Semiautomated Software to Improve Stability and Reduce Operator-Induced Variation in Vascular Ultrasound Speckle Tracking.

OBJECTIVES: Ultrasound is useful in predicting arteriovenous fistula (AVF) maturation, which is essential for hemodialysis in end-stage renal disease patients. We developed ultrasound software that measures circumferential vessel wall strain (distensibility) using conventional ultrasound Digital Imaging and Communications in Medicine (DICOM) data. We evaluated user-induced variability in measurement of arterial wall distensibility and upon finding considerable variation we developed and tested 2 methods for semiautomated measurement. METHODS: Ultrasound scanning of arteries of 10 subjects scheduled for AVF surgery were performed. The top and bottom of the vessel wall were tracked using the Kanade-Lucas-Tomasi (KLT) feature-tracking algorithm over the stack of images in the DICOM cine loops. The wall distensibility was calculated from the change of vessel diameter over time. Two semiautomated methods were used for comparison. RESULTS: The location of points selected by users for the cine loops varied significantly, with a maximum spread of up to 120 pixels (7.8 mm) for the top and up to 140 pixels (9.1 mm) for the bottom of the vessel wall. This variation in users' point selection contributed to the variation in distensibility measurements (ranging from 5.63 to 41.04%). Both semiautomated methods substantially reduced variation and were highly correlated with the median distensibility values obtained by the 10 users. CONCLUSIONS: Minimizing user-induced variation by standardizing point selection will increase reproducibility and reliability of distensibility measurements. Our recent semiautomated software may help expand use in clinical studies to better understand the role of vascular wall compliance in predicting the maturation of fistulas.

Quantitative detection of cirrhosis: towards the development of computer-assisted detection method.

There are distinct morphologic features of cirrhosis on CT examinations; however, such impressions may be subtle or subjective. The purpose of this study is to build a computer-aided diagnosis (CAD) method to help radiologists with this diagnosis. One hundred sixty-seven abdominal CT examinations were randomly divided into training (n = 88) and validation (n = 79) sets. Livers were analyzed for morphological markers of cirrhosis and logistic regression models were created. Using the area under curve (AUC) for model performance, the best model had 0.89 for the training set and 0.85 for the validation set. For radiology reports, sensitivity of reporting cirrhosis was 0.45 and specificity 0.99. Using the predictive model adjunctively, radiologists' sensitivity increased to 0.63 and specificity slightly decreased to 0.97. This study demonstrates that quantifying morphological features in livers may be utilized for diagnosing cirrhosis and for developing a CAD method for it.

Development of open-source software for free-hand 3D vascular ultrasound: Dialysis fistula application.

BACKGROUND: The arteriovenous fistula (AVF) is the preferred vascular access for End Stage Renal Disease, having superior patency and lower infection risks than prosthetic graft and catheter access. When AVF dysfunction or delayed maturation does occur, the gold standard for diagnosis is the fistula angiogram (a.k.a. fistulogram). 3D ultrasound is available for obstetrical and other specialized uses, but it is cost prohibitive and has a field of view that is too small to cover the region of interest for the dialysis fistula application. We sought to develop a point of care 3D solution using freehand 2D ultrasound data acquisition. METHODS: We developed open-source software for 3D image reconstruction and projection of an angiogram-like image of the vascular access using a 2D freehand ultrasound scanner. We evaluated this software by comparing the ultrasound "sono-angiogram" images to fistulogram images in five subjects, using visual inspection and by applying the Percent of Exact Match (PEM) as a statistic test. RESULTS: The sono-angiograms showed identifiable characteristics that matched the fistulogram results in all five subjects. The PEM ranged between 42.8% and 77.0%, with Doppler and grayscale ultrasound data, showing complementary advantages and disadvantages when used for sono-angiogram image construction. Motion from freehand ultrasound acquisition was a significant source of mismatch. 3D image generation is a potential advantage with ultrasound data. CONCLUSIONS: While further work is needed to improve the accuracy with free hand scanning, fistulogram-like "sono-angiograms" can be generated using point of care 2D ultrasound. Methods such as these may be able to assist in point-of-care diagnosis in the future. The software is open-source, and importantly, the ultrasound data used are non-proprietary and available from any standard ultrasound machine. The simplicity and accessibility of this approach warrant further study.

