Non-invasive fractional flow reserve in vessels without severe obstructive stenosis is associated with coronary plaque burden

AimsNon-invasive fractional flow reserve derived from coronary CT angiography (FFR_CT) has been shown to be predictive of lesion-specific ischemia as assessed by invasive fractional flow reserve (FFR). However, in practice, clinicians are often faced with an abnormal distal FFR_CT in the absence of a discrete obstructive lesion. Using quantitative plaque analysis, we sought to determine the relationship between an abnormal whole vessel FFR_CT (V-FFR_CT) and quantitative measures of whole vessel atherosclerosis in coronary arteries without obstructive stenosis.MethodsFFR_CT was calculated in 155 consecutive patients undergoing coronary CTA with ≥25% but less than 70% stenosis in at least one major epicardial vessel. Semi-automated software was used to quantify plaque volumes (total plaque [TP], calcified plaque [CP], non-calcified plaque [NCP], low-density non-calcified plaque [LD-NCP]), remodeling index [RI], maximal contrast density difference [CDD] and percent diameter stenosis [%DS]. Abnormal V-FFR_CT was defined as a minimum value of ≤0.75 across the vessel (at the most distal region where FFR_CT was computed).ResultsVessels with abnormal V-FFR_CT had higher per-vessel TP (554 vs 331 mm³), CP (59 vs 25 mm³), NCP (429 vs 295 mm³), LD-NCP (65 vs 35 mm³) volume and maximum CDD (21 vs 14%) than those with normal V-FFR_CT (median, p < 0.05 for all). Using a multivariate analysis to adjust for CDD and %DS, all measures of plaque volume were predictive of abnormal V-FFR_CT (OR 2.09, 1.36, 1.95, 1.95 for TP, CP, NCP and LD-NCP volume, respectively; p < 0.05 for all).ConclusionAbnormal V-FFR_CT in vessels without obstructive stenosis is associated with multiple markers of diffuse non-obstructive atherosclerosis, independent of stenosis severity. Whole vessel FFR_CT may represent a novel measure of diffuse coronary plaque burden.     

Incidence and predictors of lesion-specific ischemia by FFRCT: Learnings from the international ADVANCE registry

BackgroundTo date, the clinical utility of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) has been limited to trials and single center experiences. We herein report the incidence of abnormal FFRCT (≤0.80) and the relationship of lesion-specific ischemia to subject demographics, symptoms, and degree of stenosis in the multicenter, prospective ADVANCE registry.MethodsOne thousand patients with suspected angina having documented coronary artery disease on coronary CTA and clinically referred for FFRCT were prospectively enrolled in the registry. Patient demographics, symptom status, coronary CTA and FFRCT findings were recorded. Univariate and multivariate analyses were performed to investigate the predictors related to abnormal FFR_CT.ResultsFFR_CT data were analyzed in 952 patients (95.2%). Overall, 51.1% patients had a positive FFR_CT value (≤0.80). Patients with ≥3 risk factors had a significantly higher rate of abnormal FFR_CT than those with <3 risk factors (60.2% vs. 43.9%, p = 0.0001). On multivariate analysis, baseline diabetes (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.04–2.21, p = 0.030) and hypertension (OR 1.56, 95%CI 1.14–2.14, p = 0.005) were both predictive of abnormal FFR_CT. In addition, >70% stenosis was significantly associated with low FFR_CT (OR 31.16, 95%CI 12.25–79.22, p < 0.0001) vs. <30% stenosis. Notably, stenosis 30–49% vs. <30% had an increased likelihood of ischemia (OR 3.74, 95%CI 1.52–9.17, p < 0.0001).ConclusionsIn this real-world registry, CT angiographic stenosis severity in addition to baseline cardiovascular risk factors conferred an increased likelihood of an abnormal FFR_CT. Importantly, however, mild CT angiographic stenoses were noted to have an increased hazard for ischemia and the converse holding true for more severe stenoses as well.     

