Fusion Imaging with a Mobile C-Arm for Peripheral Arterial Disease.

BACKGROUND: Fusion imaging makes it possible to improve endovascular procedures and is mainly used in hybrid rooms for aortic procedures. The objective of this study was to evaluate the feasibility of fusion imaging for femoropopliteal endovascular procedures with a mobile flat plane sensor and dedicated software to assist endovascular navigation. MATERIALS AND METHODS: Between May and December 2017, 41 patients requiring femoropopliteal endovascular revascularization were included. Interventions were carried out in a conventional surgical room equipped with a mobile plane sensor (Cios Alpha, Siemens). The numerical video stream was transmitted to an angionavigation station (EndoNaut (EN), Therenva). The software created an osseous and arterial panorama of the treated limb from the angiographies carried out at the beginning of procedure. After each displacement of the table, the software relocated the current image on the osseous panorama, with 2D-2D resetting, and amalgamated the mask of the arterial panorama. The success rates of creation of osseous and arterial panorama and the success of relocation were evaluated. The data concerning irradiation, the volume of contrast (VC) injected, and operative times were recorded. RESULTS: Osseous panoramas could be automatically generated for the 41 procedures, without manual adjustment in 33 cases (80.5%). About 35 relocations based on a 2D-2D resetting could be obtained in the 41 procedures, with a success rate of 85%. The causes of failure were a change in table height or arch angulation. The average duration of intervention was 74.5 min. The irradiation parameters were duration of fluoroscopy 17.8 ± 13.1 min, air kerma 80.5 ± 68.4 mGy, and dose area product 2140 ± 1599 µGy m2. The average VC was 24.5 ± 14 mL. CONCLUSIONS: This preliminary study showed that fusion imaging is possible in a nonhybrid room for peripheral procedures. Imagery of mobile C-arms can be improved for femoropopliteal endovascular procedures without heavy equipment. These imagery tools bring an operative comfort and could probably reduce irradiation and the injected VC. The clinical benefit must be evaluated in more patients in a randomized comparative study with a rigorous methodology.

Use of Numerical Simulation to Predict Iliac Complications During Placement of An Aortic Stent Graft.

BACKGROUND: During endovascular aneurysm repair (EVAR), complex iliac anatomy is a source of complications such as unintentional coverage of the hypogastric artery. The aim of our study was to evaluate ability to predict coverage of the hypogastric artery using a biomechanical model simulating arterial deformations caused by the delivery system. METHODS: The biomechanical model of deformation has been validated by many publications. The simulations were performed on 38 patients included retrospectively, for a total of 75 iliac arteries used for the study. On the basis of objective measurements, two groups were formed: one with "complex" iliac anatomy (n = 38 iliac arteries) and the other with "simple" iliac anatomy (n = 37 iliac arteries). The simulation enabled measurement of the lengths of the aorta and the iliac arteries once deformed by the device. Coverage of the hypogastric artery was predicted if the deformed renal/iliac bifurcation length (Lpre) was less than the length of the implanted device (Lstent-measured on the postoperative computed tomography [CT]) and nondeformed Lpre was greater than Lstent. RESULTS: Nine (12%) internal iliac arteries were covered unintentionally. Of the coverage attributed to perioperative deformations, 1 case (1.3%) occurred with simple anatomy and 6 (8.0%) with complex anatomy (P = 0.25). All cases of unintentional coverage were predicted by the simulation. The simulation predicted hypogastric coverage in 35 cases (46.7%). There were therefore 26 (34.6%) false positives. The simulation had a sensitivity of 100% and a specificity of 60.6%. On multivariate analysis, the factors significantly predictive of coverage were the iliac tortuosity index (P = 0.02) and the predicted margin between the termination of the graft limb and the origin of the hypogastric artery in nondeformed (P = 0.009) and deformed (P = 0.001) anatomy. CONCLUSIONS: Numerical simulation is a sensitive tool for predicting the risk of hypogastric coverage during EVAR and allows more precise preoperative sizing. Its specificity is liable to be improved by using a larger cohort.

Fusion Imaging for EVAR with Mobile C-arm.

