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1.
Medicine (Baltimore) ; 98(45): e17940, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702683

RESUMO

Venous air embolism (VAE) can be observed in the right heart system on contrast-enhanced computed tomography (CT), following injection of contrast media with a power injector system. Although most VAEs are mostly asymptomatic, they may result in paradoxical air embolism (PAE).To evaluate whether the incidence of VAE on coronary CT angiography is associated with the process of preparation of the intravenous access route.We retrospectively evaluated 692 coronary CT examinations at 3 institutions. Trained CT nurses placed an intravenous cannula in the forearm. Tubes connected to the cannula were prepared in the following ways: A, using an interposed three-way cock and a 20-mL syringe filled with normal saline to collect air contamination in the tube; B, through direct connection to the power injector system without the interposed 3-way cock; and C, using an interposed three-way cock and a 100-mL normal saline drip infusion bottle system to keep the tube patent. The incidence and location of VAE and preparation of intravenous injection were assessed.The overall incidence of VAE was 55.3% (383/692), most frequently observed in the right atrium (81.5%, 312/383). Its incidence varied significantly across the 3 techniques (A: 21.6% (35/162), B: 63.2% (237/375) and C: 71.6% (111/155); P < .001). No patient demonstrated any symptom associated with VAE.Using a 3-way cock with syringe demonstrated the lowest incidence of VAE on coronary CT angiography. It is thus recommended to reduce potential complication risks related to intravenous contrast media injection.


Assuntos
Angiografia por Tomografia Computadorizada/efeitos adversos , Embolia Aérea/etiologia , Embolia Paradoxal/etiologia , Átrios do Coração/diagnóstico por imagem , Idoso , Meios de Contraste/administração & dosagem , Embolia Aérea/complicações , Embolia Aérea/epidemiologia , Embolia Paradoxal/epidemiologia , Humanos , Injeções Intravenosas/efeitos adversos , Injeções Intravenosas/instrumentação , Injeções Intravenosas/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
2.
Radiol Med ; 124(8): 753-761, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31011995

RESUMO

PURPOSE: To compare radiation exposure associated with daily practice cardiovascular (CV) examinations performed on two different multidetector computed tomography (MDCT) scanners, a conventional 64-MDCT and a third-generation dual-source (DS) MDCT. MATERIALS AND METHODS: In this retrospective study, 1458 patients who underwent CV examinations between January 2017 and August 2018 were enrolled. A single-source 64-MDCT (Lightspeed VCT, GE) scan was performed in 705 patients from January to August 2017 (207 coronary examinations and 498 vascular examinations) and 753 patients underwent third-generation 192 × 2-DSCT (Somatom FORCE, Siemens) scan from January to August 2018 (302 coronary examinations and 451 vascular examinations). Volume CT dose index (CTDIvol), dose length product (DLP), effective dose (ED), tube voltage (TV) and exposure time (ET), pitch factor (PF) were registered for each patient. Student's t test was used to compare mean values between each corresponding group of MDCT and DSCT. RESULTS: In coronary examinations with DSCT, CTDIvol was 24.4% lower (23.1 mGy vs 30.6 mGy, p < 0.0001) and DLP and ED reductions were 35.6% than with MDCT (465.0 mGy * cm vs 732.3 mGy * cm and 6.5 mSv and 10.3 mSv; vs p < 0.0001). Concerning scan parameters, kVp and ET reductions were 12.7% and 69.4%, respectively (p < 0.0001); PF increase was 73.8% (p < 0.0001). In all vascular studies, DSCT, compared with MDCT, permitted to reduce CTDIvol from 43.5 to 70.6%; DLP and ED reductions were from 50.3 to 73.1%; kVp and ET decreases were from 10.7 to 32.5% and from 26.3 to 68.7%. PF increase was from 16.7 to 58.1% (all differences with p < 0.0001). CONCLUSIONS: In daily practice, CV examinations CTDI, DLP, ED, ET and TV were lower and PF was higher with 192 × 2-DSCT compared to 64-MDCT.


Assuntos
Doenças Cardiovasculares/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Tomografia Computadorizada Multidetectores/métodos , Exposição à Radiação , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/métodos , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia por Tomografia Computadorizada/instrumentação , Angiografia Coronária/efeitos adversos , Angiografia Coronária/instrumentação , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Segurança de Equipamentos , Humanos , Tomografia Computadorizada Multidetectores/efeitos adversos , Tomografia Computadorizada Multidetectores/instrumentação , Doses de Radiação , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/efeitos adversos , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/instrumentação , Estudos Retrospectivos , Fatores de Tempo
3.
Radiology ; 291(2): 340-348, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30888934

