Venous Imaging Research Articles

Case detection and diagnosis of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism.

Even though the increasing clinical recognition of primary aldosteronism (PA) as a public health issue, its heightened risk profiles and the availability of targeted surgical/medical treatment being more understood, consensus in its diagnosis and management based on medical evidence, while recognizing the constraints of our real-world clinical practice in Taiwan, has not been reached. The Taiwan Society of Aldosteronism (TSA) Task Force acknowledges the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics into the management of PA. When there is suspicion of PA, a plasma aldosterone to renin ratio (ARR) should be obtained initially. Patients with abnormal ARR will undergo confirmatory laboratory and image tests. Subtype classification with adrenal venous sampling (AVS) or NP-59 nuclear imaging, if AVS not available, to lateralize PA is recommended when patients are considered for adrenalectomy. The strengths and weaknesses of the currently available identification methods are discussed, focusing especially on result interpretation. With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.

Imaging representation of peripheral veins

Several techniques are available for imaging of the venous system of the legs and pelvic region. In cases of suspected deep leg vein thrombosis B‑mode compression ultrasound is applied. Its accuracy is sufficient to either confirm or exclude the diagnosis with certainty. For examination of the iliac veins, however, flow information has to be added by pulsed wave (PW) Doppler or color Doppler sonography. In cases of suspected arm vein thrombosis, ultrasound is also the method of choice. The more proximal or the central parts of the venous system, i. e. brachiocephalic veins or the superior and inferior vena cava can be visualized by cross-sectional imaging procedures. Computed tomography (CT) angiography accurately shows the vessel lumen and magnetic resonance imaging (MRI) provides more details of the surrounding soft tissue. The use of classical contrast medium phlebography is nowadays restricted to interventions on proximal or central parts of the venous system. In addition, venous imaging is required in the field of chronic venous insufficiency. For both differential diagnostics and choice of treatment options, e. g. for varicose veins, the mainstay is venous ultrasound.

Enhancing contrast of magnetic resonance imaging in patients with liver cirrhosis: Conveyance times of Primovist in hepatobiliary system

Purpose: To determine transit times for excretion of gadoxetic acid (Gd-EOB-DTPA), a recent magnetic resonance imaging (MRI) contrast agent, in hepatobiliary system of patients with liver cirrhosis. Methods: Liver cirrhosis patients that underwent contrast MRI examination at Renai Hospital, Taipei City, Taiwan were included. The patients who have experienced contrast-enhanced abdominal MR examination after injection of 10 mL Gd-EOB-DTPA at 1.5-T MR from December 2009 to March 2011, were included retrospectively. The images were evaluated for the presence of contrast agent in intrahepatic bile ducts (IHD), common bile duct (CBD), gall bladder and duodenum. Results: The optimal time for arterial phase was from 15 s after injection while the optimal time for portal venous imaging was from 40 s after injection. Furthermore, the optimal time to observe changes was 20 min after contrast initiation of Gd-EOB-DTPA in 39 patients (83 %) in IHD and 37 patients (78.5 %) in CBD. Gall bladder reflux was visible in 26 patients (43 %), and duodenal excretion in 17 patients (36 %). After 30 min of contrast injection, Gd-EOB-DTPA could still be detected in 6 patients (13 %) in IHD and 7 patients (15 %) in CBD, while gall bladder reflux was visible in 10 patients (21 %), and duodenal excretion in 20 patients (55 %). Conclusion: The excretion of Gd-EOB-DTPA can be observed in liver cirrhosis patients. Keywords: Hepatocellular carcinoma, Magnetic resonance imaging (MRI), Gadoxetic acid, Common hepatic duct

OP49, PP26 - Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)

OP49, PP26 - Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)

Concordance of fetal echocardiography in the diagnosis of congenital cardiac disease utilizing updated guidelines