BACKGROUND: Fusion imaging is a technique that facilitates endovascular navigation but is only available in hybrid rooms. The goal of this study was to evaluate the feasibility of fusion imaging with a mobile C-arm in a conventional operating room through the use of an angionavigation station. METHODS: From May 2016 to June 2017, the study included all patients who underwent an aortic stent graft procedure in a conventional operating room with a mobile flat-panel detector (Cios Alpha, Siemens) connected to an angionavigation station (EndoNaut, Therenva). The intention was to perform preoperative 3D computerized tomography/perioperative 2D fluoroscopy fusion imaging using an automatic registration process. Registration was considered successful when the software was able to correctly overlay preoperative 3D vascular structures onto the fluoroscopy image. For EVAR, contrast dose, operation time, and fluoroscopy time (FT) were compared with those of a control group drawn from the department's database who underwent a procedure with a C-arm image intensifier. RESULTS: The study included 54 patients, and the procedures performed were 49 EVAR, 2 TEVAR, 2 IBD, and 1 FEVAR. Of the 178 registrations that were initialized, it was possible to use the fusion imaging in 170 cases, that is, a 95.5% success rate. In the EVAR comparison, there were no difference with the control group (n = 103) for FT (21.9 ± 12 vs. 19.5 ± 13 min; P = 0.27), but less contrast agent was used in the group undergoing a procedure with the angionavigation station (42.3 ± 22 mL vs. 81.2 ± 48 mL; P < 0.001), and operation time was shorter (114 ± 44 vs. 140.8 ± 38 min; P < 0.0001). CONCLUSIONS: Fusion imaging is feasible with a mobile C-arm in a conventional operating room and thus represents an alternative to hybrid rooms. Its clinical benefits should be evaluated in a randomized series, but our study already suggests that EVAR procedures might be facilitated with an angionavigation system.

Influencing factors of sac shrinkage after endovascular aneurysm repair.

OBJECTIVE: Sac shrinkage is considered a reliable surrogate marker of success after endovascular aneurysm repair (EVAR). Whereas sac shrinkage is the best expected outcome, predictive factors of sac shrinkage remain unclear. The aim of this study was to identify the role of preoperative and postoperative influencing factors of sac reduction after EVAR. METHODS: Online searches across MEDLINE, Embase, and Cochrane Library medical databases were simultaneously performed. Study effects were pooled using a random-effects model, and forest plots were generated for every potential influencing factor. RESULTS: A total of 24 studies with 14,754 patients were included (mean age, 73.4 years; 76% male). At a mean follow-up of 24 months, the pooled shrinkage proportion was 47%. Random-effects meta-analysis revealed that renal impairment (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.57-0.96), type I endoleaks (OR, 0.17; 95% CI, 0.08-0.39), type II endoleaks (OR, 0.21; 95% CI, 0.14-0.33), and combined type I and type II endoleaks (OR, 0.32; 95% CI, 0.22-0.47) were found to prevent sac shrinkage, whereas hypercholesterolemia (OR, 1.24; 95% CI, 1.02-1.51) and smoking (OR, 1.32; 95% CI, 1.17-1.49) have a significant positive impact on sac shrinkage. In addition, there was a trend toward the association between shrinkage and statin therapy (OR, 4.07; 95% CI, 1.02-16.32) and nearly significant negative impacts of coronary artery disease (OR, 0.84; 95% CI, 0.70-1.01), diabetes (OR, 0.79; 95% CI, 0.60-1.04), and sac thrombus (OR, 0.88; 95% CI, 0.77-1.01) on sac shrinkage. CONCLUSIONS: In this large meta-analysis of patients undergoing EVAR, we found that several comorbidity and postoperative factors were associated with postoperative sac shrinkage. These findings may contribute to a better understanding of the shrinkage process of patients undergoing EVAR.

Systematic Review and Meta-Analysis of Preoperative Risk Factors of Type II Endoleaks after Endovascular Aneurysm Repair.

