Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR.

OBJECTIVES: This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). METHODS: Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. RESULTS: Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% (n = 7) and 33.3% (n = 18) (p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 (p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 (p = .978). Median radiation exposure due to CBCT was 7 Gy cm(2) (5.25-8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8-47.3) and 11 (5-20.5) mSv, and 184 (150-240) and 91 (70-132.8) mL respectively (reduction of 68% and 50%, p < .001). CONCLUSIONS: Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

Computed tomography for pulmonary embolism: assessment of a 1-year cohort and estimated cancer risk associated with diagnostic irradiation.

BACKGROUND: The principal concern of any radiation exposure in computed tomography (CT) is the induction of stochastic risks of developing a radiation-induced cancer. The results given in this manuscript will allow to (re-)calculate yield of chest CT. PURPOSE: To demonstrate a method to evaluate the lifetime attributable risk (LAR) of cancer incidence/mortality due to a single diagnostic investigation in a 1-year cohort of consecutive chest CT for suspected pulmonary embolism (PE). MATERIAL AND METHODS: A 1-year cohort of consecutive chest CT for suspected PE using a standard scan protocol was analyzed retrospectively (691 patients, 352 men, 339 women). Normalized patient-specific estimations of the radiation doses received by individual organs were correlated with age- and sex-specific mean predicted cancer incidence and age- and sex-specific predicted cancer mortality based on the BEIR VII results. Additional correlation was provided for natural occurring risks. RESULTS: LAR of cancer incidence/mortality following one chest CT was calculated for cancer of the stomach, colon, liver, lung, breast, uterus, ovaries, bladder, thyroid, and for leukemia. LAR remains very low for all age and sex categories, being highest for cancer of the lungs and breasts in 20-year-old women (0.61% and 0.4%, respectively). Summation of all cancer sites analyzed raised the cumulative relative LAR up to 2.76% in 20-year-old women. CONCLUSION: Using the method presented in this work, LAR of cancer incidence and cancer mortality for a single chest CT for PE seems very low for all age groups and both sexes, but being highest for young patients. Hence the risk for radiation-induced organ cancers must be outweighed with the potential benefit or a treatment and the potential risks of a missed and therefore untreated PE.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]. / Recommandations pratiques pour le diagnostic et la prise en charge de la fibrose pulmonaire idiopathique ­ Actualisation 2021. Version intégrale.

BACKGROUND: Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS: Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS: After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION: These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, short version]. / Recommandations pratiques pour le diagnostic et la prise en charge de la fibrose pulmonaire idiopathique ­ Actualisation 2021. Version courte.

BACKGROUND: Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated. METHODS: Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale. RESULTS: After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis. CONCLUSION: These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients.

The aim of the present study was to describe angiographic findings and embolisation results in smokers with haemoptysis. We retrospectively reviewed the clinical data and angiographic findings from 35 patients with smoking-related bronchopulmonary disease and no associated comorbidity, who were referred for embolisation for mild (n = 6), moderate (n = 14) and severe (n = 15) haemoptysis. Spirometric classification subdivided our population into: 16 patients with chronic bronchitis but no airflow limitation; and 19 patients with chronic obstructive pulmonary disease (COPD) (stage I: n = 12; stage II: n = 5; stage III: n = 2). Bronchoscopy depicted focal submucosal vascular abnormalities in three patients and only endobronchial inflammation in 32 (91%) patients. Bronchial artery angiography revealed moderate (n = 18) or severe (n = 10) hypervascularisation in 28 (80%) patients, and normal vascularisation in seven (20%). No statistically significant difference was observed between the angiographic findings and the severity of COPD, tobacco consumption or the amount of bleeding. Cessation of bleeding was obtained by embolisation in 29 out of the 34 technically successful procedures (85%), requiring surgery in three out of five patients with recurrence. Follow-up (mean duration 7 yrs) demonstrated no recurrence of bleeding in 32 (94%) out of 34 patients and excluded late endobronchial malignancy. Smokers with various stages of COPD severity may suffer from haemoptysis that is efficiently treatable by endovascular treatment.

[CT features of right heart involvement in thoracic diseases]. / Sémiologie des atteintes du coeur droit en pathologie pulmonaire.

Numerous respiratory disorders may be responsible for right heart dysfunction, frequently suboptimally assessed in routine clinical practice. Multidetector-row CT systems with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artifacts, enabling improved evaluation of the heart. Moreover, the introduction of fast rotation speed and dedicated cardiac reconstruction algorithms exploiting the multislice acquisition scheme of the data has opened the possibility of integrating right cardiac functional information into a diagnostic CT scan of the chest, without or with ECG gating.

