Significant Luminal Narrowing Research Articles

S2825 Endoscopic Management of an Obstructing Duodenal Wall Hematoma in the Setting of Acute Pancreatitis

Introduction: Spontaneous duodenal wall hematoma is a rare condition which can be associated with acute and chronic pancreatitis. It is often complicated by small bowel obstruction. When conservative management fails, options are limited. Here we describe a case of small bowel obstruction secondary to pancreatitis-associated duodenal wall hematoma which was successfully managed endoscopically through cystduodenostomy. Case Description/Methods: A 69-year-old male with HIV and normal CD4 count presented with acute abdominal pain and non-bloody emesis with elevated lipase of 374 U/L (ULN 82). Computed tomography revealed a 5.8 cm multilobulated pancreatic pseudocyst with associated inflammation and coarse calcifications and a 10 cm circumferential submucosal mass within the duodenum with significant luminal narrowing and compression of the adjacent inferior vena cava (a). Endoscopic ultrasound confirmed a homogenous, hypoechoic subepithelial lesion obstructing the second portion of the duodenum consistent with a hematoma (b). A nasogastric-jejunal tube was placed for feeding and decompression. Due to persistent obstruction and IVC compression, on hospital day 10 endoscopic drainage of the duodenal hematoma was performed via cystduodenostomy with a 15x10 mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, MA, USA) (c). The LAMS was immediately removed after near-complete evacuation of the hematoma cavity to minimize the risk of bleeding complications. A plastic double-pigtail stent was left in place to facilitate complete drainage. The duodenum was then dilated with a 12-13.5-15mm hydrostatic balloon dilator. The pigtail stent was removed 3 days later with clinical, radiographic, and endoscopic resolution of the duodenal obstruction (d). Discussion: Duodenal hematoma is a previously described rare complication of pancreatitis. Endoscopic evacuation was a safe and effective means of relieving the duodenal obstruction in this patient. This minimally invasive option resulted in immediate resolution and can be considered when conservative management fails.Figure 1.: 10 cm duodenal wall hematoma on CT scan (a) and endoscopy (b). Endoscopic drainage via cystduodenostomy with a lumen-apposing metal stent (c). Resolution of the duodenal wall hematoma (d).

512 Megaoesophagus Presenting as Stridor: A Case Report and Review of Literature

Abstract Introduction Megaoesophagus, dilatation of the oesophagus, is a recognised late complication of achalasia cardia, Chagas disease and, less commonly, dysmotility disorders. Megaoesophagus often presents with dysphagia, regurgitation of food and chest pain. Here, we describe a case of a patient presenting with stridor secondary to chronic dysmotility in the absence of dysphagia. Case Report An 85-year-old female presented to the Emergency Department with stridor, and a history of breathlessness and intermittent coughing episodes. Flexible laryngoscopy revealed the larynx to be rotated to the right, corresponding with a palpable swelling of the left neck. A chest X-ray showed a markedly dilated oesophagus. Computed tomography revealed severe oesophageal dilatation causing compression of the tracheobronchial tree and larynx. The patient received nebulised adrenaline and intravenous dexamethasone, resulting in resolution of her stridor. A barium swallow demonstrated marked cricopharyngeal spasm causing significant luminal narrowing but no holdup of barium. The remainder of the oesophagus was chronically dilated to the gastro-oesophageal junction and appeared atonic. The findings were atypical of achalasia, there were no obstructing lesions identified and chronic dysmotility was considered most likely, which was subsequently confirmed by a gastroenterology opinion. Discussion Megaoesophagus is rare, most frequently presents with dysphagia and regurgitation of food and is most commonly caused by achalasia. A literature search identified only one previous case of obstructing megaoesophagus secondary to idiopathic dysmotility disorder; however, this case revealed the stridor to be secondary to an impacted food bolus, whereas our case did not demonstrate any obstructing lesions.

Carotid Plaque Imaging: Strategies beyond Stenosis.

