Provisional focal stenting of complex femoropopliteal lesions using the Multi-LOC multiple stent delivery system - 12-month results from the LOCOMOTIVE EXTENDED study.

Background: This study aimed to evaluate a Multiple Stent Delivery System for provisional focal stenting of the femoropopliteal artery. Patient and methods: The LOCOMOTIVE EXTENDED study (Multi-LOC for flOw liMiting Outcomes after plain old balloon angioplasty and/or drug-coated balloon Treatment in the infrainguinal position with the objectIVE to implant multiple stent segments) is a prospective, single-arm, multicentre observational study. The Multi-LOC Multiple Stent Delivery System (B.Braun, Melsungen, Germany) was used for provisional focal stenting of the femoropopliteal artery. We enrolled 357 patients with 449 femoropopliteal lesions; all had flow-limiting dissections or recoil following angioplasty. Eligibility included Rutherford classification 2 to 5 with a de novo or non-stented restenotic femoropopliteal lesion undergoing plain balloon or drug-coated balloon angioplasty. The 6- and 12-month efficacy endpoints encompassed target lesion revascularisation and primary patency rates. Results: The mean patient age was 71 ± 10 years. The mean lesion length was 16.0 ± 9.7 cm; 44.5% were TASC II C/D lesions and 31.4% were chronic total occlusions. By operator choice, 45% of the patients underwent drug-coated balloon angioplasty. On average, 4.0 stents (each 13 mm long) were placed in each lesion, resulting in a scaffolding proportion of 56% of the total lesion length with a technical success rate of 98.3%. At 6 and 12 months, the freedom from clinically driven target lesion revascularisation was 95.5% and 88.7% and the primary patency rates were 88.7% and 82.3%, respectively. At 12 months, significant improvements were noted in Rutherford categories and ankle-brachial indices. In multiple regression analyses, both diabetes mellitus and no distal run-off vessel showed a trend toward worse TLR, while other factors such as DCB predilation or the lesion length were not predictive. Conclusions: The LOCOMOTIVE EXTENDED study demonstrated the safety and efficacy of the Multi-LOC stent system for focal provisional stenting of complex femoropopliteal lesions.

Coronary Artery Fistula Unmasking the Absence of Left Pulmonary Artery in an Adult.

Coronary artery fistulae are an incidental finding in patients undergoing coronary angiography or computed tomography (CT) coronary angiography. A 60-year-old man with known coronary artery disease presented with dyspnea. Coronary angiography revealed a large fistula arising from the circumflex artery (CX) without a clear intrathoracic target vessel or chamber in the heart. CT angiography revealed the agenesis of the left pulmonary artery. The fistula arising from the CX ensured left lung tissue supply. Unilateral absence of a pulmonary artery is an extremely rare condition. In this case, the identification of a fistula from the heart triggered the correct diagnosis.

The Application of Fluorescence Optical Imaging in Systemic Sclerosis.

OBJECTIVE: The aim of this study was to visualize soft tissue inflammation using FOI on patients with Systemic Sclerosis (SSc) characterized by SSc-related Raynaud's phenomenon and to detect the therapeutic response to treatment with iloprost or alprostadil. METHODS: Twenty-one patients with SSc and Raynaud's phenomenon and twenty-six healthy controls were prospectively included. The SSc patients were intravenously treated with iloprost or alprostadil over seven days. FOI was performed at baseline and after seven days using an intravenous application of indocyanine green (ICG). The hands were divided into nineteen segments per hand. All segments were quantitatively evaluated to determine changes in ICG. RESULTS: The sensitivity and specificity of FOI in the detection of ICG enhancement in patients with SSc were 95% versus 96%. At baseline, 31.5% hand segments showed ICG enhancement. After seven days of either iloprost or alprostadil therapy a significant reduction in the ICG was observed which ranged from 40.9% to 24.7%. CONCLUSION: The study demonstrates that the FOI technique is able to visualize soft-tissue inflammation with both high sensitivity and specificity. The anti-inflammatory therapeutic effects of iloprost were slightly stronger than alprostadil. FOI offers promising benefits in the diagnosis and therapy of patients with SSc-associated Raynaud's phenomenon.