[Gadolinium-enhanced thoracic CTA: retrospective analysis of image quality and tolerability in 45 patients evaluated prior to the description of nephrogenic systemic fibrosis]. / Angioscanographie thoracique au gadolinium en TDM multicoupe du thorax: analyse rétrospective de la qualité image et de la tolérance chez 45 patients évalués antérieurement à la description de la fibrose systémique néphrogénique.

PURPOSE: To assess the accuracy and torerability of gadolinium-enhanced thoracic CTA using a 64 MDCT compared to a 16 MDCT. Because this study was started prior to the description of NSF, particular attention was paid to long-term follow-up of the patient population. MATERIALS AND METHODS: The study protocol was approved by the ethics committee of our institution and informed consent was obtained from all patients. Fourteen patients (Group 1) (9 males and 5 females; mean age: 64.3 years) with contraindication to the administration of iodinated contrast material underwent thoracic CTA (collimation: 32 x 2 x 0.6 mm; pitch: 1.2) with gadolinium administration (0.5 mml/ml) at 0.4 mmol/kg injected at 6 ml/sec with evaluation of clinical and biological tolerability of the gadolinium based contrast agent. Results from this patient population were compared to results from a population of 31 patients (21 males; 10 females; mean age: 63.2 years) (Group 2) imaged on a 16 MDCT. All patients were folloowed-up for a mean time of 22.6 months. RESULTS: Using a mean contrast volume (standard deviation) that was not significantly different (Group 1: 54.8+/-11 ml; Group 2: 53.4+/-6.9 ml) (p=0.94), patients in Group 1 underwent complete thoracic CTA whereas patients in Group 2 underwent CTA of only the middle third of the thoracic region. All CTA examinations were diagnostic for Group 1 and Group 2 patients; however, evaluation of subsegmental vessels was possible in a significantly larger proportion of patients in Group 1 (10/14; 72%) compared to Group 2 (6/31; 19%) (p=0.003). Mean attenuation values within pulmonary arterial branches were similar for Groups 1 and 2 (central arteries: 194.5+/-51.3 HU vs 180.6+/-53.8 HU; p=0.38) (lobar arteries: 208.5+/-52.5 HU vs 189.9+/-60.1 HU; p=0.33) (segmental arteries: 220.4+/-50.4 HU vs 201.5+/-54.7 HU; p=0.42). Transient alteration of renal function was recorded in one patient from Group 1 with severe pre-existing chronic renal failure. No change in renal function was observed for Group 2 patients. No case of NSF was reported in patients with pre-existing renal failure at the time of enrollment. CONCLUSION: The use of gadolinium-based contrast agent for thoracic CTA using a 64 MDCT provides diagnostic quality examinations in all patients with improved image quality compared to a 16 MDCT. No complication other than transient alteration of renal function was observed. Because the likelihood of developing NSF may vary with the type of gadolinium-based contrast agent used, the least toxic agent should be used.

[Protein-losing enteropathy revealing an idiopathic constrictive pericarditis]. / Entéropathie exsudative révélant une péricardite chronique constrictive idiopathique.

INTRODUCTION: The cause of protein-losing enteropathy is sometimes difficult to establish. It can be rarely due to a constrictive pericarditis. EXEGESIS: We report a patient presenting a protein-losing enteropathy revealing a constrictive pericarditis. CONCLUSION: Chronic pericarditis should be evoked in case of unexplained protein-losing enteropathy. Echocardiography can sometimes be normal. Therefore, chest computed tomography scan or cardiac MRI followed by confirmation right heart catheterization should be performed in case of persistent unexplained protein-losing enteropathy.

[Idiopathic pulmonary fibrosis and right-to left shunt by patent foramen ovale]. / Fibrose pulmonaire idiopathique et shunt droit-gauche par foramen ovale perméable: amélioration clinique et gazométrique après fermeture percutanée.

INTRODUCTION: The association between idiopathic pulmonary fibrosis and patent foramen ovale has rarely been described. OBSERVATION: We report the cases of two patients, 72 and 59 years old, who presented with refractory hypoxemia in the context of pulmonary fibrosis. The hypoxemia was due to a right-to-left shunt through a patent foramen ovale (PFO), diagnosed by transoesophageal contrast echocardiography. The closure of the PFO allowed a decrease in the oxygen requirement in the first case: from 8 l/min to 3 l/min (PaO2 80 mmHg), and in the second case oxygen therapy could be stopped (PaO2 76 mmHg on room air). Right-to left shunts by PFO are usually associated with pulmonary arterial hypertension (systolic pulmonary arterial pressure at 70 mmHg for case 1), but in some cases the pulmonary artery pressure is normal (case 2), the shunt being due to an anatomical conformation. CONCLUSION: These two cases underline the importance of diagnosing right-to-left shunts in patients who have pulmonary fibrosis with severe hypoxemia, in order to reduce their oxygen needs.