Atherosclerosis at the carotid bifurcation in the neck is common and the result of turbulent hemodynamics in the bulb. Carotid bulb plaques cause disabling strokes. Carotid vessel wall imaging characterizes the atherosclerotic plaque, documents disease progression, and assesses lesion severity by plaque morphology in addition to the degree of stenosis. This in turn optimizes treatment selection for the individual patient. The aim of vessel wall imaging in patients of stroke is to distinguish stable plaques that may be conserved with best medical management from unstable or vulnerable plaques that require more aggressive medical treatment, carotid stenting, or carotid endarterectomy. Growing evidence suggests that depending on luminal stenosis measurements alone for management decisions will result in underestimating a number of plaques whose size may be small, but where the plaque morphology is unstable, there is a high likelihood of the patient developing a thromboembolic stroke in the near future. In today's context of aggressive management of even transient ischemic attacks and minor strokes, vessel wall imaging should be particularly performed in cryptogenic strokes without significant luminal narrowing on angiography to identify a subset of patients with nonstenotic but unstable atherosclerotic plaques that may be covert etiologies of stroke. If patients receiving the best medical management have recurrent strokes on the same side as a carotid plaque with “vulnerable” plaque features, they may deserve surgical or endovascular intervention even if they do not meet the conventional stenosis thresholds. Improved techniques for stroke imaging and consequent management have a remarkable effect in decreasing individual and public health burdens.

Coronary Artery Vasospasm: A Under-recognized Phenomenon in Orthotopic Heart Transplant

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

Value of Coronary Angiography in the Cardiac Myxoma.

Preoperative coronary angiography for cardiac myxoma not only excludes coronary artery disease but also detects the artery feeding the cardiac myxoma, which has several clinical implications. In this study, we examined cardiac myxoma cases in two tertiary hospitals using coronary angiography to identify the artery feeding the myxoma. We retrospectively reviewed 42 patients with cardiac myxoma who had undergone surgical removal between July 2008 and December 2015 in two tertiary hospitals, and recorded their baseline characteristics, echocardiographic findings, and coronary angiography. Among those 42 patients, 23 (55%) had coronary angiography before surgery and in no case was significant luminal narrowing observed. In 21 of the coronary angiograms, the artery feeding the cardiac myxoma had a vascular branch (100%), clusters of tortuous vessels with contrast medium pooling (67%), an arteriocavity fistula (33%), and a mobile feeding artery (67%). No significant relationship was found between coronary artery dominance type and the origin of the artery feeding the cardiac myxoma (P = 0.362). Identification of the artery feeding the cardiac myxoma, with a distinctive vascular appearance in coronary angiography, is important for several clinical applications such as helping to diagnose cardiac myxoma and to plan the surgical approach. Clin. Anat. 33:833-838, 2020. © 2019 Wiley Periodicals, Inc.

Role of multi-parametric ultrasound in transient perivascular inflammation of the carotid artery syndrome.

The term "carotidynia" has been used to describe a symptom or a nosologic entity characterized by pain in the lateral neck region and over the carotid bifurcation. Recent advances in diagnostic imaging and the introduction of diagnostic criteria have led to the adoption of term "Transient perivascular inflammation of the carotid artery" (TIPIC) syndrome. A retrospective analysis of the Radiology Department's database was performed to identify cases with the diagnosis of TIPIC syndrome. The purpose was to identify ultrasound images including B-mode technique, colour, power Doppler technique and contrast-enhanced ultrasound (CEUS). In total, five patients with the diagnosis of TIPIC syndrome are presented in this review. TIPIC syndrome is a clinic-radiologic entity characterized by pain over the carotid area, a symptom referring to a wide differential diagnosis where imaging plays a crucial role for proper diagnosis and treatment. Characteristic imaging findings on conventional ultrasound and CEUS are presented in this review. TIPIC syndrome can be investigated with virtually any imaging modality. Ultrasound typically reveals perivascular infiltration and a hypoechoic intimal plaque, while no significant luminal narrowing is appreciated. Computed tomography angiography and magnetic resonance angiography also demonstrate these vascular wall changes primarily affecting the distal common carotid artery, the carotid bulb and possibly the internal carotid artery proximal part. Contrast enhancement is a very characteristic and constant finding of TIPIC lesions, suggestive of the inflammatory nature of the disease and can be appreciated on computed tomography angiography and magnetic resonance angiography. CEUS has been recently used and successfully observed contrast enhancement of the lesions, similar to computed tomography angiography and magnetic resonance angiography. Ultrasound remains the first-line modality for the evaluation of TIPIC syndrome, capable of providing all the information needed, especially if supplemented with the administration of microbubbles so that the enhancement of lesions can be evaluated.

