Effective training program for antenatal diagnosis of placenta accreta spectrum disorder.

OBJECTIVE: To develop and evaluate a training program for diagnosing placenta accreta spectrum (PAS) disorder in obstetrics/gynecology and radiology residents. METHODS: This single-center prospective study was based on 177 ultrasound images of pathologically confirmed PAS extracted from 534 cases of placenta previa suspicious for PAS. First- to third-year residents were evaluated before training to assess experience and ability to diagnose PAS. They attended a principal lecture followed by weekly self-study exercises over 5 weeks. Post-course tests evaluated the efficacy of the training program for improving diagnosis of PAS after the program. RESULTS: Twenty-three (38.3%) obstetrics/gynecology and 37 (61.7%) radiology residents were trained. Before the training program, 98.3% reported minimal experience and 100% low confidence to correctly diagnose PAS. During the program, the overall accuracy of all participants in diagnosing PAS increased from 71.3% before to 95.2% after training (P < 0.001). Regression analyses showed that ability to diagnose PAS increased 2.52-fold (P < 0.001) following the program. The retention of knowledge at 1, 3, and 6 months posttest was 84.7%, 87.5%, and 87.7%, respectively. CONCLUSION: An antenatal diagnosis of PAS training program can be effective as a residency training program, considering the globally rising cesarean delivery rates.

Popliteal artery branching variations on computed tomography angiography of 1542 lower limbs and its associated factors.

BACKGROUND: The identification of popliteal artery branching variation is of anatomical importance for surgical and endovascular procedures in the posterior region of the knee and below. PURPOSE: To evaluate the variations and associated factors of popliteal artery branching by computed tomography angiography (CTA). MATERIAL AND METHODS: CTA of the lower extremities of 1542 lower limbs in 771 patients (513 men and 258 women) were retrospectively reviewed to assess the popliteal artery branching patterns. The patient's sex, side of lower limbs, and population were recorded and evaluated for their association with popliteal artery branching patterns. P < 0.05 was considered to indicate statistical significance. RESULTS: Variations in the branching of the popliteal artery were recorded in 9.3% of patients. The three most common variations were found to be hypoplastic-aplastic posterior tibial artery (PT) (3.6%), trifurcation (2.0%), and hypoplastic-aplastic anterior tibial artery (0.8%). A new pattern was detected in 2 (0.1%) cases, which were described as double PTs. Statistically significant differences were noted in the proportion of variation branching between the male and female groups (odds ratio = 1.52; 95% confidence interval = 1.07-2.16; P = 0.02). CONCLUSION: The findings on popliteal variational branching patterns in the present study were in conformance to previous reports. Our study identified a novel variation of popliteal artery branching, which has not been mentioned in the literature so far. Sex was found to be an associated factor of branching variation.

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

OBJECTIVE: There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. METHODS: The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. RESULTS: All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. CONCLUSION: This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Predicting Infection Related Complications After Endovascular Repair of Infective Native Aortic Aneurysms.

OBJECTIVE: Endovascular aortic repair (EVAR) as surgical treatment for infective native aortic aneurysm (INAA) is associated with superior survival compared with open surgery, but with the risk of infection related complications (IRCs). This study aimed to assess the association between baseline clinical and computed tomography (CT) features and the risk of post-operative IRCs in patients treated with EVAR for INAA. It also sought to develop a model to predict long term IRCs in patients with abdominal INAA treated with EVAR. METHODS: All initial clinical details and CT examinations of INAAs between 2005 and 2020 at a major referral hospital were reviewed retrospectively. The images were scrutinised according to aneurysm features, as well as peri-aortic and surrounding organ involvement. Data on post-operative IRCs were found in the patient records. Cox regression analysis was used to derive predictors for IRCs and develop a model to predict five year IRCs after EVAR in abdominal INAA. RESULTS: Of 3 780 patients with the diagnosis of aortic aneurysm or aortitis, 98 (3%) patients were treated with EVAR for abdominal INAAs and were thus included. The mean follow up time was 52 months (range 0 ‒ 163). The mean transaxial diameter was 6.5 ± 2.4 cm (range 2.1 ‒14.7). In the enrolled patients, 38 (39%) presented with rupture. The five year IRC rate in abdominal INAAs was 26%. Female sex, renal insufficiency, positive blood culture, aneurysm diameter, and psoas muscle involvement were predictive of five year IRC in abdominal INAA after EVAR. The model had a C-index of 0.76 (95% CI 0.66 - 0.87). CONCLUSION: Pre-operative clinical and CT features have the potential to predict IRC after endovascular aortic repair in INAA patients. These findings stress the importance of rigorous clinical, laboratory, and radiological follow up in these patients.