BACKGROUND: Type II endoleaks (T2Es) remain the Achilles heel of endovascular aneurysm repair (EVAR), involving a close follow-up and sometimes leading to reintervention. Identifying risk factors impacting T2Es is of concern to improve decision making and optimize follow-up. However, it has led to contradictory results, with supporting evidence for the majority of factors being weak. METHODS: A systematic review and meta-analysis was conducted to study risk factors of T2Es following EVAR to identify risk factors and measure their dedicated strength of association. Using a literature search of MEDLINE, EMBASE, and the Cochrane Library, 31 retrospective studies including a total of 15,793 patients were identified and fulfilled the strict specified inclusion criteria. Random-effects meta-analysis was conducted for each factor to combine effect estimate across studies. A total of 21 factors related to demography, preoperative treatment, comorbidity, and morphology were statistically pooled. RESULTS: On the basis of the pooled odds ratios and their 95% confidence intervals, patency of aortic side branches, represented by the patency of the inferior mesenteric artery, lumbar arteries, or total number of aortic side branches, were found to be significant harmful risk factors of T2Es. Women were also found to have nearly significant higher risk of developing T2Es than men. On the contrary, the following were found to have a significant protective role: smoking, peripheral artery disease, and thrombus load, represented by the maximum thickness at the maximum aneurysm diameter, the presence of circumferential thrombus, or the presence of thrombus at the level of inferior mesenteric artery. CONCLUSION: Identifying significant risk factors of development of T2Es is mandatory to improve decision making and optimize surveillance planning in EVAR.

Predictive Models of Complications after Endovascular Aortic Aneurysm Repair.

BACKGROUND: The risk of long-term complications after endovascular aneurysm repair (EVAR) is still higher than open surgery and is a critical issue. This study aims to make available reliable statistical predictive models of complications after EVAR. METHODS: Two hundred and thirteen patients who underwent EVAR between 2002 and 2012 were included in this study. The preoperative computed tomography scans were analyzed with a dedicated workstation to provide spatially correct 3-dimensional data. Age, gender, operation-related factors, and 21 morphologic variables were measured and included in the analyses. Five postoperative outcomes were studied. After an initial selection of predictors based on univariate analysis, binomial logistic regression models were proposed for each outcome. The ability to predict each outcome was assessed with receiver operating characteristic curves considering that an area under the curve (AUC) > 0.70 is generally considered sufficiently accurate. RESULTS: The mean age was 74.8 ± 8.6 years with a mean follow-up of 43.8 ± 22.1 months. Respectively, rates and risk factors of each outcome were 25.3% (n = 51) for abdominal aortic aneurysm (AAA) enlargement (age, number of patent sac branches, iliac calcifications and tortuosity, aneurysmal thrombus), 7% (n = 15) for type IA endoleak (neck calcification and AAA diameter), 3.7% (n = 8) for type IB endoleak (iliac tortuosity, AAA diameter, neck thrombus), 19.8% (n = 40) for type II endoleak (female, number of patent sac branches), and 25.9% (n = 55) for reintervention from any cause (neck calcification). The risk associated to each outcome can be calculated with a combination of these different preoperative variables. AUC for each outcome were 79.6% for AAA enlargement, 70.4% for reintervention, 81.3% for type IA endoleak, 92.3% for type IB endoleak, 70.6% for type II endoleak. CONCLUSIONS: This study shows that an exhaustive description of the preoperative anatomy before EVAR is a powerful and reliable tool to predict the risk of developing the most common complications after EVAR.

Evaluation by Magnetic Resonance Imaging of Silent Brain Infarcts in Preoperative and Postoperative Asymptomatic Carotid Surgery.