Endovascular Repair of Bilateral Carotid Dissection in a Near Hanging Victim

IntroductionThere is much debate in the literature regarding the management of blunt cervical carotid injuries. This report describes a case of bilateral carotid artery dissection in the very uncommon case of a near hanging victim and the treatment controversies regarding its management.ReportA 50 year old male patient was admitted after attempted suicide through hanging, having been swiftly rescued by a bystander. On admission, six hours after the event there was no neurological deficit. There was evidence of soft tissue damage related to the rope position, subcutaneous emphysema, and neck swelling. The CT angiogram showed dissection of both common carotid arteries with significant luminal narrowing as well as fracture of the thyroid cartilage; brain injury was excluded. Heparin infusion was started and an endovascular repair with bilateral covered stent placement, requiring coverage of the external carotid artery on the left side, was performed. The vascular procedure was uneventful. The patient was discharged 36 days after the event, on dual antiplatelet drugs and under regular psychiatric and speech therapy care, and is currently alive and well 22 months after surgery with no neurological damage.DiscussionThe choice of treatment was not straightforward as there are no guidelines or consensus around its management. In this case, however, an endovascular repair seemed suitable and the result was optimal, with no neurological damage and a good result after 22 months.

Diagnostic Performance of Self-navigated Whole-Heart Contrast-enhanced Coronary 3-T MR Angiography

Purpose To evaluate the diagnostic performance of self-navigated whole-heart coronary 3-T magnetic resonance (MR) angiography by using conventional invasive coronary angiography (ICA) as the reference gold standard. Materials and Methods This study was approved by the local ethics committee. Written informed consent was obtained from each patient before the study. Thirty-nine consecutive patients underwent coronary MR angiography and later underwent ICA. Coronary MR angiography was performed with a 3-T imager with contrast agent enhancement during free breathing with self-navigated affine motion correction reconstruction. Coronary segments with reference diameters larger than 1.5 mm were included in the comparison between coronary MR angiography and ICA. The coronary MR angiography images were evaluated by two experienced readers blinded to the ICA results to identify significant luminal narrowing (>50% diameter reduction in reference ICA). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were performed to detect significant coronary artery stenosis. Results Coronary MR angiography examinations were successfully performed in all 39 patients. A total of 327 coronary segments had reference luminal diameter larger than 1.5 mm. Of these 327 coronary segments, 303 (92.7%) segments had a quality score greater than 1 at coronary MR angiography and were included in the analysis. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 78.2%, 75.0%, 81.8%, 70.6%, and 76.9%, respectively, on a per-patient basis. Conclusion Contrast-enhanced self-navigated coronary 3-T MR angiography is a promising technique for the noninvasive detection of clinically significant coronary stenosis. © RSNA, 2016.

Utility of Multimodality Imaging in the Morphologic Characterization of Anomalous Aortic Origin of a Coronary Artery.