Optimized energy of spectral coronary CT angiography for coronary plaque detection and quantification

BackgroundTo optimize spectral coronary computed tomography angiography (CTA) for quantification of coronary artery plaque components.Materials and methodsFifty-one subjects were prospectively enrolled (88.2% male) (NCT02740699). Dual energy coronary CTA was performed at 90/Sn150 kVp using a 3rd generation dual-source CT scanner (SOMATOM Force, Siemens Healthcare). Dual energy images were reconstructed with a) linear mixed blending of 90 and Sn150 kVp data, b) virtual monoenergetic algorithm from 40 to 150 keV (at 10- keV intervals), and c) noise-optimized virtual monoenergetic algorithm from 40 to 150 keV. Image noise, iodine signal-to-noise-ratio (SNR), and contrast-to-noise ratio (CNR) for calcified and non-calcified plaque were measured. Qualitative readings of image quality were performed. Semi-automated software (QAngioCT, Medis) was used to quantify coronary plaque. Linear mixed-models that account for within-subject correlation of plaques were used to compare the results.Results100–150 keV noise-optimized virtual monoenergetic images had lower image noise than linear mixed images (all P < 0.05). The highest iodine SNR was achieved in 40 keV noise-optimized virtual monoenergetic images (33.3 ± 0.6 vs 23.3 ± 0.7 for linear mixed images, P < 0.001). 40–70 keV noise-optimized virtual monoenergetic images and 70 keV virtual monoenergetic images had superior coronary plaque CNR versus linear mixed images (all P < 0.01) with a maximum improvement of 20.1% and 22.7% for calcified plaque and non-calcified plaque (38.8 ± 2.2 vs 32.3 ± 2.3 and 17.3 ± 1.3 vs 14.1 ± 1.4, respectively). Using 90/Sn150 kVp linear mixed images as a reference, the plaque quantity was similar for 70 keV noise-optimized virtual monoenergetic images whereas low keV images (e.g. 40 keV) yielded significantly higher coronary plaque volumes (all P < 0.001).ConclusionSpectral coronary CTA with low energy (40–70 keV) post-processing can improve the CNR of coronary plaque components. However, low energies (such as 40 keV) resulted in different absolute volumes of coronary plaque compared to “conventional” mixed 90/Sn150 kVp images.     

Relationship of the Duke jeopardy score combined with minimal lumen diameter as assessed by computed tomography angiography to the hemodynamic relevance of coronary artery stenosis

ObjectivesTo study the diagnostic performance of the ratio between the Duke jeopardy score (DJS) and the minimal lumen diameter (MLD) (DJS/MLDCT ratio) as assessed by coronary computed tomographic angiography (CTA) for differentiating functionally significant from non-significant coronary artery stenoses, with reference to invasive fractional flow reserve (FFR).MethodsPatients who underwent both coronary CTA and FFR measurement during invasive coronary angiography (ICA) within 2 weeks were retrospectively included in the study. Invasive FFR measurement was performed in patients with intermediate to severe coronary stenoseis. DJS/MLDCT ratio and anatomical parameters were recorded. Lesions with FFR ≤0.80 were considered to be functionally significant.ResultsOne hundred and sixty-one patients with 175 lesions were included into the analysis. Diameter stenosis in CT, area stenosis, plaque burden, lesion length (LL), ICA-based stenosis degree, DJS, LL/MLD⁴ ratio, DJS/MLA ratio as well as DJS/MLD ratio were all significantly different between hemodynamically significant and non-significant lesions (p<0.05 for all). ROC curve analysis determined the optimal cut-off value for DJS/MLD_CT ratio to be 1.96 (area under curve = 0.863, 95 % confidence interval = 0.803–0.910), yielding a high diagnostic accuracy (86.9%, 152/175).ConclusionsIn coronary artery stenoses detected by coronary CTA, the DJS/MLD ratio is able to predict hemodynamic relevance.     

CT-based total vessel plaque analyses improves prediction of hemodynamic significance lesions as assessed by fractional flow reserve in patients with stable angina pectoris