BACKGROUND: To report the prevalence of silent brain infarcts (SBI) at magnetic resonance imaging (MRI) before and after surgery for asymptomatic high grade carotid stenosis. METHODS: This is a single center retrospective observational study. Asymptomatic patients who underwent carotid endarterectomy between October 2012 and October 2014 were included. The preoperative assessment included a Doppler and a computed tomographic (CT) scan dating less than 3 months. A neurological examination was performed during the anesthesia consultation and in the 15 days before surgery. An MRI angiography was performed the day before and 3 days after surgery and was analyzed by an independent neuroradiologist. Preoperative analysis focused on the presence of ischemic events at MRI. The type of plaque, the supra aortic trunk lesions, and the quality of the circle of Willis were analyzed using Doppler and CT scanning. Postoperatively, we searched for signs of postoperative ischemic events at MRI. RESULTS: Forty-one patients were included (85.4% of men), and the mean age was 72.4 ± 8.3 years. We noted 7 (17.1%) contralateral stenoses (>50%) and 2 (4.9%) contralateral thromboses, 6 (14.6%) vertebral stenoses, and 7 (17.1%) abnormalities of the circle of Willis. The morphological analysis described 6 unstable plaques including 4 ulcerated, 1 pseudodissection, and 1 intraplaque hemorrhage. Preoperatively, we noted the presence of 21 (51.2%) ischemic lesions including 9 (21.9%) multiple lacunar ischemic events and 12 (29.3%) silent arterial territory infarcts. Eversion was performed for all patients except for 6 (14.6%), for whom a bypass was necessary. No deaths or major complications were observed in the 30 postoperative days. Postoperatively, MRI showed 3 (7.3%) asymptomatic recent ischemic strokes, 1 ipsilateral middle cerebral artery (MCA) stroke, and 2 contralateral (cerebellar and MCA) strokes. CONCLUSIONS: Patients with asymptomatic significant carotid stenosis show many preoperative SBI indicating a significant embolic risk. It is difficult to conclude about intraoperative embolic risk, but we hope that more data could demonstrate the importance of MRI for the preoperative evaluation of carotid plaques and brain parenchyma, to identify high-risk embolic patients.

Preoperative CT-scan-based sizing and in-stent restenosis in peripheral endovascular revascularizations.

Objectives This study evaluates the effect of stent sizing with CT-scan on the incidence of restenosis in peripheral arterial disease. Methods This retrospective study included 59 patients with 66 arterial lesions who underwent a endovascular procedure for peripheral arterial disease between April 2013 and October 2013. All patients had de novo iliac or femoral lesions, were candidates for an endovascular procedure alone and underwent CTA preoperatively. The stent actually implanted, whose dimensions were chosen on the basis of the operator's experience on an intraoperative 2D angiography, was compared to the "ideal" stent chosen retrospectively on the basis of precise lesion sizing by the preoperative CTA. Planning was considered "discordant" if there was a difference in length of more than 20 mm and/or a difference in diameter of more than 1 mm between the ideal stent and the actual stent. Results For iliac lesions, discordance essentially concerned stent diameter (36.1%), whereas stent length was the main reason for discordance for femoral lesions (36.7%). The median length of follow-up was 18 months (range 6-24). For iliac lesions, freedom from restenosis at 24 months was higher for patients with concordant planning (90% vs. 62.5%, p = 0.045). Most restenoses occurred in the external iliac artery, where there was a tendency towards oversizing of the implanted stent. For femoral lesions, the restenosis-free rate at 24 months was higher for patients with concordant planning (77.8% vs. 50%, p = 0.057). A multivariate analysis was conducted on the prediction of restenosis. Among factors, only discordant planning was found to be a significant predictor of restenosis with an odds ratio of 0.115 (95% confidence interval, 0.02-0.674; p = 0.016). Conclusion The absence of sizing for peripheral lesions engenders a tendency to choose the wrong stent, in particular in terms of diameter in iliac arteries and length in femoral arteries.

Endovascular Treatment of Infrarenal Aneurysms: Comparison of the Results of Second- and Third-Generation Stent Grafts.