Anomalous aortic origin of a coronary artery from the wrong Sinus of Valsalva (AAOCA) is a rare congenital anomaly and is associated with sudden cardiac death. Morphologic features considered to be "high risk" are significant luminal narrowing, acute coronary angulation at its origin, intramural course, and long interarterial course. A consistent approach for characterization of these features is lacking. A retrospective single-center review of all patients diagnosed with AAOCA using echocardiogram and computed tomography (CT)/magnetic resonance imaging (MRI) studies was performed. Twenty-nine patients were identified (25 using CT and 4 using MRI) with subsequent three-dimensional data sets. The MRI data sets lacked adequate resolution and were excluded. Twenty-five patients (median age 15.1, range 10-39.5 years, 72% male) were further analyzed using echocardiogram and CT. Morphologic assessment focused on luminal stenosis, coronary angulation, and interarterial length. Additional morphologic features focusing on cross-sectional area and degree of ellipticity were also assessed. Echocardiography tended to yield smaller measurements compared to CT and had poor interobserver reproducibility for measurements pertaining to the narrowest proximal and distal coronary segments. Computed tomography showed good inter-/intraobserver reproducibility for the same. Agreement between both modalities for coronary angulation at its origin was excellent. There was good agreement for measurements of interarterial length between echocardiography and CT, but echocardiography had superior reproducibility. Assessment of luminal cross-sectional area and elliptical shape by CT had excellent inter-/intraobserver reproducibility. The combination of echocardiography and CT characterizes morphologic features of anomalous origin of the coronary artery more reliably than either modality alone.

Effect of smoking status on coronary artery disease among Chinese post-menopausal women.

Smoking is a prominent risk factor of cardiovascular diseases. The occurrence of myocardial infarction and mortality in smokers with cardiovascular diseases is several times higher than that in non-smokers. Smoking is associated with gender-independent enhanced mortality. We determined the effect of smoking status on coronary artery disease (CAD) and coronary computed tomography angiography (CCTA) in Chinese post-menopausal women. Among these patients, those with significant CAD (≥50% luminal narrowing) were further classified into one-, two-, or three-vessel disease according to CCTA results. The following events were recorded: all-cause mortality, non-fatal infarction and unstable angina. 2332 patients evaluated with CCTA included 1668 never smokers (71.5%), 475 former smokers (20.4%), and 189 current smokers (8.1%). The current smokers exhibit greater luminal narrowing as observed on CCTA (p<0.001) than the other subjects. During the median 685±269.8days follow-up period, never-smoking women have a low incidence of events, whereas former and current smokers are associated with an increased incidence of such event (p<0.001). Furthermore, current smoking and the presence of multiple-vessel disease on CCTA are independently associated with the events in the logistic regression analysis. Smoking status is related to significant CAD and luminal narrowing on CCTA in the Chinese post-menopausal smoking women. In addition, current smoking and the presence of multiple-vessel disease on CCTA can independently predict events of all-cause mortality, non-fatal infarction or unstable angina.

Acute decompensated heart failure and acute kidney injury due to bilateral renal artery stenosis

Atherosclerotic renal artery stenosis (RAS) may result in hypertension, azotemia, and acute pulmonary edema. We report on a renal angioplasty with stent placement for bilateral RAS in a patient with acute decompensated heart failure and acute kidney injury. A 67-year-old female patient was admitted to our hospital with acute shortness of breath and generalized edema. Echocardiography showed left ventricular wall motion abnormality and the follow up electrocardiography showed T wave inversion in the precordial leads. We performed a coronary angiography to differentiate ischemic heart disease from non-cardiac origin for the cause of the heart failure. The coronary angiography showed no significant luminal narrowing, but bilateral RAS was confirmed on the renal artery angiography, therefore, we performed renal artery revascularization. After the procedure, the pulmonary edema was improved and the serum creatinine was decreased. Two weeks later, an echocardiography showed improvement of the left ventricular systolic function.