Is there a role for Digital X-ray Radiogrammetry as surrogate marker for radiological progression and imaging of structural integrity in rheumatoid arthritis?

INTRODUCTION: The established scoring techniques based on radiographs present limitations in the evaluation of structural integrity due to high effectiveness of innovative therapeutic strategies. The aim of this study was to evaluate the periarticular mineralisation as detected by Digital X-ray Radiogrammetry (DXR) as surrogate marker for structural integrity during the course of rheumatoid arthritis (RA). METHODS: 11 centers throughout Germany contributed data of 94 patients with verified RA. The patients were treated with leflunomide or methotrexate during a mean observation period of 22 months. All patients underwent complete computerized calculations of bone mineral density (BMD) and metacarpal index (MCI) by DXR using digitized hand radiographs. The radiological assessment of disease progression was estimated by the Sharp Score. RESULTS: The Sharp Score revealed no significant change during the study period. DXR-BMD revealed minimal decrease of -1.4 % (leflunomide group) versus a higher reduction of -4.3 % (methotrexate group). Regarding DXR-MCI, a reduction of -2.2 % (leflunomide group) and -4.9 % (methotrexate group) was observed. CONCLUSION: Quantitative data of hand bone mass estimated by the presented DXR-technique may be a complementary precise tool in the identification of RA-related radiographic changes and in the assessment of structural integrity.

Influence of angulation on metacarpal bone mineral density measurements using digital X-ray radiogrammetry.

OBJECTIVE: Digital X-ray radiogrammetry (DXR) is a computer-assisted technique used to quantify cortical bone density of the metacarpals. The influence of metacarpal bone rotation and type of cast material on bone mineral density (BMD) measurements using the DXR technique was tested. METHODS: The bone mineral density of the hand was measured by DXR, and rotation error (DXR-RE) as coefficients of variation were calculated, to verify reliability and reproducibility of this radiogeometric technique to assess in particular minor disease-related changes in the metacarpal bone mass. The reproducibility of the DXR measurements was also investigated using different cast materials (mull, elastic, and plastic). RESULTS: There were no significant changes in absolute values of DXR-BMD observed between 0 to [Formula: see text] angulation. The relative DXR-RE ranged between 0 % (degree 1) and 0.70 % (degrees 15 and 19) for DXR-BMD. Regarding the different cast materials, DXR-BMD revealed a coefficient of variation with 0.41 % (mull cast) and 0.21 % (elastic cast). For the plastic cast, the DXR technique was not able to perform an analysis of DXR-BMD. CONCLUSION: The study revealed no significant influence of metacarpal rotation on the measurements of metacarpal bone mineral density as estimated by DXR. DXR measurements are not optimal when cast material is used. DXR can accurately quantify periarticular cortical bone mass. This is significant especially for rheumatoid arthritis and related conditions where X-ray imaging of arthritic hands with varying degrees of deformity is performed.

Detection and classification of different liver lesions: comparison of Gd-EOB-DTPA-enhanced MRI versus multiphasic spiral CT in a clinical single centre investigation.