Sono-angiography for dialysis vascular access based on the freehand 2D ultrasound scanning.

INTRODUCTION: Dialysis vascular access, preferably an autogenous arteriovenous fistula, remains an end stage renal disease (ESRD) patient's lifeline providing a means of connecting the patient to the dialysis machine. Once an access is created, the current gold standard of care for maintenance of vascular access is angiography and angioplasty to treat stenosis. While point of care 2D ultrasound has been used to detect access problems, we sought to reproduce angiographic results comparable to the gold standard angiogram (fistulogram) using ultrasound data acquired from a conventional 2D ultrasound scanner. METHODS: A 2D ultrasound probe was used to acquire a series of cross sectional images of the vascular access including arteriovenous anastomosis of a subject with a radio-cephalic fistula. These 2D B-mode images were used for 3D vessel reconstruction by binary thresholding to categorize vascular versus non-vascular structures followed by standard image segmentation to select the structure representative of dialysis vascular access and morphologic filtering. Image processing was done using open source Python Software. RESULTS: The open source software was able to: (1) view the gold standard fistulogram images, (2) reconstruct 2D planar images of the fistula from ultrasound data as viewed from the top, analogous to computerized tomography images, and (3) construct a 2D representation of vascular access similar to the angiogram. CONCLUSION: We present a simple approach to obtain an angiogram-like representation of the vascular access from readily available, non-proprietary 2D ultrasound data in the point of care setting. While the sono-angiogram is not intended to replace angiography, it may be useful in providing 3D imaging at the point of care in the dialysis unit, outpatient clinic, or for pre-operative planning for interventional procedures. Future work will focus on improving the robustness and quality of the imaging data while preserving the straightforward freehand approach used for ultrasound data acquisition.

Detecting High-Resolution Intramural Vascular Wall Strain Signals Using DICOM Data.

Maintaining dialysis vascular access is a source of considerable morbidity in patients with end-stage renal disease (ESRD). High-resolution radiofrequency (RF) ultrasound vascular strain imaging has been applied experimentally in the vascular access setting to assist in diagnosis and management. Unfortunately, high-resolution RF data are not routinely accessible to clinicians. In contrast, the standard DICOM formatted B-mode ultrasound data are widely accessible. However, B-mode, representing the envelope of the RF signal, is of much lower resolution. If strain imaging could use open-source B-mode data, these imaging techniques could be more broadly investigated. We conducted experiments to detect wall strain signals with submillimeter tracking resolutions ranging from 0.2 mm (3 pixels) to 0.65 mm (10 pixels) using DICOM B-mode data. We compared this submillimeter tracking to the overall vascular distensibility as the reference measurements to see if high-strain resolution strain could be detected using open-source B-Mode data. We measured the best-fit coefficient of determination between signals, expressed as the percentage of strain waveforms that exhibited a correlation with a p value of 0.05 or less. The lowest percentage was 86.7%, and most were 90% and higher. This indicates high-resolution strain signals can be detected within the vessel wall using B-mode DICOM data.

Ultrasound speckle tracking to detect vascular distensibility changes from angioplasty and branch ligation in a radio-cephalic fistula: Use of novel open source software.

We used novel open source software, based on an ultrasound speckle tracking algorithm, to examine the distensibility of the vessel wall of the inflow artery, anastomosis, and outflow vein before and after two procedures. An 83-year-old white man with a poorly maturing radio-cephalic fistula received an angioplasty at the anastomosis followed by branch ligation 28 days later. Duplex Doppler measurements corroborated the blood flow related changes anticipated from the interventions. The experimental distensibility results showed that it is technically feasible to measure subtle vessel wall motion changes with high resolution (sub-millimeter) using standard Digital Imaging and Communications in Medicine (DICOM) ultrasound data, which are readily available on conventional ultrasound scanners. While this methodology was originally developed using high resolution radiofrequency from ultrasound data, the goal of this study was to use DICOM data, which makes this technology accessible to a wide range of users.