The eff ect of intracoronary administration of ergonovine on the contralateral coronary artery in a provocation test for the diagnosis of variant angina

Background Little is known about the effects of selective intracoronary administration of ergonovine into a coronary artery on the artery on the other side. This study aimed to evaluate the effect of intracoronarily administered ergonovine on the contralateral coronary artery.Subjects and methods From June 2011 to August 2013, coronary spasm provocation tests were performed in 85 consecutive patients using selective intracoronary administration of methylergometrine maleate (ER). The doses increased in a step-wise manner up to 60 μg for the left coronary artery (LCA) and up to 50 μg for the right coronary artery (RCA). The coronary artery diameters were measured and analysed by repeated-measures ANOVA.Results Twenty-four (28%) patients had a spasm-positive result. The mean diameter of the spasm segment in the contralateral artery decreased from 2.83 to 2.68 mm (5.1 ± 0.1% change, P< 0.001) in the negative spasm group and from 2.40 to 2.10 mm (11.1 ± 2.2% change, P= 0.001) in the positive spasm group. There were no serious procedure-related complications.Conclusions Intracoronary administration of ER resulted in a statistically significant decrease of lumen diameter of the contralateral coronary artery. However, from the clinical perspective, the extent of the decrease was relatively small and the test may be conducted safely unless there is a significant coronary artery luminal narrowing.

Primary ALK positive Anaplastic large cell lymphoma of T-cell type of jejunum: Report of a rare extranodal entity with review of literature

The gastrointestinal tract (GI tract) is the most common site for extranodal lymphomas with the majority of the non-Hodgkin's B-cell type. It involves any part of the GI, the most frequent sites in the order of occurrence are the stomach, small intestine, and ileocecal region. A 17-year-old male presented with intermittent abdominal pain, altered bowel habits associated with vomiting of 1 month duration. Computerized tomography of the abdomen revealed an eccentric mass in the jejunum with significant luminal narrowing. Limited resection of jejunum showed an intraluminal polypoidal growth with a homogenous cut surface. Microscopic examination of the mass revealed a diffusely infiltrating monotonous population of large lymphoid cells with round to oval vesicular nucleus, prominent nucleoli and moderate to scanty cytoplasm, admixed with few multinucleated giant cells with wreath like arrangement of nuclei, binucleated cells, and atypical mitosis. The tumor was involving the submucosa, infiltrating the muscularis propria and extending into the sub serosa. Immunohistochemistry showed diffuse positivity for CD45, CD30, anaplastic lymphoma kinase-1 (ALK-1), and focal positivity for CD43. The immunohistochemical stains for B-cell lineage CD20, CD79a, T-cell markers CD3, CD2, CD4, CD8, CD7, and other markers namely bcl2, bcl6, CD5, CD138, CD56, Mum1, and PAX-5 were negative. Six lymph nodes isolated showed features of reactive follicular hyperplasia and were free of tumor. A diagnosis of primary ALK positive anaplastic large cell lymphoma of T-cell type of jejunum was made. Patient has completed three cycles of chemotherapy comprising of cyclophosphamide, prednisone, vincristine, and doxorubicin and is in remission until the last follow-up.

Repair of congenital supravalvular aortic stenosis in an adult patient

Supravalvular aortic stenosis (SVAS) is an unusual form of obstructive lesions of left ventricular outflow tract (LVOT) located above the aortic valve. A 45-year-old male case who was admitted with a complaint of dyspnea was diagnosed of SVAS, leading to significant gradient and luminal narrowing. The case was treated successfully through twosinus reconstruction and ascending aorta replacement. We conclude that the graft replacement of aorta in such cases would be a safe and an effective procedure.

Whole-body MRI and MRA for evaluation of the prevalence of atherosclerosis in a cohort of subjectively healthy individuals

ObjectivesTo assess the prevalence of cardiovascular findings in asymptomatic individuals by means of 1.5-T whole-body magnetic resonance imaging and angiography.MethodsA cohort of 138 individuals (118 men, 20 women) with a mean age of 54 years (SD ± 7.55) was referred to whole-body MRI at 1.5-T, including contrast-enhanced whole-body MR angiography (MRA) and cardiac MRI. A total of 2,065/2,070 vessel segments (99.8%) and cardiac function were evaluated.ResultsApproximately one-fourth of the participating individuals had vascular abnormalities. In 17 subjects (12.3% of all subjects) significant luminal narrowing was observed in at least one vascular segment. Luminal narrowing (mild to severe) was observed in 1 (0.7% of all subjects respectively) of the renal arteries, 7 (5.0%) of the carotid arteries, and 3 (2.2%) of the pelvic and upper leg arteries, and in 17 segments (12.3%) of arteries in the lower leg.In cardiac function and perfusion imaging, wall motion disorders were observed in six patients (4.3%), with additional delayed enhancement and isolated delayed enhancement present in two cases. Functional parameters differed from reference values in 55 cases.ConclusionsEven in an asymptomatic cohort of middle-aged predominantly male individuals, atherosclerotic disease is not uncommon and is detectable by whole-body MRI.Main Messages In middle-aged predominantly male individuals, atherosclerotic disease is not uncommon. Even in an asymptomatic collective, approximately one fourth had vascular abnormalities. Using whole-body MR angiography (MRA), 99.8% of 2,070 vessel segments could be evaluated.