OBJECTIVE: To compare the diagnostic efficacy of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) vs. multidetector computed tomography (MDCT) for the detection and classification of focal liver lesions, differentiated also for lesion entity and size; a separate analysis of pre- and postcontrast images as well as T2-weighted MRI sequences of focal and exclusively solid lesions was integrated. METHODS: Twenty-nine patients with 130 focal liver lesions underwent MDCT (64-detector-row; contrast medium iopromide; native, arterial, portalvenous, venous phase) and MRI (1.5-T; dynamic and tissue-specific phase 20 min after application of Gd-EOB-DTPA). Hepatic lesions were verified against a standard of reference (SOR). CT and MR images were independently analysed by four blinded radiologists on an ordinal 6-point-scale, determining lesion classification and diagnostic confidence. RESULTS: Among 130 lesions, 68 were classified as malignant and 62 as benign by SOR. The detection of malignant and benign lesions differed significantly between combined and postcontrast MRI vs. MDCT; overall detection rate was 91.5% for combined MRI and 80.4% for combined MDCT (p<0.05). Considering all four readers together, combined MDCT achieved sensitivity of 66.2%, specificity of 79.0%, and diagnostic accuracy of 72.3%; combined MRI reached superior diagnostic efficacy: sensitivity 86.8%, specificity 94.4%, accuracy 90.4% (p<0.05). Differentiated for lesion size, in particular lesions <20mm revealed diagnostic benefit by MRI. Postcontrast MRI also achieved higher overall sensitivity, specificity, and accuracy compared to postcontrast MDCT for focal and exclusively solid liver lesions (p<0.05). CONCLUSION: Combined and postcontrast Gd-EOB-DTPA-enhanced MRI provided significantly higher overall detection rate and diagnostic accuracy, including low inter-observer variability, compared to MDCT in a single centre study.

Magnetic resonance venography of the upper venous system with blood pool contrast agent: comparison of two different T1-weighted sequences.

OBJECTIVE: Image quality of gadofosveset trisodium-enhanced magnetic resonance venography (MRV) of the upper extremities was evaluated. MATERIAL AND METHODS: Imaging was performed using a 3D Fast Low Angle Shot gradient recalled echo sequence (3D FLASH) and 3D gradient echo Volumetric Interpolated Breath-hold Examination with fat suppression (3D VIBE FS). Image quality was evaluated by two raters. RESULTS: 3D FLASH sequences demonstrated good image quality for depiction of the central venous system; 3D VIBE FS sequences showed good image quality for peripheral veins. CONCLUSION: MRV using Gadofosveset trisodium enables good quality depiction of the venous system of the upper extremities.

Joint damage in rheumatoid arthritis: assessment of a new scoring method.

INTRODUCTION: The aim of this study was to assess a novel approach for the quantification of finger joint space narrowing and joint destruction in patients with rheumatoid arthritis (RA) focusing on the peripheral hand articulations. METHODS: A total of 280 patients with verified RA underwent computerized semi-automated measurements of joint space distance at the finger articulations based on radiographs. The Z-Score, which can differentiate between joint space alterations caused by RA versus age/gender-related changes, was calculated as a comparative parameter. The severity of joint space narrowing was also quantified by the Sharp Score. Sensitivity and specificity of the Z-Score (based on joint space widths differentiated for each peripheral finger joint) were evaluated to reveal the potential for the occurrence of erosions. Additionally, the potential of the Z-Score regarding the differentiation of therapeutic effects on joint space widths in patients under a therapy of methotrexate versus leflunomide was performed. RESULTS: The Z-Scores of finger articulations in patients with RA were generally decreased. Metacarpal-phalangeal (MCP) joint articulations showed a continuous significant decline of -1.65±0.30 standard deviations dependent on the Sharp Score. The proximal-interphalangeal joints also revealed a significant reduction of the Z-Score (-0.96±0.31 standard deviations). The sensitivity and specificity of MCP joint space distance for the detection of erosions were 85.4% versus 55.2%. The Sharp Score for joint space narrowing was not able to detect different treatments, whereas an accentuated stabilization of joint space narrowing could be identified for the Z-Score of the MCP joints in patients treated with leflunomide and methotrexate. CONCLUSION: The Z-Scoring method based on computer-aided analysis of joint space widths was able to reliably quantify severity-dependent joint space narrowing in RA patients. In the future, calculation of a Z-Score based on gender-specific and age-specific reference data shows the potential for a surrogate marker of RA progression that comprehends the early identification of patients with RA, and in particular those with erosive course of the disease, enabling a timely therapeutic strategy for cartilage protection.

The role of first-pass perfusion deficit in the detection of cardiac subendocardial manifestation in patients with autoimmune vasculitis.