Objective: We sought to examine the concordance of prenatally diagnosed congenital cardiac disease with postnatal echocardiography.Study design: Patients who underwent fetal echocardiograms performed by pediatric cardiologists at a single referral center from January to December 2014 were reviewed. Fetal echocardiography exams were performed in accordance with guidelines by the American Institute of Ultrasound in Medicine (AIUM) and the American Heart Association (AHA) guidelines (2013 and 2014, respectively). The concordance of prenatal diagnosis was compared to postnatal echocardiograms.Result: One hundred and six patients were included. Overall, the prenatal diagnosis precisely matched the postnatal diagnosis in 69.8%, minor discrepancies were seen in 14.2% and major differences were seen in 16% of cases. Three cases with major differences resulted in a more guarded postnatal prognosis; all three were fetuses with complex disease where the additional finding of total anomalous pulmonary venous return (TAPVR) was missed.Conclusion: Fetal echocardiograms performed in our specialized fetal cardiology program are in high agreement with postnatal diagnosis of congenital cardiac disease. A worse postnatal prognosis is uncommon. Emphasis on pulmonary venous imaging in complex congenital heart disease is vital.

Venous collateral drainage patterns predict clinical worsening in dural venous sinus thrombosis

BackgroundDural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. The condition of approximately...

Forearm versus upper arm grafts for vascular access.

Forearm and upper arm arteriovenous grafts perform similarly in terms of patency and complications. Primary patency at 1 year for forearm arteriovenous grafts versus upper arm grafts ranges from 22%-50% versus 22%-42%, and secondary patency at 1 year ranges from 78%-89% versus 52%-67%), respectively. Secondary patency at 2 years, ranges from 30%-64% versus 35%-60% for forearm and upper arteriovenous graft, respectively. Ample pre-operative planning is essential to improved clinical success and the decision to place a graft at one location versus the other should be based solely on previous access history, physical exam, appropriate venous imaging, and other factors that make up the clinical picture. Operative implant strategies and risk of complications are very similar between the two configurations. Postoperative ischemia due to steal syndrome is a potential complication that requires immediate attention. Utilization of the proximal radial or ulnar artery for inflow for the graft can minimize risk of clinically relevant steal syndrome.

Abstract TP329: Venous Collateral Drainage Patterns Predict Clinical Worsening in Dural Venous Sinus Thrombosis

Background: Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. Approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration. Methods: From our institutional database, we identified patients with documented DVST on dedicated venous imaging (MR, CT or catheter angiography) from January 2010 to July 2016. Patients were excluded for thrombosis related to arteriovenous fistulae. The VCS (Table) was created and scores were determined from cerebrovascular venous imaging at presentation by two reviewers blinded to subsequent imaging and clinical data. Results: Among 28 patients that met criteria, median age was 42 (IQR 24-57) and 50% (14/28) were female. Presentation symptoms included intracranial hemorrhage in 40% (11/28) and headache without hemorrhage in 18% (5/28). Transverse sinus occlusion was present in 68% (19/28), and superior sagittal sinus occlusion in 39% (11/28). 82% (23/28) of patients were treated with anticoagulation, and 18% (5/28) with endovascular thrombectomy. New hemorrhage or expansion of initial hemorrhage occurred in 21% (6/28). In-hospital mortality occurred in 18% (5/28). VCS was 0 in 18% (5/28), 1 in 39% (11/28), and 2 in 46% (12/28). Lower VCS was significantly associated with development of new hemorrhage or expansion of initial hemorrhage (62% vs. 0%, VCS 0-1 vs. 2, p<0.01). VCS demonstrated excellent discrimination for in-hospital clinical worsening (C-statistic 0.85). Conclusions: The type and quality of venous collaterals influence outcome in DVST. VCS helps identify patients who are likely to deteriorate and may need additional early interventions.

In Patients With a Femoral Vein Deep Venous Thrombosis, Central Venous Imaging May Identify Potentially Treatable Iliocaval Thrombosis

In Patients With a Femoral Vein Deep Venous Thrombosis, Central Venous Imaging May Identify Potentially Treatable Iliocaval Thrombosis

Blood pool contrast agents for venous magnetic resonance imaging.