Angiographic Lesion Severity and Subsequent Myocardial Infarction

We sought to determine the angiographic severity of coronary lesions leading to ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) with a focus on determining the impact of interval from initial angiogram to subsequent clinical event. In the late 1980s angiographic data on lesion characteristics that culminated in STEMI and NSTEMI were obtained from angiograms obtained several months before MI. It is not clear whether the conclusions on lesion severity would be different if elapsed interval from baseline angiogram to clinical event was factored in the analysis. From 2003 through 2010, we identified 84 patients with NSTEMI and 41 patients with STEMI in vessels without previous intervention. These patients had ≥1 previous angiographic study at our center. Angiograms were reanalyzed with quantitative coronary angiography, and relevant clinical data were obtained from medical records. Similar to previous studies, 71% of patients with STEMI and 63% of patients with NSTEMI had <50% baseline stenosis at the culprit site when the interval from initial angiogram to MI was >3 months. Interestingly, lesions that led to STEMI ≤3 months after evaluation were more severe than those leading to STEMI in >3 months (59 ± 31% vs 36 ± 21%, p = 0.02) with 57% of lesions having >50% stenosis. Although most MIs occurred at sites that did not have significant obstruction when examined >3 months before MI, most baseline lesions showed significant luminal narrowing when examined ≤3 months before STEMI. In conclusion, high-grade coronary stenosis may be an important predictor of STEMI in subsequent months.

In Vivo Assessment of Ergonovine-Induced Coronary Artery Spasm by 64-Slice Multislice Computed Tomography

The potential of multislice CT (MSCT) to predict coronary spasm has not been elucidated. The aim of this study was to investigate whether the morphological features observed on MSCT at the site of ergonovine-induced epicardial spasm could be used as diagnostic criteria for coronary spasm. A total of 296 plaques in 199 patients with clinically suspected coronary spastic angina without coronary stenosis (<75%) who underwent invasive angiography with intravenous ergonovine provocative testing were analyzed by MSCT. Calcification, CT attenuation, and patterns of vascular remodeling were evaluated in each plaque by MSCT. Plaques were divided into spasm group or nonspasm group based on the results of the ergonovine provocative test. On a per-plaque basis, noncalcified plaques were more frequently observed in the spasm group (96% versus 20%, P<0.01). Intermediate attenuation plaques (CT density ≥53.8 Hounsfield units identified by receiver operating characteristic analysis) were more common in the spasm group (93% versus 28%, P<0.01), as was negative remodeling (67% versus 11%, P<0.01). Multivariable analysis revealed noncalcified (odds ratio [OR], 48.7; 95% CI, 8.81-269; P<0.01), intermediate attenuation (OR, 19.3; 95% CI, 4.96-75.4; P<0.01); negative remodeling (OR, 8.83; 95% CI, 2.87-27.2; P<0.01); and male sex (OR, 4.55; 95% CI, 1.24-16.6; P=0.02) as predictors of the plaque associated with coronary spasm. MSCT can detect differences in individual plaque composition and morphology among atherosclerotic plaques without significant luminal narrowing in areas of inducible vasospasm compared to areas without vasospasm.