RESUMO

Background Patient preference is pivotal for widespread adoption of tests in clinical practice. Patient preferences for invasive versus other noninvasive tests for coronary artery disease are not known. Purpose To compare patient acceptance and preferences for noninvasive and invasive cardiac imaging in North and South America, Asia, and Europe. Materials and Methods This was a prospective 16-center trial in 381 study participants undergoing coronary CT angiography with stress perfusion, SPECT, and invasive coronary angiography (ICA). Patient preferences were collected by using a previously validated questionnaire translated into eight languages. Responses were converted to ordinal scales and were modeled with generalized linear mixed models. Results In patients in whom at least one test was associated with pain, CT and SPECT showed reduced median pain levels, reported on 0-100 visual analog scales, from 20 for ICA (interquartile range [IQR], 4-50) to 6 for CT (IQR, 0-27.5) and 5 for SPECT (IQR, 0-25) (P < .001). Patients from Asia reported significantly more pain than patients from other continents for ICA (median, 25; IQR, 10-50; P = .01), CT (median, 10; IQR, 0-30; P = .02), and SPECT (median, 7; IQR, 0-28; P = .03). Satisfaction with preparation differed by continent and test (P = .01), with patients from Asia reporting generally lower ratings. Patients from North America had greater percentages of "very high" or "high" satisfaction than patients from other continents for ICA (96% vs 82%, respectively; P < .001) and SPECT (95% vs 79%, respectively; P = .04) but not for CT (89% vs 86%, respectively; P = .70). Among all patients, CT was preferred by 54% of patients, compared with 18% for SPECT and 28% for ICA (P < .001). Conclusion For cardiac imaging, patients generally favored CT angiography with stress perfusion, while study participants from Asia generally reported lowest satisfaction. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Woodard and Nguyen in this issue.


Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária , Preferência do Paciente/estatística & dados numéricos , Idoso , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/psicologia , Angiografia Coronária/efeitos adversos , Angiografia Coronária/métodos , Angiografia Coronária/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Processual , Estudos Prospectivos
4.
Thromb Res ; 177: 172-179, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30921536

RESUMO

BACKGROUND: CTPA is the gold standard investigation for evaluating suspected pulmonary embolism (PE) in the general population however is sometimes considered second line in pregnant and post-partum patients with a normal CXR due to its higher breast dose and the increased radio-sensitivity of breast tissue during this period. Guidelines advocating for scintigraphy over CTPA, however, quote significantly higher breast doses than those achievable with optimised low dose strategies. Defining the radiation dose achievable with a specific low-dose CTPA protocol is therefore imperative. As decreasing dose is associated with increased image noise, demonstrating the image quality and validity of a negative low-dose CTPA in out-ruling PE in this population is necessary. METHODS: The OPTICA study is a prospective multicentre observational study aiming to validate the clinical utility and safety of an optimised low-dose CTPA protocol in pregnancy. An optimised low-dose CTPA protocol has been agreed across all study sites with equivalent CT capabilities. Pregnant women undergoing CTPA for suspected PE will be included. Independent review of CTPAs by two radiology consultants, image data analysis and 3-month patient follow up will be performed. The primary outcome is the 3-month incidence of VTE in pregnant patients in whom PE was excluded at baseline CTPA. Secondary outcomes will confirm the associated radiation dose and image quality of this protocol. The radiation dose will be calculated using the Monte Carlo method and will include maternal effective, breast and foetal doses. Image quality will be assessed objectively by measuring opacification of the main pulmonary trunk, signal-to-noise and contrast-to-noise ratios and subjectively using a grading scale and inter-reader variability of CTPA results. CONCLUSION: The OPTICA study is the first prospective trial of a low-dose CTPA protocol in the pregnant population. It will provide high-quality evidence defining the achievable dose, image quality and safety of an optimised CTPA for this population. It will assist other institutes with similar CT capabilities in achieving comparable low doses for its patients and provide an evidence base upon which modern CTPA protocols can be appropriately compared to scintigraphy in the pregnant population.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Adulto , Angiografia por Tomografia Computadorizada/efeitos adversos , Feminino , Humanos , Gravidez , Estudos Prospectivos , Controle de Qualidade , Adulto Jovem
5.
Int J Cardiovasc Imaging ; 35(7): 1379-1386, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30850908

