Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: data from a practice-based longitudinal cohort.

BACKGROUND AND AIMS: A large prospective multicentre cohort study with systematic follow-up recently reported a 2.3% two-year cumulative incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). The present investigation aimed to determine the reported prevalence and incidence of CTEPH diagnosis after acute PE in real-world practice over a twelve-year period. METHODS: This study was based on nationwide ambulatory billing claims and drug prescription data of all residents with public health insurance in Germany from 2010 to 2021. RESULTS: A total of 573,972 patients with acute PE (median age 71 years; 57.4% women) were identified between 2010 and 2021. Prevalence of CTEPH among patients with history of PE increased during period from 0.4% in 2010 to 0.9% in 2021. CTEPH was diagnosed in 2556 patients after acute PE, with most (17.6%) diagnoses reported within the first three months after the index PE event. The cumulative incidence rate after 3 months (1st quarter) was calculated at 0.08%, and after the first two years (8th quarter) at 0.36%; it was 0.75% over the entire (90-month) follow-up period. Patients with CTEPH diagnosis during follow-up more often had right ventricular dysfunction at the index acute PE (14.9% vs. 8.3%; p<0.001). CONCLUSIONS: The low CTEPH incidence rate after acute PE in the present analysis suggests low awareness of CTEPH. It further suggests a lack of systematic follow-up protocols for acute PE survivors in the real world. Improved implementation of existing recommendations on follow-up strategies post PE is warranted.

Prospective comparison of positron emission tomography (PET)/magnetic resonance and PET/computed tomography dosimetry in hepatic malignant neoplastic disease after 90Y radioembolization treatment.

Background: 90Y radioembolization is an established treatment modality for hepatic malignancies. Successful radioembolization requires optimal dose delivery to tumors while minimizing dosages to parenchyma. Post-treatment positron emission tomography (PET)/computed tomography (CT) dosimetry is the established benchmark, whereas PET/magnetic resonance (MR) is an emerging modality. The goal of this study was to assess the intermodality agreement between PET/MR and PET/CT 90Y dosimetry. Methods: In this single-institution study, 18 patients (20 treatment sessions) with a primary or metastatic hepatic malignancy underwent both PET/MR and PET/CT after 90Y radioembolization. Patients were randomized to undergo one modality first, followed by the other. The region of interest was delineated using MR images and tumor and liver dosimetry was calculated. Intermodality agreement was assessed using the Bland-Altman method. A generalized linear model was used to assess the effect of baseline variables on intermodality dose differences. Results: PET/MR underestimated tumor and liver absorbed doses when compared to PET/CT by -3.7% (P=0.042) and -5.8% (P=0.029), respectively. A coverage probability plot demonstrated that 80% and 90% of tumor dose measurements fell within intermodality differences of 11% and 18%, respectively. PET/MR underestimated tumor dose at both low (<1 GBq) and high (>3 GBq) injected activity levels (P<0.001) by -22.3 [standard deviation (SD) =13.5] and -24.3 (SD =18.7), respectively. Conclusions: Although PET/MR significantly underestimated the absorbed dose when compared to PET/CT, the intermodality agreement was high and the degree of underestimation was better than previously reported. Intermodality differences were more pronounced at low and high injected doses. Additional studies are required to assess the clinical implications of these findings.

Prediction of Mortality and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Placement: Baseline and Longitudinal Body Composition Measurement.

PURPOSE: To investigate effects of baseline and early longitudinal body composition changes on mortality and hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: This is a case-control study with analysis of a TIPS registry (1995-2020) including data from patients with cirrhosis with computed tomography (CT) scans obtained within 1 month before and 3 months after TIPS. Core muscle area (CMA), macroscopic subcutaneous adipose tissue (mSAT), macroscopic visceral adipose tissue (mVAT) area, and muscle adiposity index (MAI) on CT were obtained. Multipredictor Cox proportional hazards models were used to assess the effect of body composition variables on mortality or HE. RESULTS: In total, 280 patients (158 men; median age, 57.0 years; median Model for End-stage Liver Disease-sodium [MELD-Na] score, 14.0) were included. Thirty-four patients had post-TIPS imaging. Median baseline CMA was 68.3 cm2 (interquartile range, 57.7-83.5 cm2). Patients with higher baseline CMA had decreased risks of mortality (hazard ratio [HR]: 0.82; P = .04) and HE (HR: 0.82; P = .009). It improved prediction of mortality over MELD-Na and post-TIPS right atrial pressure alone (confidence interval = 0.729). An increase in CMA (HR: 0.60; P = .043) and mSAT (HR: 0.86; P = .022) or decrease in MAI (HR: 1.50; P = .049) from before to after TIPS was associated with a decreased risk of mortality. An increase in mSAT was associated with an increased risk of HE (HR: 1.11; P = .04). CONCLUSIONS: CMA on CT scan 1 month before TIPS placement predicts mortality and HE in patients with cirrhosis. Changes in body composition on CT measured 3 months after TIPS placement independently predict mortality and HE.