Imaging of the venous system plays a vital role in the diagnosis and management of a wide range of clinically significant disorders. There have been great advances in venous imaging techniques, culminating in the use of magnetic resonance venography (MRV). Although MRV has distinct advantages in anatomic and quantitative cross sectional imaging without ionizing radiation, there are well-known challenges in acquisition timing and contrast administration in patients with renal impairment. The latest advancement involves the addition of new contrast media agents, which have emerged as valuable alternatives in these difficult scenarios. In this review, we will focus on a group of specific contrast agents called blood pool agents and discuss their salient features and clinical applications.

Advanced venous imaging and image-guided venous interventions.

Venous disease, particularly venous thromboembolism, is associated with significant mortality and morbidity. Over 200,000 first lifetime cases of venous thromboembolism occur every year in the United States. If the disease remains undetected, long-term morbidity can be significant. Up to 40% of patients with symptomatic deep vein thrombosis (DVT) develop post-thrombotic syndrome within 2 years, with markedly increased risk for those who suffer from recurrent episodes of DVT. Furthermore, approximately 5% of patients with pulmonary embolism (PE) secondary to venous thrombotic disease develop chronic pulmonary hypertension with decreased cardiopulmonary capacity.

Lower-limb magnetic resonance angiography: performance of extracellular contrast agents versus blood pool contrast agent for both dynamic and high spatial resolution imaging in extended phase

To prospectively compare the performance of extracellular space contrast agents (ECSCAs) versus a blood-pool contrast agent (BPCA) for a comprehensive lower-limb magnetic resonance angiography (MRA) protocol in patients with either claudication or critical ischaemia. Thirty patients with claudication underwent lower-limb magnetic resonance angiography (MRA) (dynamic crural, three-station bolus chase, and infra-inguinal high resolution) using a triphasic injection method with both a ECSCA and BPCA to allow intra-individual comparison, and 30 patients with critical ischaemia were scanned with either a ECSCA or BPCA. The dynamic, bolus chase, and high-resolution images were scored for quality on a Likert scale (from 1-5). Signal- and contrast-to-noise ratios were analysed and statistical analysis performed. Overall, there was no statistically significant difference between the ECSCAs and BPCA for arteriographic dynamic imaging, bolus chase MRA, or the high spatial resolution imaging. Venous image quality was rated higher quality for BPCA scans than for ECSCA images for calf veins (not significantly for thigh veins). Venous imaging signal intensity measures were higher for BPCA imaging. Extended-phase imaging using an ECSCA with this protocol provides arteriographic image quality equal to imaging with a BPCA. Venous depiction is good using ECSCAs with this approach, although better with BPCA.

Modalities to Treat Venous Ulcers: Compression, Surgery, and Bioengineered Tissue.

Venous leg ulcers (VLUs) represent the most common ulcers of the lower extremity. VLUs are notorious for delayed and prolonged healing with high rates of recurrence. Most patients with VLUs also have significant comorbidities that interfere with primary wound healing. Thus, caring for patients with VLUs requires an interdisciplinary approach that addresses the abnormal venous anatomy and the downstream effects that lead to inflammation, ulceration, and a hostile wound microenvironment. The current literature regarding venous ulcer treatment with an emphasis on compression, surgical options, and use of bioengineered tissue was reviewed. A combination of society guidelines, Cochrane reviews, and over 80 primary articles with high-level evidence were utilized to develop this summary and algorithm for an integrated approach to treating patients with venous ulcers. Details regarding compression modalities and venous diagnostic imaging are presented to help the clinician understand the rationale for using these technologies. The comprehensive approach to the patient with chronic venous insufficiency (CVI) includes advances in compression, diagnostics, minimally invasive surgical treatment of venous disease, wound bed preparation, and bioengineered skin and soft tissue substitutes. An algorithm that incorporates early treatment of the ulcer and the venous disease leading to healing with prevention of recurrence is presented. Utilizing guidelines that incorporate evidence-based modalities will lead to the highest quality outcomes with the most appropriate resource utilization. A proactive approach to treating venous disease will alleviate suffering and prevent the long-term sequelae of CVI.