RESUMO

New protocols for coronary computed tomography angiography (CCTA) could lower the radiation dose for patients but influence the image quality. To compare image quality and radiation exposure in step-and-shoot CCTA and high-pitch spiral CCTA. Fifty-nine pairs of patients matched for weight, height, sex and heart rate were included in this study (74 m, 44 f, average age 60 years, age range 29-94 years). Step-and-shoot CCTA and high-pitch spiral CCTA was performed on a third generation dual-source CT in equally sized patient groups. The signal-to-noise ratio (SNR) in the ascending aorta and the coronary arteries were determined for each dataset. Image quality was rated using a five-point scale. We used the t-test for paired samples to compare SNR and effective dose, and the Wilcoxon test to compare image quality scores. Mean effective dose for the step-and-shoot protocol (4.15 ± 3.07 mSv) was significantly higher in comparison to the high-pitch spiral protocol (1.2 ± 0.69 mSv; p < 0.0001). Mean SNR was higher with the step-and-shoot protocol compared to the high-pitch spiral protocol in the aorta, in the left main and peripheral coronary arteries (p < 0.01), in the proximal right coronary artery (p = 0.027). Image quality scores were significantly better for the step-and-shoot protocol (p = 0.0003). Step-and-shoot CCTA has significantly better SNR and overall image quality compared to high-pitch spiral CCTA, but with a mean effective dose more than thrice as high.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Doses de Radiação , Exposição à Radiação , Tomografia Computadorizada Espiral/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Exposição à Radiação/efeitos adversos , Interpretação de Imagem Radiográfica Assistida por Computador , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada Espiral/efeitos adversos
6.
Int J Cardiovasc Imaging ; 35(2): 367-374, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30684082

RESUMO

Assess image quality and radiation dose of ECG-triggered High-Pitch Dual-Source CTA for the evaluation central vascular stents in children. We included all children ≤ 21 years old with one or more central vascular stents and available prospective ECG-triggered High-Pitch Dual-Source CTA performed at our institution between January 2015 and August 2017. Demographic and scanner information was retrieved. Two board-certified pediatric radiologists blinded to the clinical data, independently reviewed and scored each case using a four-point quality score. Scores 1, 2 and 3 were considered of diagnostic image quality. Inter-observer agreement and non-parametric test were used. 18 patients (10 girls, 8 boys) with a mean age of 9.47 ± 7.38 years (mean ± SD) met inclusion criteria. Thirty-two central vascular stents were evaluated. Mean quality score was 2.07 ± 0.94 with 12.5% (4/32) of the cases classified as unevaluable. Interobserver agreement was excellent (k = 0.86). There is no significant difference between quality score and stent location (p = 0.07). There is a significant difference with stent material as all non-diagnostic scores were only seen in covered stents made of platinum-iridium (p < 0.001). There was no association between image quality and age, height, weight, BSA, heart rate, radiation dose or stent lumen size (p > 0.05). ECG-triggered high-pitch spiral DS-CTA offers appropriate image quality for assessment of central vascular stents in children.


Assuntos
Técnicas de Imagem de Sincronização Cardíaca , Angiografia por Tomografia Computadorizada/métodos , Eletrocardiografia , Procedimentos Endovasculares/instrumentação , Doença Arterial Periférica/cirurgia , Doses de Radiação , Exposição à Radiação , Stents , Adolescente , Fatores Etários , Técnicas de Imagem de Sincronização Cardíaca/efeitos adversos , Criança , Pré-Escolar , Angiografia por Tomografia Computadorizada/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Desenho de Prótese , Exposição à Radiação/efeitos adversos , Interpretação de Imagem Radiográfica Assistida por Computador , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
7.
J Stroke Cerebrovasc Dis ; 28(3): 649-654, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30527789

RESUMO

GOAL: Computed tomography angiography (CTA) is a well-tolerated, noninvasive study of the intracranial vascular circulation; however, contrast-induced nephropathy (CIN) has been reported in 5%-7% of patients undergoing CTA. Limited studies have evaluated the risks of CIN in patients undergoing CTA. Our study was designed to evaluate the prevalence and risk factors for CIN in patients with ischemic stroke who receive a CTA. MATERIALS AND METHODS: Single-center, nested, case-control study of patients with ischemic stroke who received a CTA between June 18, 2012 and January 1, 2016. Patients were grouped based on development of CIN. FINDINGS: A total of 209 patients were included in the final analysis (178 controls, 31 cases). The prevalence of CIN during the time period studied was 14.8% (95% confidence interval [CI]: 10.2-20.2). A higher proportion of patients who developed CIN had a history of diabetes mellitus (37 [20.56%] versus 15 [48.39%]; P = .0009) and reported taking no medications prior to admission (35 [19.44%] versus 11 [35.48%]; P = .0458). However, a lower proportion of patients who developed CIN had a history of smoking (59 [32.78] versus 3 [9.68]; P = .0091). After statistical adjustment, only a history of diabetes (odds ratio [OR] 4.15 [95% CI: 1.765, 9.754), taking no medications prior to admission (OR 3.56 [95% CI: 1.417, 8.941]) and a self-reported history of smoking (OR 0.204 [95% CI: 0.057, 0.721]) remained associated with the development of CIN. CONCLUSIONS: Those patients with a history of diabetes mellitus or not taking medications prior to admission should be monitored closely for the development of contrast-induced nephropathy CIN.