BACKGROUND: The stent grafts used for endovascular abdominal aortic repair (EVAR) profited from many technological changes since their appearance. The objective of this study was to compare the medium-term results of the second- and third-generation stent grafts. METHODS: Three hundred thirty-four patients treated by EVAR between 2005 and 2013 were included in this retrospective study. Demographic, anatomical, perioperative, and follow-up data were collected in a prospective way in an electronic database and compared between 2 groups. The preoperative angio-computed tomographies were all analyzed in depth on a suitable three-dimensional work station. Group 1 (n = 219) represented the patients treated by second-generation stent grafts (Medtronic Talent(®), Cook Medical Zenith Flex(®), Vascutek-Terumo Anaconda(®), Gore Excluder low-porosity(®)) and group 2 (n = 115) represented the patients treated with third-generation stent grafts (Medtronic Enduring I and II(®), Cook Medical Zenith LP(®), Gore Excluder C3(®)). RESULTS: The mean follow-up was 42.4 ± 26.8 months with a longer duration in group 1 (52.4 ± 27.2 vs. 23.2 ± 10.9 months, P < 0.0001). The patients of group 2 had significantly more risk factors and cardiovascular comorbidities (coronary disease, tobacco addiction, dyslipidemia, peripheral arterial disease, chronic renal insufficiency). Anatomical characteristics were similar in the 2 groups, in particular regarding the iliac arteries which were significantly more calcified and had a smaller diameter in group 2. The rate of perioperative complications was similar in the 2 groups, in particular for complications related to the iliac axes (3.7% vs. 2.6%, P = 0.96). During the follow-up, there was no significant difference between the 2 groups in the rates of survival, reinterventions, or endoleaks and the progression of the aneurysmal sac. CONCLUSIONS: This study shows that third-generation stent grafts allow results comparable with those of the second-generation stent grafts in spite of more complex iliac anatomies. These results make it possible to expand the indications of EVAR to patients presenting more cardiovascular comorbidities without increasing the risk of complications in the short and medium term.

Sealing zones have a greater influence than iliac anatomy on the occurrence of limb occlusion following endovascular aortic aneurysm repair.

Limb occlusion is a well-known complication following endovascular aortic aneurysm repair (EVAR), and it very often leads to reoperation. The aim of this study is to identify predictive factors for limb occlusion following EVAR. Two hundred and twenty-four patients undergoing EVAR between 2004 and 2012 were included in this retrospective study. Demographics, anatomic, and follow-up data were compared between two groups (with or without thrombosis). Preoperative anatomy was analyzed with a dedicated workstation, using the Society of Vascular Surgery reporting standards. Eleven (4.9%) patients presented with a limb occlusion during follow-up (46 ± 12 months). Univariate analyses were first performed to investigate the influence of preoperative variables on limb occlusion. Then, variables with a p value <0.1 were included in the multivariate analysis and showed that in the occlusion group there was a greater rate of chronic renal failure (18.2% vs. 3.8%, p = 0.012), a more frequent occurrence of distal landing zones in the external iliac artery (15.4% vs. 2.1%, p = 0.006), and a smaller aortic neck diameter (21.0 ± 2.9 mm vs. 23.6 ± 3.3 mm, p = 0.014). Although iliac anatomy does not appear to have a significant influence on limb occlusion rate in the multivariate analysis, proximal and distal sealing zones appear to be involved in this complication.

Combined frozen elephant trunk and endovascular repair for extensive thoracic aortic aneurysms.

BACKGROUND: We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment. METHODS: In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used ("trombone" mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.). RESULTS: The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications). CONCLUSIONS: The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.

Deep-learning approach to automate the segmentation of aorta in non-contrast CTs.

Purpose: Segmentation of vascular structures in preoperative computed tomography (CT) is a preliminary step for computer-assisted endovascular navigation. It is a challenging issue when contrast medium enhancement is reduced or impossible, as in the case of endovascular abdominal aneurysm repair for patients with severe renal impairment. In non-contrast-enhanced CTs, the segmentation tasks are currently hampered by the problems of low contrast, similar topological form, and size imbalance. To tackle these problems, we propose a novel fully automatic approach based on convolutional neural network. Approach: The proposed method is implemented by fusing the features from different dimensions by three kinds of mechanisms, i.e., channel concatenation, dense connection, and spatial interpolation. The fusion mechanisms are regarded as the enhancement of features in non-contrast CTs where the boundary of aorta is ambiguous. Results: All of the networks are validated by three-fold cross-validation on our dataset of non-contrast CTs, which contains 5749 slices in total from 30 individual patients. Our methods achieve a Dice score of 88.7% as the overall performance, which is better than the results reported in the related works. Conclusions: The analysis indicates that our methods yield a competitive performance by overcoming the above-mentioned problems in most general cases. Further, experiments on our non-contrast CTs demonstrate the superiority of the proposed methods, especially in low-contrast, similar-shaped, and extreme-sized cases.

Patient-specific finite element simulation of peripheral artery percutaneous transluminal angioplasty to evaluate the procedure outcome without stent implantation.