A Single Center Study on the Risks of Peri-Intervention Stroke in Thoracic Endovascular Aortic Repair (TEVAR) and Endovascular Abdominal Aortic Repair (EVAR).

(1) Background: The risk factors of peri-intervention stroke (PIS) in thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair (EVAR) are different. This study aimed to compare the risks of PIS in both interventions. (2) Methods: Patients who had suffered a PIS related to TEVAR or EVAR from January 2008 to June 2015 in Songklanagarind Hospital were selected as the cases, while patients who had not suffered PIS were randomly selected to create a 1:4 case: control ratio for analysis. The associations between the factors from pre- to post-intervention and PISs in TEVAR or EVAR cases were analyzed by univariable analysis (p < 0.1). The independent risks of PIS were identified by multivariable analysis and presented in odds ratios (p < 0.05). (3) Results: A total of 17 (2.2%) out of 777 patients who had undergone TEVAR or EVAR experienced PIS, of which 9/518 (1.7%) and 8/259 (3.1%) cases were in TEVAR and EVAR groups, respectively. PIS developed within the first 24 h in nine (52.9%) cases. Large vessel ischemic stroke or watershed infarctions were the most common etiologies of PIS. The independent risks of PIS were the volume of intra-intervention blood loss (1.99 (1.88-21.12), p < 0.001) in the TEVAR-related PIS, and intervention time (2.16 (1.95-2.37), p = 0.010) and post-intervention hyperglycemia (18.60 (1.60-216.06), p = 0.001) in the EVAR-related PIS. There were no differences in the rate of PIS among the operators, intervention techniques, and status of the interventions performed. (4) Conclusion: The risks of PIS in TEVAR or EVAR in our center were different and possibly independent of the operator expertise and intervention techniques.

Features of infective native aortic aneurysms on computed tomography.

BACKGROUND: Infective native aortic aneurysm (INAA) is a rare clinical diagnosis. The purpose of this study was to describe the CT findings of INAAs in detail. METHODS: This was a retrospective single-center study of INAA patients at a major referral hospital between 2005 and 2020. All images were reviewed according to a protocol consisting of aneurysm features, periaortic findings, and associated surrounding structures. RESULTS: One hundred and fourteen patients (mean age, 66 years [standard deviation, 11 years]; 91 men) with 132 aneurysms were included. The most common locations were infrarenal (50.8%), aortoiliac (15.2%), and juxtarenal (12.9%). The mean transaxial diameter was 6.2 cm. Most INAAs were saccular (87.9%) and multilobulated (91.7%). Calcified aortic plaque was present in 93.2% and within the aneurysm in 51.5%. INAA instability was classified as contained rupture (27.3%), impending rupture (26.5%), and free rupture (3.8%). Rapid expansion was demonstrated in 13 of 14 (92.9%) aneurysms with sequential CT studies. Periaortic inflammation was demonstrated as periaortic enhancement (94.7%), fat stranding (93.9%), soft-tissue mass (92.4%), and lymphadenopathy (62.1%). Surrounding involvement included psoas muscle (17.8%), spondylitis (11.4%), and perinephric region (2.8%). Twelve patients demonstrated thoracic and abdominal INAA complications: fistulas to the esophagus (20%), bronchus (16%), bowel (1.9%), and inferior vena cava (IVC) (0.9%). CONCLUSION: The most common CT features of INAA were saccular aneurysm, multilobulation, and calcified plaques. The most frequent periaortic findings were enhancement, fat stranding, and soft-tissue mass. Surrounding involvement, including psoas muscle, IVC, gastrointestinal tract, and bronchi, was infrequent but may develop as critical INAA complications.

