Mortality and Rates of Secondary Intervention After EVAR in an Unselected Population: Influence of Simple Clinical Categories and Implications for Surveillance

Introduction

Post-EVAR surveillance has a major impact upon patients, carers and healthcare resources. We hypothesised that elective indication, on-IFU anatomy, use of a modern device or normal first CTA, or a combination of these categories, might predict a rate of secondary intervention low enough to alter current surveillance protocols.

Methods

Patients undergoing EVAR in our institution between 01.05.2007 and 28.02.2013 were assessed. Data on indication (elective, emergency), anatomy relative to IFU, device, first month CTA result, secondary intervention and mortality were obtained. Kaplan–Meier charts of mortality and freedom from secondary intervention were produced. Statistical analysis was by log-rank test and Cox proportional hazard modelling.

Results

234 patients underwent EVAR (188 elective, 208 on-IFU). Most implants were Endurant (106) or Talent (98). 151 patients had a normal first CTA. By median follow-up of 38.6 months, 39 patients underwent secondary intervention. A normal first CTA and elective indication were significantly associated with reduced risk of secondary intervention (p < 0.001 and p = 0.042 respectively), but device type and placement on- or off-IFU were not. Elective placement with a normal first CTA was 93 % predictive of freedom from secondary intervention by 32 months post-EVAR. Of nine patients undergoing secondary intervention in this group, eight presented symptomatically.

Discussion

In optimal procedural circumstances with normal post-procedural imaging, only 7 % of patients undergoing EVAR require secondary intervention, a minority of which is driven by surveillance. These data support a change to surveillance more tailored to the individual patient, and highlight the need for further qualitative and quantitative research.

     

The Influence of Preoperative Aneurysmal Thrombus Quantity and Distribution on the Development of Type II Endoleaks with Aneurysm Sac Enlargement After EVAR of AAA

Purpose

To determine the influence of preoperative aneurysmal thrombus quantity and distribution on the development of type II endoleak with aneurysm sac enlargement after endovascular aneurysm repair (EVAR).

Materials and Methods

We retrospectively analyzed the pre- and postoperatively performed CT scans of 118 patients who had follow-up imaging for at least 1 year after EVAR available. We assessed preoperative thrombus perimeter (T _Peri), diameter (T _Dia), cross-sectional area (T _CSA), and volume (T _Vol). The preoperative thrombus distribution was classified into no thrombus, semilunar-shaped (anterior, right side, left side, posterior) thrombus, and circumferential type thrombus. The number of preoperative patent aortic side branches (ASB) was identified. Endpoint was type II endoleak with aneurysm volume (A _Vol) increase of ≥5 % during follow-up.

Results

During follow-up (2 years, range 1–9 years), 17 patients with type II endoleak had significant A _Vol increase. Less preoperative T _Peri, T _Dia, T _CSA, and T _Vol were associated with A _Vol increase. A circumferential thrombus distribution significantly protected against aneurysm enlargement (p = 0.028). The variables with the strongest significance for A _Vol increase were preoperative T _Vol/A _Vol ratio (OR 0.95; p = 0.037) and number of patent ASB (OR 3.52; p < 0.001).

Conclusion

A low preoperative T _Vol/A _Vol ratio and a high number of patent ASB were associated with aneurysm sac enlargement after EVAR.

     

Multicenter European Registry for Patients with AAA Undergoing EVAR Evaluating the Performance of the 36-mm-Diameter Endurant Stent-Graft

Introduction

The use of and results with the Endurant stent-graft have been reported extensively. However, there has been little if any focus placed on performance and outcomes when a 36-mm-diameter device is used.

Methods

Data were collected and retrospectively analyzed on EVAR patients treated with a 36-mm-diameter Endurant device at 3 European academic vascular centers between 2007 and 2015. Primary endpoints were the absence of type Ia endoleak in the early and mid-term follow-up period, and aneurysm sac stabilization or shrinkage. Secondary endpoints were 30-day mortality, overall survival and secondary interventions. Subgroup analysis of outcomes in the on-label (ONL) versus off-label (OFL) device use cohorts was also performed.

Results

Seventy-three patients were included in the study. Mean follow-up was 30.1 ± 16.2 months. Mean aortic neck diameter was 29.5 ± 1.9. Primary technical success was achieved in 69 patients (94.5%). Five patients (6.8%) were found to have developed a type Ia endoleak, 3 during the first month, and the other 2 at 2 years. Overall EVAR-related mortality was 4.1% (n = 3). Subgroup analysis focused on the OFL cohort (n = 44) versus the ONL patients (n = 29). Two of the OFL patients (4.5%) had a type Ia endoleak, and 3 (10.3%) in the ONL group.