The Use of Readily Available Longitudinal Data to Predict the Likelihood of Surgery in Crohn Disease.

BACKGROUND: Although imaging, endoscopy, and inflammatory biomarkers are associated with future Crohn disease (CD) outcomes, common laboratory studies may also provide prognostic opportunities. We evaluated machine learning models incorporating routinely collected laboratory studies to predict surgical outcomes in U.S. Veterans with CD. METHODS: Adults with CD from a Veterans Health Administration, Veterans Integrated Service Networks (VISN) 10 cohort examined between 2001 and 2015 were used for analysis. Patient demographics, medication use, and longitudinal laboratory values were used to model future surgical outcomes within 1 year. Specifically, data at the time of prediction combined with historical laboratory data characteristics, described as slope, distribution statistics, fluctuation, and linear trend of laboratory values, were considered and principal component analysis transformations were performed to reduce the dimensionality. Lasso regularized logistic regression was used to select features and construct prediction models, with performance assessed by area under the receiver operating characteristic using 10-fold cross-validation. RESULTS: We included 4950 observations from 2809 unique patients, among whom 256 had surgery, for modeling. Our optimized model achieved a mean area under the receiver operating characteristic of 0.78 (SD, 0.002). Anti-tumor necrosis factor use was associated with a lower probability of surgery within 1 year and was the most influential predictor in the model, and corticosteroid use was associated with a higher probability of surgery. Among the laboratory variables, high platelet counts, high mean cell hemoglobin concentrations, low albumin levels, and low blood urea nitrogen values were identified as having an elevated influence and association with future surgery. CONCLUSIONS: Using machine learning methods that incorporate current and historical data can predict the future risk of CD surgery.

Angioplasty Induced Changes in Dialysis Vascular Access Compliance.

Dialysis vascular access remains vitally important to maintain life and functional capacity with end stage renal disease. Angioplasty is an integral part of maintaining dialysis access function and patency. To understand the effect of angioplasty balloon dilation on vascular wall mechanics, we conducted a clinical study to evaluate the elastic modulus of the anastomosis in five subjects with anastomosis stenoses, before and after six angioplasty procedures, using B-mode ultrasound DICOM data. A novel and open source vascular ultrasound high-resolution speckle tracking software tool was used. The median lumen diameter increased from 3.4 to 5.5 mm after angioplasty. Meanwhile, the median elastic modulus of the 18 measurements at the anastomosis increased by 52.2%, from 2.24 × 103 to 3.41 × 103 mmHg. The results support our hypothesis that the structural changes induced in the vessel wall by balloon dilation lead to reduced vascular compliance and a higher elastic modulus of the vessel wall.

Intravascular ultrasound-guided true lumen reentry device for recanalization of unilateral chronic total occlusion of iliac arteries: technique and follow-up.