Assuntos
Angiografia Cerebral/efeitos adversos , Angiografia por Tomografia Computadorizada/efeitos adversos , Meios de Contraste/efeitos adversos , Nefropatias/induzido quimicamente , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral/métodos , Meios de Contraste/administração & dosagem , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Nefropatias/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Prevalência , Terapia de Substituição Renal , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Tennessee/epidemiologia , Fatores de Tempo
8.
J Vasc Surg ; 69(4): 1045-1058.e3, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30527938

RESUMO

OBJECTIVE: The objective of this study was to analyze the impact of advanced imaging applications and cone beam computed tomography (CBCT) on radiation exposure of the patient and operator and detection of technical problems during fenestrated-branched endovascular aortic repair (F-BEVAR) for treatment of pararenal aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: We reviewed the clinical data of 386 consecutives patients (289 male; mean age, 75 ± 8 years) treated by F-BEVAR for 196 pararenal aneurysms and 190 TAAAs (mean, 3.4 ± 0.9 targeted vessels/patient) between 2007 and 2017. Radiation exposure (cumulative air kerma) was analyzed in three fixed imaging systems used between 2007 and 2011 (system 1), 2012 and 2016 (system 2), and 2016 and 2017 (system 3). Onlay fusion and CBCT were available with systems 2 and 3, whereas digital zoom with fusion overlay was used with system 3. Operator effective dose was measured per month using a radiation dosimeter badge. Computed tomography angiography and CBCT were analyzed for findings requiring immediate revision or secondary interventions. End points were patient radiation exposure; operator effective dose; procedure technical success; and 30-day rates of mortality, major adverse events, and secondary interventions. RESULTS: F-BEVAR was performed using system 1 in 98 patients, system 2 in 198 patients, and system 3 in 90 patients. Use of onlay fusion/CBCT was 0% with system 1, 42% with system 2, and 98% with system 3. Procedures performed with onlay fusion/CBCT had significantly (P < .05) higher technical success (99.4% vs 98.8%) and lower contrast material volume (155 ± 58 mL vs 172 ± 80 mL), fluoroscopy time (83 ± 34 minutes vs 94 ± 49 minutes), and cumulative air kerma (2561 ± 1920 mGy vs 3767 ± 2307 mGy). Despite higher case volume and increasing complexity during the experience, operator effective dose decreased to 9 ± 4 × 10-2 mSv/case with system 3 compared with 26 ± 3 × 10-2 mSv/case with system 1 and 20 ± 2 × 10-2 mSv/case with system 2 (P = .001). Among 219 patients who had no CBCT, 18 (8%) had computed tomography angiography findings that prompted secondary interventions before dismissal. Conversely, among 167 patients who had CBCT, 14 patients (8%) had intraoperative CBCT findings requiring immediate revision, with no additional secondary interventions. Patients treated with onlay fusion/CBCT had significantly (P < .05) lower mortality (4% vs 1%), major adverse events (43% vs 19%), and secondary interventions (10% vs 4%) at 30 days. CONCLUSIONS: Radiation exposure and operator effective dose significantly decreased with evolution of F-BEVAR experience and use of advanced imaging applications such as onlay fusion and CBCT. CBCT allowed immediate assessment and identified intraoperative technical problems, leading to immediate revision and avoiding early secondary interventions.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Aortografia/métodos , Implante de Prótese Vascular , Angiografia por Tomografia Computadorizada , Tomografia Computadorizada de Feixe Cônico , Procedimentos Endovasculares , Exposição Ocupacional/prevenção & controle , Exposição à Radiação/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/efeitos adversos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada/efeitos adversos , Tomografia Computadorizada de Feixe Cônico/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Exposição Ocupacional/efeitos adversos , Valor Preditivo dos Testes , Desenho de Prótese , Doses de Radiação , Exposição à Radiação/efeitos adversos , Interpretação de Imagem Radiográfica Assistida por Computador , Estudos Retrospectivos , Stents , Resultado do Tratamento
9.
J Vasc Surg ; 69(4): 1003-1010, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30528407