BackgroundCoronary stenosis and plaque evaluation by coronary computed tomography angiography (CTA) may contribute to identify hemodynamically relevant lesions. We evaluated the most stenotic lesion including plaques proximal to it versus a total vessel analyses combined with stenosis for ischemia.MethodsPatients scheduled for clinically indicated invasive coronary angiography (ICA) for suspected coronary artery disease underwent coronary CTA and ICA including fractional flow reserve (FFR) as part of the NXT trial (clinicaltrials.gov NCT01757678). Stenoses were visually graded ≤50%, 51–70%, and >70% on coronary CTA. Semi-automated plaque analyses were performed using a proximal to the FFR pressure sensor location (including the most severe lesion to the coronary ostium) versus a total vessel (vessel diameter ≥2 mm) approach. Coronary stenosis and plaque parameters were evaluated for discrimination of ischemia by logistic regressions and combined models analyzed using receiver operating characteristics (ROC) with invasive FFR≤ 0.80 as reference standard.ResultsIn 254 patients, mean (±SD) age 64 (±10) years, 64% male, a coronary CTA stenosis >50% was present in 239 (49%) vessels. Invasive FFR was ≤0.80 in 100 (21%) vessels. Coronary stenosis severity and low-density non-calcified plaque (LD-NCP) volume were independent predictors of ischemia in the “proximal” and “total-vessel” analyses. Stenosis severity + total vessel LD-NCP assessment performed better than stenosis severity + proximal LD-NCP evaluation (Area under curve [AUC] (95%CI): 0.83 (0.78–0.87) vs 0.81 (0.76–0.86), p-value = 0.009), whereas stenosis severity + proximal LD-NCP performed better than stenosis alone (AUC (95%CI): 0.81 (0.76–0.86) vs 0.78 (0.73–0.83), p-value = 0.019).ConclusionAdding total vessel high-risk plaque volume to stenosis severity improves discrimination of ischemia in coronary CTA performed in patients with stable angina pectoris.     

Long-term Outcomes of Coil Packing for Visceral Aneurysms: Correlation between Packing Density and Incidence of Coil Compaction or Recanalization

PurposeTo evaluate the correlation between packing density and the incidence of coil compaction or recanalization of visceral artery aneurysms (VAAs) after coil packing.Materials and MethodsBetween July 2004 and April 2012, coil packing was performed for 46 true visceral aneurysms (16 splenic, 11 pancreaticoduodenal, eight renal, six hepatic, three superior mesenteric, one right gastric, and one gastroepiploic) in 42 patients. The size and volume of the aneurysm, packing density, and the incidences of compaction and recanalization were evaluated retrospectively.ResultsThe mean follow-up period was 37 months ± 8 (range, 11–80 mo). The mean packing density was 19% ± 8 (range, 5%–42%), mean aneurysm size was 19 mm ± 8 (range, 5–40 mm), and mean volume was 4,108 mm³ ± 5,435 (range, 72–26,235 mm³). Compaction and recanalization occurred in two (4%) and 12 aneurysms (26%), respectively. The mean packing density was significantly lower in aneurysms with compaction or recanalization than in unaffected aneurysms (12% vs 22%; P = .00014). There was a significant difference in mean packing density between small (< 20 mm; 22%) and large (≥ 20 mm) aneurysms (15%; P = .0045). The mean size and volume were significantly larger for coil-compacted or recanalized aneurysms than for unaffected aneurysms (P < .05). In aneurysms with a packing density of at least 24%, no compaction or recanalization occurred.ConclusionsCoil compaction or recanalization after coil packing for VAAs more often occurs after insufficient embolization with low packing density and in patients with large aneurysms.     

Rationale and design of advantage (additional diagnostic value of CT perfusion over coronary CT angiography in stented patients with suspected in-stent restenosis or coronary artery disease progression) prospective study

BackgroundRecent studies demonstrated a significant improvement in the diagnostic performance of coronary CT angiography (CCTA) for the evaluation of in-stent restenosis (ISR). However, coronary stent assessment is still challenging, especially because of beam-hardening artifacts due to metallic stent struts and high atherosclerotic burden of non-stented segments. Adenosine-stress myocardial perfusion assessed by CT (CTP) recently demonstrated to be a feasible and accurate tool for evaluating the functional significance of coronary stenoses in patients with suspected coronary artery disease (CAD). Yet, scarce data are available on the performance of CTP in patients with previous stent implantation.Aim of the studyWe aim to assess the diagnostic performance of CCTA alone, CTP alone and CCTA plus CTP performed with a new scanner generation using quantitative invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR) as standard of reference.MethodsWe will enroll 300 consecutive patients with previous stent implantation, referred for non-emergent and clinically indicated invasive coronary angiography (ICA) due to suspected ISR or progression of CAD in native coronary segments. All patients will be subjected to stress myocardial CTP and a rest CCTA. The first 150 subjects will undergo static CTP scan, while the following 150 patients will undergo dynamic CTP scan. Measurement of invasive FFR will be performed during ICA when clinically indicated.ResultsThe primary study end points will be: 1) assessment of the diagnostic performance (diagnostic rate, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy) of CCTA, CTP, combined CCTA-CTP and concordant CCTA-CTP vs. ICA as standard of reference in a territory-based and patient-based analysis; 2) assessment of sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of CCTA, CTP, combined CCTA-CTP and concordant CCTA-CTP vs. invasive FFR as standard of reference in a territory-based analysis.ConclusionsThe ADVANTAGE study aims to provide an answer to the intriguing question whether the combined anatomical and functional assessment with CCTA plus CTP may have higher diagnostic performance as compared to CCTA alone in identifying stented patients with significant ISR or CAD progression.     