BACKGROUND: Endovascular revascularization of chronic total occlusion (CTO) of the iliac arteries is rapidly becoming first-line treatment, with surgical aortofemoral bypass procedures reserved for failure of endovascular treatment. Percutaneous subintimal recanalization is the most common endovascular revascularization technique for CTO of the iliac arteries. The primary reason for failure of the subintimal recanalization technique is failure to reenter the true lumen. This report describes the benefits of using true lumen reentry devices to improve the success and safety of conventional subintimal recanalization for revascularization of CTO of the iliac arteries. METHODS: This is a retrospective review of 11 patients with CTO of the iliac arteries in whom true lumen reentry was not successful using conventional subintimal recanalization. An intravascular ultrasound (IVUS)-guided true lumen reentry device was used in all patients to assist true lumen reentry. Clinical records, procedural records, angiographic imaging, and follow-up data were analyzed. Indications for intervention, length and location of the lesion treated, access site(s), location of true lumen reentry, stent use, procedural times, technical success, and complications were analyzed in all patients. RESULTS: The technical success of true lumen reentry at the desired point was 100%. Total procedure time from the start of reentry device manipulation to achieve reentry was <10 min (routinely <5 min). Mean patient follow-up was 10.5 months. At follow-up, all patients had palpable femoral pulses. The ankle-brachial index normalized (>0.9) in six patients and improved significantly in the remaining five patients. Rest pain resolved and claudication improved in all patients. Out of seven patients who had foot ulcers, the ulcers healed completely in five and demonstrated improved healing in two, with the clinical manifestation of osteomyelitis resolved in two. No procedure-related complications were noted. The amputation-free survival was 100%. CONCLUSION: True lumen reentry devices greatly improve the technical success and safety of percutaneous recanalization procedures in CTO of the iliac arteries. There are significant reductions in procedure time and complication rates associated with the use of these devices.

Routine stent implantation vs. percutaneous transluminal angioplasty in femoropopliteal artery disease: a meta-analysis of randomized controlled trials.

AIMS: We performed a meta-analysis of randomized controlled trials comparing routine stenting (ST) with percutaneous transluminal angioplasty (PTA) for symptomatic superficial femoral-popliteal artery (SFPA) disease. METHODS AND RESULTS: Ten trials were pooled randomizing patients to ST (n = 724 limbs) or PTA with provisional stenting (n = 718 limbs) with a follow-up period of 9-24 months. The mean lesion length was similar in the two groups (45.8 mm in the ST group and 43.3 mm in the PTA group). We calculated the summary risk ratios (RRs) for immediate technical failure, restenosis, and target vessel revascularization (TVR) using random-effects models. The immediate technical failure was higher in the PTA group than in the ST group [17.1 vs. 5.9%, respectively, RR = 0.28, 95% confidence interval (CI) = 0.15-0.54, P < 0.001], with 10.3% of the PTA patients undergoing stenting because of suboptimal result. There was a trend for lower restenosis in the ST group (37.6% in ST vs. 45.3% in PTA, RR = 0.85, 95% CI = 0.69-1.06, P = 0.146), but no difference in the need for TVR (20% in ST vs. 20.2% in PTA, RR = 0.98, 95% CI = 0.78-1.23, P = 0.89). In an analysis restricted to nitinol stents, there was a trend towards reduction in TVR (RR = 0.79, 95% CI = 0.59-1.06, P = 0.12). CONCLUSION: Despite the higher immediate success, routine stenting was not associated with a significant reduction in the rate of restenosis or TVR. Our data do not support use of routine stenting as the primary endovascular treatment for short SFPA lesions.

Eustachian valve endocarditis: a rare complication of automatic implantable cardioverter defibrillator placement.

Eustachian valve (EV) endocarditis is extremely rare and often difficult to diagnose. An extensive review of the English literature has shown no report of EV endocarditis as a complication of the automatic implantable cardioverter defibrillator (AICD). A rare case is reported following AICD placement that was diagnosed by clinical findings of sepsis and positive blood cultures, and supported (using transesophageal echocardiography) by the presence of vegetations attached to the EV. Previously reported cases of EV endocarditis are reviewed, and its significance discussed in the setting of an increased use of AICD.

The effect of gender on outcomes of aortoiliac artery interventions for claudication.

OBJECTIVE: To explore the relationship between gender, native artery diameters, and outcomes of stent revascularization (ST) in the "Claudication: Exercise versus Endoluminal Revascularization" trial. METHODS: A comparative analysis was performed of the impact of gender, age, weight, height, body mass index, and body surface area on revascularization outcomes at baseline and 6months in 55 arterial segments of aorta, common iliac artery, and external iliac artery (EIA). RESULTS: Women demonstrated smaller diameter of the EIA. However, the clinical outcomes of revascularization were not negatively affected by the gender-based differences. CONCLUSION: Gender-based differences are unlikely to significantly impact outcome of ST.