RESUMO

OBJECTIVE: The objective of this study was to evaluate the effect of image fusion (IF) technology in thoracic endovascular aortic repair (TEVAR) on reducing radiation exposure (dose and time), amount of injected iodinated contrast medium needed, and procedure time. METHODS: We performed a review of our institutional endovascular aortic database of patients who had undergone TEVAR between 2008 and 2016 before and after the installation of a three-dimensional (3D) IF computed tomography system in our hybrid operating room. All patients were operated on using the same radiologic equipment with or without IF. RESULTS: The 146 patients who had undergone elective or emergent TEVAR with preoperative computed tomography angiography done in 1-mm-thick slices were divided into two groups: the IF group (98 patients), in which TEVAR was performed using intraoperative IF with the two-dimensional-3D registration method; and 48 controls without the use of IF. The IF group received a significantly reduced dose of contrast material, with a median of 70 mL (interquartile range [IQR], 50-101 mL) compared with controls receiving 104 mL (IQR, 69-168 mL; P < .001).Patients who underwent hybrid TEVAR had a significantly reduced procedure time under IF guidance (n = 25) compared with controls (n = 11; median, 162 minutes [IQR, 139-199 minutes] vs 213 minutes [IQR, 189-298 minutes]; P = .015). In addition, the intraoperative fluoroscopy time was reduced to 9 minutes (IQR, 6-13 minutes) vs 23 minutes (IQR, 12-45 minutes; P < .005). However, the radiation dose (dose-area product) was similar for the two groups (P = .37).In patients who underwent plain TEVAR (n = 74) without a carotid-subclavian bypass, the IF group needed significantly less contrast material (median, 64 mL [IQR, 43-81 mL]) compared with the control group (median, 98 mL [IQR, 60-180 mL]; P = .003), whereas intraoperative radiation exposition, procedure time, and fluoroscopy time did not statistically significantly differ between the two groups. CONCLUSIONS: The IF technology using the two-dimensional-3D registration method was associated with reduced intraoperative contrast material volume in performing TEVAR. IF seemed to shorten the operation and radiation times in the more complicated (hybrid) TEVAR cases. However, a prospective study is needed to look at the dose-area product, fluoroscopy time, and procedure time in a larger cohort of patients.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Aortografia/métodos , Implante de Prótese Vascular/métodos , Angiografia por Tomografia Computadorizada/métodos , Meios de Contraste/administração & dosagem , Procedimentos Endovasculares/métodos , Imagem Tridimensional/métodos , Duração da Cirurgia , Radiografia Intervencionista/métodos , Cirurgia Assistida por Computador/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/efeitos adversos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada/efeitos adversos , Meios de Contraste/efeitos adversos , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Fluoroscopia , Humanos , Imagem Tridimensional/efeitos adversos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Valor Preditivo dos Testes , Doses de Radiação , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Stents , Cirurgia Assistida por Computador/efeitos adversos , Cirurgia Assistida por Computador/instrumentação , Fatores de Tempo , Resultado do Tratamento
10.
J Vasc Surg ; 69(4): 1111-1120, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30301693

RESUMO

OBJECTIVE: Three-dimensional (3D) image fusion is associated with lower radiation exposure, contrast agent dose, and operative time during endovascular abdominal aortic aneurysm repair. Therefore, we evaluated the impact of this technology on carotid artery stenting (CAS). METHODS: We identified consecutive CAS procedures from 2009 to 2017 and compared those performed with and without 3D image fusion. For image fusion, we created a 3D reconstruction of the aortic arch anatomy based on preoperative computed tomography or magnetic resonance angiography that we merged with two-dimensional fluoroscopy, allowing 3D image overlay. We compared radiation exposure, fluoroscopy time, contrast agent dose, time to common carotid artery (CCA) cannulation, time from CCA cannulation to completion angiography, and total procedure time in procedures with and without image fusion. We also assessed rates of 30-day stroke/death, in-hospital and 30-day stroke, and acute kidney injury. We used multivariable linear regression to adjust for patient and procedural characteristics and used these models to compute the marginal effects of image fusion compared with no image fusion. RESULTS: There were 46 patients who underwent CAS with a 3D image fusion system and 70 patients without. Patients undergoing CAS with image fusion experienced 31% lower radiation exposure compared with the control group (207 ± 23 mGy vs 300 ± 26 mGy, respectively; P < .01), shorter fluoroscopy time (21 ± 6 minutes vs 24 ± 8 minutes; P = .02), shorter time to carotid cannulation (21 ± 9 minutes vs 31 ± 8 minutes; P < .001), and shorter total procedure time (47 ± 13 minutes vs 54 ± 18 minutes; P = .03). There was no difference in contrast material volume, time from CCA cannulation to completion angiography, or total in-room time. After multivariable adjustment, 3D image fusion remained associated with lower radiation dose, shorter fluoroscopy time, and shorter time to carotid cannulation (all P < .05). The rate of 30-day stroke/death was 2.7% (three strokes and no deaths at 30 days), and the rate of acute kidney injury was 1.8%. CONCLUSIONS: CAS with 3D image fusion was associated with lower radiation exposure and shorter time to CCA cannulation. These results represent the potential technical advantage gained with image fusion and add to the growing body of evidence demonstrating its impact on radiation exposure and operative times during complex endovascular procedures.