Creating arteriovenous fistulas in patients with chronic central venous obstruction.

Central venous obstruction Occlusion (CVO) has been considered a contraindication for creating a vascular access due to fear of developing a swollen extremity. However, many of these individuals developed large collateral veins and are asymptomatic. We report our experience constructing arteriovenous fistulas (AVFs) in these challenging patients. Patients with a new AVF constructed in the presence of known CVO were identified. Venous imaging confirmed proximal obstruction and extensive collateral venous return. The AVF was constructed in the extremity with the most favorable ultrasound vessel mapping and collateral central venous outflow. Arterial inflow via the radial artery was utilized when feasible. AVFs associated with known CVO were constructed in 19 patients during an eight-year time period. The mean age was 53 years, 63% were female, and 58% diabetic. Arterial inflow was from the radial artery in 15 patients and the brachial or axillary artery in 5 individuals. Post-operative AVF flow volumes were 415-910 mL/min (mean = 640 mL/min). Eight patients (42%) developed some degree of arm edema. Two resolved without intervention. The others required inflow banding (n = 2), outflow branch coiling (n = 1), and/or recanalization with angioplasty (n = 4) of the CVO to resolve swelling. Mean follow-up was 14 months. Two AVFs failed at 8 and 16 months. Primary and cumulative patency rates were 49% and 100% at 12 months and 39% and 80% at 24 months, respectively. CVO need not preclude the creation of a successful AVF. Extensive venous collaterals and avoiding high-flow AVFs are important elements for success. Cumulative patency was 80% at 24 months.

Liver Surface Nodularity Quantification from Routine CT Images as a Biomarker for Detection and Evaluation of Cirrhosis

Purpose To determine the accuracy, reproducibility, and intra- and interobserver agreement of a computer-based quantitative method to measure liver surface nodularity (LSN) from routine computed tomographic (CT) images as a biomarker for detection and evaluation of cirrhosis. Materials and Methods For this institutional review board-approved HIPAA-compliant retrospective study, adult patients with healthy livers (n = 24) or various stages of hepatitis C virus-induced chronic liver disease (n = 70) with routine nonenhanced and portal venous phase contrast agent-enhanced liver CT imaging with thick-section (5.0 mm) and thin-section (1.25-1.50 mm) axial images obtained between January 1, 2006, and March 31, 2011, were identified from the electronic medical records. A computer algorithm was developed to measure LSN and derive a score. LSN scores, splenic volume, and the ratio of left lateral segment (LLS) to total liver volume (TLV) were measured from the same multiphasic liver CT examinations. Accuracy for differentiating cirrhotic from noncirrhotic livers was assessed by area under the receiver operating characteristic curve. Intra- and interobserver agreement was assessed by intraclass correlation coefficient. Results Median LSN scores from nonenhanced thick-section CT images in cirrhotic livers (3.16; 56 livers) were significantly higher than in noncirrhotic livers (2.11; 38 livers; P < .001). LSN scores from the four CT imaging types (94 patients for each type) were very strongly correlated (range of Spearman r, 0.929-0.960). LSN scores from portal venous phase contrast-enhanced thick-section CT images had significantly higher accuracy (area under the receiver operating characteristic curve, 0.929) than splenic volume (area under the receiver operating characteristic curve, 0.835) or LLS-to-TLV ratio measurements (area under the receiver operating characteristic curve, 0.753) for differentiating cirrhotic from noncirrhotic livers (P = .038 and .003, respectively; n = 94). Intra- and interobserver agreements that used nonenhanced thick CT images were very good (intraclass correlation coefficient, 0.963 and 0.899, respectively). Conclusion Quantitative measurement of LSN on routine CT images accurately differentiated cirrhotic from noncirrhotic livers and was highly reproducible. (©) RSNA, 2016 Online supplemental material is available for this article.