Body Composition Features Predict Overall Survival in Patients With Hepatocellular Carcinoma.

OBJECTIVES: Existing prognostic models for patients with hepatocellular carcinoma (HCC) have limitations. Analytic morphomics, a novel process to measure body composition using computational image-processing algorithms, may offer further prognostic information. The aim of this study was to develop and validate a prognostic model for HCC patients using body composition features and objective clinical information. METHODS: Using computed tomography scans from a cohort of HCC patients at the VA Ann Arbor Healthcare System between January 2006 and December 2013, we developed a prognostic model using analytic morphomics and routine clinical data based on multivariate Cox regression and regularization methods. We assessed model performance using C-statistics and validated predicted survival probabilities. We validated model performance in an external cohort of HCC patients from Parkland Hospital, a safety-net health system in Dallas County. RESULTS: The derivation cohort consisted of 204 HCC patients (20.1% Barcelona Clinic Liver Cancer classification (BCLC) 0/A), and the validation cohort had 225 patients (22.2% BCLC 0/A). The analytic morphomics model had good prognostic accuracy in the derivation cohort (C-statistic 0.80, 95% confidence interval (CI) 0.71-0.89) and external validation cohort (C-statistic 0.75, 95% CI 0.68-0.82). The accuracy of the analytic morphomics model was significantly higher than that of TNM and BCLC staging systems in derivation (P<0.001 for both) and validation (P<0.001 for both) cohorts. For calibration, mean absolute errors in predicted 1-year survival probabilities were 5.3% (90% quantile of 7.5%) and 7.6% (90% quantile of 12.5%) in the derivation and validation cohorts, respectively. CONCLUSION: Body composition features, combined with readily available clinical data, can provide valuable prognostic information for patients with newly diagnosed HCC.

Endovascular treatment of thrombosed inferior vena cava filters: Techniques and short-term outcomes.

PURPOSE: To present the techniques for endovascular treatment of thrombosed filter-bearing inferior vena cavae (IVCs), along with short-term clinical and imaging follow-up. MATERIALS AND METHODS: A total of 45 consecutive patients (17 females and 28 males), aged 19-79 years (mean age of 49 years), who had IVC filter placement complicated by symptomatic acute or chronic iliocaval thrombosis and underwent endovascular therapy were studied. All patients presented with lower extremity swelling and/or pain. One patient also had bilateral lower extremity swelling and chronic gastrointestinal (GI) bleeding which was secondary to chronic systemic to portal venous collaterals. Patients underwent one or more of the following endovascular treatments depending on the chronicity and extent of thrombosis: (a) catheter-directed thrombolysis (CDT) (n = 25), (b) pharmacomechanical thrombolysis (PMT) (n = 15), (c) balloon angioplasty (n = 45), and/or (d) stent placement across the filter (n = 42). In addition, 16 patients underwent groin arteriovenous fistula (AVF) creation (36%) and 3 (7%) had femoral venous thrombectomy to improve flow in the recanalized iliac veins and IVCs. RESULTS: Anatomical success was achieved in all patients. Follow-up was not available in 10 patients (lost to follow-up, n = 4; expired due to comorbidities, n = 2; lost to follow-up after re-intervention, n = 4). At a mean follow-up time of 13.3 months (range 1-48 months), clinical success was achieved in 27 patients (60%), i.e. in 21 patients without re-intervention and in 6 patients with re-intervention. Clinical success was not achieved despite re-intervention in eight patients. Higher clinical success was noted in patients who did not require repeat interventions (P = 0.03) and the time to re-intervention was significantly shorter in patients who had clinical failure (P = 0.01). AVF creation did not improve the clinical success rate (P = 1). There was no significant difference in clinical success between patients who had acute or subacute thrombosis compared to those who had chronically occluded filter-bearing IVCs (P = 1). CONCLUSION: This study suggests that endovascular therapy for thrombosed filter-bearing IVCs is safe and technically feasible.