTP) for acute...

Hodgkin’s Lymphoma Transformation into Diffuse Large B Cell Lymphoma Presented as a Right Atrial Mass: A Case Report

Cardiac involvement can occur in lymphoma, with the right heart being predominantlyaffected. The prognosis for patients with cardiac involvement is poor. A 28-year-old man,with a 4-year history of Hodgkin’s lymphoma, presented with progressive shortnessof breath and ascites. Chest X-ray (CXR) and CT scan revealed multiple masses in themediastinum. To exclude a pulmonary embolism, the patient underwent CT angiography,which incidentally revealed a filling defect in the right atrium. Trans-esophagealechocardiography confirmed the presence of a mass in the right atrium. Surgery wasperformed to obtain samples of the mediastinal masses and the right atrium mass.Pathological results indicated that the nature of the right atrium mass was diffuse largeB-cell lymphoma (DLBCL), suggesting that the Hodgkin’s lymphoma had transformedinto DLBCL. The transformation of Hodgkin’s lymphoma to DLBCL can occur, and cardiacinvolvement is not common. Given that the transformation of Hodgkin’s lymphoma intoDLBCL can occur many years after the initial diagnosis, the authors recommend followup of these patients, as the prognosis may be worse than for non-transformed subtypes.

Surgical strategies and efficacy analysis for aortic dissection complicating intractable mesenteric artery ischemia

Objective: To explore the surgical strategies and clinical efficacy for aortic dissection combined with refractory superior mesenteric artery (SMA) ischemia. Methods: This is a retrospective case series study. Clinical data of 24 patients with aortic dissection and refractory SMA ischemia admitted to the Department of Vascular Surgery, Zhongshan Hospital, Fudan University from August 2010 to August 2020 were retrospectively collected. Of the 24 patients, 21 were males and 3 were females, with an age of (50.3±9.9) years (range: 44 to 72 years).Among them, 9 cases were Stanford type A aortic dissection, and 15 cases were type B. All patients underwent CT angiography upon admission, and based on imaging characteristics, they were classified into three types. Type Ⅰ: severe stenosis/occlusion of the SMA true lumen only; Type Ⅱ: stenosis of the true lumens in the descending aorta and SMA (isolated type); Type Ⅲ: stenosis of the true lumens in the thoracoabdominal aorta and SMA (continuation type). Surgical procedures, complications, mortality, and reintervention rates were recorded. Results: Among the 24 patients, 17 (70.8%) were classified as Type Ⅰ, 4 (16.7%) as Type Ⅱ, and 3 (12.5%) as Type Ⅲ. Fourteen cases of Type Ⅰ underwent thoracic endovascular aortic repair combined with SMA stent implantation. Additionally, 3 Type Ⅰ and 1 Type Ⅱ patients underwent only SMA reconstruction (with one case of chronic TAAD treated with iliac artery-SMA bypass surgery). Moreover, 3 Type Ⅱ and 3 Type Ⅲ patients underwent descending aorta combined with SMA stent implantation. There were 5 patients (20.8%) who underwent small bowel resection, either in the same sitting or in a staged procedure. During hospitalization, 4 patients died, resulting in a mortality rate of 16.7%. Among these cases, two patients succumbed to severe intestinal ischemia resulting in multiple organ dysfunction syndrome. The follow-up duration was (46±9) months (range: 13 to 72 months). During the follow-up, 2 patients died, unrelated to intestinal ischemia. The 5-year freedom from reintervention survival rate was 86.1%, and the 5-year cumulative survival rate was 82.6%. Conclusions: Patients with aortic dissection and refractory SMA ischemia have a high perioperative mortality. However, implementing appropriate surgical strategies according to different clinical scenarios can reduce mortality and alleviate intestinal ischemia.

Accuracy and image quality of wide-detector revolution CT angiography combined with prospective ECG-triggered CT angiography in the diagnosis of congenital aortic arch anomalies in Chinese children.