Validation of venous duplex ultrasound imaging in determining iliac vein stenosis after standard treatment of active chronic venous ulcers.

Chronic venous ulcer (CVU) is a potentially debilitating condition that remains the most common etiology for leg ulcers. The condition has significant associated costs and effect on patient quality of life. That truncal reflux can be worsened by iliac vein occlusive disease is well known. However, there has not been systematic investigation of venous duplex ultrasound (VDUS) criteria to correlate common femoral vein (CFV) reflux with iliac vein stenosis. We sought to correlate VDUS criteria for predicting iliac vein stenosis and to investigate venous outflow factors associated with CVU recurrence. We conducted a systematic retrospective review of a consecutive series of 36 patients who received standard therapies, including compression therapy along with ablation of incompetent great saphenous veins for treating CVU, but in whom the treatment failed. Elevated CVF reflux was considered as reflux duration (RD) measured by VDUS to last >1second. A receiver operator characteristic curve analysis wasperformed to determine the optimal CFV threshold value to predict 50% iliac vein stenosis measured by intravascular ultrasound. The 36 patients presented with 54 CVUs on 38 limbs. The median (25th-75th quartiles) age was 61.2 (57.6-68.8) years, body mass index was 36.8 (25.2-52.3) kg/m(2), CFV RD was 2.7 (1.6-3.5) seconds, ulcer diameter was 4.2 (3.0-4.0) cm, and ulcer depth was 2.5 (2.0-3.0) mm. The optimal cutoff RD value was >2.5seconds by receiver operator characteristic curve analysis, with an area under the curve of 0.77 (P= .001). CVUs associated with an RD >2.5seconds had significantly more iliac vein stenosis >50% by intravascular ultrasound (24 of 30; 80%) than those with an RD<2.5seconds (6 of 24; 25%; P< .001). Likewise, >50% stenosis for those above and below an RD >1second was 61.4% vs 30%, respectively (P= .089). Significantly less recurrence of CVU was found for patients taking pentoxifylline (43.6% vs 80.0%; P= .031) and those with stents placed (40.0% vs 70.8%; P= .031). A nonsignificant trend was found for iliac vein interrogation (44.4% vs 72.2%; P=.082). This study highlights the utility of VDUS in diagnosing iliac vein stenosis with 2.5seconds to predict ≥50% iliac vein stenosis. Stent placement and pentoxifylline were associated with ulcer healing and reduced risk of venous ulcer recurrence.

Central venous thrombosis in children with intestinal failure on long-term parenteral nutrition

PurposeCentral venous thrombosis (CVT) is a serious complication of long-term central venous access for parenteral nutrition (PN) in children with intestinal failure (IF). We reviewed thse incidence of CVT and possible risk factors. MethodsChildren with IF on home PN (2010–2014) with central venous imaging were reviewed. Patient demographics, catheter characteristics and related complications, and markers of liver function were compared between children with and without CVT. Serum thrombophilia markers were reviewed for patients with CVT. ResultsThirty children with central venous imaging were included. Seventeen patients had thrombosis of ≥1 central vein, and twelve had ≥2 thrombosed central veins. Patients with and without CVT had similar demographics and catheter characteristics. Patients with CVT had a significantly lower albumin level (2.76±0.38g/dL vs. 3.12±0.41g/dL, p=0.0223). The most common markers of thrombophilia in children with CVT were antithrombin, protein C and S deficiencies, and elevated factor VIII. There was a statistically significant correlation between a combined protein C and S deficiency and having >1 CVT. ConclusionsChildren with IF on long-term PN are at high risk for CVT potentially owing to low levels of natural anticoagulant proteins and elevated factor FVIII activity, likely a reflection of liver insufficiency and chronic inflammation.