Assuntos
Aortografia/métodos , Doenças das Artérias Carótidas/terapia , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/instrumentação , Imagem Tridimensional , Exposição à Radiação/prevenção & controle , Radiografia Intervencionista/métodos , Stents , Idoso , Aortografia/efeitos adversos , Doenças das Artérias Carótidas/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Fluoroscopia , Humanos , Imagem Tridimensional/efeitos adversos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Doses de Radiação , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
11.
Arch Cardiovasc Dis ; 112(1): 12-21, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30041863

RESUMO

BACKGROUND: Cardiac catheterization is the gold-standard modality for investigation of cardiovascular morphology before bidirectional cavopulmonary connection, but requires general anaesthesia and is associated with procedural risk. AIMS: To assess the diagnostic accuracy and safety of computed tomography in diagnosing great vessel stenosis/hypoplasia compared with cardiac catheterization and surgical findings. METHODS: Twenty-seven patients (10 after Norwood stage I) underwent computed tomography before surgery between January 2010 and June 2016; 16 of these patients also underwent cardiac catheterization. Proximal and distal pulmonary artery, aortic isthmus and descending aorta measurements, radiation dose and complications were compared via Bland-Altman analyses and correlation coefficients. RESULTS: The accuracy of computed tomography in detecting stenosis/hypoplasia of either pulmonary artery was 96.1% compared with surgical findings. For absolute vessel measurements and Z-scores, there was high correlation between computed tomography and angiography at catheterization (r=0.98 for both) and a low mean bias (0.71mm and 0.48; respectively). The magnitude of intertechnique differences observed for individual patients was low (95% of the values ranged between -0.9 and 2.3mm and between -0.7 and 1.7, respectively). Four patients (25%) experienced minor complications from cardiac catheterization, whereas there were no complications from computed tomography. Patients tended to receive a higher radiation dose with cardiac catheterization than with computed tomography, even after exclusion of interventional catheterization procedures (median 2.5 mSv [interquartile range 1.3 to 3.4 mSv] versus median 1.3 mSv [interquartile range 0.9 to 2.6 mSv], respectively; P=0.13). All computed tomography scans were performed without sedation. CONCLUSIONS: Computed tomography may replace cardiac catheterization in identification of great vessel stenosis/hypoplasia before bidirectional cavopulmonary connection when no intervention before surgery is required. Computed tomography carries lower morbidity, can be performed without sedation and may be associated with less radiation.


Assuntos
Aorta/diagnóstico por imagem , Aorta/cirurgia , Cateterismo Cardíaco , Angiografia por Tomografia Computadorizada , Técnica de Fontan , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/cirurgia , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Aorta/anormalidades , Aorta/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Angiografia por Tomografia Computadorizada/efeitos adversos , Constrição Patológica , Feminino , Cardiopatias Congênitas/fisiopatologia , Hemodinâmica , Humanos , Masculino , Valor Preditivo dos Testes , Artéria Pulmonar/anormalidades , Artéria Pulmonar/fisiopatologia , Doses de Radiação , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco
12.
Ann Vasc Surg ; 55: 166-174, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30092429

RESUMO

BACKGROUND: Fusion imaging is a technique that facilitates endovascular navigation but is only available in hybrid rooms. The goal of this study was to evaluate the feasibility of fusion imaging with a mobile C-arm in a conventional operating room through the use of an angionavigation station. METHODS: From May 2016 to June 2017, the study included all patients who underwent an aortic stent graft procedure in a conventional operating room with a mobile flat-panel detector (Cios Alpha, Siemens) connected to an angionavigation station (EndoNaut, Therenva). The intention was to perform preoperative 3D computerized tomography/perioperative 2D fluoroscopy fusion imaging using an automatic registration process. Registration was considered successful when the software was able to correctly overlay preoperative 3D vascular structures onto the fluoroscopy image. For EVAR, contrast dose, operation time, and fluoroscopy time (FT) were compared with those of a control group drawn from the department's database who underwent a procedure with a C-arm image intensifier. RESULTS: The study included 54 patients, and the procedures performed were 49 EVAR, 2 TEVAR, 2 IBD, and 1 FEVAR. Of the 178 registrations that were initialized, it was possible to use the fusion imaging in 170 cases, that is, a 95.5% success rate. In the EVAR comparison, there were no difference with the control group (n = 103) for FT (21.9 ± 12 vs. 19.5 ± 13 min; P = 0.27), but less contrast agent was used in the group undergoing a procedure with the angionavigation station (42.3 ± 22 mL vs. 81.2 ± 48 mL; P < 0.001), and operation time was shorter (114 ± 44 vs. 140.8 ± 38 min; P < 0.0001). CONCLUSIONS: Fusion imaging is feasible with a mobile C-arm in a conventional operating room and thus represents an alternative to hybrid rooms. Its clinical benefits should be evaluated in a randomized series, but our study already suggests that EVAR procedures might be facilitated with an angionavigation system.