This report describes the potential of cardiac magnetic resonance imaging (cMRI) based on myocardial first-pass perfusion imaging in the visualization of cardiac manifestations in autoimmune vasculitis, which in the heart are typically localized at the level of small subendocardial vessels. Two patients with primary or secondary autoimmune vasculitis were investigated in this study. Myocardial first-pass perfusion imaging was performed using an ECG-gated T1-weighted MRI sequence after the injection of intravenous bolus of gadolinium chelate. In both cases, the cMRI showed findings of subendocardial first-pass perfusion deficit (FPPD), a phenomenon so far described as microvascular obstruction (MVO) only in patients with acute cardiac infarction due to thromboembolic obstruction of small myocardial vessels. The two patients showed local subendocardial and myocardial hypoenhancement (characterized by a darker appearance than normal myocardial tissue), which is the typical morphological stigma of FPPD initially after injection of contrast media. The perfusion deficit, although morphologically very similar to the well-known phenomenon of MVO in acute cardiac infarction, was conceivably caused by different vasculitis-specific mechanisms such as occlusion of the microvasculature with erythrocytes, neutrophils and cellular debris. This study indicates that FPPD is useful for the non-invasive assessment of the microvasculature in patients with acute cardiac involvement in primary and secondary vasculitis.

The usefulness of computer-aided joint space analysis in the assessment of rheumatoid arthritis.

OBJECTIVE: Computer-aided joint space analysis (CAJSA) is a newly developed technique for the measurement of radiogeometrically detectable joint space widths of the metacarpal-phalangeal (JSD-MCP) and proximal-interphalangeal articulations (JSD-PIP). The aim of this study was to verify the sensitivity and specificity of these CAJSA measurements in the assessment of established RA. METHODS: Four hundred and fifty-eight participants (248 healthy subjects, 210 RA patients) underwent computerized semi-automated measurements of the JSD-MCP and JSD-PIP articulations (CAJSA, Radiogrammetry Kit, Version 1.3.6) based on digitally performed radiographs. The Sharp joint space narrowing score was also performed to determine RA-related joint space narrowing. RESULTS: The significant severity-dependent reduction for JSD-MCP was -44.0% and for JSD-PIP, -25.94% between Sharp scores 0 and 3. The sensitivity and specificity of JSD-MCP (total) was 88.1% versus 77.8%, respectively (AUC = 0.920; P < 0.001). Furthermore, JSD-PIP (total) revealed a lower sensitivity and specificity with 61.4% and 88.7% (AUC = 0.878; P < 0.001). CONCLUSION: The CAJSA method presented a reliable assessment of disease-related joint space narrowing in patients suffering from RA with excellent sensitivity and specificity. By providing quantitative data, other scoring methods could be significantly improved, and thereby the accuracy of the diagnosis and a better therapeutic evaluation could be achieved.

Quantitative first pass perfusion in cardiovascular magnetic resonance for determination of peak ventricular transit time--a technique for evaluation of heart function.

BACKGROUND: The aim of this study was to determine peak ventricular transit time (PVTT) using cardiac magnetic resonance (cMRI) imaging with first-pass perfusion and to evaluate PVTT as a potential new predictor of cardiac failure. METHODS AND RESULTS: cMRI was performed on 150 patients. The PVTT between the right and left ventricle was measured. Patients were divided into three groups based on their pump function: (1) severely reduced pump function (left ventricular ejection fraction, LVEF<30%), (2) moderately reduced pump function (left ventricular ejection fraction, LVEF 30-54%), and (3) normal pump function (LVEF>55%). PVTT from the right to left ventricle was significantly prolonged in patients with a reduced LVEF compared to the group with a normal pump function. The longest PVTT (13.4±4.8 s) was measured in patients with a severely reduced pump function, prolonged PVTT was also found in the group with moderately reduced pump function (8.5±2.1 s). The shortest PVTT (6.3±1.8 s) was observed in the group with a normal pump function. Additionally, a highly significant negative correlation was revealed between PVTT and LVEF (r=-0.696, p<0.01). PVTT presented a positive significant correlation to end diastolic volume (EDV, r=0.572, p<0.01) and to end systolic volume (ESV, r=0.666, p<0.01). CONCLUSION: Peak ventricular transit times measured by cMRI may be an additional and simple tool to evaluate cardiac function in patients, independent of the other common cardiac functional parameters.