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction.

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction.

Original approach for thrombolytic therapy in patients with Ilio-femoral deep vein thrombosis : 2years follow-up.

ObjectiveThe aim of the study was to discuss the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT) evaluating the safety and effectivness of an easy access such as the Great Saphenous Vein.Methods and materialsA total of 22 consecutive patients with iliofemoral thrombosis and two patients with femoro-popliteal thrombosis on recent onset diagnosed with Ultrasound Doppler and contrast venography underwent intrathrombus drip infusion of urokinase while intravenous heparin was continued using saphenical access. Residual venous stenosis were treated in six patients by percutaneous balloon Angioplasty and stenting. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months and every 6 months thereafter.ResultsComplete patency of thrombosed veins was restored in 22 patients (91 %) with prompt symptomatic relief. There were no major complications in the immediate outcomes. At follow-up, two patients reported a persistant slim iliac vein stenosis, two patients had post-thrombotic syndrome, and two patients showed Deep Vein Reflux.ConclusionLocal thrombolysis using saphenical access was a safe and effective approach for the treatment of acute iliofemoral deep vein thrombosis. It seems to be a valid, easy and safe alternative, reducing the risks of haematoma and venous lesions, which can be observed when using femoral, popliteal, and trans-jugular access.

Prostate cancer on computed tomography: A direct comparison with multi-parametric magnetic resonance imaging and tissue pathology

ObjectivesMulti-parametric prostate magnetic resonance imaging (MRI) is considered the current imaging standard for detection and staging of prostate cancer. The combination of anatomical and functional imaging provided in this exam significantly increases the accuracy of prostate cancer detection. Computed tomography (CT) imaging has so far been found to be lacking in this regard, however observations at our academic institution as well as evidence present in the literature support the proposition that CT could indeed be helpful in detecting prostate abnormalities that correspond to neoplasm. The purpose of this study was to prove that areas of focal mass-like enhancement on CT imaging directly correlate with prostate neoplasms as revealed on multi-parametric MRI and follow-up targeted biopsy. Materials and methodsThis was a single institution retrospective study with 27 male subjects. Inclusion criteria required subjects to have a multi-parametric MRI of the prostate between January 1, 2014 and June 1, 2015 and a pelvic venous phase contrast-enhanced CT study between January 1, 2000 and June 1, 2015. Two blinded Radiologists read subjects' CT scans for any abnormalities of the prostate. CT and multi-parametric MRI results were compared and were considered concordant if focal or mass like enhancement to a greater degree than the background parenchyma was detected in the same areas of the prostate on CT scan as areas of decreased T2 signal, perfusion abnormalities, and restricted diffusion on multi-parametric MRI. ResultsCT results were directly compared to multi-parametric MRI findings and biopsy results. The overall agreement of MRI and CT is 85.19% (95% CI: 67.52–94.08%). The positive percent agreement is 78.95% (95% CI: 54.43–93.95%) and the negative percent agreement is 100.0% (95% CL: 63.06–100.0%). When CT results are directly compared to biopsy results, sensitivity and specificity of CT are 63.64% (95% CI: 30.79–89.07%) and 100.0% (95% CI: 47.82–100.0%). The positive predictive value (PPV) is 100.0% (95% CI: 59.04–100.0%) and the negative predictive value (NPV) is 55.56% (95% CI: 21.2–86.3%). When compared to MRI, CT has a lower sensitivity and a higher specificity, as well as a higher PPV and NPV. Logistic regression analysis did not show a significant relationship between concordance of MRI and CT and Gleason score, time between studies, age, and Prostate-specific antigen (PSA) level. ConclusionIncidental focal areas of mass-like enhancement in the peripheral prostate detected on venous phase contrast-enhanced CT imaging may indeed correlate with prostate neoplasm and it would be prudent to suggest further work-up with PSA and perhaps multi-parametric MRI, especially in high-risk patients.