The purpose of this work is to present a patient-specific (PS) modeling approach for simulating percutaneous transluminal angioplasty (PTA) endovascular treatment and assessing the balloon sizing influence on short-term outcomes in peripheral arteries, i.e. without stent implantation. Two 3D PS stenosed femoral artery models, one with a dominant calcified atherosclerosis while the other with a lipidic plaque, were generated from pre-operative computed tomography angiography images. Elastoplastic constitutive laws were implemented within the plaque and artery models. Implicit finite element method (FEM) was used to simulate the balloon inflation and deflation for different sizings. Besides vessel strains, results were mainly evaluated in terms of the elastic recoil ratio (ERR) and lumen gain ratio (LGR) attained immediately after PTA. Higher LGR values were shown within the stenosed region of the lipidic patient. Simulated results also showed a direct and quantified correlation between balloon sizing and LGR and ERR for both patients after PTA, with a more significant influence on the lumen gain. The max principal strain values in the outer arterial wall increased at higher balloon sizes during inflation as well, with higher rates of increase when the plaque was calcified. Results show that our model could serve in finding a compromise for each stenosis type: maximizing the achieved lumen gain after PTA, but at the same time without damaging the arterial tissue. The proposed methodology can serve as a step toward a clinical decision support system to improve angioplasty balloon sizing selection prior to the surgery.

Uncovering a 70-year-old permafrost degradation induced disaster in the Arctic, the 1952 Niiortuut landslide-tsunami in central West Greenland.

On December 15th 1952, at approximately 14:00 local time a mass of 5.9 × 106 m3 of permafrozen talus deposits failed in a landslide close to the Niiortuut mountain on the south coast of the Nuussuaq peninsula, central West Greenland. Between 1.8 and 4.5 × 106 m3 of the material entered the sea and generated a tsunami that propagated through the Vaigat strait (Sullorsuaq). Here we describe this catastrophic event for the first time by analysis of historical material supplemented by recent fieldwork and discuss the implications for the state of contemporary permafrozen slopes. The tsunami killed a fisherman working on the shore of southern Nuussuaq, 10 km south-east of the landslide. In the mining town of Qullissat, 30 km south of the landslide, it had a runup height of 2.2-2.7 m and caused minor material damage. Morphological evidence show that the basal surface of rupture was 80 m inside the permafrost cemented talus slope, whose degradation was a dynamic conditioning factor for the landslide. The 1952 Niiortuut landslide is the first historically recorded event of permafrost degradation induced landslide-tsunamis in the Arctic. We infer that the landslide and its cascading consequences occurred due to the early-twentieth century warming that started in the late 1910's in the Arctic. Warming is now increasingly affecting this region, as shown by an enhanced recent landslide activity.

Evolution of the upper and lower landing site after endovascular aortic aneurysm repair.

BACKGROUND: The evolution and correlation between the aortic neck and distally located iliac necks after endovascular treatment of abdominal aortic aneurysms (AAAs) was studied. METHODS: Of 179 patients who had undergone AAA repair between 2003 and 2007, 61 received the same radiologic follow-up and were included in this retrospective study. Data for 61 aortic necks and 115 iliac arteries were analyzed using the preoperative scan, 1-month visit, and final follow-up, with a minimum mean follow-up of 24 ± 15.2 months. Three measurements were taken of the aortic neck: subrenal (D1a), 15 mm below the lowest renal artery (D1b), and at the origin of the aneurysm (D1c). Three measurements were taken at the level of the iliac arteries: origin (Da), middle (Db), and the iliac bifurcation (Dc). These measurements were analyzed using analysis of variance and Spearman correlation coefficient. The results were evaluated for subsequent endoleaks, migrations, and reinterventions. All diameters were compared between patients with a regression of >10% in the greatest diameter of AAA at last follow-up (group A, n = 35) and those without (group B, n = 26). RESULTS: All diameters (in mm) increased significantly over time at the level of the proximal neck (D1a = 3.7 ± 2.8, P = .018; D1b = 4.4 ± 2.5, P = .016; D1c = 4.3 ± 3.1, P = .036) and iliac arteries (Da = 2.1 ± 0.2, P = .0006; Db = 2.5 ± 0.5, P = .0006; Dc = 3 ± 0.7, P = .007). The increase in diameters at the proximal neck and iliac arteries evolved independently (insignificant correlation), with the exception of D1b and Dc (P = .006), which showed a weak correlation (r = 0.363). The group A patients presented increases in all diameters, although to a less significant extent (P < .05) than group B patients. During follow-up, a proximal endoleak and a distal endoleak occurred, both requiring reintervention. CONCLUSIONS: Our results show a trend toward dilatation of the aortic neck and iliac arteries, with no correlation between the two levels, even in patients with a regression of the aneurysm sac during follow-up. Although this study found no correlation with the occurrence of endoleaks, our results suggest the need for a longer follow-up, especially on the landing sites.

