Objectives
Standard treatment for severe coronary artery disease (CAD) is coronary artery bypass grafting (CABG). An underreported branch of the internal mammary artery, the lateral costal artery ...(LCA), can cause a steal phenomenon after CABG, resulting in angina. The aim of this study was to determine the prevalence and length of LCA based on CT angiography (CTA).
Methods
This retrospective study included adult patients undergoing a thoracic CTA between January 2016 and August 2018. Exclusion criteria were prior CABG, insufficient clinical information, or inadequate image quality. Two blinded, independent readers reviewed all studies for the prevalence of the LCA. Positive cases were reviewed by two readers (R1/R2) for side distribution and vessel length, measured in intercostal spaces (ICS). Study indication, aortic size, and coronary calcification were noted.
Results
LCA was present in up to 42/389 (11%) of studies (60.3 ± 16.7 years, 30 males). The LCA was most commonly unilateral (
n
= 23, 55%). Median vessel length was 2 ICS (IQR 0; 3). Logistic regression was not significant in vessel distribution for sex (OR 0.6, 95% CI 0.28–1.15;
p
= 0.11). Inter-observer agreement in detecting LCA was substantial (kappa 0.71, 95% CI 0.59–0.83) and excellent for side/length distribution (kappa 0.94, 95% CI 0.82–1.0; ICC 0.96, 95% CI 0.93–0.98).
Conclusion
The LCA is uncommon and most often unilateral and extends the third rib. Radiologists should be aware of this vessel and its potential role in angina after CABG, particularly when large.
Key Points
• LCA is an uncommon normal variant that is reported to cause angina pectoris after CABG.
• CT angiography can reliably detect the LCA. It is most often unilateral and spans two intercostal spaces.
Ex vivo lung perfusion (EVLP) is an advanced platform for isolated lung assessment and treatment. Radiographs acquired during EVLP provide a unique opportunity to assess lung injury. The purpose of ...our study was to define and evaluate EVLP radiographic findings and their association with lung transplant outcomes.
We retrospectively evaluated 113 EVLP cases from 2020-21. Radiographs were scored by a thoracic radiologist blinded to outcome. Six lung regions were scored for 5 radiographic features (consolidation, infiltrates, atelectasis, nodules, and interstitial lines) on a scale of 0 to 3 to derive a score. Spearman's correlation was used to correlate radiographic scores to biomarkers of lung injury. Machine learning models were developed using radiographic features and EVLP functional data. Predictive performance was assessed using the area under the curve.
Consolidation and infiltrates were the most frequent findings at 1 hour EVLP (radiographic lung score 2.6 (3.3) and 4.6 (4.3)). Consolidation (r = -0.536 and -0.608, p < 0.0001) and infiltrates (r = -0.492 and -0.616, p < 0.0001) were inversely correlated with oxygenation (∆pO
) at 1 hour and 3 hours of EVLP. First-hour consolidation and infiltrate lung scores predicted transplant suitability with an area under the curve of 87% and 88%, respectively. Prediction of transplant outcomes using a machine learning model yielded an area under the curve of 80% in the validation set.
EVLP radiographs provide valuable insight into donor lungs being assessed for transplantation. Consolidation and infiltrates were the most common abnormalities observed in EVLP lungs, and radiographic lung scores predicted the suitability of donor lungs for transplant.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by chronic organised fibrotic ...clots, despite adequate anticoagulation. The pulmonary hypertension is also caused by concomitant microvasculopathy which may progress without timely treatment. Timely and accurate diagnosis requires the combination of imaging and haemodynamic assessment. Optimal therapy should be individualised to each case and determined by an experienced multidisciplinary CTEPH team with the ability to offer all current treatment modalities. This report summarises current knowledge and presents key messages from the International CTEPH Conference, Bad Nauheim, Germany, 2021. Sessions were dedicated to 1) disease definition; 2) pathophysiology, including the impact of the hypertrophied bronchial circulation, right ventricle (dys)function, genetics and inflammation; 3) diagnosis, early after acute pulmonary embolism, using computed tomography and perfusion techniques, and supporting the selection of appropriate therapies; 4) surgical treatment, pulmonary endarterectomy for proximal and distal disease, and peri-operative management; 5) percutaneous approach or balloon pulmonary angioplasty, techniques and complications; and 6) medical treatment, including anticoagulation and pulmonary hypertension drugs, and in combination with interventional treatments. Chronic thromboembolic pulmonary disease without pulmonary hypertension is also discussed in terms of its diagnostic and therapeutic aspects.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a challenging diagnosis that can occur even in the absence of a prior thrombotic event. The main screening test is ventilation-perfusion (VQ) ...scintigraphy. The gold standard treatment for CTEPH is pulmonary endarterectomy (PEA), however, balloon pulmonary angioplasty (BPA) is an emerging treatment, especially for CTEPH at the segmental level. We report on a case of a patient with segmental CTEPH diagnosed by lung subtraction iodine mapping (LSIM) in the context of a chest wall vascular malformation. CTEPH was treated with BPA and by embolization and ligation of their vascular malformation.