Respiration-induced Deformations of the Superior Mesenteric and Renal Arteries in Patients with Abdominal Aortic Aneurysms

PurposeTo quantify respiration-induced deformations of the superior mesenteric artery (SMA), left renal artery (LRA), and right renal artery (RRA) in patients with small abdominal aortic aneurysms (AAAs).Materials and MethodsSixteen men with AAAs (age 73 y ± 7) were imaged with contrast-enhanced magnetic resonance angiography during inspiratory and expiratory breath-holds. Centerline paths of the aorta and visceral arteries were acquired by geometric modeling and segmentation techniques. Vessel translations and changes in branching angle and curvature resulting from respiration were computed from centerline paths.ResultsWith expiration, the SMA, LRA, and RRA bifurcation points translated superiorly by 12.4 mm ± 9.5, 14.5 mm ± 8.8, and 12.7 mm ± 6.4 (P < .001), and posteriorly by 2.2 mm ± 2.7, 4.9 mm ± 4.2, and 5.6 mm ± 3.9 (P < .05), respectively, and the SMA translated rightward by 3.9 mm ± 4.9 (P < .01). With expiration, the SMA, LRA, and RRA angled upward by 9.7° ± 6.4, 7.5° ± 7.8, and 4.9° ± 5.3, respectively (P < .005). With expiration, mean curvature increased by 0.02 mm^?1 ± 0.01, 0.01 mm^?1 ± 0.01, and 0.01 mm^?1 ± 0.01 in the SMA, LRA, and RRA, respectively (P < .05). For inspiration and expiration, RRA curvature was greater than in other vessels (P < .025).ConclusionsWith expiration, the SMA, LRA, and RRA translated superiorly and posteriorly as a result of diaphragmatic motion, inducing upward angling of vessel branches and increased curvature. In addition, the SMA exhibited rightward translation with expiration. The RRA was significantly more tortuous, but deformed less than the other vessels during respiration.     

Quantitative Assessment of Lipiodol Deposition after Chemoembolization: Comparison between Cone-Beam CT and Multidetector CT

PurposeTo evaluate the ability of cone-beam computed tomography (CBCT) performed directly after transarterial chemoembolization to assess ethiodized oil (Lipiodol) deposition in hepatocellular carcinoma (HCC) and compare it with unenhanced multidetector computed tomography (CT).Materials and MethodsConventional transarterial chemoembolization was used to treat 15 patients with HCC, and CBCT was performed to assess Lipiodol deposition directly after transarterial chemoembolization. Unenhanced multidetector CT was performed 24 hours after transarterial chemoembolization. Four patients were excluded because the margin of tumor or area of Lipiodol deposition was unclear. The image enhancement density of the entire tumor and liver parenchyma was measured by ImageJ software, and tumor-to-liver contrast (TLC) was calculated. In addition, volumetric measurement of tumor and Lipiodol was performed by semiautomatic three-dimensional volume segmentation and compared using linear regression to evaluate consistency between the two imaging modalities.ResultsThe mean value of TLC on CBCT was not significantly different from TLC on multidetector CT (337.7 HU ± 233.5 vs 283.0 HU ± 152.1, P = .103).The average volume of the whole tumor and of only the regions with Lipiodol deposition and the calculated average percentage of Lipiodol retention on CBCT were not significantly different compared with multidetector CT (tumor volume, 9.6 cm³ ± 11.8 vs 10.8 cm³ ± 14.2, P = .142; Lipiodol volume, 6.3 cm³ ± 7.7 vs 7.0 cm³ ± 8.1, P = .214; percentage of Lipiodol retention, 68.9% ± 24.0% vs 72.2% ± 23.1%, P = .578). Additionally, there was a high correlation in the volume of tumor and Lipiodol between CBCT and multidetector CT (R² = 0.919 and 0.903).ConclusionsThe quantitative image enhancement and volume analyses demonstrate that CBCT is similar to multidetector CT in assessing Lipiodol deposition in HCC after transarterial chemoembolization.     