Stretched reconstruction based on 2D freehand ultrasound for peripheral artery imaging.

PURPOSE: Endovascular revascularization is becoming the established first-line treatment of peripheral artery disease (PAD). Ultrasound (US) imaging is used pre-operatively to make the first diagnosis and is often followed by a CT angiography (CTA). US provides a non-invasive and non-ionizing method for the visualization of arteries and lesion(s). This paper proposes to generate a 3D stretched reconstruction of the femoral artery from a sequence of 2D US B-mode frames. METHODS: The proposed method is solely image-based. A Mask-RCNN is used to segment the femoral artery on the 2D US frames. In-plane registration is achieved by aligning the artery segmentation masks. Subsequently, a convolutional neural network (CNN) predicts the out-of-plane translation. After processing all input frames and re-sampling the volume according to the vessel's centerline, the whole femoral artery can be visualized on a single slice of the resulting stretched view. RESULTS: 111 tracked US sequences of the left or right femoral arteries have been acquired on 18 healthy volunteers. fivefold cross-validation was used to validate our method and achieve an absolute mean error of 0.28 ± 0.28 mm and a median drift error of 8.98%. CONCLUSION: This study demonstrates the feasibility of freehand US stretched reconstruction following a deep learning strategy for imaging the femoral artery. Stretched views are generated and can give rich diagnosis information in the pre-operative planning of PAD procedures. This visualization could replace traditional 3D imaging in the pre-operative planning process, and during the pre-operative diagnosis phase, to identify, locate, and size stenosis/thrombosis lesions.

The Use of "Tail-Pedometers" to Evaluate the Impact of Dipterans in Feeder Cattle.

Hematophagous flies are a pest for livestock; their direct impact reduces productivity, and they are vectors of parasites, bacteria and viruses. Their control using insecticides is inefficient and highly polluting. The validation of new control tools requires efficacy and cost-effectiveness evaluation. The quantification of hematophagous insects' impact in livestock is a challenging prerequisite. Tail flicks counts can reliably evaluate fly-burden; however, visual records are tedious and time-consuming. In the present study, automation of tail flick counts was made through the use of pedometers attached to the tail, in two groups of feeder cattle. Group A was kept in a pen under the protection of a mosquito net, and Group B was kept in an open-air pen. The fly density of Group B was evaluated using fly traps. The apparent density per trap ranged from 130 to 1700 in the study. The mean pedometer records per 24 h ranged from 957+/-58 bits in Group A to 11,138+/-705 bits in Group B. The night/day records observed in Group A (200/800 bits) were drastically increased in Group B (1000-4000/4000-14,000 bits) and variable along seasons. A very high correlation was observed between fly density and visual records or pedometer records (PR). Two-hour PRs proved to be a reliable predictive tool for fly density. Moreover, the pedometers revealed an unsuspected but significant nuisance of mosquitoes, which should be thoroughly investigated.

Numerical simulation of fenestrated graft deployment: Anticipation of stent graft and vascular structure adequacy.

