Peripheral Artery Disease: Why Do We Need CT Imaging?

The most common cause of peripheral arterial disease (PAD) is atherosclerosis. PAD can be considered a global pandemic, as it affected a quarter billion people worldwide in 2013 [1]. The prevalence and complexity of the disease is increasing due to aging populations and the rise in risk factors including diabetes and kidney disease.

Can angiographic Flat Detector Computed Tomography blood volume measurement be used to predict final infarct size in acute ischemic stroke?

INTRODUCTION AND PURPOSE: Flat detector computed tomography (FD-CT) technology is becoming more widely available in the angiography suites of comprehensive stroke centers. In patients with acute ischemic stroke (AIS), who are referred for endovascular therapy (EVT), FD-CT generates cerebral pooled blood volume (PBV) maps, which might help in predicting the final infarct area. We retrospectively analyzed pre- and post-recanalization therapy quantitative PBV measurements in both the infarcted and hypoperfused brain areas of AIS patients referred for EVT. MATERIALS AND METHODS: We included AIS patients with large vessel occlusion in the anterior circulation referred for EVT from primary stroke centers to our comprehensive stroke center. The pre- and post-recanalization FD-CT regional relative PBV (rPBV) values were measured between ipsilateral lesional and contralateral non-lesional areas based on final infarct area on post EVT follow-up cross-sectional imaging. Statistical analysis was performed to identify differences in PBV values between infarcted and non-infarcted, recanalized brain areas. RESULTS: We included 20 AIS patients. Mean age was 63 years (ranging from 36 to 86 years). The mean pre- EVT rPBV value was 0.57 (±0.40) for infarcted areas and 0.75 (±0.43) for hypoperfusion areas. The mean differences (Δ) between pre- and post-EVT rPBV values for infarcted and hypoperfused areas were respectively 0.69 (±0.59) and 0.69 (±0.90). We found no significant differences (p > 0.05) between pre-EVT rPBV and ΔrPBV values of infarct areas and hypoperfusion areas. CONCLUSION: Angiographic PBV mapping is useful for the detection of cerebral perfusion deficits, especially in combination with the fill run images. However, we were not able to distinguish irreversibly infarcted tissue from potentially salvageable, hypoperfused brain tissue based on quantitative PBV measurement in AIS patients.

Flat Detector CT with Cerebral Pooled Blood Volume Perfusion in the Angiography Suite: From Diagnostics to Treatment Monitoring.

C-arm flat-panel detector computed tomographic (CT) imaging in the angiography suite increasingly plays an important part during interventional neuroradiological procedures. In addition to conventional angiographic imaging of blood vessels, flat detector CT (FD CT) imaging allows simultaneous 3D visualization of parenchymal and vascular structures of the brain. Next to imaging of anatomical structures, it is also possible to perform FD CT perfusion imaging of the brain by means of cerebral blood volume (CBV) or pooled blood volume (PBV) mapping during steady state contrast administration. This enables more adequate decision making during interventional neuroradiological procedures, based on real-time insights into brain perfusion on the spot, obviating time consuming and often difficult transportation of the (anesthetized) patient to conventional cross-sectional imaging modalities. In this paper we review the literature about the nature of FD CT PBV mapping in patients and demonstrate its current use for diagnosis and treatment monitoring in interventional neuroradiology.

Pseudoaneurysm of a Bronchial Artery: An Unusual Cause of Chest Pain.

We report a case of a bronchial artery pseudoaneurysm presenting as acute retrosternal pain. We want to discuss and to announce the extremely rare finding of a bronchial artery pseudoaneurysm. Bronchial artery aneurysms and pseudoaneurysms are uncommon; however, missing this diagnosis is associated with significant morbidity and mortality. When suspecting this pathology urgent CT angiography and selective angiography (DSA) are crucial. Urgent treatment with transarterial embolization is preferred. LEARNING POINTS: Bronchial artery pseudoaneurysms are uncommon; however, missing this diagnosis is associated with significant morbidity and mortality.Haemoptysis and chest pain are the most common symptoms of bronchial artery pseudoaneurysms.Diagnosis is made with CT angiography and selective angiography (DSA). Transarterial embolization is the preferred type of treatment.

Fluorescence-Guided Thoracic Duct Dissection in Robotic en Bloc Esophagectomy.

En bloc resection of the thoracic duct compartment enhances adequate lymph node removal and may improve oncologic outcomes in esophagectomy for malignant esophageal diseases. However, it also increases the risk of postoperative chylothorax, with a reported incidence of 5% to 20%. This report describes a technique that facilitates intraoperative identification of the thoracic duct, as well as proximal and distal ligation, during robot-assisted esophagectomy by lymphangiography-guided injection of indocyanine green in the right groin in a patient in the left lateral position. This approach can be swiftly applied at any time during any thoracoscopic procedure using the lateral position when visualization of the thoracic duct anatomy is needed.

Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia.

Background: To analyse the long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) in the treatment of chronic mesenteric ischemia (CMI), and to assess predictive factors for a better clinical outcome. Patients and methods: Retrospective analysis of 76 consecutive patients, treated percutaneously for CMI between January 1999 and January 2018 and followed up until the end of 2018. Patients' pre-, peri- and post-interventional clinical and radiological data were gathered from the institutional electronic medical records. The Kaplan Meier method with log rank test or the Cox model were used to analyse overall survival; the cumulative incidence function with Pepe and Mori test or the Fine and Grey model were used to analyse relapse-free survival, considering death as a competing event. Results: Seventy-six consecutive patients with a mean age of 72 years were included in the study. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23 (29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical success was achieved in n=68 (89.5%), and procedural complications were observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n=21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0% and 28.2% after two, five and ten years of follow-up, respectively. A trend towards longer relapse-free survival was found in the circumferential stenosis group (78.2% at five years) compared with the non-circumferential stenosis group (55.5%) (P=0.063). Conclusions: Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite a substantial number of patients experiencing clinical relapse over time. Patients with focal, circumferential stenosis might have longer relapse-free survival than patients with non-circumferential stenosis.

Intranodal Lymphangiography With High-Dose Ethiodized Oil Shows Efficient Results in Patients With Refractory, High-Output Postsurgical Chylothorax: A Retrospective Study.

OBJECTIVE. The purpose of this study is to evaluate the safety and efficacy of intranodal lymphangiography (INL) with high-dose ethiodized oil in patients with postoperative refractory chylothorax. MATERIALS AND METHODS. A retrospective review of a cohort of 18 patients with refractory postoperative chylothorax seen between May 2015 and March 2019 was conducted. All patients underwent intranodal lymphangiography with high doses of ethiodized oil (mean, 75 mL; range, 40-140 mL). The following information was gathered from the institutional database: patient demographics, type of surgery, output volumes, interval between surgery and lymphangiography, imaging results, amount of ethiodized oil injected, clinical success, and time to resolution. RESULTS. Of the 18 patients, 11 (61%) had previously undergone thoracic duct ligation, and seven (39%) had not. A lymphatic leak was confirmed by lymphangiography in 12 of 18 patients (67%). A total of five patients underwent a second session of INL, which was successful in three of the patients (60%). Removal of all chest tubes was possible in 15 of 18 patients (83%) after a mean of 12 days (range, 1-25 days). Two patients had an anastomotic leak develop after esophagectomy and died with their chest tubes in situ. One patient underwent thoracic duct ligation after two failed INL procedures. No complications were recorded. CONCLUSION. INL with a high dose of injected ethiodized oil is a safe and effective procedure for the management of postsurgical refractory chylothorax, with chest tube removal in 83% of patients.

Initial Experience With the Microvascular Plug in Selective Renal Artery Embolization.

PURPOSE: To evaluate the safety and efficacy of the microvascular plug (MVP) for selective renal artery embolization. METHODS: Retrospective review was performed on a cohort of 6 patients undergoing renal artery embolization using the MVP between July 2015 and August 2018. Patients' demographics, indication for embolization, technical details of the embolization procedure, and clinical events were gathered from the patients' electronic medical records. RESULTS: The patients underwent selective renal artery embolization with a MVP for iatrogenic vascular injuries (n = 3), traumatic vascular injuries (n = 2), and for elective embolization of an angiomyolipoma (n = 1), in native kidneys (n = 4) or in renal allografts (n = 2). Immediate occlusion of the feeding artery was achieved with 1 MVP device in 4 patients. In 1 patient, a second MVP was needed, and in another patient, additional 0.018-inch microcoils were used to completely occlude the injured artery. Technical success was achieved in all patients. The volume of the resulting renal infarction was estimated less than 5% of the renal volume. No other procedure-related complications occurred. CONCLUSION: The MVP is a safe and effective device allowing superselective renal artery embolization. Therefore, we recommend the MVP as a valuable embolic in superselective renal artery embolization. Additionally, a single device is sufficient in most cases, potentially reducing the cost, duration, and radiation exposure of the procedure.

Therapeutic intranodal lymphangiography for refractory chylous ascites complicating acute necrotic pancreatitis.

Chylous ascites is a rare complication of acute pancreatitis. However, the incidence of intraperitoneal chyle leakage related to severe pancreatitis may be much higher. This is probably the result of direct damage to the cisterna chyli or its tributaries by pancreatic enzymes. In this case, conservative treatment failed to resolve the chyle leak. For the first time, to our knowledge, ultrasound guided therapeutic intranodal lymphangiography was shown to be a successful, minimally invasive treatment option in chylous ascites complicating acute necrotic pancreatitis.