Assuntos
Aneurisma Aórtico/cirurgia , Aortografia/instrumentação , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada/instrumentação , Procedimentos Endovasculares/instrumentação , Radiografia Intervencionista/instrumentação , Cirurgia Assistida por Computador/instrumentação , Tomógrafos Computadorizados , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/diagnóstico por imagem , Aortografia/efeitos adversos , Angiografia por Tomografia Computadorizada/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Fluoroscopia/instrumentação , Humanos , Masculino , Duração da Cirurgia , Modelagem Computacional Específica para o Paciente , Projetos Piloto , Estudos Prospectivos , Doses de Radiação , Exposição à Radiação , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista/efeitos adversos , Cirurgia Assistida por Computador/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
13.
Am J Emerg Med ; 37(5): 895-901, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30104092

RESUMO

We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results. By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.


Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Embolia Pulmonar/diagnóstico , Adulto , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia por Tomografia Computadorizada/economia , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade
14.
Int J Cardiovasc Imaging ; 35(1): 179-183, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30084106

RESUMO

Coronary artery calcium (CAC) scoring is used in asymptomatic patients to improve their clinically predicted risk for future cardiovascular events. Current CT protocols seek to reduce radiation exposure without diminishing image quality. Reported radiation exposure remains widely variable (0.8-5 mSv) depending on the type of protocol. In this study, we report the radiation exposure of CAC scoring from the Society for Heart Attack Prevention and Eradication (SHAPE) early detection program cohort sites, which spanned multiple centers using 64-MDCT (multi-detector computed tomography) scanners. We reviewed radiation exposure in milliSieverts (mSv) for 82,214 participants from the SHAPE early detection program cohort who underwent CAC scoring. This occurred over a 2.5-year period (2012-2014) divided among 33 sites in 7 countries with four different types 64-MDCT scanners. The effective radiation dose was reported as mSv. Mean radiation dosing amongst all 82,214 participants was 1.03 mSv, a median dose of 0.94 mSv. The mean radiation dose ranged from 0.76 to 1.31 mSv across the 33 sites involved with the SHAPE program cohort. Subgroup analysis by age, gender or body mass index (BMI) less than 30 kg/m2 showed no variability. Radiation dose in patients with BMI > 30 kg/m2 were significantly greater than other subgroups (µ = 1.96 mSv, p < 0.001). The use of 64-MDCT scanners and protocols provide the effective radiation dose for CAC scoring, which is approximately 1 mSv. This is consistently lower than previously reported for CAC scanning, regardless of scanner type, age or gender. In contrast, a greater BMI influenced mean radiation doses.


Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Infarto do Miocárdio/prevenção & controle , Doses de Radiação , Exposição à Radiação , Calcificação Vascular/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/terapia , Diagnóstico Precoce , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/efeitos adversos , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Segurança do Paciente , Valor Preditivo dos Testes , Prognóstico , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Medição de Risco , Fatores de Risco , Emirados Árabes Unidos , Estados Unidos , Calcificação Vascular/complicações , Calcificação Vascular/terapia , Adulto Jovem
15.
J Cardiol ; 73(1): 58-64, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29937106

RESUMO

BACKGROUND: Although subtraction coronary computed tomography angiography (S-CCTA) has recently been developed to improve the diagnostic ability in patients with severe calcification, increase in radiation exposure remains a concern. The usefulness of S-CCTA using a low-radiation dose protocol was investigated. METHODS: S-CCTA in 320-row area detector CT was performed on 84 consecutive patients with suspected obstructive coronary artery disease with Agatston score ≥100. Reconstruction and radiation dose were changed according to the slow filling time (SF) (137.5ms

Assuntos
Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doses de Radiação , Calcificação Vascular/diagnóstico por imagem , Idoso , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Exposição à Radiação/efeitos adversos
16.
J Vasc Surg ; 69(6): 1776-1785.e2, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30583890

RESUMO

OBJECTIVE: Endovascular aneurysm repair (EVAR) has increasingly been used as the primary treatment approach for abdominal aortic aneurysm (AAA). This study examined the hypothesis that EVAR leads to an increased risk of abdominal cancer within the radiation field compared with open AAA repair. METHODS: The nationwide English Hospital Episode Statistics database was used to identify all patients older than 50 years who received an AAA repair in 2005 to 2013. EVAR and open AAA repair groups were compared for the incidence of postoperative cancer using inverse probability weights and G-computation formula to adjust for selection bias and confounding. RESULTS: Among 14,150 patients who underwent EVAR and 24,645 patients who underwent open AAA repair, follow-up was up to 7 years. EVAR was associated with an increased risk of postoperative abdominal cancer (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.03-1.27) and all cancers (HR, 1.09; 95% CI, 1.02-1.17). However, there was no difference between the groups in the risk of lung cancer (HR, 1.04; 95% CI, 0.92-1.18) or obesity-related nonabdominal cancer (HR, 1.12; 95% CI, 0.69-1.83). Within the EVAR group, use of computed tomography surveillance was not associated with any increased risk of abdominal cancer (HR, 0.94; 95% CI, 0.71-1.23) or all cancers (HR, 0.97; 95% CI, 0.81-1.17). CONCLUSIONS: This study suggests an increased risk of abdominal cancer after EVAR compared with open AAA repair. The differential cancer risk should be further explored in alternative national populations, and radiation exposure during EVAR should be measured as a quality metric in the assessment of EVAR centers.