Apparent Diffusion Coefficient of Uterine Leiomyoma as a Predictor of the Potential Response to Uterine Artery Embolization

PurposeTo determine the utility of the apparent diffusion coefficient (ADC) of uterine leiomyoma for prediction of the potential response to uterine artery embolization (UAE).Materials and MethodsThis prospective study included 49 patients with uterine leiomyomas who underwent diffusion-weighted magnetic resonance (MR) imaging before UAE between May 2011 and January 2012. All patients also underwent 3-month follow-up MR imaging after UAE. Using conventional and diffusion-weighted MR imaging sequences, 72 uterine leiomyomas ≥ 3 cm were prospectively evaluated. The volume of each leiomyoma was calculated, and quantitative measurement of ADC was performed. Regression analysis was used to evaluate the relationship between ADC and volumetric response after UAE. Receiver operating characteristic curve analysis was performed to determine the sensitivity and specificity of ADC for prediction of the potential response to UAE. Interclass correlation coefficient analysis was used to assess interobserver variability between two radiologists.ResultsVolume reduction rates of leiomyomas after UAE ranged from 0.2%–89.1% (mean, 44.1%). ADC ranged from 0.559 × 10^?3 mm²/s to 1.814 × 10^?3 mm²/s (mean, 1.170 × 10^?3 mm²/s). ADC was statistically significantly related to volumetric response of leiomyomas (P = .014). Using a threshold of 1.092 × 10^?3 mm²/s, the sensitivity and specificity of ADC for prediction of > 50% volume reduction of the leiomyoma after UAE were 82.6% and 52.3%, respectively. Using a threshold of 1.023 × 10^?3 mm²/s, the sensitivity and specificity of ADC for prediction of < 30% volume reduction were 80.8% and 33.3%, respectively. The interclass correlation coefficient for measuring ADC of uterine leiomyomas between two radiologists was 0.98.ConclusionsADC of uterine leiomyomas was significantly related to the volume reduction after UAE. ADC may be useful in predicting the potential response to UAE. A high ADC of the uterine leiomyoma may be associated with a greater volume reduction after UAE.     

Inhibition of Growth in a Rabbit VX2 Thigh Tumor Model with Intraarterial Infusion of Carbon Dioxide–Saturated Solution

PurposeTo evaluate the efficacy of intraarterial infusion of CO₂-saturated solution in rabbit VX2 thigh tumors.Materials and MethodsFourteen Japanese white rabbits had VX2 tumors implanted in the right femoral muscle 3 weeks before intraarterial infusion. Rabbits were divided into control and CO₂ groups (n = 7 each). Fifty milliliters of solution (saline solution and CO₂-saturated solution for the control and CO₂ groups, respectively) was administered via a 24-gauge catheter in the ipsilateral iliac artery close to the feeding artery of the VX2 tumor. All rabbits were killed for tumor harvest on day 3 after the procedure. Tumor volume was evaluated with in vivo direct caliper measurement and contrast-enhanced computed tomography (CT). Tumor apoptotic changes were examined by DNA fragmentation assay and immunoblot analysis. The tumor growth ratio and apoptotic cell rate were analyzed.ResultsBody weight was equally increased in both groups, but the mean tumor growth ratio was significantly decreased in the CO₂ group compared with the control group (−9.5% ± 7.9 vs 27.2% ± 6.6 and 4.1% ± 4.4 vs 35.7% ± 4.5 measured by calipers and contrast-enhanced CT, respectively; P < .01). Apoptotic activity in the CO₂ group was higher than in the control group (number of apoptotic cells per area, 215.0 ± 58.7 vs 21.8 ± 5.4; adjusted relative density of cleaved caspase-3, 0.23 ± 0.07 vs 0.04 ± 0.01; P < .01).ConclusionsIntraarterial infusion of CO₂-saturated solution inhibits rabbit VX2 thigh tumor growth by activation of apoptotic cell death through cleaved caspase-3 upregulation.     