Purpose
To determine the prognostic value of sarcopenia measurements done on staging 2-18F FDG PET/CT together with metabolic activity of the tumor in patients with adenocarcinoma esophagogastric ...cancer with surgical treatment.
Methods
Patients with early-stage, surgically treated esophageal adenocarcinoma and available pre-treatment 2-18F FDG PET/CT were included. The standard uptake value (SUV) and SUV normalized by lean body mass (SUL) were recorded. Skeletal muscle index (SMI) was measured at the L3 level on the CT component of the PET/CT. Sarcopenia was defined as SMI < 34.4cm
2
/m
2
in women and < 45.4cm
2
/m
2
in men.
Results
Of the included 145 patients. 30% were sarcopenic at baseline. On the univariable Cox proportional hazards analysis, ECOG, surgical T and N staging, lymphovascular invasion (LVI) positive lymph nodes, and sarcopenia were significant prognostic factors concerning RFS and OS. On multivariable Cox regression analysis, surgical N staging (
p
= 0.025) and sarcopenia (
p
= 0.022) remained significant poor prognostic factors for OS and RFS. Combining the clinical parameters with the imaging-derived nutritional evaluation of the patient but not metabolic parameters of the tumor showed improved predictive ability for OS and RFS.
Conclusion
Combining the patients’ imaging-derived sarcopenic status with standard clinical data, but not metabolic parameters, offered an overall improved prognostic value concerning OS and RFS.
Surgical risk in chronic thromboembolic pulmonary hypertension (CTEPH) depends on the proximity of thromboembolism on CT pulmonary angiography (CTPA). We assessed interobserver agreement for the ...quantification of thromboembolic lesions in CTEPH using a novel CTPA scoring index.
Forty CTEPH patients (mean age, 58 ± 16 years; 19 men) with preoperative CTPA who underwent pulmonary endarterectomy (PEA) (08/2020-09/2021) were retrospectively included. Three radiologists scored each CTPA for chronic thromboembolism (occlusions, eccentric thickening, webs) using a 32-vessel model of the pulmonary vasculature, with interobserver agreement evaluated using Fleiss’ kappa. CT level of disease was determined by the most proximal chronic thromboembolism: level 1 (main pulmonary artery), 2 (lobar), 3 (segmental) and 4 (subsegmental), and compared to surgical level at PEA.
Interobserver agreement for CT level of disease was moderate overall (κ = 0.52). Agreement was substantial overall at the main/lobar level (κ, mean = 0.71) when excluding the left upper lobe (κ = 0.17). Though segmental and subsegmental agreement suffered (κ = 0.31), we found substantial agreement for occlusions (κ = 0.72) compared to eccentric thickening (κ = 0.45) and webs (κ = 0.14). Correlation between CT level and surgical level was strong overall (τb = 0.73) and in the right lung (τb = 0.68), but weak in the left lung (τb = 0.42) (p < 0.05). Radiologists often over- and underestimated the proximal extent of disease in right and left lung, respectively.
CT level of disease demonstrated good agreement between radiologists and was highly predictive of the surgical level in CTEPH. Occlusions were the most reliable sign of chronic thromboembolism and are important in assessing the segmental vasculature.