Conclusion

The use of the largest diameter Endurant stent-graft device emerges as a reasonable option for EVAR treatment of AAA featuring a large-diameter proximal neck. Assessment of a larger group of patients followed in the long term will be necessary for a more definitive statement on such strategy.

     

Ventricular Ectopy as a Predictor of Death

‘Best of the Literature’ presents summaries of sports medicine—related articles culled from more than 30 medical journals. Experts comment on what the new findings add to current medical thinking and on the implications for practice     

Future Liver Remnant Indocyanine Green Plasma Clearance Rate as a Predictor of Post-hepatectomy Liver Failure After Portal Vein Embolization

CardioVascular and Interventional Radiology - To evaluate the utility of future liver remnant plasma clearance rate of indocyanine green (ICGK-F) for predicting post-hepatectomy liver failure...     

Prostate Zonal Volumetry as a Predictor of Clinical Outcomes for Prostate Artery Embolization

Purpose

To determine prostate baseline zonal volumetry and correlate these findings with clinical outcomes for patients who underwent prostate artery embolization (PAE) for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

Materials and Methods

This is a retrospective study that included patients treated by PAE from 2010 to 2014. Baseline and 6-month follow-up evaluations included prostate MRI with whole prostate (WP) and central gland (CG) volume measurements—as well as prostate zonal volumetry index (ZVi) calculation, defined as the CG/WP volumes relation—the International Prostate Symptom Score (IPSS), and the Quality of life (QoL) index. Baseline WP, CG, and ZVi were statistical compared to IPSS and QoL values at 6 months.

Results

A total of 93 consecutive patients were included, with mean age of 63.4 years (range, 51–86). Clinical failure, defined as IPSS > 7 or QoL > 2, was seen in four cases (4.3%). Mean reductions in prostate volumes after PAE were of 30.6% and 31.2% for WP and CG, respectively (p < 0.0001). Clinical parameters had mean decrease from 21 to 3.3 points for IPSS, and from 4.7 to 1.2 points for QoL (p < 0.0001). Baseline WP, CG, and ZVi correlated to the degree of clinical improvement (p < 0.05 for all). The baseline ZVi cut-off calculated for better clinical outcomes was > 0.45, with 85% sensitivity and 75% specificity.

Conclusions

Baseline CG and WP volumes as well as ZVi presented strong correlation with clinical outcomes in patients undergoing PAE, and its assessment should be considered in pre-treatment evaluation whenever possible. Both patients and medical team should be aware of the possibility of less favorable outcomes when ZVi < 0.45.

     

窦性心律震荡对急性心肌梗死患者心血管事件的预测

目的：通过研究窦性心律震荡与急性心肌梗死患者再发心脏事件的关系,评价窦性心律振荡在急性心肌梗死患者再发心脏事件中的预测价值。方法：选择符合入选标准的40例急性心肌梗死患者和36例健康对照,收集入选者的24h动态心电图,计算窦性心律震荡的To、Ts指标。结果：急性心肌梗死组To升高、Ts降低,差异有统计学意义。急性心肌梗死患者再发组与无再发组比较,再发组To值高于无再发组,Ts值低于无再发组。结论：窦性心律震荡的指标在AMI患者及再发患者中都存在减弱现象,它们可以作为评价心肌梗死患者自主神经功能状态、再发心脏事件危险性预测的指标。     

MTT Heterogeneity in Perfusion CT Imaging as a Predictor of Outcome after Aneurysmal SAH