To explore the accuracy and image quality of wide-detector revolution CT angiography combined with prospective ECG-triggered CT angiography in the diagnosis of congenital aortic arch anomalies in Chinese children. From January 2020 to July 2022, the clinical data of 57 children with congenital aortic arch anomalies confirmed by surgery were collected. All patients underwent CT angiography (CTA) with Revolution CT and transthoracic echocardiography (TTE) before the operation. The accuracy of CTA and TTE in the diagnosis of aortic arch anomalies was compared with the surgical results. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CTA and TTE for congenital aortic arch anomalies (including intracardiac and extracardiac structural abnormalities) were 92.2% and 85.5%, 99.4%, and 99.1%, 97.4% and 95.6%, 98.1% and 96.9%, and 97.2% and 95.2%, respectively. Regarding extracardiac structural malformations, the sensitivity of CTA was 100%, whereas that of TTE was 78.6% (P < 0.001). Regarding intracardiac structural malformations, the sensitivity of CTA was 84.5%, whereas that of TTE was 92.5% (P < 0.001). Regarding satisfaction with the images in aortic arch anomalies, surgeons noted that the CTA images were more useful for diagnosis and operation planning compared with TTE. Wide-detector revolution CT angiography combined with prospective ECG triggering can be routinely used to assess congenital aortic arch anomalies, providing adequate image quality and high diagnostic accuracy. However, limitations in the identification of intracardiac structural abnormalities are noted.

S2557 An Unusual Cause of Obscure Gastrointestinal Bleeding

Introduction: Obscure gastrointestinal bleeding is bleeding of unknown origin, that persists or recurs, after a negative initial or primary endoscopy. It accounts for approximately 5% of all cases of gastrointestinal bleeding and is usually due to a lesion in the small bowel. We present a case of rare cause of obscure gastrointestinal bleeding. Case Description/Methods: 68 year old male, was admitted with history of passing black coloured stools since last 2 weeks. History of weightloss was present. History of squamous cell carcinoma vocal cord in the past and he underwent radiation therapy. Blood investigations showed anemia. Endoscopy showed antral erosions. Colonoscopy revealed caecal angiodysplasia and was treated with Argon plasma coagulation. In view of persistent melena, patient underwent CT angiography, which revealed bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum (Fig 1). Spiral enteroscopy revealed an ulceroproliferative neoplasm about 4 x 3 cm, involving more than half the circumference of jejunum (Fig 2). He was discharged after stabilisation. Two weeks later, patient was admitted with abdominal pain. CT abdomen revealed dilated jejunal loops with bowel wall thickening and eccentric cavitation. A small loculated collection of size 3.6x1.8cm with a tiny air foci was seen along with minimal free fluid (Fig 3). On laparotomy, a perforated tumor in proximal jejunum, 25 cm away from DJ flexure, was identified. He underwent resection and end to end anastomosis. On histopathology, sections from jejunum showed transmural infiltration by a tumour arranged in sheets. The tumour cells were polygonal to epithelioid, with heterogeneously clumped chromatin. Interspersed proliferated blood vessels were noted. The neoplastic cells show diffuse strong positivity for Pan CK , Vimentin and patchy positivity for CK 7,CD31. CD34 highlighted the vessels. They were negative for p40, CDX2, CK20, CK 5/6, WT1, HMB45, SMA, CD117 and DOG 1. Histopathology was suggestive of a poorly differentiated sarcoma, with IHC suggestive of epitheliod angiosarcoma. Discussion: Primary angiosarcoma of small intestine is very rare. Epithelioid angiosarcomas are rare tumors, accounting for less than 1%. Angiosarcoma of small bowel may be associated with previous radiation treatment, chemotherapy, and chemical toxin exposure, specifically polyvinyl chloride. Angiosarcoma of small intestine can be considered as a rare cause in a patient who presents with obscure gastrointestinal bleed.Figure 1.: Bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum, Fig 2: Spiral enteroscopy , Fig 3: Dilated jejunal loops with bowel wall thickening and eccentric cavitation, Fig 4/5 Histopathology , Fig 6: Immunohistochemistry.

Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure

To investigate the effectiveness of free anterolateral thigh flap (ALTF) with fascia lata in repairing diabetic foot ulcers (DFUs) with bone exposure. Between January 2019 and January 2021, 20 patients with DFUs with bone exposure were admitted. There were 17 males and 3 females with a median age of 57.5 years (range, 48-76 years). There were 10 cases of Wagner grade 3 and 10 cases of grade 4. The DFUs formed 1 to 14 months, with a median time of 3 months. The patients underwent CT angiography, which showed extensive atherosclerosis in both lower limbs; 6 of them were severely narrowed or occluded and underwent percutaneous transluminal angioplasty. The size of wound ranged from 7 cm×6 cm to 27 cm×10 cm after applied first-stage debridement combined with vacuum sealing drainage treatment. In the second-stage, free ALTF with fascia lata was used to repair wounds and partial defects of tendons. The size of flap ranged from 8 cm×5 cm to 28 cm×11 cm. The wound of the donor site was sutured directly. The survival of the flap, the healing time of the wound, and the complications were recorded. The laser speckle blood flow imaging system was used to detect the blood perfusion of the flap and the skin around the flap at 2 weeks and 6 months after operation. The foot function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months after operation. After operation, effusion under the flap happened in 6 cases, which cured after symptomatic treatment. Flaps survived completely in 14 cases. The tissue necrosis at the edges of the flaps occurred in 3 cases and healed after dressing changes. Venous crisis of flaps occurred in 3 cases, of which 1 case was completely necrotic after exploration, and the other 2 cases were partially alive. The wounds of 3 cases were repaired with skin grafts after debridement and dressing. The flap survival rate was 95.0%, and the limb salvage rate was 100%. The wound healing time after flap transplantation was 14-30 days, with an average of 19.1 days. Two patients had recurrence of peripheral skin ulcers of the flaps within 1 month after healing, which healed after conservative dressing changes. Eighteen cases of incisions at donor site healed by first intention, 2 cases had local skin necrosis and healed by debridement and suture. All patients were followed up 6-30 months, with a median time of 11 months. The texture, appearance, and elasticity of the flaps were good. All patients could walk alone without pain. At 6 months after operation, the AOFAS score was 75.9±11.9, which was significantly different from that (44.7±18.4) before operation ( t=-7.025, P=0.000). The blood perfusion value increased from (38.1±7.8) PU at 2 weeks to (42.7±10.3) PU, and the difference was significant ( t=-4.680, P=0.001). Free ALTF with fascia lata has a rich blood supply and a high survival rate. It can be used to repair DFUs with bone exposure. After the free skin flap healed, it can promote revascularization of the affected foot, reduce the probability of ulcer recurrence, and avoid amputation.

Blood Pressure Discrepancy and Pulse Differential in Patients Undergoing CT Angiography for Suspected Acute Aortic Dissection

Blood Pressure Discrepancy and Pulse Differential in Patients Undergoing CT Angiography for Suspected Acute Aortic Dissection

Peripheral intravascular lithotripsy to facilitate transfemoral TAVR: a multicentric prospective registry

Abstract Background The presence of severe calcific atherosclerotic disease at iliac artery level is a contraindication to transfemoral (TF) TAVI procedures, challenging TF delivery in 15–20% of cases. Many case reports described the efficacy of Intravascular lithotripsy (IVL) to facilitate TF access but only one prospective registry has been reported in literature and dates back 2018. For this reason a new multicenter prospective registry was ideated to confirm the role of IVL technology in facilitating TF TAVR. Aims The aims of this study were 1)to analyze the trend of TF TAVR compared to alternative approaches in the last 5 years and 2)to evaluate the prevalence of IVLassistedTAVR since it was introduced in this specific setting in 2018 3) to evaluate the success rate in terms of valve performance and procedural success of TF-TAVR system delivery after IVL lesion preparation. Materials and methods We prospectively collected data from all consecutive TAVRprocedures performed between Jan2016 andDec2020 at 4Italian and 1 Denmark centres. All patients underwent CT angiography of lower extremity before the procedure in order to assess the severity of aorto-iliac-femoral calcification and to select those patients who required specific lesion preparation to preserve TF access. For each target calcified lesion we measured length, diameter and %of stenosis, circumferential extension and minimal cross-sectional area. Angiographic IVL-related and access site complications (dissection, perforation, major bleeding) were examined. Results Between 2016 and 2020, a total of 3710 TAVR were performed, 3428 (92%) via TF route while the remaining 240 (8%) included alternative approaches mainly represented by subclavian and transapical access. IVL-assisted TAVR were 0 in 2016 and 2017, 13 (2%) in 2018 when the first IVL-assisted aortic valve implantation was performed and doubled in 2019, reaching a total of 112 in the whole 5-year period considered. The number of IVL-facilitated TAVR has been increased in the 5-year period, achieving 7% of the TF procedures while non-TF TAVR decreased considerably from 10% to 6%. Common and external iliac axis was the target lesion in the majority of cases (54%) followed by common iliac artery alone. lesion minimum diameter 4.7mm, with average stenosis of 50%. The maximum calcium angle was 332°. The majority of IVL was performed with a 7-mm catheter (78.6%). 1 balloon per lesion was employed. 1 perforation and 2 severe dissections occurred, that required stent placement. In 55% of cases the aortic regurgitation was absent or minimal. Conclusions TF approach remained the first choice for TAVR procedure in the majority of cases compared to non-TF thanks to the progressive increase of IVLassistedTAVR that allowed operators to preserve TF route. Peripheral IVL appeared feasible, safe and effective in patients with severe peripheral artery disease, with high success rate in terms of valve performance and low rate of complications. Funding Acknowledgement Type of funding sources: None.