A Novel Resorbable Embolization Microsphere for Transient Uterine Artery Occlusion: A Comparative Study with Trisacryl-Gelatin Microspheres in the Sheep Model

PurposeTo evaluate angiographic recanalization, inflammatory reaction, and uterine damage after sheep uterine artery embolization (UAE) with a novel calibrated resorbable embolization microsphere (REM) and compare the results with control nonresorbable microspheres.Materials and MethodsSix hormonally artificially cycled sheep underwent bilateral UAE until stasis with either REM or trisacryl-gelatin microspheres (TGMS). At 7 days, control angiograms were obtained to assess the residual vascularization at arterial and parenchymal phases. The animals were then sacrificed for analysis of the presence of microspheres, inflammatory foreign body reaction, and surface areas of uterine damage.ResultsMean volume of microspheres injected per uterine artery (UA) or per animal did not differ between groups. At day 7, the flow was normal for six of six UAs that received embolization with REM versus only three of six UAs with TGMS (P = .0455, χ² test). Uterine parenchymography showed no defects in six UAs in the REM group versus five defects in six UAs in the TGMS group (P = .0060, χ² test). No REM or residual fragments of microspheres were observed on histologic analysis. TGMS were observed in tissues and accompanied by a mild inflammatory response. Necrosis rates were not significantly different between the two products, either in endometrium (REM 23.5% ± 28.8% [median 8.1%] vs TGMS 21.8% ± 23.7% [median 14.6%]) or in myometrium (REM 8.2% ± 22.7% [median 0.0%] vs TGMS 8.8% ± 20.8% [median 0.9%]). Endometrium alteration rate was lower with REM than with TGMS (39.7% ± 25.7% [median 34%] vs 60.6% ± 27.1% [median 71%]; P = .0060, Mann-Whitney test). Myometrium alteration rates were not significantly different between REM (45.7% ± 37.1% [median 63.0%]) and TGMS (37.8% ± 34.0% [median 19.1%]).ConclusionsAt 1 week after sheep UAE with REM, the recanalization was complete, the microspheres were completely degraded, and there was no remnant inflammatory response.     

Incidentally detected atherosclerosis in the abdominal aorta or its major branches on computed tomography is highly associated with coronary heart disease in asymptomatic adults

BackgroundAtherosclerotic lesions in the abdominal aorta or its major branches are often incidentally detected on abdominal CT. However, clinical implications and optimal subsequent management are mostly left undetermined.MethodsConsecutive, asymptomatic adults (age≥30) who underwent both abdominal CT and coronary computed tomography angiography as part of a self-referred health check-up were investigated (n = 1494).ResultsAdjusted for cardiovascular risk factors, abdominal atherosclerotic lesions with stenosis<25% were associated with significant coronary stenosis, especially in the abdominal aorta (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 0.99–11.45) and any common iliac artery (aOR 2.99, 95% CI 1.43–6.26). The association was higher in atherosclerotic lesions with stenosis≥25%, respectively (aOR 16.39, 95% CI 4.00–67.11; aOR 7.32, 95% CI 2.84–18.86). Furthermore, any major abdominal artery stenosis added predictive value to significant coronary stenosis (area under the receiver operating curve: 0.7598 vs. 0.8019, P < 0.001). The extent of arterial territory involvement was associated with the presence of significant coronary stenoses (P for trend <0.001).ConclusionStenotic atherosclerotic lesions in the abdominal aorta or its major branches incidentally detected on abdominal CT are relatively prevalent and carry high risk for asymptomatic coronary arterial disease.     