BACKGROUND AND PURPOSE:Impairment of tissue oxygenation caused by inhomogeneous microscopic blood flow distribution, the so-called capillary transit time heterogeneity, is thought to contribute to delayed cerebral ischemia after aneurysmal SAH but has so far not been systematically evaluated in patients. We hypothesized that heterogeneity of the MTT, derived from CTP parameters, would give insight into the clinical course of patients with aneurysmal SAH and may identify patients at risk of poor outcome.MATERIALS AND METHODS:We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation in CTP scans from 132 patients. A multivariable logistic regression model was used to model the dichotomized mRS outcome. Linear regression was used to eliminate variables with high linear dependence. T tests were used to compare the means of 2 groups. Furthermore, the time of the maximum coefficient of variation for MTT after bleeding was evaluated for correlation with the mRS after 6 months.RESULTS:On average, each patient underwent 5.3 CTP scans during his or her stay. Patients with high coefficient of variation for MTT presented more often with higher modified Fisher (P = .011) and World Federation of Neurosurgical Societies grades (P = .014). A high coefficient of variation for MTT at days 3–21 after aneurysmal SAH correlated significantly with a worse mRS score after 6 months (P = .016). We found no correlation between the time of the maximum coefficient of variation for MTT after bleeding and the patients'' outcomes after 6 months (P = .203).CONCLUSIONS:Heterogeneity of MTT in CTP after aneurysmal SAH correlates with the patients'' outcomes. Because the findings are in line with the pathophysiologic concept of the capillary transit time heterogeneity, future studies should seek to verify the coefficient of variation for MTT as a potential imaging biomarker for outcome.

From the 9 in 100,000 individuals with an aneurysmal SAH (aSAH) per year, up to 40% die within 1 month despite improved intensive care and current treatment strategies.^1-4 Subsequent physical impairment, cognitive impairment, and secondary long-term psychosocial deterioration mean that most survivors cannot return to their former work life.^5,6The etiology of the detrimental long-term changes after SAH remains poorly understood. In terms of temporal progression, 2 distinct harmful phases of pathophysiologic changes can be distinguished. The term “early brain injury” describes initial pathophysiologic changes within the first 3 days, whereas “delayed cerebral ischemia” (DCI) represents a complex of reactions that occur later during the course of the disease.⁷During DCI, various pathophysiologic reactions and mechanisms result in cerebral ischemia and neuronal energy depletion. DCI likely involves microvascular dysfunction; disturbances in cerebral microcirculation; angiographic vasospasms; thrombosis of cerebral, primarily cortical, vessels; cortical spreading depolarization and ischemia; as well as inflammatory reactions.^7-10 Finally, DCI may lead to cerebral infarction and, therefore, irreversible loss of function.In general, the important factors for brain tissue survival are adequate oxygenation and glucose supply, among others. Historically, it was assumed that oxygenation mainly relies on the CBF, and previously macroscopic, angiographically visible vasospasms were assumed to be the main driver of DCI. However, it turned out that for this simplified assumption, the blood flow in capillaries must be identical throughout the whole capillary bed, which is not the case. In addition to the CBF, the microvascular blood distribution across capillaries, also known as the capillary transit time heterogeneity (CTH), was found to be the a crucial factor for the oxygenation of brain tissue.^11,12 Recently, Østergaard et al¹¹ presumed that the CTH also contributes to DCI-related ischemia. According to the group''s model, an increased CBF can lead to better tissue oxygenation as long as the CTH has not crossed a critical threshold. If the threshold is exceeded, any further increase in CBF will lead to a reduced oxygen extraction efficacy in brain tissue, due to capillary shunting in hyperemic areas, resulting in hypoxic brain tissue.¹² Østergaard et al defined this state as malignant CTH.^11,12 In such a case, adequate oxygenation of the brain tissue may be achieved only by reducing the CBF and thereby slowing the flow of erythrocytes through the shunting capillaries. This mechanism could be an explanation for the occurrence of vasospasm in patients with aSAH.¹¹CTH has been mainly evaluated in simulations, rodent models, and humans predominately with ischemic stroke or neurodegenerative diseases, such as Alzheimer disease. In the patient population, evaluation has so far mainly relied on MR imaging. Moreover, Østergaard et al¹¹ recently established the relative transit time heterogeneity (RTH) as the ratio of CTH to MTT.¹³ In doing so, the inherent dependency of CTH on the MTT was removed, making the RTH an improved indicator of the capillary transit heterogeneity.¹³ Furthermore, Østergaard et al have based the calculation of CTH and RTH on elaborated Bayesian approaches, and CTH evaluation is not readily available in clinical software for perfusion evaluation. Hence, to date, there is no routinely available radiologic readout for the CTH or RTH in the clinical setting of aSAH.So far, the concept of capillary transit time heterogeneity has not been systemically evaluated in patients with aSAH. We hypothesized that the higher heterogeneity of MTT derived from CTP parameters will allow us to gain insight into the clinical course of patients with aSAH and to predict a worse outcome. In the present study, we, therefore, retrospectively analyzed the heterogeneity of MTT in CTP scans obtained within 3 weeks after SAH and assessed a potential association with the initial neurologic status on admission and clinical outcome after 6 months.     