Emergency Thoracic US: The Essentials.

Acute thoracic symptoms are common among adults visiting emergency departments in the United States. Adults with these symptoms constitute a large burden on the overall resources used in the emergency department. The wide range of possible causes can make a definitive diagnosis challenging, even after clinical evaluation and initial laboratory testing. In addition to radiography and computed tomography, thoracic ultrasonography (US) is an alternative imaging modality that can be readily performed in real time at the patient's bedside to help diagnose many thoracic diseases manifesting acutely and in the trauma setting. Advantages of US include availability, relatively low cost, and lack of ionizing radiation. Emergency thoracic US consists of two main parts, lung and pleura US and focused cardiac US, which are closely related. Acoustic mismatches among aerated lungs, pleura, chest wall, and pathologic conditions produce artifacts useful for diagnosis of pneumothorax and pulmonary edema and help in detection of subpleural, pleural, and chest wall pathologic conditions such as pneumonia, pleural effusion, and fractures. Visual assessment of cardiac contractility and detection of right ventricular dilatation and pericardial effusion at focused cardiac US are critical in patients presenting with acute dyspnea and trauma. Additional US examinations of the inferior vena cava for noninvasive volume assessment and of the groin areas for detection of deep venous thrombosis are often performed at the same time. This multiorgan US approach can provide valuable information for emergency treatment of both traumatic and nontraumatic thoracic diseases involving the lungs, pleura, chest wall, heart, and vascular system. Online supplemental material is available for this article. (©)RSNA, 2016.

Trauma Ultrasound.

Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.

Correlation of caval index, inferior vena cava diameter, and central venous pressure in shock patients in the emergency room.

OBJECTIVES: This study aims to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in patients with shock in the emergency room. MATERIALS AND METHODS: This is a prospective double-blind observational study conducted in the emergency room of a tertiary care center. All patients who presented with shock and had a central venous catheter insertion performed were enrolled. The caval index was calculated as a relative decrease in the IVC diameter during the normal respiratory cycle. The correlation of CVP and the caval index were calculated by Pearson's product-moment correlation coefficient. RESULTS: Among the 30 patients enrolled, the median age was 59.90±21.81 years and 17 (56.7%) patients were men. The summary statistics that were generated for the participants' characteristics were divided into CVP <10 cm H2O, 10-15 cm H2O, and >15 cm H2O. The correlation of the CVP measurement with the ultrasound IVC caval index was r=-0.721 (P=0.000) by two-dimensional mode ultrasound and r=-0.647 (P=0.001) by M-mode. The correlations of CVP with the end-expiratory IVC diameter were r=0.551 (P=0.002) by two-dimensional mode ultrasound and r=0.492 (P=0.008) by M-mode. The sensitivity and specificity of the caval index were calculated to predict the CVP. The results showed that the cut-off points of the caval index were 30, 20, and 10 at CVP levels <10 cm H2O, 10-15 cm H2O, and >15 cm H2O, respectively. CONCLUSION: The caval index calculated from the IVC diameter measured by bedside ultrasound in the emergency room has a good correlation with CVP.

Congenital absence of left circumflex artery detected by computed tomography coronary angiography: a case report.

The congenital absence of the left circumflex artery (LCx) is a very rare congenital anomaly of coronary arteries, but it is benign. Currently, the best modality for the diagnosis of coronary anomalies is computed tomography coronary angiography (CTCA). We report a case of congenitally absent LCx with an atypical chest pain.