Patient-specific left atrium contraction quantification associated with atrial fibrillation: A region-based approach.

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is a widespread cardiac arrhythmia that significantly impacts heart function. AF disrupts atrial mechanical contraction, leading to irregular, uncoordinated, and slow blood flow inside the atria which favors the formation of clots, primarily within the left atrium (LA). A standardized region-based analysis of the LA is missing, and there is not even any consensus about how to define the LA regions. In this study we propose an automatic approach for regionalizing the LA into segments to provide a comprehensive 3D region-based LA contraction assessment. LA global and regional contraction were quantified in control subjects and in AF patients to describe mechanical abnormalities associated with AF. METHODS: The proposed automatic approach for LA regionalization was tested in thirteen control subjects and seventeen AF patients. After dividing LA into standard regions, we evaluated the global and regional mechanical function by measuring LA contraction parameters, such as regional volume, global and regional strains, regional wall motion and regional shortening fraction. RESULTS: LA regionalization was successful in all study subjects. In the AF group compared with control subjects, results showed: a global impairment of LA contraction which appeared more pronounced along radial and circumferential direction; a regional impairment of radial strain which was more pronounced in septal, inferior, and lateral regions suggesting a greater reduction in mechanical efficiency in these regions in comparison to the posterior and anterior ones. CONCLUSION: An automatic approach for LA regionalization was proposed. The regionalization method was proved to be robust with several LA anatomical variations and able to characterize contraction changes associated with AF.

Virtual histology-intravascular ultrasound as a diagnostic alternative for morphological characterization of carotid plaque: comparison with histology and high-resolution magnetic resonance findings.

BACKGROUND: Stroke is the third most common cause of death and one of the most common cause of long-term disability in the Western world. Carotid plaque morphology is the main predictor of cerebrovascular accidents, more than the degree of stenosis. AIMS: The primary aim was to validate virtual histology- intravascular ultrasound (VH-IVUS) as a diagnostic tool for carotid plaque characterization, by comparison with histology, through ex-vivo evaluation of carotid plaques. The secondary target was to compare VH-IVUS with high-resolution MRI (HR-MRI) through in-vivo evaluation of carotid artery plaques. MATERIALS AND METHODS: In the ex-vivo study, data were acquired from six carotid arteries explanted from six symptomatic male patients with a mean age of 72 W 9.64 years. Sectional images obtained with the IVUS catheter were compared with digitalized histological images. Twelve consecutive patients (eight men, four women, mean age of 75 W 6.33 years), candidates for carotid artery stenting, were included in the in-vivo study. All histological and HR-MR images were converted to a digital format and the exact percentages of the four plaque components were determined. RESULTS: Forty-two images were used for correlation between VH-IVUS and histology. Quantitative analysis of different plaque components revealed a good concordance (0.82) between the two methods [95% confidence interval (CI) 0.69-0.92]. Precision rates of VH-IVUS for concordance with true histology of different plaque components were 99.4% for fibrous tissue, 85.9% for fibrolipid tissue, 71.4% for calcium and 83.4% for necrosis. Comparison between HR-MRI and VH-IVUS was performed on 27 images. Concordance between the two methods was 0.84 (95% CI 0.69-0.92). Precision rates were, respectively, 85.3, 95.2, 90.2 and 82.0%. CONCLUSION: We believe that VH-IVUS may be useful when a quick intraprocedural evaluation of a carotid plaque before or after stent placement is required, but is not suitable for the accurate in-vivo differentiation between stable and unstable plaques prone to rupture, due to the suboptimal assessment of the necrotic component, fibrous cap thickness and rupture signs. We do believe, however, that these results need further evaluation in larger populations to be confirmed.

Intravascular ultrasound assisted carotid artery stenting: randomized controlled trial. Preliminary results on 60 patients.