C-反应蛋白在原发性大肝癌患者肝动脉化疗栓塞前后变化规律及其临床意义

目的 研究原发性大肝癌患者血清C-反应蛋白(C-reactive protein,CRP)在肝动脉化疗栓塞(TACE)前后变化规律及其临床意义.资料与方法 回顾性分析2003年10月至2007年12月128例因原发性大肝癌行TACE患者的术前和术后1～8天血清CRP变化情况.52例术前CRP处于正常范围(阴性组),76例术前CRP高于正常值(阳性组).随访观察治疗效果和患者生存率及复发率;利用散射免疫比浊法定量测定患者TACE前后血清中的CRP值.结果 TACE后血清CRP浓度均在术后迅速增高,在术后4天达到峰值,以后逐渐降低,并于术后第8天下降到术前水平;CRP阴性组术后肿瘤体积缩小率高于阳性组,阴性组患者总生存率及有效肿瘤体积缩小率明显高于阳性组,复发率低于阳性组.结论 TACE疗效与患者血清CRP变化呈负相关,TACE后CRP升高幅度大提示预后不良.TACE术前CRP可作为原发性大肝癌患者TACE后疗效及判断预后的参考指标.     

CT Angiography Findings in Carotid Blowout Syndrome and Its Role as a Predictor of 1-Year Survival

BACKGROUND AND PURPOSE:Carotid blowout is a serious late complication of prior treatment of advanced head and neck cancer. We evaluate the efficacy of CTA in the diagnosis of impending carotid blowout syndrome in patients with head and neck cancer, and its capability to predict clinical outcome.MATERIALS AND METHODS:The clinical data of 29 patients with impending carotid blowout who underwent CTA were collected and analyzed. Imaging signs included tissue necrosis, exposed artery, viable perivascular tumor, pseudoaneurysm, and contrast extravasation. DSA was obtained in 20 patients. One-year outcomes were compared based on management.RESULTS:The most common CTA finding was necrosis (94%), followed by exposed artery (73%), viable tumor (67%), pseudoaneurysm (58%), and contrast extravasation (30%). Exposed artery, pseudoaneurysm, and contrast extravasation were the 3 CTA findings related to outcomes. All of the pseudoaneurysm and contrast extravasation cases were associated with an exposed artery. An exposed artery was the most important prognostic predictor and could not be diagnosed on DSA. Patients without the 3 findings on CTA (group 1) had the best survival rate at 1-year follow-up, followed by patients with the 3 findings treated immediately by permanent artery occlusion (group 2). Patients with the 3 findings who had no immediate treatment (group 3) had the worst outcomes (P < .001 in group 1 vs group 3 and group 2 vs group 3; P = .056 group 1 vs group 2).CONCLUSIONS:CTA, with its ability to diagnose an exposed artery compared with DSA, may offer important management and prognostic information in patients with impending carotid blowout.

Carotid blowout syndrome (CBS) is defined as rupture of the carotid artery and its branches and is a serious complication after treatment of advanced head and neck cancer. Potential causes of CBS include radical resection, radiation therapy and radiation necrosis, carotid exposure, wound infection, pharyngocutaneous fistula, and recurrent or persistent carcinoma.¹ The overall incidence of carotid blowout after neck dissection has been reported to be as high as 4.3%, and the risk is increased another 7.6-fold with further radiation therapy.² CBS typically occurs 2–20 years after surgery or radiation therapy,^3,4 and average estimates of cumulative neurologic morbidity and mortality are above 60% and 40%, respectively, in patients with CBS.⁵ CBS can be categorized into 1 of 3 categories: threatened, impending, and acute carotid blowout.¹ Threatened carotid blowout is defined as physical examination or imaging results that suggest inevitable hemorrhage from 1 of the carotid arteries or its branches if no action is taken. Impending carotid blowout (also called sentinel hemorrhage) is defined as transient hemorrhage that resolves spontaneously or with packing or pressure. Acute carotid blowout represents hemorrhage that cannot be controlled by packing or pressure.¹ Surgical management of carotid blowout is usually technically difficult and is associated with high morbidity and mortality rates.^1,2,6,7 After surgical ligation or permanent arterial occlusion (PAO) of the carotid artery, the incidence of immediate or delayed cerebral ischemic complications can be as high as 15%–20%.^7,8–12 The complication rate of a balloon occlusion test before PAO of the carotid artery is reported to be as high as 3.2%, and it may be even higher in fragile postirradiation vessels.¹³ Delayed ischemia after passing the balloon occlusion test is yet another concern.^10,14,15 Stent-graft deployment, with or without coiling, is another endovascular treatment of CBS. Stent-grafting can preserve the affected carotid flow but has a high rate of early and delayed complications.^16–19 No significant difference in short-term outcome between stent-graft deployment and PAO has been reported,²⁰ and long-term results have not been reported.¹⁷CTA has become widely available and is sensitive and specific in the detection of hemorrhagic vascular disorders such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, and intracranial dissections. Contrast extravasation on CTA predicts hematoma expansion, mortality, and clinical outcome in primary intracerebral hemorrhage.^21–26 To our knowledge, there have been no past reports about the use of CTA in the diagnosis of CBS or as an outcome predictor. The aim of our study was to evaluate the efficacy of CTA in the diagnosis of impending CBS, and its capability to predict clinical outcome after management.     