Comparison between amputation-induced demineralization and age-related bone loss using digital X-ray radiogrammetry.

Digital X-ray radiogrammetry (DXR) is a computer-assisted automatic osteodensitometric tool. This study was performed to compare DXR measurements between bone changes following amputation trauma and age-related bone loss. Thirty-five men, who had undergone finger amputations, received a baseline examination and 2--3 serial measurements. As a second group, 215 males older than 70yr were enrolled. All patients obtained standardized hand radiographs. The following DXR parameters evaluating metacarpals were considered: cortical bone mineral density (DXR-BMD), cortical thickness (DXR-CT), metacarpal index (DXR-MCI), outer bone diameter (width; DXR-W), and inner medullary diameter (DXR-MD). In the amputation group, the DXR parameters showed an accentuated initial decrease between first and second measurements (DRX-BMD--12.7%, DXR-CT--14.2%, DXR-W--8.6%, DXR-MCI--6.1%; p<0.001) followed by a less pronounced reduction between second and third radiographs (DRX-BMD--0.5%, DXR-CT--1.5%, DXR-W--0.1%, DXR-MCI--1.3%). DXR-MD revealed a reduction of--3.6% (p<0.05) between first and second estimates and a non-significant increase (+1.1%) between second and third measurements. When compared with the second and third estimates in the amputation group, men older than 70yr presented lower DXR-BMD, DXR-CT, and DXR-MCI values (p<0.001), but larger metacarpal outer and inner bone diameters (DXR-W and DXR-MD; p<0.001). DXR-MD of the elderly men group was also more extended when compared with the baseline measurements of the amputation cohort (p<0.001). The early accentuated cortical bone loss and particularly the pronounced decrease of the outer bone width seem to be characteristic for amputation-induced osteoporosis, suggesting that this might be a distinct secondary osteoporosis entity. When compared with amputation-associated osteoporosis, where the bone loss occurs to a higher extent in the outer bone diameter than in the medullary cavity, the age-related bone changes lead more to an increase of the medullary diameter than of the outer bone width.

Quantitative evaluation of MR perfusion imaging using blood pool contrast agent in subjects without pulmonary diseases and in patients with pulmonary embolism.

OBJECTIVE: To assess the feasibility of time-resolved parallel three-dimensional magnetic resonance imaging (MRI) for quantitative analysis of pulmonary perfusion using a blood pool contrast agent. METHODS: Quantitative perfusion analysis was performed using novel software to assess pulmonary blood flow (PBF), pulmonary blood volume (PBV) and mean transit time (MTT) in a quantitative manner. RESULTS: The evaluation of lung perfusion in the normal subjects showed an increase of PBF, PBV ventrally to dorsally (gravitational direction), and the highest values at the upper lobe, with a decrease to the middle and lower lobe (isogravitational direction). MTT showed no relevant changes in either the gravitational or isogravitational directions. In comparison with normally perfused lung areas (in diseased patients), the pulmonary embolism (PE) regions showed a significantly lower mean PBF (20 ± 0.6 ml/100 ml/min, normal region 94 ± 1 ml/100 ml/min; P < 0.001), mean PBV (2 ± 0.1 ml/100 ml, normal region 9.8 ± 0.1 ml/100 ml; P < 0.001) and mean MTT (3.8 ± 0.1 s; normal region 6.3 ± 0.1; P < 0.001). CONCLUSION: Our results demonstrate the feasibility of using time-resolved dynamic contrast-enhanced MRI to determine normal range and regional variation of pulmonary perfusion and perfusion deficits in patients with PE. KEY POINTS: • Recently introduced blood pool contrast agents improve MR evaluation of lung perfusion • Regional differences in lung perfusion indicating a gravitational and isogravitational dependency. • Focal areas of significantly decreased perfusion are detectable in pulmonary embolism.

Reproducibility and influence of hand rotation on computer-aided joint space analysis.