Significant coronary stenosis detected by coronary computed angiography in asymptomatic HIV infected subjects

increased incidence of acute coronary events, high rate of abnormal surrogate markers of atherosclerosis and increased amount of coronary calcium have been described in HIV infected population. To expand knowledge on coronary artery disease (CAD) in HIV patients, cardiac CT scan was performed in asymptomatic subjects with low cardiovascular (CV) risk. A cross-sectional study using dual-source CT (MDCT) coronary angiography.was conducted in HIV-infected subjects with the following characteristics: Framingham Risk Score (FRS) ≤10, absence of metabolic syndrome, negative echocardiographic and ECG stress-test. A luminal narrowing exceeding 50% was defined as a clinically significant coronary stenosis. Calcium score was quantified using the Agatston Calcium Score method. Fifty-five subjects were enrolled. Significant coronary stenoses, requiring coronary angiography, were found in 16/55 (29.1%). At multivariate analysis older age was the only variable independently associated with the presence of significant luminal narrowing (p=0.011). MDCT showed an unexpected, age-associated high rate of significant coronary stenosis in asymptomatic HIV positive subjects with low CV risk. These findings suggest that aggressive screening programs for coronary artery disease may be appropriate in this population; further studies are recommended to assess the appropriateness of MDCT for this purpose.

Complementary Value of Cardiac FDG PET and CT for the Characterization of Atherosclerotic Disease

For decades, the identification of significant luminal narrowing has been the hallmark to characterize the presence and extent of coronary artery disease. However, it is now known that characterizations of systemic atherosclerosis burden and inflammation, as well as the local quality of plaque composition and morphology, allow better characterization of coronary artery disease and thus may allow improved prediction of adverse cardiovascular events. Plaque characterized histologically as a thin-cap fibroatheroma (ie, an atheroma with a thin fibrous cap, an underlying lipid-rich necrotic core, and inflammatory activity) has been recognized as representing vulnerable or high-risk plaque. Positron emission tomography (PET) and cardiac computed tomography (CT) are noninvasive modalities that provide metabolic (PET) and morphologic (CT) information about atherosclerotic plaque. PET allows the quantification of the uptake of fluorine 18 fluorodeoxyglucose (FDG) within the arterial wall, which provides a measure of macrophage activity within atheromatous plaque. Coronary CT allows the depiction of plaque morphology and composition. Thus, integrated imaging with PET and CT (PET/CT) permits coregistration of FDG activity with the presence and morphology of plaque and may lead to improved characterization of vulnerable plaque or vulnerable patients, or both. This review details the methods and principles of cardiac FDG PET and coronary CT and provides an overview of the research, with an emphasis on the identification and characterization of vulnerable plaque.

Evaluation of the small intestinal submucosa covered stent in preventing restenosis after percutaneous transluminal angioplasty in the swine

To compare the performance of small intestinal submucosa (SIS)-covered endografts (SCEs) to bare nitinol stents (BSs) in injured swine iliac arteries. Twenty-eight nitinol stents were used: 14 externally SCEs and 14 BSs. Devices were implanted in each side of balloon-injured external iliac arteries of 14 swine via carotid approach. Arteriograms were obtained before and after implantation and before animal sacrifice at 4, 8, and 12 weeks. Histopathological and electron microscopy studies of explanted specimens were performed. Implantation of all SCEs and BSs was technically successful, but one SCE and one BS were obstructed at 8 weeks after implantation. At sacrifice, the other 26 stents were patent, with angiogram showing no significant different luminal narrowing between SCEs and BSs. Proliferating cell nuclear antigen (PCNA) immunohistochemistry examination revealed that the percentage of PCNA(+) cells were lower in SCEs (p<0.05). Additionally, histomorphological analysis indicated that the neointima area and percentage of narrowing area were greater in SCEs, but there was no statistical significance. Greater endothelial cell count in SCEs than in BSs per visual field at 4000 times magnification by scanning electron microscope (p<0.05). Compared to BSs, no definite decrease of neointima and restenosis was found in SCEs in the present study. However, it is effective in promoting endothelial regeneration and strengthening endothelial function.