Quantitative Flow Measurements of Pelvic Venous Vasculature Using 4D Flow MRI.

RATIONALE AND OBJECTIVES: To evaluate 4D Flow magnetic resonance imaging (MRI) sequences for quantitative flow measurements of the pelvic venous vasculature. MATERIALS AND METHODS: A prospective study of healthy volunteers was performed. After informed consent all subjects underwent 4D flow sequences at a 3 T MRI scanner with different isotropic resolution and different velocity encoding (Venc) settings: (sequence #1) voxel size (VS) 1.63 mm3, Venc 50 cm/s; (sequence #2) VS 1.63 mm3, Venc 100 cm/s and (sequence #3) VS 2.03 mm3, Venc 50 cm/s. Perfusion parameters were calculated for all venous vessel segments starting at the level of the inferior vena cava and extending caudally to the level of the common femoral vein. For reference, arterial flow was calculated using 1.63 mm3 isotropic resolution with a Venc of 100 cm/s. RESULTS: Ten healthy subjects (median age 28 years, interquartile range [IQR]: 26.25-28 years) were enrolled in this study. Median scanning time was 12:12 minutes (IQR 10:22-13:32 minutes) for sequence #1, 11:02 minutes (IQR 9:57-11:19 minutes) for sequence #2 and 6:10 minutes (IQR 5:44-6:47 minutes) for sequence #3. Flow measurements were derived from all sequences. The venous pelvic vasculature showed similar perfusion parameters compared to its arterial counterpart, for example the right common iliac arterial segment showed a perfusion of 8.32 ml/s (IQR: 6.94-10.68 ml/s) versus 7.29 ml/s (IQR: 4.70-8.90 ml/s) in the corresponding venous segment (P = 0.218). The venous flow measurements obtained from the three investigated sequences did not reveal significant differences. CONCLUSION: 4D Flow MRI is suitable for quantitative flow measurement of the venous pelvic vasculature. To reduce the scanning time without compromising quantitative results, the resolution can be decreased while increasing the Venc. This technique may be utilized in the future for the diagnosis and treatment response assessment of iliac vein compression syndromes.

Noninvasive and invasive imaging of lower-extremity acute and chronic venous thrombotic disease.

The spectrum of venous thromboembolic (VTE) disease encompasses both acute deep venous thrombosis (DVT) and chronic postthrombotic changes (CPC). A large percentage of acute DVT patients experience recurrent VTE despite adequate anticoagulation, and may progress to CPC. Further, the role of iliocaval venous obstruction (ICVO) in lower-extremity VTE has been increasingly recognized in recent years. Imaging continues to play an important role in both acute and chronic venous disease. Venous duplex ultrasound remains the gold standard for diagnosing acute VTE. However, imaging of CPC is more complex and may involve computed tomography, magnetic resonance, contrast-enhanced ultrasound, or intravascular ultrasound. In this narrative review, we aim to discuss the full spectrum of venous disease imaging for both acute and chronic venous thrombotic disease.

A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty.

BACKGROUND: Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations. AIMS: We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world. METHODS: In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding). RESULTS: Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well. CONCLUSIONS: Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.

Multiparametric ultrasound for upper extremity dialysis access evaluation.

The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.

Endovascular treatment of symptomatic hepatic venous outflow obstruction post major liver resection.