Ongoing advances in precision cancer therapy have increased the number of molecularly targeted and immuno-oncology agents for a variety of cancers, many of which have been associated with a risk of ...pulmonary complications, among the most concerning being drug-induced interstitial lung disease/pneumonitis (DI-ILD). As the number of patients undergoing treatment with novel anticancer agents continues to grow, DI-ILD is expected to become an increasingly significant clinical challenge. Trastuzumab deruxtecan (T-DXd) is an antibody–drug conjugate targeting human epidermal growth factor receptor 2 that is gaining widespread use in the metastatic breast cancer setting and is undergoing exploration for other oncologic indications. ILD/pneumonitis is an adverse event of special interest associated with T-DXd, which has potentially fatal consequences if left untreated and allowed to progress. When identified in the asymptomatic stage (grade 1), T-DXd-related ILD can be monitored and treated effectively with the possibility of treatment continuation. Delayed diagnosis and/or treatment, however, results in progression to grade 2 or higher toxicity and necessitates immediate and permanent discontinuation of this active agent. Strategies are, therefore, needed to optimize careful monitoring during treatment to ensure patient safety and optimize outcomes. Several guidance documents have been developed regarding strategies for the early identification and management of T-DXd-related ILD, although none have been within the context of the Canadian health care environment. A Canadian multidisciplinary steering committee was, therefore, convened to evaluate existing recommendations and adapt them for application in Canada. A multidisciplinary approach involving collaboration among medical oncologists, radiologists, respirologists, and allied health care professionals is needed to ensure the proactive identification and management of T-DXd-related ILD and DI-ILD associated with other agents with a similar toxicity profile.
Peribronchiolar metaplasia (PBM) is a histological finding of uncertain significance commonly seen in interstitial lung disease (ILD). PBM is thought to be secondary to small airway injury from ...insults such as tobacco smoke and other environmental exposures. The term PBM‐ILD has been proposed for patients with ILD where PBM is the major histologic finding, however a lack of radiographic changes supportive of ILD in previously reported cases has limited recognition of the diagnosis. We present a rare case of welding‐associated ILD with clinical, radiographic, and histologic evidence consistent with the proposed definition of PBM‐ILD. We outline an approach to its consideration as a diagnosis based on our experience through multidisciplinary discussion.
We present a rare case of welding‐associated PBM‐ILD with clinical, radiographic, and histologic evidence consistent with the disease. We outline an approach to the diagnosis of PBM‐ILD based on our experience through multidisciplinary discussion.
Summary
Definitions for chronic lung allograft dysfunction (CLAD) phenotypes were recently revised (2019 ISHLT consensus). Post‐CLAD onset phenotype transition may occur as a result of change in ...obstruction, restriction, or RAS‐like opacities (RLO). We aimed to assess the prevalence and prognostic implications of these transitions. This was a single‐center, retrospective cohort study of bilateral lung transplants performed in 2009–2015. CLAD phenotypes were determined per ISHLT guidelines. CLAD phenotype transition was defined as a sustained change in obstruction, restriction or RLO. We specifically focused on phenotype changes based on RLO emergence. Association of RLO development with time to death or retransplant were assessed using Kaplan–Meier and Cox proportional hazards models. Among 211 patients with CLAD, 47 (22.2%) experienced a phenotype transition. Nineteen patients developed RLO. Development of RLO phenotype after CLAD onset was associated with a shorter time to death/retransplant when considering the entire CLAD patient cohort (HR = 4.00, CI 2.74–5.83, P < 0.001) and also when restricting the analysis to only patients with a Non‐RLO phenotype at CLAD onset (HR 9.64, CI 5.52–16.84, P < 0.0001). CLAD phenotype change based on emergence of RAS‐like opacities implies a worse outcome. This highlights the clinical importance of imaging follow‐up to monitor for phenotype transitions after CLAD onset.
We assessed the prevalence and prognostic implications of post CLAD onset phenotype transitions in a large cohort of lung transplant recipients. We have shown that CLAD patients who later changed their phenotype due to the appearance of RAS‐like opacities had a significantly worse outcome. Potential event leading to these changes also described.