CT pulmonary angiogram with 60% dose reduction: Influence of iterative reconstructions on image quality.

GOALS: To compare the quality of low-dose CT images with sinogram affirmed iterative reconstruction (SAFIRE), and full-dose CT with filtered back projection reconstructions (FBP). MATERIALS AND METHODS: Fifty pulmonary CT performed by a dual-source technique (120kVp; 110mAs) with (a) the same energy in both tubes, and (b) the distribution of reference mAs with 40% in tube A (44mAs) and 60% in tube B (66mAs). Each acquisition allowed reconstruction of: (a) full-dose images (with both tubes) with FBP reconstructions (group 1); and (b) low-dose images (from tube A) reconstructed with SAFIRE (group 2). RESULTS: Group 2 images presented: (a) a significant objective reduction in noise measured in the trachea on mediastinal (16.04±5.66 vs 17.66±5.84) (P=0.0284) and pulmonary (29.77±6.79 vs 37.96±9.03) (P<0.0001) images; (b) a similar subjective perception of noise and overall image quality (P=1), which was considered to be excellent in 66% (33/50) of the cases, with no influence on the detection of elementary pulmonary lesions of infiltration (98.4%; 95% CI=[96.9%-99.9%]). CONCLUSION: Despite a 60% reduction in radiation dose, the image quality with iterative reconstruction is objectively better and subjectively similar to full-dose FBP images.

Respiratory involvement in relapsing polychondritis. Clinical, functional, endoscopic, and radiographic evaluations.

Although respiratory involvement occurs in 50% of patients with relapsing polychondritis (RP) and augurs a poor prognosis, few previous studies have provided complete descriptions of respiratory tract involvement. For this reason, we investigated the respective role of clinical, functional, endoscopic, and radiographic (computed tomography [CT]) examinations in 9 consecutive patients with RP and lower respiratory tract localization. All exhibited cough, dyspnea, and wheezing. Eight had a nonreversible obstructive pattern with a marked decrease of the maximal flow ratio at 75% and 25% of vital capacity. Rotman functional criteria were evaluated to differentiate upper from lower respiratory tract involvement; they were consistent with the results of other examinations in 4/9 cases. Endoscopic examination showed moderate to severe inflammation in 8/9 patients; tracheal stenosis was present in 6/9 patients, bronchial stenosis in 4/9 patients, and tracheal collapse in 7 cases. CT showed tracheal stenosis in 8/9 patients (diffuse, 7; localized, 1) and bronchial stenosis in 6/9 patients. Tracheobronchial wall thickening and/or calcifications were observed in 7 cases. Clinical symptoms are of poor specificity for defining respiratory involvement precisely, although degree of dyspnea is correlated to the decrease in forced expiratory volume in 1 second (FEV1). Functional criteria were helpful in evaluating the obstructive ventilatory defect but did not differentiate, in most cases, the respective part of lower and upper respiratory involvement when using Rotman criteria. Compared to CT findings, endoscopic examination failed to identify tracheal and bronchial stenosis and tracheal wall alterations at an early stage of the disease. In our series CT appears to be a reliable method to identify tracheal and bronchial involvement and can be repeated safely during the course of the disease.

The "adult" form of the scimitar syndrome.

One hundred twenty-two cases of the adult form of the scimitar syndrome were collected from different cardiologic centers. The clinical, radiographic and hemodynamic findings are described. The scimitar syndrome is defined as an anomalous right pulmonary venous drainage, partial or complete, to the inferior vena cava. Additional characteristics of this syndrome such as hypoplasia and abnormalities of the vascular supply to the right lung, dextrocardia and abnormalities of the bronchial segmentation are common; bronchiectases are rare. The left to right shunt was less than 50% in 100 of the 122 patients. The pulmonary arterial pressures were normal in 94 patients and slightly elevated in 28. A follow-up study of these patients showed that, without surgical correction, they lead a normal life. An awareness of this syndrome may avoid unnecessary invasive diagnostic procedures and surgical treatment for most patients.

Right-to-left shunting through a patent foramen ovale without pulmonary hypertension. Transient improvement after balloon catheter closure.

A patient had a history of right tuberculosis and severe hypoxemia secondary to right-to-left shunting through a patent foramen ovale without pulmonary hypertension. A balloon tip catheter was positioned in the left atrium and retracted against the atrial septum and the hypoxemia was temporarily resolved.