Collateral Assessment by CT Angiography as a Predictor of Outcome in Symptomatic Cervical Internal Carotid Artery Occlusion

BACKGROUND AND PURPOSE:Cervical internal carotid artery occlusion can present with varied clinical manifestations such as transient ischemic attack, stroke, and chronic ocular ischemia, or can be asymptomatic. The outcome in these patients is considerably influenced by cerebral hemodynamic compensatory adaptation of the intracranial collateral pathways. Our aim was to study whether collateral circulation as assessed by CT angiography can predict 3-month outcome and initial stroke severity in patients with symptomatic cervical ICA occlusion.MATERIALS AND METHODS:This was a retrospective study of 65 patients with symptomatic cervical ICA occlusion from January 2011 to December 2013. The collateral vessels (anterior and posterior communicating arteries, ophthalmic artery, and leptomeningeal arteries) were assessed by CTA. The outcome at 3 months was defined as poor if the modified Rankin Scale score was ≥3.RESULTS:The mean age of subjects was 57 ± 11.6 years (range, 32–80 years), and 92% were men. Thirty-three (50.8%) patients had poor outcome. Absence of the ipsilateral ophthalmic artery, poor leptomeningeal collaterals, and <2 collaterals were predictors of stroke severity at onset and poor 3-month outcome in univariate analysis. In the multiple logistic regression analysis, inadequate flow through the secondary collaterals (ipsilateral ophthalmic artery or leptomeningeal collaterals; OR, 4.5; 95% CI, 1.4–14.9; P = .01) and higher NIHSS score at stroke onset (OR, 19.2; 95% CI, 2.2–166.2; P = .007) independently predicted poor outcome at 3 months.CONCLUSIONS:Assessment of collateral circulation with CTA can be a useful predictor of 3-month outcome in patients with symptomatic cervical ICA occlusion.

Cervical ICA occlusion can present with varied clinical manifestations such as transient ischemic attack, stroke, and chronic ocular ischemia, or can be asymptomatic. The outcome in these patients is influenced by cerebral hemodynamic compensatory adaptation, with the intracranial collateral pathways playing an important role in maintaining adequate perfusion to the ischemic zone.¹In large-artery occlusion, the primary collaterals (anterior and posterior communicating arteries) act as the immediate flow diverters and the secondary collaterals (leptomeningeal and ophthalmic arteries [OAs]) further enhance the cerebral perfusion.² The role of collaterals as predictors of stroke severity, response to thrombolysis, and outcome in patients with acute stroke and large-vessel occlusion has been investigated in multiple studies.^3–5 Good leptomeningeal collateral circulation and the presence of ≥2 collaterals were found to be associated with good outcome in patients with cervical large-vessel occlusion.^6,7Most of the earlier studies on collaterals have focused on the prognostic implications of primary collateral circulation and cerebrovascular autoregulation in patients with stroke. Only a very few of them have explored the clinical significance of secondary collaterals, especially the ophthalmic artery, in ICA occlusion. The earlier studies were also limited by the nonuniformity of study protocols, especially the imaging technique with a combination of either MRA, DSA, CTA, or transcranial Doppler for assessing the cerebral collaterals. We analyzed both primary and secondary collaterals by using CTA, which is a noninvasive technique currently recommended for the evaluation of vascular anatomy in stroke. The main objective of our study was to determine whether collateral circulation as assessed by CTA helps in predicting the 3-month outcome and initial stroke severity in patients with symptomatic cervical ICA occlusion.     

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.