PURPOSE: To evaluate efficacy, safety, and outcomes of endovascular treatment of hepatic vein stenosis post major liver resection. METHODS: A retrospective data analysis was performed including all interventional treatments of hepatic vein stenosis post major liver resection since 2010. Post procedural course and clinical parameters including amount of ascites accumulation and relevant laboratory values were assessed during the follow-up period. Primary and primary assisted hepatic venous patency time were calculated. RESULTS: Twelve patients (median age 55.5, IQR 49.75 to 61.5 years) undergoing a total of 16 interventions were included. Interventions were primary stent placement (n = 3), primary balloon angioplasty (n = 8), three re-interventions and two aborted interventions (no significant pressure gradient). Technical success was 100% (16/16). Permanent reduction and / or complete resolution of ascites was achieved in 72% (8/11). Laboratory parameters related to liver function did not show significant improvement after intervention. Median follow-up period was 6 months (IQR: 1.5 to 18 months). The median primary patency time for patients with balloon angioplasty was 11 months (IQR: 1.375 to 22.25 months) and assisted patency time was 13.25 months (IQR: 4.5 to 22.25 months). The median primary patency time for patients with angioplasty and stent placement was 1 months (IQR: 1.0 to 1.5 months) and assisted patency time was 2.0 months (IQR: 1.5 to 2.5months). CONCLUSION: An endovascular approach for the treatment of hepatic venous stenosis post major liver resection is safe and efficient to reduce and / or resolve refractory ascites. However, liver function parameters seem not to be improved by the procedure. Stent placement can be a reasonable option in patients with significant residual stenotic disease post angioplasty.

Pre-procedure imaging planning for dialysis access in patients with end-stage renal disease using ultrasound and upper extremity computed tomography angiography: a narrative review.

Background and Objective: The incidence of patients with end-stage renal disease (ESRD) and subsequent need for dialysis is continuously rising. The detailed preoperative planning and careful creation of a functioning access for hemodialysis as a bridge to transplant or as a long-term solution, has a crucial role to reduce vascular access associated morbidity and mortality and improve quality of life of the ESRD patient population. In addition to a detailed medical workup including physical exam, a variety of imaging modalities exist to support further decision making with regard to the best suited vascular access for each individual patient. These modalities provide both, a comprehensive anatomical overview of the vascular tree and specific pathologic findings, which may increase the likelihood of access failure or insufficient access maturation. This manuscript aims to provide a comprehensive review of current literature and an overview of the different imaging modalities in vascular access planning. Additionally, we provide a step-by-step planning algorithm for hemodialysis access creation. Methods: After searching in PubMed and Cochrane database of systematic review, we reviewed eligible English literatures published up to 2021, including guidelines and meta-analyses, retrospective and prospective cohort studies. Key Content and Findings: Duplex ultrasound is widely accepted as first line imaging tool for preoperative vessel mapping. However, this modality has its inherent limitations, therefore specific questions can be assessed using digital subtraction angiography (DSA) or venography and computed tomography angiography (CTA). These modalities are more invasive, are associated with radiation exposure and require nephrotoxic contrast agents. Magnetic resonance angiography (MRA) may be an alternative in selected centers with available expertise. Conclusions: Pre-procedure imaging recommendations are mainly based on retrospective (register-) studies and case-series. Prospective studies and randomized trials are primarily related to access outcomes in ESRD patients who underwent preoperative duplex ultrasound. Comparative prospective data related to invasive DSA and non-invasive cross-sectional imaging (CTA or MRA) are lacking.

Thoracic central venous occlusion from the interventional radiology perspective.

Central venous occlusion is a common condition in certain patient populations, with significant associated morbidity. Symptoms range from mild arm swelling to respiratory distress and can be particularly troublesome in the end stage renal disease population when related to dialysis access and function. Crossing completely occluded vessels is often the most challenging step and various techniques exist to accomplish this. Traditionally, blunt and sharp recanalization techniques are used to cross occluded vessels and are described in detail. Even with experienced providers there are lesions which prove to be too difficult and are refractory to traditional approaches. We discuss advanced techniques such as with radiofrequency guidewires as well as newer technologies which offer an alternative pathway to re-establishing access. These emerging methods have demonstrated procedural success in the majority of cases where traditional techniques were futile. Following recanalization, angioplasty with or without stenting is typically performed and restenosis is a commonly encountered complication. We discuss angioplasty and the emerging use of drug-eluting balloons in venous thrombosis. Subsequently, in regards to stenting we discuss the indications and multitude of available types including novel venous stents with their respective strengths and drawbacks. Potential feared complications such as venous rupture with balloon angioplasty and stent migration are discussed along with our recommendations to reduce their risk of occurrence and promptly manage them when they do unfortunately occur.

Non-contrast MR angiography of pelvic arterial vasculature using the Quiescent interval slice selective (QISS) sequence.