Bronchial arteries in the pig before and after permanent pulmonary artery occlusion.

RATIONALE AND OBJECTIVES: The authors study the bronchial arteries in the adult pig before and after pulmonary artery occlusion. METHODS: The bronchial artery anatomy was analyzed on postmortem aortograms in six pigs in group 1. In 20 animals in group 2, the left diaphragmatic lobar pulmonary artery (DLPA) was proximally (n = 12), medially (n = 5), or distally (n = 3) occluded via angiographic procedures; an unintentional embolization of coils in the right DLPA led to an incomplete pulmonary arterial occlusion. Eight to 12 weeks later, postmortem bronchial angiograms and pathologic studies were performed systematically in group 2. RESULTS: Outcomes in group 1 were: (A) a common trunk to the right and left bronchial arteries found in five animals, and (B) bronchopulmonary anastomoses found in the five lungs optimally injected. Outcomes in group 2 were: (A) the absence of pulmonary infarct and the development of a collateral bronchial supply were constant in the left lung; (B) the left DLPAs were patent beyond the coils and opacified via bronchopulmonary anastomoses; (C) dilated subpleural bronchial arteries were constant in the interlobular septa of the lung parenchyma devoid of pulmonary arterial perfusion; (D) the right bronchial arteries were normal after incomplete pulmonary artery occlusion. CONCLUSIONS: Because of an anastomosed dual circulation, the pig is a reliable experimental model for interventional and surgical procedures.

Computed tomographic evaluation of silicosis and coal workers' pneumoconiosis.

The introduction of computed tomography (CT) has modified the radiologic approach to silicosis and coal worker's pneumoconiosis considerably, allowing earlier recognition and more precise characterization of pulmonary abnormalities than chest radiography. An optimal approach to CT recognition requires an understanding of the main physiologic and pathologic features that are known to occur in both pneumoconioses. This report focuses on the most common CT features of simple and complicated forms of silicosis and coal worker's pneumoconiosis as well as on the optimal scanning protocol. The respective roles of chest radiographs and CT scans in the recognition of pneumoconiosis and follow-up of exposed workers are discussed.

The "horseshoe" lung: six new cases.

Six cases of horseshoe lung have been found in a group of 147 scimitar syndrome cases collected in a cooperative multicenter study. These cases were associated either with the severe infantile or with the benign adult form of the scimitar syndrome. The aim of this paper is to describe the clinical and imaging signs as well as the prognosis of 6 new cases of horseshoe lung in association with scimitar syndrome. The authors conclude (1) that the diagnosis of horseshoe lung may be strongly suspected on standard chest radiographs and confirmed by thoracic CT scan; (2) that the prognosis of scimitar syndrome does not seem to be worse when associated with horseshoe lung.

Computed tomography assessment of ground-glass opacity: semiology and significance.

Among the computed tomography (CT) signs of parenchymal lung disease, the ground-glass pattern is the one most difficult to diagnose and most influenced by CT technique. Ground-glass opacity may result from changes in the airspaces or interstitial tissues in acute or chronic infiltrative lung disease. It may also be seen as a consequence of increased capillary blood volume in redistribution of blood flow due to airway disease, emphysema, or pulmonary thromboembolism. Definition of this sign on high-resolution CT (HRCT) images, its various HRCT patterns, and potential pitfalls in its recognition are described with special attention to optimal HRCT technique.

Multidimensional imaging of the thorax: practical applications.

Over the past decade, faster CT scan times, thinner collimation, and the development of multirow detectors, coupled with the increasing capability of computers to process large amounts of data in short periods of time, have lead to an expansion in the ability to create diagnostically useful two-dimensional (2D) and three-dimensional (3D) images within the thorax. Applications within the thorax include, but are not limited to, evaluation of pulmonary and systemic vasculature, evaluation of the tracheobronchial tree, and delineation of diffuse lung disease. Pulmonary nodule volume and growth can be more accurately predicted, and represents an improvement in the evaluation of the solitary pulmonary nodule. Multiplanar images increase our understanding of thoracic anatomy and can help to guide bronchoscopic procedures. Because there are strengths and weaknesses to all the reconstruction algorithms, the utility of any given technique is dependent on the clinical question to be answered. For instance, although maximum intensity projection imaging (MIP) is helpful in the evaluation of micronodular lung disease, it is of little value in the diagnosis of aortic dissection. As the ability to generate faster and more precise multidimensional images grow, the demand for such imaging is likely to increase. In this review, the authors discuss the various reconstruction techniques available, followed by a discussion of the clinical applications.