Assuntos
Neoplasias Abdominais/epidemiologia , Aneurisma da Aorta Abdominal/cirurgia , Aortografia/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Neoplasias Induzidas por Radiação/epidemiologia , Radiografia Intervencionista/efeitos adversos , Neoplasias Abdominais/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/epidemiologia , Bases de Dados Factuais , Inglaterra/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neoplasias Induzidas por Radiação/diagnóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
18.
J Cardiovasc Comput Tomogr ; 12(6): 451-466, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30392926

RESUMO

This expert consensus statement from the Society of Cardiovascular Computed Tomography (SCCT) provides an evidence synthesis on the use of computed tomography (CT) imaging for diagnosis and risk stratification of coronary artery disease in women. From large patient and population cohorts of asymptomatic women, detection of any coronary artery calcium that identifies females with a 10-year atherosclerotic cardiovascular disease risk of >7.5% may more effectively triage women who may benefit from pharmacologic therapy. In addition to accurate detection of obstructive coronary artery disease (CAD), CT angiography (CTA) identifies nonobstructive atherosclerotic plaque extent and composition which is otherwise not detected by alternative stress testing modalities. Moreover, CTA has superior risk stratification when compared to stress testing in symptomatic women with stable chest pain (or equivalent) symptoms. For the evaluation of symptomatic women both in the emergency department and the outpatient setting, there is abundant evidence from large observational registries and multi-center randomized trials, that CT imaging is an effective procedure. Although radiation doses are far less for CT when compared to nuclear imaging, radiation dose reduction strategies should be applied in all women undergoing CT imaging. Effective and appropriate use of CT imaging can provide the means for improved detection of at-risk women and thereby focus preventive management resulting in long-term risk reduction and improved clinical outcomes.


Assuntos
Cardiologia/normas , Angiografia por Tomografia Computadorizada/normas , Angiografia Coronária/normas , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Saúde da Mulher/normas , Angiografia por Tomografia Computadorizada/efeitos adversos , Consenso , Angiografia Coronária/efeitos adversos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/terapia , Feminino , Humanos , Valor Preditivo dos Testes , Gravidez , Prognóstico , Doses de Radiação , Exposição à Radiação , Reprodutibilidade dos Testes , Fatores de Risco , Fatores Sexuais
19.
J Cardiovasc Comput Tomogr ; 12(6): 472-479, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30201310

RESUMO

BACKGROUND: The aim of this prospective, randomized trial was to evaluate whether the use of coronary computed tomography angiography (CCTA) as the first-line anatomical test in patients with suspected significant coronary artery disease (CAD) may reduce the number of coronary invasive angiographies (ICA), and expand the use of CCTA in patients currently diagnosed invasively. METHODS: 120 patients (age:60.6 ±â€¯7.9 years, 35% female) with indications to ICA were randomized 1:1 to undergo CCTA versus direct ICA. Outcomes were evaluated during the diagnostic and therapeutic periods. RESULTS: The number of invasively examined patients was reduced by 64.4% in the CCTA group as compared to the direct ICA group (21vs59,p < 0.0001). The number of patients with ICAs not followed by coronary intervention was reduced by 88.1% with the CCTA strategy (5vs42,p < 0.0001). Over the diagnostic and therapeutic course there were no significant differences regarding the median volume of contrast (CCTA 80.3 ml[65.0-165.0] vs ICA 90.0 ml[55.0-100.0], p = 0.099), while a non-significant trend towards higher radiation dose in the CCTA group was observed (9.9 mSv[7.0-22.1] vs 9.4 mSv[5.2-14.0], p = 0.05). There were no acute cardiovascular events. CONCLUSIONS: CCTA may hypothetically act as an effective 'gatekeeper' to the catheterization laboratory in the diagnosis of stable patients with current indications for ICA. This strategy may result in non-invasive, outpatient-based triage of two thirds of individuals without actionable CAD, obviating unnecessary invasive examinations. However, the longer follow-up is indispensable. CLINICALTRIALS. GOV NUMBER: NCT02591992.


Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Idoso , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada/efeitos adversos , Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Doses de Radiação , Exposição à Radiação , South Carolina , Triagem
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