To evaluate Quiescent Interval Slice Selective (QISS) balanced steady-state free precession (bSSFP) and QISS fast low-angle shot (FLASH) sequences for non-contrast Magnetic Resonance Angiography (MRA) of iliac arteries regarding image quality and diagnostic confidence in order to establish these sequences in daily clinical practice. A prospective study of healthy subjects (n = 10) was performed. All subjects underwent the QISS MRI protocol with bSSFP und FLASH sequences. Vessel contrast-to-background ratio (VCBR) were measured in pre-defined vessel segments. Image quality and diagnostic confidence was assessed using a Likert scale (five-point scale). Inter-reader agreement was determined using Cohen's kappa coefficient (κ). Ten healthy subjects (median age 29 years, IQR: 26.25 to 30 years) were included in this prospective study. Median MR examination time was 2:05 min (IQR 1:58 to 2:16) for QISS bSSFP and 4:11 min (IQR 3:57 to 4:32) for QISS FLASH. Both sequences revealed good VCBR in all examined vessel segments. VCBR (muscle tissue) were marginally higher for FLASH sequences (e.g., 0.82 vs. 0.78 in the right femoral artery, p = 0.035*), while bSSFP sequence showed significantly higher VCBR (fat tissue) in the majority of examined arterials vessels (e.g., 0.78 vs. 0.62 in right femoral artery, p = 0.001*). The image quality and diagnostic confidence of both sequences were rated as good to excellent. Moderate to good inter-reader agreement was found. QISS MRA using bSSFP and FLASH sequences are diagnostic for visualization of iliac arterial vasculature. The QISS bSSFP sequence might offer advantages due to the markedly shorter exam time and superior visualization of smaller vessels. The QISS FLASH sequence seems to be a robust alternative for non-contrast MRA since it is less sensitive to magnetic field inhomogeneities.

Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant.

PURPOSE: Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant. MATERIAL AND METHODS: A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure. RESULTS: Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution. CONCLUSION: pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.

Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting.

Emergency imaging of the scrotum is part of routine medical practice. Indications include epididymitis/epididymo-orchitis, testicular torsion, trauma, tumors and infarction. Prompt diagnosis and management are needed to ensure optimal patient outcome. Ultrasound (US) is the initial, and often the only, imaging modality for testicular pathologies. Usually, B-mode and color Doppler US are adequate. In challenging cases, contrast-enhanced US (CEUS) facilitates final diagnosis or increases the examiner's confidence by confirming findings on non-enhanced US. This paper elaborates on the examination technique of CEUS for testicular pathologies, thereby showing its added value over baseline US techniques in the emergency setting.

Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review.

Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.

Assessment of Clinical Outcomes, Clinical Manifestations, and Risk Factors for Hepatic Infarction After Transjugular Intrahepatic Portosystemic Shunt Placement (TIPS): A Retrospective Comparative Study.

PURPOSE: To describe the imaging findings of hepatic infarction after transjugular intrahepatic portosystemic shunt (TIPS) placement and identify risk factors, clinical manifestations, and outcomes of infarction after TIPS. MATERIALS AND METHODS: In this retrospective analysis of a TIPS registry (1995-2021), cirrhotic patients with hepatic infarction (n = 33) and control patients without infarct (n = 33) after TIPS were identified. Laboratory values, ultrasound findings, and clinical variables were compared between groups to identify risk factors and differences in outcomes. A Cox proportional hazards regression model with propensity score was used to assess the effect of hepatic infarction on mortality and acute-on-chronic liver failure (ACLF) score. RESULTS: Hepatic infarction involved the right posterior segments (segments VI or VII) in 32 of 33 patients. Prolonged vasopressor requirement (p = 0.003) and intensive care unit stay (p = 0.001) were seen in patients with hepatic infarct, as well as trends toward lower post-TIPS portosystemic pressure gradient (p = 0.061) and higher risk of ACLF (p = 0.056). Procedure-related portal vein thrombosis or hepatic artery injury was identified in 12 and 5 patients with infarct, respectively. Patients with infarct had higher postprocedural aspartate aminotransferase (p < 0.001) and alanine aminotransferase (p < 0.001) levels, higher international normalized ratio (p = 0.016), lower platelet count (p = 0.042), and a greater decrease in hemoglobin level (p = 0.003). CONCLUSION: Hepatic infarction most frequently affects the right posterior hepatic segments after TIPS and results in a worse postprocedural course. Procedure-related complications and critically low portosystemic pressure gradient may contribute to TIPS-associated hepatic infarct.