AIMS: The primary aim is the evaluation of the usefulness of intravascular ultrasound (IVUS) in the identification of otherwise unnoticed complications during carotid stenting. The secondary aim is the evaluation of the impact of IVUS assistance in the procedural outcomes and long-term patency rates of carotid artery stenting. MATERIALS AND METHODS: Sixty patients who underwent carotid artery stenting (CAS) during a 14-month period were evaluated prospectively. Thirty patients (50%) underwent IVUS assisted CAS, 30 patients (50%) underwent CAS using angiography as the unique diagnostic tool. All patients were enrolled through a primary duplex ultrasound evaluation; as a secondary evaluation, 54 patients (90%) underwent a preprocedural magnetic resonance angiography, whereas six patients (10%) underwent computed tomography-angiography. Patients with preocclusive stenoses (>85%) were excluded. Mean follow-up was 23 W 5.3 months. RESULTS: No periprocedural or late complications were observed. No statistical significance was observed in long-term stent patency between the two groups. Mean procedural time length of IVUS-assisted procedures was 10.3 W 5 min longer than non-IVUS-assisted procedures. Virtual histology (VH) IVUS evaluation of plaque morphology led to a different stent choice in three patients. In two cases, the IVUS assessment revealed a suboptimal stent deployment, solved by angioplasty; in one patient VH-IVUS detected plaque protrusion through stent cells, immediately treated by manual aspiration. CONCLUSIONS: Though not recommended as a routine intraprocedural evaluation, IVUS may be useful for a real-time CAS control when treating challenging plaques, such as 'soft' or lipidic ones or those prone to rupture, or whenever an intraprocedural morphologic evaluation is required for the appropriate stent choice, or when higher embolic risk is evaluated.

Rearfoot Transcutaneous Oximetry is a Useful Tool to Highlight Ischemia of the Heel.

PURPOSE: To demonstrate the usefulness of rearfoot transcutaneous oximetry to assess the peripheral arterial disease in diabetic patients with heel ulcer. METHODS: From our database of 550 critical limb ischemia diabetic patients followed after a percutaneous transluminal angioplasty, we have selected patients with below the knee arterial disease. Patients were grouped according to the dorsal transcutaneous oximetry value (Group A < 30 mmHg; Group B ≥ 30 mmHg). Patients of Group B had a second oximetry performed at the rearfoot, close to the lesion localized in all cases at the heel. Finally, the analysis of the arterial pattern disease has been done. RESULTS: We selected 191 patients: Group A (151 patients), dorsal transcutaneous oximetry of 11.8 ± 0.7 mmHg; Group B (40 patients), dorsal transcutaneous oximetry of 44.2 ± 10.1 mmHg. In Group B, rearfoot oximetry was 20.5 ± 5 mmHg, significantly lower than dorsal oximetry (p = 0.0179). The anterior tibial artery was involved in all patients of Group A. In Group B, the anterior tibial artery was involved in 15 subjects and never alone; the posterior tibial artery was involved in 20 subjects and in 11 cases alone. The peroneal artery was affected in 20 subjects and in 14 patients alone. CONCLUSION: When a heel lesion is present and the transcutaneous oximetry recorded on the dorsum of the foot does not confirm the presence of critical limb ischemia (not ≤30 mmHg), a second oximetry recorded on the rearfoot is useful to point out ischemia of the peroneal artery and/or of the posterior tibial artery.

Degenerative lumbar spinal stenosis treatment with Aperius™ PerCLID™ system and Falena® interspinous spacers: 1-year follow-up of clinical outcome and quality of life.

PURPOSE: Evaluation of the efficacy of the Falena(®) and Aperius™ PerCLID™ interspinous devices in the treatment of degenerative lumbar spinal stenosis with neurogenic intermittent claudication refractory to conservative treatment. MATERIALS AND METHODS: We retrospectively analyzed data from 24 patients (20 male and 4 female patients; 61 ± 7 years old), treated with an implantation of the AperiusTM PerCLID™ system, and from 35 patients (29 male and 6 female patients; 65 ± 9 years old) treated with the Falena(®) interspinous device.Patient pain intensity was evaluated by a 10-point visual analog scale (VAS), with a score (ranging from 0 = no pain to 10 = unbearable pain) that was collected before the procedure, at baseline; and at months 1, 6 and 12 after the interventional procedure. The assessment of quality of life (QOL) impairment was evaluated by the Oswestry Disability Index (ODI) questionnaire, which was administered beforehand at baseline; and at months 1, 6 and 12 after the interventional procedure. The vertebral canal area was measured by magnetic resonance imaging (MRI) scans before the treatment and at the one-year follow-up. RESULTS: All patients completed the study with no complications. Both the Falena group and Aperius group of surgery patients showed a statistically significant reduction of their VAS and ODI scores at the 6- and 12-month follow-up (p < 0.0001). A statistically significant increase in the vertebral canal area was observed both in the group that received Falena (p < 0.0001) and in the group that received Aperius (p = 0.0003). At the 1-year follow-up, we observed that there was a higher increase of vertebral canal area in those patients whom were treated with the Falena device (p < 0.001). CONCLUSIONS: The implantation of Falena(®) and Aperius™ PerCLID™ interspinous devices is an effective and safe procedure, in the medium term.

Long-term follow-up of endovascular treatment of renal artery aneurysms with covered stent deployment.

BACKGROUND: The aim of this study was to assess the technical success and clinical long-term results of renal artery aneurysm (RAA) treatment using covered stents. METHODS: We performed a retrospective study on endovascular treatment of nine patients with 10 RAAs, arising from the main renal artery or from the proximal portion of large segmental arteries. All procedures were performed in our department between 2004 and 2011. The aneurysms were excluded using covered stents. Our follow-up included laboratories indexes, Computed Tomography-angiography (CTA) at 1-6-12-24 months and 48-month Duplex-ultrasound examination. RESULTS: Study population included 4 males and 5 females (mean age: 63.5±7.3 y.o.). Six were affected by fibromuscular dysplasia and associated renal artery stenosis. The population showed a significant decrease of arterial blood pressure (from baseline values of 163.9±19.4/98.9±9.2 mmHg to 128.9±6.5/79.4±4.6 mmHg at 24 months follow-up) and of drug posology (baseline 3.7±0.7 drugs to 1.6±0.7 drugs at 24 months). Also they showed a significant decrease of serum creatinine levels (baseline 1.9±1.4 mg/dL vs.1.1±0.4 mg/dL at 12 months) and increase of glomerular filtration rate (from baseline values 46.9±23 mL/min/1.73 m2 to 69.1±20 mL/min/1.73 m2 at 24 months follow-up). CTA demonstrated patency of the cover stents, absence of endoleaks and re-stenosis in all patients. Only in one patient the inferior segmental artery was sacrificed due to the presence of its early origin, resulting in a small area of renal parenchyma infarction with no significant clinical consequences. CONCLUSIONS: The procedure revealed to be safe for renal function, feasible and effective for the exclusion of the aneurismal sac and restoring vessel patency.

Treatment of type II endoleak after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization.

PURPOSE: To assess the technical and midterm results in the treatment of type II endoleaks comparing nonselective (nTCE) vs. selective (sTCE) transcaval embolization. METHODS: During a 4-year period, 26 patients (18 men; median age 73 years, range 68-78) underwent direct transcaval aneurysm puncture followed by embolization of the sac (nTCE, n=9) or of the feeding vessels (sTCE, n=17). Intrasac pressure was recorded immediately after aneurysm sac puncture and at the end of the procedure. Technical success was defined as successful deployment of embolization material in the sac or in the feeding vessel. Clinical success was defined as absence of endoleak with stabilization of the sac on follow-up CTA. RESULTS: Technical success was 100% in the 9 patients treated with nTCE. Mean intrasac pressures before and after nTCE were 58.6±18.4 (range 51-105) and 6.5±1.2 mmHg (range 4-9), respectively. Over a mean 25.9±11.0 months of follow-up, 4 patients developed recurrent endoleak at a mean 9.7±3.9 months. Three patients were subsequently treated with sTCE, while the last patient underwent emergency surgery for aneurysm rupture due to an enlarging sac 5 months after nTCE. The 20 patients in the sTCE group had a successful procedure with no recurrence in a follow-up of 24.1±7.2 months. Mean intrasac pressure was reduced after sTCE from 63.6±15.2 mmHg (range 43-120) to 7.8±2.3 mmHg (range 5-12). CONCLUSION: The selective TCE approach appears to be a feasible and effective primary therapeutic option for treating type II endoleak.

Acute COPD exacerbation: 3 T MRI evaluation of pulmonary regional perfusion--preliminary experience.

OBJECTIVES: To compare pulmonary perfusion parameters by means of dynamic perfusion magnetic resonance in patients affected by chronic obstructive pulmonary disease (COPD), during and after acute exacerbation. METHODS: Fifteen patients were successfully evaluated with perfusional MRI during an acute exacerbation of COPD and upon clinical stabilization. Inclusion criteria were a PaCO2 > 45 mmHg and respiratory acidosis (arterial blood pH < 7.35) at admittance. RESULTS: In the acute phase a reduction of pulmonary blood flow (PBF) and pulmonary blood volume (PBV), and a significant prolonging of the mean transit time (MTT) and time to peak (TTP) were observed in all patients. In the stabilization phase a significant increase of PBF and PBV and a significant reduction of MTT and TTP were observed in 6 patients; no significant variations were observed in the other 9 patients. CONCLUSION: 3D time-resolved contrast-enhanced MRI allows quantitative evaluation of pulmonary regional perfusion in patients affected by COPD, identifying patients in which perfusion defects are resolved in the clinical-stabilization phase. This technique might allow the identification of patients in whom vasospasm may be the main responsible of pulmonary hypoperfusion during acute COPD exacerbation, with potential advantages on the clinical management of these patients.

Chronic obstructive pulmonary disease (COPD) patients with osteoporotic vertebral compression fractures (OVCFs): improvement of pulmonary function after percutaneous vertebroplasty (VTP).

OBJECTIVES: To investigate the changes of respiratory function in patients affected by chronic obstructive pulmonary disease (COPD) with single dorsal osteoporotic vertebral compression fractures (OVCFs) treated with vertebroplasty (VTP). METHODS: Forty-five patients affected by COPD and single dorsal OVCF underwent VTP (29 men, 16 women; mean age 71.4 years, range 65-77 years). Inclusion criteria were magnetic resonance findings of bone marrow oedema, without intracanal bone fragments and refractory pain to medical treatment for at least 3 months. Osteoporosis was assessed by bone densitometry. Spirometry was performed before and after treatment. RESULTS: A significant VAS-score decrease was observed 1 week after VTP, with a subsequent decrease over time; vital capacity (VC) and forced vital capacity (FVC) improved over time, reaching a plateau at 3 months. Forced expiratory volume at 1 s (FEV1) did not significantly differ between the pre-VTP values and follow-up values. A significant correlation was observed between VAS-score values and VC, and VAS-score values and FVC. No significant correlation was observed between VAS-score values and FEV1 values. CONCLUSIONS: VTP improves restrictive ventilatory impairment in patients with moderate and severe COPD affected by single thoracic OVCFs. We recommend this treatment in the management of these patients. KEY POINTS: • Osteoporosis is a major comorbidity in chronic obstructive pulmonary disease (COPD) patients. • Pain due to osteoporotic vertebral compression fractures worsens respiratory failure in COPD. • Vertebroplasty improves ventilatory impairment in COPD patients with osteoporotic vertebral compression fractures.

Thoraco-lumbar traumatic vertebral fractures augmentation by osteo-conductive and osteo-inductive bone substitute containing strontium-hydroxyapatite: our experience.

INTRODUCTION: The aim of our study was to evaluate the effectiveness of osteointegrable strontium-hydroxyapatite (Sr-HA) bone cement in the treatment of thoracolumbar traumatic vertebral fractures by percutaneous vertebroplasty (VTP). METHODS: We treated 35 patients [29 (82.85 %) men, 6 (17.14 %) women, mean age 34.05 ± 8.36 years (range 21-54 years)] with single type A1.1 and A1.2 thoracolumbar traumatic vertebral fracture without endospecal bone fragments. Pain intensity was evaluated before and at 1 day; 1 week; and 1, 6, and 12 months after VTP by a 10-point visual analog scale (VAS) score (0 = no pain, 10 = unbearable pain). Physical status and quality of life were evaluated by Oswestry Disability Index (ODI) questionnaire before and 1, 6, and 12 months after VTP. RESULTS: Procedural technical success was achieved in all patients with no deaths observed during follow-up. In three patients (8.57 %), postprocedural CT showed cement leakages: one intradiscal and two in venous plexus. No adjacent vertebral body fractures nor intrasomatic recollapse was detected. The VAS and ODI scores showed a statistically significant reduction 1 week after procedure (P value <0.0001) with a progressive statistically significant reduction during follow-up (P value <0.0001). Twenty-three patients (65.71 %) assigned a value of 0 to the VAS scale at 1 year after treatment. CONCLUSIONS: Strontium-hydroxyapatite bone cement is an effective and safe bone filler in percutaneous vertebroplasty with low leakage rate and absence of major complications when performed by a skilled equipe. It allows an immediate and long-lasting stabilization with a significant pain reduction and quality of life improvement.

Intracranial atheromatous disease treatment with the Wingspan stent system: evaluation of clinical, procedural outcome and restenosis rate in a single-center series of 21 consecutive patients with acute and mid-term results.

BACKGROUND: Intracranial atherosclerosis may be the underlying pathology in up to 15% of ischemic strokes, but may account for about 40% of strokes in some populations. After an ischemic event determined by intracranial atherosclerosis, patients have a 12% annual risk of stroke recurrence, mostly during the first year. OBJECTIVE: To evaluate procedural safety, clinical outcome and restenosis rate of Wingspan stent placement. METHODS: Twenty-one caucasoid patients were enrolled. Target patients were affected by high-grade, symptomatic, intracranial atherosclerotic lesions, were on antithrombotic therapy and at high stroke risk. All patients were treated with the Wingspan stent system. RESULTS: Technical success resulted 100%, with all target lesions being reduced to <50%. No stroke or death were observed at 30. The mean percent of stenosis was reduced from a middle value of 84% to a middle value of 17% after stent placement. Medium follow-up was 19.5months (range 6-36months). No stroke or death occurred in any patient. None of the patients presented a <50% stent patency rate at follow-up. CONCLUSIONS: The short-term results and follow up analysis provide evidence demonstrating the safety of the Wingspan system when used in high-risk patient population. Due to concerns regarding long-term stent patency and ischemic events occurrence emerged from clinical trials such as the SAMMPRIS, intracranial angioplasty and stent with the Wingspan system should be considered only for high risk patients in which it may be considered the only viable therapeutic option.

Randomized control study of the outback LTD reentry catheter versus manual reentry for the treatment of chronic total occlusions in the superficial femoral artery.

PURPOSE: To assess the efficacy and safety of the Outback device in patients with a chronic total occlusion (CTO) of the superficial femoral artery and evaluate its impact on fluoroscopy and procedural times. MATERIALS AND METHODS: From October 2006 to March 2007, 52 patients affected by TASC II-D superficial femoral artery CTO were treated with subintimal recanalization. Clinical indications for endovascular recanalization were: claudication, tissue loss, and at rest leg pain with critical limb ischemia. In 26 patients the manual reentry technique was used and in 26 the OUTBACK(®) LTD Re-Entry Catheter was used. Total procedure time, fluoroscopy time and precision in targeting the expected reentry site have been compared. RESULTS: Technical success was achieved in all cases (100%). In group 2, the planned in-target re-entry was achieved in 11/26 cases (42.3%). The procedure was performed with a traditional antegrade approach in 23/26 (88.4%) cases and in three cases (11.6%) a combined antegrade/retrograde approach was necessary. In group 1, the in-target re-entry was achieved in 26/26 cases (100%). In group 2, the mean procedural time was 55.4 ± 14.2 min with a mean fluoroscopy time 39.6 ± 13.9 min compared to 36.0 ± 9.4 min and 29.8 ± 8.9 min, respectively, of group 1 (P < 0.0001). CONCLUSIONS: In our experience, the use of this device is very useful for the revascularization of chronic femoral occlusions, even calcific, in which an accurate re-entry cannot be achieved with the conventional subintimal technique. In these cases, the Outback device grants high technical success rates and a significant reduction of procedural and fluoroscopy times.