Modified Prehospital Acute Stroke Severity (mPASS) Scale to Predict Emergent Large Arterial Occlusion.

Introduction To date, identifying emergent large vessel occlusion (ELVO) patients in the prehospital stage is important but still challenging. In this present study, we aimed to design a modified prehospital acute stroke severity (mPASS) scale to identify ELVO patients and compared the scale to the PASS scale which has been published. Methods We retrospectively evaluated a consecutive cohort of acute ischemic stroke (AIS) in our stroke unit who visited the emergercy department. These patients underwent CT angiography (CTA), MR angiography (MRA), or digital subtraction angiography (DSA) at admission. The mPASS scale was calculated based on the National Institutes of Health Stroke Scale (NIHSS) items retrospectively, including the level of consciousness commands, gaze, arm weakness, and aphasia/dysarthria. Receiver operating characteristic (ROC) analysis was used to obtain the area under the curve (AUC) of the mPASS scale, NIHSS, and PASS scale. U-statistics was used to compare the AUC of the mPASS scale to the NIHSS and PASS scale. Results A total of 382 AIS patients were enrolled. The AUC and specificity of the mPASS scale (0.92, 84.4) were all higher than those of the PASS scale. Cortical symptoms such as gaze palsy and consciousness disorder were more specific indicators for ELVO than motor deficits. Conclusions The mPASS scale had a better discrimination for identifying ELVO than the PASS scale in our retrospective cohort. It might predict ELVO in an effective and simple way for paramedics in the prehospital triage stage or emergency stage. Moreover, cortical symptoms might have relatively high specificities to predict ELVO on their own.

Interobserver Agreement Of On-site Ct Derived Ffr In Patients Undergoing Ct Angiography For Suspected Cad By Experience Level

Introduction: Functional assessment of coronary stenosis using computational fluid dynamics is increasingly used, however technical performance requires knowledge of CT coronary anatomy. We assessed the interobserver agreement (experienced vs. less experienced observer) for CT-derived fractional flow reserve (CT-FFR) in patients with suspected coronary artery disease (CAD) undergoing coronary computed tomographic angiography (CCTA).