Combined Antegrade Femoral Artery and Retrograde Popliteal Artery Recanalization for Chronic Occlusions of the Superficial Femoral Artery

PurposeTo evaluate the efficacy and safety of a dual femoral–popliteal approach in the supine position after failed antegrade recanalization attempts in chronic total occlusion (CTO) of the superficial femoral artery (SFA).Materials and MethodsFrom May 2011 to October 2012, 21 patients underwent dual femoral–popliteal recanalization for CTO of the SFA, with a mean lesion length of 87.4 mm ± 5.8. When contralateral antegrade recanalization of SFA occlusions via the common femoral artery could not be achieved, the occlusions were intrainterventionally accessed by retrograde approach via the popliteal artery, which was punctured anteriorly with gently flexed knee and crus extorsion. When the SFA had been recanalized, further angioplasty and stent placement procedures were completed via the femoral artery.ResultsA technical success rate of 100% (entailing puncture of the popliteal artery and SFA recanalization) was achieved, and no hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, or other complications developed. During a mean follow-up of 9.8 months ± 1.5, claudication severity, rest pain, and toe ulcers improved significantly. The pulse of the distal arteries, as well as the filling of the veins, could be distinctly felt. Ankle-brachial index changed from 0.48 ± 0.17 to 0.84 ± 0.11 at 1 year after intervention (P < .001), and patency rates at 1, 6, and 12 months after interventions were 100%, 80%, and 42%, respectively.ConclusionsA dual femoral–popliteal approach in the supine position is an alternative backup option after failed attempts at the antegrade approach for patients with proximal barriers in CTO or lesions with major extending collateral vessels.     

Embolization of Angiographically Visible Type I and II Utero-ovarian Anastomoses during Uterine Artery Embolization for Fibroid Tumors: Impact on Symptom Recurrence and Permanent Amenorrhea

PurposeTo compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE).Materials and MethodsA retrospective, institutional review board–approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05.ResultsTwenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1).ConclusionsThere were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.     

Image Guidance for Endovascular Repair of Complex Aortic Aneurysms: Comparison of Two-dimensional and Three-dimensional Angiography and Image Fusion

PurposeTo evaluate the feasibility of image fusion (IF) of preprocedural arterial-phase computed tomography with intraprocedural fluoroscopy for roadmapping in endovascular repair of complex aortic aneurysms, and to compare this approach versus current roadmapping methods (ie, two-dimensional [2D] and three-dimensional [3D] angiography).Materials and MethodsThirty-seven consecutive patients with complex aortic aneurysms treated with endovascular techniques were retrospectively reviewed; these included aneurysms of digestive and/or renal arteries and pararenal and juxtarenal aortic aneurysms. All interventions were performed with the same angiographic system. According to the availability of different roadmapping software, patients were successively placed into three intraprocedural image guidance groups: (i) 2D angiography (n = 9), (ii) 3D rotational angiography (n = 14), and (iii) IF (n = 14). X-ray exposure (dose–area product [DAP]), injected contrast medium volume, and procedure time were recorded.ResultsPatient characteristics were similar among groups, with no statistically significant differences (P ≥ .05). There was no statistical difference in endograft deployment success between groups (2D angiography, eight of nine patients [89%]; 3D angiography and IF, 14 of 14 patients each [100%]). The IF group showed significant reduction (P < .0001) in injected contrast medium volume versus other groups (2D, 235 mL ± 145; 3D, 225 mL ± 119; IF, 65 mL ± 28). Mean DAP values showed no significant difference between groups (2D, 1,188 Gy·cm² ± 1,067; 3D, 984 Gy·cm² ± 581; IF, 655 Gy·cm² ± 457; P = .18); nor did procedure times (2D, 233 min ± 123; 3D, 181 min ± 53; IF, 189 min ± 60; P = .59).ConclusionsThe use of IF-based roadmapping is a feasible technique for endovascular complex aneurysm repair associated with significant reduction of injected contrast agent volume and similar x-ray exposure and procedure time.     

Coronary plaque characteristics in computed tomography and 2-year outcomes: The PREDICT study