Fenestrated endovascular aneurism repair (FEVAR) is a minimally invasive technique, and its success depends on the adequacy of the correspondence between the visceral arteries ostia and position of the fenestrations of the stent graft (SG) during its deployment in juxtarenal aneurisms. However, the fenestration position is generally determined from a preoperative computerised tomography (CT) scan, without considering the vascular deformation induced by the insertion of the endovascular tools. Catheterisation difficulties may occur during clinical procedures. Accordingly, the objective of this work is to present an initial proof of concept aimed at anticipating and optimising the position of the fenestrations, while considering the vascular deformation induced by the insertion of the endovascular tools. The proposed method relies on the finite element method to simulate the SG deployment in a vascular structure (VS), and considers the vascular deformation induced by the tools. After determining the optimal simulation parameters for a patient-specific case, the robustness of the method is demonstrated on six other representative anatomies. The simulated SG is also compared with post-deployment CT observations, and demonstrates good adequacy. The results show that the numerically corrected fenestration positions, as determined from the simulated results following the insertion of the endovascular tools, deviate from those of the standard plan (as determined from the preoperative CT scan). This indicates that the SG-VS adequacy could be improved via simulation-based planning, to anticipate potential catheterisation difficulties.

Influence of balloon design, plaque material composition, and balloon sizing on acute post angioplasty outcomes: An implicit finite element analysis.

In this work we propose a generic modeling approach for simulating percutaneous transluminal angioplasty (PTA) endovascular treatment, and evaluating the influence of balloon design, plaque composition, and balloon sizing on acute post-procedural outcomes right after PTA, without stent implantation. Clinically-used PTA balloons were classified into two categories according to their compliance characteristics, and were modeled correspondingly. Self-defined elastoplastic constitutive laws were implemented within the plaque and artery models, after calibration based on experimental and clinical data. Finite element method (FEM) implicit solver was used to simulate balloon inflation and deflation. Besides balloon profile at max inflation, results are mainly assessed in terms of the elastic recoil ratio (ERR) and lumen gain ratio (LGR) obtained immediately after PTA. No variations in ERR nor LGR values were detected when the balloon design changed, despite the differences observed in their profile at max inflation. Moreover, LGR and ERR inversely varied with the augmentation of calcification level within the plaque (-11% vs. +4% respectively, from fully lipidic to fully calcified plaque). Furthermore, results showed a direct correlation between balloon sizing and LGR and ERR, with noticeably higher rates of change for LGR (+18% and +2% for LGR and ERR respectively for a calcified plaque and a balloon pressure increasing from 10 to 14 atm). However a larger LGR comes with a higher risk of arterial rupture. This proposed methodology opens the way for evaluation of angioplasty balloon selections towards clinical procedure optimization.

Sizing for endovascular aneurysm repair: clinical evaluation of a new automated three-dimensional software.

BACKGROUND: To assess the reproducibility and accuracy of the sizing procedure before aortic endograft implantation using new sizing automated software as compared with standard radiological procedures. METHODS: On the basis of original spiral-computed tomography images, the sizing of 32 patients with abdominal aortic aneurysm treated by endovascular aneurysm repair (EVAR) was retrospectively compared. The first sizing was performed by a radiologist using a standard workstation (General electrics) and software (Advanced vessel analysis). The second was performed twice by two surgeons using a personal computer with automatic three-dimensional sizing software (Endosize; Therenva, Rennes, France). All diameters and lengths required before EVAR were measured (17 items). Moreover, 13 qualitative criteria regarding EVAR feasibility, including neck length, were compared. Intra- and interobserver variability with Endosize, as well as the variability between the two measurement methods were analyzed using the intraclass correlation coefficient (ICC) and Bland and Altman's method. Qualitative variables were analyzed using Fischer's exact test and kappa coefficient. RESULTS: Intraobserver variability with Endosize proved to be efficient. None of the ICCs were lower than 0.9, and more than 90% of the absolute differences between two measurements were less than 2 mm. Interobserver variability with Endosize was assessed in a similar manner. Measurement variability of vessel diameters was less marked than that of vessel lengths. This trend was observed for all datasets. Comparison of the two measurement methods demonstrated a good correlation (minimum ICC = 0.697; maximum ICC = 0.974), although less so than that observed using Endosize. Mean time consumption using Endosize was 13.1 ± 4.53 minutes (range: 7.2-32.7). Analysis of the alarm sets demonstrated a high agreement between observers (kappa coefficient = 0.81). CONCLUSIONS: Sizing using the Endosize software is as reliable as conventional radiological procedures. Sizing by surgeons using an automated, user-friendly, and mobile tool appears to be reproducible.