ENOXAPERIN-INDUCED THROMBOCYTOPENIA LEADING TO SADDLES EMBOLISM

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Heparin-induced thrombocytopenia ( HIT) is a life-threatening complication most commonly caused by unfractionated heparin. We present a rare case of enoxaparin induced HIT leading to saddle pulmonary embolism during medical treatment of femur fracture repair on prophylactic enoxaparin. CASE PRESENTATION: A 69-year-old Caucasian female presented in the emergency department with the chief complaint of shortness of breath. Shortness of breath was sudden, associated with palpitation. Her past medical history was significant for recently treated femur fracture 10 days before presentation and she was discharged on prophylactic enoxaparin 40mg daily for the prevention of DVT. On exam, her blood pressure was 107/63 mmHg and heart rate at 107 beats per minute. Initial investigation revealed thrombocytopenia with platelet count at 50 × 103 cells/μl dropped from 157 × 103 cells/μl after starting on the enoxaparin 10 days ago. X-ray chest was normal but because of high Wells score patient underwent CT angiography of chest, which revealed bilateral saddle pulmonary embolism. Her troponin was elevated at 1.4 ng/ml with elevated pro BNP at 2304 pg/ml. Her echocardiogram showed the right heart stain pattern. Interventional radiology was consulted and the patient underwent mechanical thrombectomy for submissive pulmonary embolism. Because of the high HIT score, enoxaparin was stopped, and the patient started on argatroban. Her labs for heparin-induced thrombocytopenia were sent which came out positive for PF4 antibodies and later high positive serotonin release assay. After ruling out systemic causes of thrombocytopenia and later laboratory confirmation for HIT, our patient was meeting the criteria for HIT secondary to enoxaparin because of 1. new thrombus formation in pulmonary vein 2. > 50% drop of platelets on admission day 3. positive PF4 and serotonin release assay. 4. heparin naive status. The patient later bridged with warfarin for pulmonary embolism for 3 months. She had an uneventful recovery with complete recovery of platelet counts to normal. DISCUSSION: Thrombocytopenia because of heparin therapy was first described in the late 1960s. The diagnosis of HIT includes a 50% fall in platelet count, beginning between five and 14 days after initial exposure to heparin of any dose or type, and detection of the HIT antibody against the PF4–heparin complex is necessary. We diagnosed enoxaparin-induced thrombocytopenia because of the clinical features, the patient’s heparin-naïve state, and the laboratory finding of antibodies against PF4 and heparin complexes. CONCLUSIONS: We report our experience with enoxaparin-induced thrombocytopenia during the medical treatment of femur fracture DVT prophylaxis. Although rare, LMWH such as enoxaparin may induce thrombocytopenia, which could be a life-threatening complication. Paying close attention to this rare side effect of enoxaparin can save someone's life. Reference #1: Kelton JG, Warkentin TE. Heparin-induced thrombocytopenia: a historical perspective. Blood. 2008;112:2607–2616. [PubMed] [Google Scholar] Reference #2: Cuker A. Recent advances in heparin-induced thrombocytopenia. Curr Opin Hematol. 2011;18:315–322. [PubMed] [Google Scholar] Reference #3: Ahmed I, Majeed A, Powell R. Heparin-induced thrombocytopenia: diagnosis and management update. Postgrad Med J. 2007;83:575–582. [PMC free article] [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Muhammad Aamir, source=Web Response No relevant relationships by Muhammad Afzal, source=Web Response No relevant relationships by Fatima Ayub, source=Web Response No relevant relationships by Adil Cheema, source=Web Response No relevant relationships by Muhammad Talha Khan, source=Web Response No relevant relationships by Danish Thameem, source=Web Response

Diagnostic Accuracy of Color Doppler and Calcium Scoring versus Dual-Energy Computed Tomography Angiography in the Assessment of Peripheral Arterial Diseases of Lower Limb.

Objectives:Peripheral arterial disease (PAD) leads to narrowing and hardening of arteries which leads to increased risk of lower extremity amputation. Hence, the accuracy of non-invasive diagnostic methods such as calcium scoring and color Doppler needs to be assessed in comparison to the gold standard dual-energy computed tomography (DECT) angiography. This study aims to evaluate the accuracy of color Doppler and calcium scoring when compared to DECT angiography in the assessment of PAD of the lower limb. It is a cross- sectional retrospective study.Material and Methods:The study included 55 patients aged between 40 and 70 years. All the patients with symptoms suggestive of PAD underwent color Doppler study of lower limb arterial system. Afterward, the patient underwent CT angiography. The first plain images were taken for calcium scoring following which contrast was given and further images were taken.Results:As compared to CT angiography assessment, Doppler assessment was 88.1% sensitive but only 69.2% specific with diagnostic accuracy of 83.6%. For angiographically detected atheromatous changes, color Doppler had sensitivity and specificity of 86.2% and 76.9%. The derived cutoff value >149.1 of calcium score in lower limb arteries was in 100% agreement with CT angiography detected PAD, whereas, for atheromatous changes, total calcium score at a cutoff value of >842.2 had sensitivity and specificity of 75.9% and 80.8%.Conclusion:Calcium scoring as compared to color Doppler has a higher diagnostic efficacy for the detection of DECT angiography confirmed PAD, whereas calcium score lacks adequate sensitivity at projected cutoff in the evaluation of atheromatous changes.

Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist

Objective: To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. Methods: From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People's Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. Results: Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. Conclusions: The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.