BackgroundCoronary computed tomography angiography (CCTA) not only provides information regarding luminal stenoses but also allows for visualization of mural atheromatous changes (coronary plaques).ObjectiveWe sought to elucidate whether plaques seen on CCTA enable prediction of 2-year outcomes in patients with suspected and known coronary artery disease (CAD).MethodsOf 3015 patients who underwent CCTA, the images and 2-year clinical courses of 2802 patients were independently analyzed. The primary endpoint was the composite of all-cause death and acute coronary syndrome.ResultsDuring the 2-year observation period, 49 (1.7%) patients developed the primary outcome. The 2-year rates of the primary outcome in the normal (n = 515, no mural lesions), calcium (n = 654, calcified lesion alone), and plaque groups (n = 1633, presence of noncalcified or partially calcified plaques) were 0.2%, 2.0%, and 2.1%, respectively (P = 0.0028). Adverse plaque features such as low attenuation, positive remodeling, spotty calcification, and the napkin-ring sign (low-attenuation core with a higher-attenuation rim) were assessed by an independent core laboratory. Stepwise multivariate Cox proportional hazard analysis showed that a plaque with two or more characteristics (adjusted hazard ratio, 1.98; 95% confidence interval, 1.09–3.60; P = 0.0254), age of ≥67 years (mean), statin treatment after CCTA, and obstructive stenosis remained independent predictors of the primary outcome.ConclusionsPlaque imaging in CCTA has predictive value for the 2-year outcome and is a useful identifier for high-risk patients among those with known and suspected CAD.     

Serum MicroRNA-210 as a Predictive Biomarker for Treatment Response and Prognosis in Patients with Hepatocellular Carcinoma undergoing Transarterial Chemoembolization

PurposeTo investigate whether serum microRNA-210 (miR-210) level can serve as an indicator of prognosis and a predictor of efficacy of transarterial chemoembolization in patients with hepatocellular carcinoma (HCC).Materials and MethodsSerum miR-210 level was measured in 113 patients with HCC before transarterial chemoembolization (t1), 3 days after transarterial chemoembolization (t2), and 4 weeks after transarterial chemoembolization (t3) and compared with 39 healthy control subjects. The correlations between miR-210 levels and clinicopathologic factors, tumor responsiveness, and prognosis were analyzed. The modified Response Evaluation Criteria in Solid Tumors assessment was conducted at t3.ResultsA higher mean baseline miR-210 level was observed in patients with HCC compared with control subjects (3.69 ± 2.04 vs 1.08 ± 0.45, P < .001). A positive correlation between baseline miR-210 level and tumor size (P < .001), vascular invasion (P = .005), tumor differentiation (P = .037), and Barcelona Clinic Liver Cancer stage (P < .001) was observed. Elevated baseline miR-210 level also served as an independent prognostic factor predicting poor overall survival (risk ratio, 2.082; P = .003). Patients who did not respond to transarterial chemoembolization had higher baseline miR-210 levels than patients who did respond to treatment (4.34 ± 1.67 vs 3.28 ± 2.15, P < .001). In addition, miR-210 levels increased significantly 4 weeks after transarterial chemoembolization in nonresponders (5.79 ± 2.06 at t3 vs 4.34 ± 1.67 at t1, P < .001), whereas no significant change was observed in responders (3.53 ± 2.20 at t3 vs 3.28 ± 2.15 at t1, P = .116). Lastly, an inverse correlation was identified between miR-210 change t1–t3 with the time to radiologic progression (P < .001).ConclusionsSerum miR-210 may represent a novel biomarker for predicting efficacy of transarterial chemoembolization and overall survival for patients with HCC.     

Effect of Stent Implantation on the Deformations of the Superficial Femoral Artery and Popliteal Artery: In Vivo Three-Dimensional Deformational Analysis from Two-Dimensional Radiographs

The objective of this work was to develop a system for three-dimensional (3D) reconstruction of the femoropopliteal artery from two angiographic views and to quantify the in vivo 3D deformations in 18 patients before balloon angioplasty and after primary stent implantation. The procedure had an insignificant effect on the bending behavior of the artery, as the average mean curvature change within the lesion remained constant before (0.04 cm⁻¹ ± 0.03) and after stent implantation (0.03 cm⁻¹ ± 0.04). A significant effect of stent implantation was measured in terms of a decrease in arterial shortening during leg flexion.     

Transcatheter CT Arterial Portography and CT Hepatic Arteriography for Liver Tumor Visualization during Percutaneous Ablation

PurposeTo evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure.Materials and MethodsStudy participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40–76 y) with unresectable liver-only malignancies—14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)—that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30–60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months.ResultsTechnical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0–12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions).ConclusionsIn patients with technically unresectable liver-only malignancies, single-session CT arterial portography–guided or CT hepatic arteriography–guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity.