Computed Tomography Angiography After Transcatheter and Surgical Aortic Interventions.

This comprehensive article reviews the complex realm of aortic surgical and endovascular interventions, focusing on the aortic root, ascending aorta, aortic arch, descending aorta, and abdominal aorta. It outlines the nuances of various procedures, emphasizing the importance of computed tomography angiography acquisition for an accurate assessment. Detailed discussions encompass expected postsurgical/endovascular findings and complications, covering various scenarios, from hematoma and infection to pseudoaneurysms and graft-related issues. This article serves as a crucial resource for radiologists, offering invaluable insights into the complexities of aortic interventions and their subsequent imaging, fostering a comprehensive understanding of diagnostic and management strategies.

Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review.

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.

ACR Appropriateness Criteria® Dialysis Fistula Malfunction.

The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Preprocedural Planning for Transcatheter Aortic Valve Replacement: 2023 Update.

This document discusses preprocedural planning for transcatheter aortic valve replacement, evaluating the imaging modalities used in initial imaging for preprocedure planning under two variants 1) Preintervention planning for transcatheter aortic valve replacement: assessment of aortic root; and 2) Preintervention planning for transcatheter aortic valve replacement: assessment of supravalvular aorta and vascular access. US echocardiography transesophageal, MRI heart function and morphology without and with IV contrast, MRI heart function and morphology without IV contrast and CT heart function and morphology with IV contrast are usually appropriate for assessment of aortic root. CTA chest with IV contrast, CTA abdomen and pelvis with IV contrast, CTA chest abdomen pelvis with IV contrast are usually appropriate for assessment of supravalvular aorta and vascular access. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Novel Imaging Approaches to Cardiac Manifestations of Systemic Inflammatory Diseases: JACC Scientific Statement.

Derangements in the innate and adaptive immune responses observed in systemic inflammatory syndromes contributes to unique elevated atherosclerotic risk and incident cardiovascular disease. Novel multimodality imaging techniques may improve diagnostic precision for the screening and monitoring of disease activity. The integrated application of these technologies lead to earlier diagnosis and noninvasive monitoring of cardiac involvement in systemic inflammatory diseases that will aid in preclinical studies, enhance patient selection, and provide surrogate endpoints in clinical trials, thereby improving clinical outcomes. We review the common cardiovascular manifestations of immune-mediated systemic inflammatory diseases and address the clinical and investigational role of advanced multimodality cardiac imaging.

Magnetic Resonance Angiography of the Arteries of the Upper and Lower Extremities.

Magnetic resonance angiography (MRA) is a powerful tool for assessing upper and lower extremity artery pathologies. In addition to the classic advantages of MRA, such as the absence of radiation and iodinated contrast exposure, it can provide high temporal resolution/dynamic images of the arteries with high soft tissue contrast. Although it has a relatively lower spatial resolution than computed tomography angiography, MRA does not cause blooming artifacts in heavily calcified vessels, which is crucial in small vessel assessment. Although contrast-enhanced MRA is the most preferred technique to assess extremity vascular pathologies, recent advances in non-contrast MRA protocols provide an alternative imaging technique for patients with chronic kidney disease.

Diagnostic Impact and Prognostic Value of Cardiac Magnetic Resonance in Patients With Ventricular Arrhythmias.

BACKGROUND: Cardiac magnetic resonance (CMR) characterizes myocardial substrate relevant to sudden cardiac death (SCD). However, its clinical value in patients presenting with ventricular arrhythmias is still being defined. OBJECTIVES: The authors sought to examine the diagnostic and prognostic value of multiparametric CMR in a cohort of consecutive patients referred for assessment of ventricular arrhythmias. METHODS: Consecutive patients undergoing CMR for nonsustained ventricular tachycardia (NSVT) (n = 345) or sustained ventricular tachycardia (VT)/aborted SCD (n = 297) were followed over a median of 4.4 years. Major adverse cardiac events included death, recurrent VT/ventricular fibrillation requiring therapy, and hospitalization for congestive heart failure. RESULTS: Of the 642 patients, 256 were women (40%), mean age was 54 ± 15 years, and median left ventricular ejection fraction was 58% (IQR: 49%-63%). A structurally abnormal heart by CMR assessment was detected in 40% of patients with NSVT and 66% in those with VT/SCD (P < 0.001). CMR assessment yielded a diagnostic change in 27% of NSVT patients vs 41% of those with VT/SCD (P < 0.001). During follow-up, 51 patients (15%) with NSVT and 104 patients (35%) with VT/SCD experienced major adverse cardiac events (MACE). An abnormal CMR was associated with a higher annual rate for MACE for both NSVT (0.7% vs 7.7%; P < 0.001) and VT/SCD (3.8% vs 13.3%; P < 0.001) patients. In a multivariate model including left ventricular ejection fraction, an abnormal CMR remained strongly associated with MACE in NSVT (HR: 5.23 [95% CI: 2.28-12.0]; P < 0.001) and VT/SCD (HR: 1.88 [95% CI: 1.07-3.30]; P = 0.03). Adding CMR assessment to the multivariable model for MACE yielded a significant improvement in the integrated discrimination improvement and an improvement in the C-statistic in the NSVT cohort. CONCLUSIONS: In patients presenting with ventricular arrhythmias, multiparametric CMR assessment provides diagnostic clarification and effective risk stratification beyond current standard of care.

Developing Validated Tools to Identify Pulmonary Embolism in Electronic Databases: Rationale and Design of the PE-EHR+ Study.

BACKGROUND: Contemporary pulmonary embolism (PE) research, in many cases, relies on data from electronic health records (EHRs) and administrative databases that use International Classification of Diseases (ICD) codes. Natural language processing (NLP) tools can be used for automated chart review and patient identification. However, there remains uncertainty with the validity of ICD-10 codes or NLP algorithms for patient identification. METHODS: The PE-EHR+ study has been designed to validate ICD-10 codes as Principal Discharge Diagnosis, or Secondary Discharge Diagnoses, as well as NLP tools set out in prior studies to identify patients with PE within EHRs. Manual chart review by two independent abstractors by predefined criteria will be the reference standard. Sensitivity, specificity, and positive and negative predictive values will be determined. We will assess the discriminatory function of code subgroups for intermediate- and high-risk PE. In addition, accuracy of NLP algorithms to identify PE from radiology reports will be assessed. RESULTS: A total of 1,734 patients from the Mass General Brigham health system have been identified. These include 578 with ICD-10 Principal Discharge Diagnosis codes for PE, 578 with codes in the secondary position, and 578 without PE codes during the index hospitalization. Patients within each group were selected randomly from the entire pool of patients at the Mass General Brigham health system. A smaller subset of patients will also be identified from the Yale-New Haven Health System. Data validation and analyses will be forthcoming. CONCLUSIONS: The PE-EHR+ study will help validate efficient tools for identification of patients with PE in EHRs, improving the reliability of efficient observational studies or randomized trials of patients with PE using electronic databases.

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update.

Arterial claudication is a common manifestation of peripheral artery disease. This document focuses on necessary imaging before revascularization for claudication. Appropriate use of ultrasound, invasive arteriography, MR angiography, and CT angiography are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update.

Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Impact of coronary artery calcium testing on patient management.

BACKGROUND: Coronary artery calcium (CAC) scoring can identify individuals who may benefit from aggressive prevention therapies. However, there is a paucity of contemporary data on the impact of CAC testing on patient management. METHODS: Retrospective cohort study of adults who underwent CAC testing at Brigham and Women's Hospital between 2015 and 2019. Information on baseline medications, follow-up medications, lifestyle modification, and downstream cardiovascular testing within one-year post-CAC were obtained from electronic health records. RESULTS: Of the 839 patients with available baseline and follow-up data, 376 (45%) had a CAC â€‹= â€‹0, 289 (34%) had CAC â€‹= â€‹1-99, and 174 (21%) had CAC≥100. The mean age at time of CAC testing was 59 â€‹± â€‹9.7 years. Patients with higher CAC scores were more likely to be male, have diabetes and hypertension, and have higher low-density lipoprotein cholesterol and lower high-density lipoprotein cholesterol. A non-zero CAC score was associated with initiation of aspirin (41% increase, p â€‹< â€‹0.001), anti-hypertensives (9% increase, p â€‹= â€‹0.031), and lipid-lowering therapies (114% increase, p â€‹< â€‹0.001), whereas CAC â€‹= â€‹0 was not. Among individuals with CAC≥100, 75% were started on new or more intense lipid-lowering therapy. Higher calcium scores correlated with increased physician recommendations for diet (p â€‹= â€‹0.008) and exercise (p â€‹= â€‹0.004). The proportion of cardiovascular downstream testing following CAC was 9.1%, and the majority of patients who underwent additional testing post-CAC had CAC scores ≥100. CONCLUSION: Approximately half of individuals referred for CAC testing had evidence of calcified coronary plaque, and of those who had significant calcifications (CAC≥100), nearly 90% were prescribed lipid-lowering therapies post-CAC. Rates of downstream non-invasive testing were low and such testing was mostly performed in patients who had at least moderate CAC.

Prognostic Value of T1 Mapping and Feature Tracking by Cardiac Magnetic Resonance in Patients With Signs and Symptoms Suspecting Heart Failure and No Clinical Evidence of Coronary Artery Disease.

Background The ability of left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) by cardiac magnetic resonance for risk stratification in suspected heart failure is limited. We aimed to evaluate the incremental prognostic value of cardiac magnetic resonance-assessed extracellular volume fraction (ECV) and global longitudinal strain (GLS) in patients with signs and symptoms suspecting heart failure and no clinical evidence of coronary artery disease. Methods and Results A total of 474 consecutive patients (57±21 years of age, 56% men) with heart failure-related symptoms and absence of coronary artery disease underwent cardiac magnetic resonance. After median follow-up of 18 months, 59 (12%) experienced the outcome of all-cause death or heart failure hospitalization (DeathCHF). In univariate analysis, cardiac magnetic resonance-assessed LVEF, LGE, GLS, and ECV were all significantly associated with DeathCHF. Adjusted for a multivariable baseline model including age, sex, LVEF and LGE, ECV, and GLS separately maintained a significant association with DeathCHF (ECV, hazard ratio [HR], 1.44 per 1 SD increase; 95% CI 1.13-1.84; P=0.003, and GLS, HR, 1.78 per 1 SD increase; 95% CI, 1.06-2.96; P=0.028 respectively). Adding both GLS and ECV to the baseline model significantly improved model discrimination (C statistic from 0.749 to 0.782, P=0.017) and risk reclassification (integrated discrimination improvement 0.046 [0.015-0.076], P=0.003; continuous net reclassification improvement 0.378 [0.065-0.752], P<0.001) for DeathCHF, beyond LVEF and LGE. Conclusions In patients with signs and symptoms suspecting heart failure and no clinical evidence of coronary artery disease, joint assessment of GLS and ECV provides incremental prognostic value for DeathCHF, independent of LVEF and LGE.

Multimodality Imaging of Large-Vessel Vasculitis, From the AJR Special Series on Inflammation.

Large-vessel vasculitis (LVV) is a noninfectious inflammation of the large vessels, including the aorta and its main branches. Imaging plays an essential role in diagnosing LVV given the challenges of tissue biopsy. This article reviews the types of LVV and the multimodality imaging tools available to establish its diagnosis. The cornerstone of imaging diagnosis is morphologic assessment using gray-scale ultrasound (US), gray-scale US combined with color Doppler US, CTA, or MRA. In the last decade, substantial progress has been made in functional and molecular imaging with FDG PET/CT for the diagnosis of LVV. Investigation is ongoing to develop novel MRA techniques and new PET tracers to assess disease activity and to differentiate the various vasculitides. An algorithm is provided to guide imaging technique selection based on the patient's specific clinical presentation.