Improving diagnostic accuracy for arteries of lower extremities with dual-energy spectral CT imaging

PurposeInvestigate the clinical value of improving diagnostic accuracy for arteries of lower extremities with low energy images in dual-energy spectral CT (DEsCT) imaging. Method110 (mean age, 67 ± 10 years) and 72 (mean age, 65 ± 13 years) patients underwent CT angiography (CTA) in the lower extremities using dual-energy and conventional (100kVp) imaging mode, retrospectively. The 50 keV monochromatic images were reconstructed in the DEsCT group for analysis. The quantitative and qualitative image quality of the two groups were compared using various statistical analysis methods and the diagnostic accuracy for the degree of vessel stenosis was compared using DSA as the gold standard. Consistency test was used for intra-group evaluation. A P < 0.05 was considered statistically significant. ResultsThe use of 50 keV images in DEsCT significantly increased the enhancement in arteries of LKS (544.91 ± 106.37HU vs. 339.65 ± 83.74HU, P < 0.001) and provided higher SNR (19.92±9.39 vs. 17.39±4.99, P = 0.04) and CNR (45.60±16.61 vs. 38.70±18.17, P < 0.01) compared with conventional 100kVp images. Mann-Whitney test showed that the subjective image quality of the arteries of lower knee segment (LKS) in the DEsCT group was higher than in the conventional group (P = 0.01). The diagnostic efficiency of DEsCT group was better than that of conventional group, mainly in arteries of LKS (95.91 % vs. 87.85 %, for 50 % stenosis, P<0.001; 94.32 % vs. 89.58 % for occlusion, P = 0.02). ConclusionsThe use of 50 keV DEsCT images enhances the contrast in the lower extremity arteries and improves the diagnostic accuracy for the arteries of LKS, compared with the conventional CTA protocols.

Radiology workload in clinical implementation of thrombectomy for acute ischemic stroke: experience from The Netherlands.

To investigate the number of acute stroke patients undergoing CT angiography (CTA) for suspected large vessel occlusion (LVO) and those eligible for thrombectomy in relation to the population. Consecutive patients in a Western population who underwent CTA for suspected LVO of the proximal anterior circulation between January and August 2019 were included. The date and time of CTA and the number of patients eligible for thrombectomy were assessed. Our hospital's service area population was estimated using the Central Bureau for Statistics data. One-way analysis of variance with post-hoc tests and chi-squared tests were used for statistical analyses. Of 520 patients (49% males, mean age of 72years) undergoing CTA, 84 (16.2%) were eligible for thrombectomy. Our hospital's service area population was estimated at 420,000. Therefore, 3.6 CTA scans were performed and 0.6 patients were eligible for thrombectomy per 100,000 people per week. The number of patients undergoing CTA and the number of patients eligible for thrombectomy both did not significantly differ between any days of the week (P > 0.05). A total of 236 (45%) and 284 patients (55%) underwent CTA during office and on-call hours, respectively. The percentage of patients eligible for thrombectomy did not significantly differ between office and on-call hours (P = 0.834). Our study estimated the number of stroke patients undergoing CTA for suspected LVO and those eligible for thrombectomy in relation to the population. Numbers were essentially the same throughout the week, and during office and on-call hours. Our data can be used to make adequate staffing plans.

2762 Median Arcuate Ligament Syndrome: A Rare but Overlooked Cause of Post-Prandial Abdominal Pain

INTRODUCTION: Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is defined as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. The median arcuate ligament is a fibrous arch that crosses the aorta and links the crura of the diaphragm. This ligament typically passes superior to the origin of the celiac artery, however about 10% of the population (with strong female predominance) has a low-lying ligament that causes compression of the celiac trunk that is usually asymptomatic. We report a case of median arcuate ligament syndrome presenting similar to chronic mesenteric ischemia but without the typically associated cardiovascular risk factors. CASE DESCRIPTION/METHODS: A 54-year-old woman with no significant past medical history presented to the emergency department with a 6-month history of post-prandial abdominal pain associated with nausea, nonbilious emesis, sitophobia and a 60lb weight loss in the past 6 months. Vital signs were unremarkable. Her physical exam was entirely benign aside from mild epigastric tenderness to deep palpation. Labs were significant for a WBC 11.4, Hb 19.0 (baseline 13-15), K + 2.9. Gastroenterology was consulted and the patient underwent EGD which showed normal appearance of the esophagus, stomach, and duodenum with negative biopsies. Due to concern for mesenteric ischemia, the patient underwent CT Angiography of the abdomen which demonstrated 70% stenosis of the proximal celiac artery highly suggestive of median arcuate ligament syndrome. All other vessels were patent. DISCUSSION: Median arcuate ligament syndrome is a rare cause of post-prandial abdominal pain and weight loss that can often be challenging to diagnosis unless suspected by the clinician. Many patients undergo extensive workups for abdominal pain before being diagnosed. This syndrome presents similar to chronic mesenteric ischemia however many of these patients lack the typical cardiovascular risks factors associated with mesenteric ischemia as the demographic for MALS is typically middle-aged females ranging from age 40-60 years old. Patients are also often misdiagnosed with functional dyspepsia. Patients diagnosed with this disease should undergo laparoscopic celiac artery decompression which cures the majority of the patients with symptom recurrence occurring in approximately 6% of patients.

Stroke progression and clinical outcome in ischemic stroke patients with a history of migraine.

Patients with migraine might be more susceptible of spreading depolarizations, which are known to affect vascular and neuronal function and penumbra recovery after stroke. We investigated whether these patients have more severe stroke progression and less favorable outcomes after recanalization therapy. We included patients from a prospective multicenter ischemic stroke cohort. Lifetime migraine history was based on the International Classification of Headache Disorders II criteria. Patients without confirmed migraine diagnosis were excluded. Patients underwent CT angiography and CT perfusion <9 h of onset and follow-up CT after three days. On admission, presence of a perfusion deficit, infarct core and penumbra volume, and blood brain barrier permeability (BBBP) were assessed. At follow-up we assessed malignant edema, hemorrhagic transformation, and final infarct volume. Outcome at three months was evaluated with the modified Rankin Scale (mRS). We calculated adjusted relative risks (aRR) or difference of means (aB) with regression analyses. We included 600 patients of whom 43 had migraine. There were no differences between patients with or without migraine in presence of a perfusion deficit on admission (aRR: 0.98, 95%CI: 0.77-1.25), infarct core volume (aB: -10.8, 95%CI: -27.04-5.51), penumbra volume (aB: -11.6, 95%CI: -26.52-3.38), mean blood brain barrier permeability (aB: 0.08, 95%CI: -3.11-2.96), malignant edema (0% vs. 5%), hemorrhagic transformation (aRR: 0.26, 95%CI: 0.04-1.73), final infarct volume (aB: -14.8, 95%CI: 29.9-0.2) or outcome after recanalization therapy (mRS > 2, aRR: 0.50, 95%CI: 0.21-1.22). Elderly patients with a history of migraine do not seem to have more severe stroke progression and have similar treatment outcomes compared with patients without migraine.

CT aortic annulus parameters for pre-operative TAVI assessment: A comparative study between manual post processing and automated software tool

ObjectiveA comparative study of manual and automated post processing software tools to measure CT parameters before Transcatheter Aortic Valve Implantation (TAVI). Patients and methods51 patients were included; all admitted to the Cardiology Department with clinically established severe aortic stenosis, in whom TAVI was the treatment of choice. All patients underwent CT angiography (CTA) pre-TAVI. The CT images were post processed and the needed CT parameters were calculated using both manual and automated methods. The results were compared for statistical analysis. ResultsOnly 43 patients completed the study, with mean age 65 years old. The automated software provided accurate almost similar results as the manual method, especially for aortic annulus area and aortic circumference measurements (p-value = 1 and 0.548) and was accepted for left and right coronary artery ostium height (p-value = 0.191 and 0.635).However, there was a statistically significant difference for the minor diameter axis and mean annular diameter (p-value = 0.001 and 0.021). ConclusionThe automated software introduced rapid, accurate and reliable measurements for the aortic annulus in cases prepared for TAVI and can be used as a standard method. Also, it can be performed by junior staff with avoidable human errors.

Pediatric blunt cerebrovascular injury: the McGovern screening score.

OBJECTIVE The objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing. METHODS This is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0-15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI. RESULTS A total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as "low risk" and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin. CONCLUSIONS With a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.

Aortic pseudocoarctation: a very rare finding

A 52-year-old Caucasian woman with a history of hypertension since age 30 was referred to cardiology department due to aortic stenosis. She had exertional dyspnoea, without thoracic pain or syncope....