OBJECTIVES: Computer-aided joint space analysis (CAJSA) is a recently developed, semi-automated tool to aid in the measurement of joint space margins based on hand radiographs. The objective of this study is to verify the potential effect of hand rotation during X-ray imaging on the measurement of joint space width using CAJSA and to evaluate the reproducibility of the CAJSA technique in healthy subjects and in patients with rheumatoid arthritis. METHODS: All joint space distance (JSD) measurements were performed using CAJSA-technology at the metacarpophalangeal articulation based on conventional and digital hand radiographs. RESULTS: I. Hand rotation showed an effect on the reproducibility with CV ranging between 0.39% (angulation 1°) and 1.66% (angulation 19°). II. Regarding the overall reproducibility of the CAJSA method, the intra-radiograph reproducibility of JSD was calculated with CV=0.54% for conventional images and CV=0.38% for digital images. The inter-radiograph reproducibility error was observed with CV=0.66% (conventional images) and CV=0.63% (digital images). III. The study revealed a reproducibility for CAJSA measurements in RA ranging between 0.37% (JSD-MCP ring finger; van der Heijde-modification of the Sharp method score 1) to 1.37% (JSD-MCP index finger; van der Heijde-modification of the Sharp method score 3). CONCLUSION: CAJSA measures JSD at the metacarpophalangeal articulation with high reproducibility in healthy subjects and in patients with differing stages of rheumatoid arthritis. Additional findings show that hand rotation during X-ray imaging has an impact on the CAJSA measurements; thus avoiding acquisition of hand radiographs with a rotation error of more than 15 degrees can be recommended.

Compatibility of temporary pacemaker myocardial pacing leads with magnetic resonance imaging: an ex vivo tissue study.

The presence of temporary myocardial pacing leads is considered a safety contraindication for magnetic resonance imaging (MRI). The aim of this ex vivo tissue study was to measure the heating effects at the tip of the leads using proton magnetic resonance spectroscopy ((1)HMRS) thermometry. The tissue effects were verified by histological analyses. Pig hearts with implanted temporary pacemaker myocardial pacing leads were examined by whole-body MRI at 1.5 Tesla. The tests were performed either by a sequence with high specific absorption rate (SAR) or by standard clinical sequences with lower SAR. Temperature changes were detected via (1)HMRS thermometry, by monitoring the frequency difference between water protons and the reference signals of N-methyl protons of creatine/phosphocreatine (Cr/PCr) and trimethylamine (TMA). Histology was performed using several staining techniques. Standard low-SAR and high-SAR sequences did not cause significant temperature increases in the myocardial tissue surrounding the implanted leads. There were no histopathological signs of thermal damage around the tips of the leads in any of the hearts or in a control implanted heart not subjected to MRI. The present data suggest that temporary pacemaker myocardial pacing leads may be compatible with MR scanning at 1.5 Tesla. However, further in vivo studies and carefully monitored patient studies are needed before final safety recommendations can be made.

Magnetic resonance VIBE venography using the blood pool contrast agent gadofosveset trisodium--an interrater reliability study.

PURPOSE: In this study, image quality of leg veins and vena cava inferior was scored by independent raters using the new intravascular magnetic resonance imaging (MRI) contrast agent gadofosveset trisodium using fat-suppressed 3D gradient echo Volume Interpolated Breath-hold Examination. MATERIAL AND METHODS: The leg venous system without clinical signs of deep venous thrombosis (DVT) and sonography-ruled out DVT were imaged using a fat-suppressed 3D gradient echo Volume Interpolated Breath-hold Examination (VIBE FS). Image interpretation was done independently by two experienced radiologists (raters) using a 5-point scoring system. RESULTS: High diagnostic image quality with an overall mean visibility score of 4.8±0.1 was acquired in patients enrolled in the study using gadofosveset trisodium-enhanced MRI for the venous system of the leg. There were no cases with moderate, poor or nondiagnostic image quality. Additionally, an excellent interrater reliability was observed. CONCLUSIONS: This study shows the feasibility of acquiring high resolution images with excellent image quality of the venous system of the leg using gadofosveset trisodium.