Because stent implantation for disease of the superficial femoral artery has been associated with high rates of late clinical failure, percutaneous transluminal angioplasty is preferred for ...endovascular treatment, and stenting is recommended only in the event of suboptimal technical results. We evaluated whether primary implantation of a self-expanding nitinol (nickel-titanium) stent yielded anatomical and clinical benefits superior to those afforded by percutaneous transluminal angioplasty with optional secondary stenting.
We randomly assigned 104 patients who had severe claudication or chronic limb ischemia due to stenosis or occlusion of the superficial femoral artery to undergo primary stent implantation (51 patients) or angioplasty (53 patients). Restenosis and clinical outcomes were assessed at 6 and 12 months.
The mean (+/-SD) length of the treated segment was 132+/-71 mm in the stent group and 127+/-55 mm in the angioplasty group. Secondary stenting was performed in 17 of 53 patients (32 percent) in the angioplasty group, in most cases because of a suboptimal result after angioplasty. At 6 months, the rate of restenosis on angiography was 24 percent in the stent group and 43 percent in the angioplasty group (P=0.05); at 12 months the rates on duplex ultrasonography were 37 percent and 63 percent, respectively (P=0.01). Patients in the stent group were able to walk significantly farther on a treadmill at 6 and 12 months than those in the angioplasty group.
In the intermediate term, treatment of superficial-femoral-artery disease by primary implantation of a self-expanding nitinol stent yielded results that were superior to those with the currently recommended approach of balloon angioplasty with optional secondary stenting. (ClinicalTrials.gov number, NCT00281060.).
This study is to evaluate if different locations of the primary entry tear result in primary complicated, secondary complicated, or uncomplicated acute type B aortic dissection.
Sixty-five patients ...were analyzed. Patients were stratified according to the location of the primary entry tear. Primary entry tears in axial computed tomographic scans at the upper circumference (180°) of the distal aortic arch were defined as convex (group A) and the remaining as concave (group B). Detailed morphometry was done and the clinical outcome, including need for thoracic endovascular aortic repair, was evaluated.
Forty-two patients (group A) had the primary entry tear at the convexity and 23 patients (group B) had the primary entry tear at the concavity of the distal aortic arch. There was a significant difference with regard to the incidence of primary complicated type B aortic dissection (group A 21% vs group B 61%, p = 0.003) and with regard to the development of complications in group A (9 days; 9 to 37) versus group B (0 days; 0 to 13, p = 0.03). Cox regression analysis revealed a primary entry tear at the concavity to be the only independent predictor of primary or secondary development of a complicated acute type B aortic dissection (hazard ratio, 1.8; 95% confidence interval, 1.0 to 3.2).
A primary entry tear at the concavity of the distal aortic arch is associated with a significant increase of the occurrence of complicated acute type B aortic dissection. Due to low procedural risk and high success rates, closure of the primary entry tear with thoracic endovascular aortic repair is strongly recommended in this newly defined high-risk subgroup of patients.
To evaluate the influence of baseline clinical and morphological parameters on the occurrence of a late stent graft related endoleak (srEL; types 1 and 3) after endovascular aneurysm repair (EVAR).
...This is a retrospective case control study of patients who were routinely followed up after EVAR of abdominal aortic aneurysms. Pre-interventional, pre-discharge, and last available multislice computed tomography angiogram (MSCTA) of 279 patients were analysed. Stent graft related endoleaks detected by follow up MSCTA at least six months after EVAR were specified as late srEL. Baseline demographic characteristics and morphological variables were derived from the pre-interventional and pre-discharge MSCTA. Univariable and multivariable analysis with a Cox proportional hazards model were used to determine baseline factors associated with the occurrence of a late srEL.
Twenty-four (8.6%) of 279 patients suffered a late srEL, during a mean MSCTA follow up of 30.9 ± 25.8 (23.5, IQR 10.6–42.8) months. In the univariable analysis, age (hazard ratio HR 1.09; p = .001), female sex (HR 3.25; p = .014), right iliac sealing diameter (HR 10.04; p = .03), left iliac sealing diameter (HR 8.65; p = .001), infrarenal aortic neck angulation (HR 1.02; p = .011), and suprarenal fixation level (HR 3.47; p = .014) were significantly associated with an increased incidence of late srEL. Age (HR 1.08; p = .012), female sex (HR 2.72; p = .049), and left iliac sealing diameter (HR 4.48; p = .033) proved to be risk factors significantly associated with a higher incidence of late srEL in multivariable analysis.
Older patients, those with female gender, and those with larger left iliac sealing diameters seem to experience higher rates of late srEL. Independent confirmation of these must be addressed in larger studies.
Purpose
To test the hypothesis that simultaneous closure of at least 2 independent
vascular territories supplying the spinal cord and/or prolonged hypotension
may be associated with symptomatic ...spinal cord ischemia (SCI) after thoracic
endovascular aortic repair (TEVAR).
Methods
A pattern matching algorithm was used to develop a risk
model for symptomatic SCI using a prospective 63-patient single-center
cohort to test the positive predictive value (PPV) of prolonged
intraoperative hypotension and/or simultaneous closure of at least 2 of 4
the vascular territories supplying the spinal cord (left subclavian,
intercostal, lumbar, and hypogastric arteries). This risk model was then
applied to data extracted from the multicenter European Registry on
Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the
19 centers participating in EuREC reported 38 (1.7%) cases of
symptomatic spinal cord ischemia among the 2235 patients in the
database.
Results
In the single-center cohort, direct correlations were seen between the
occurrence of symptomatic SCI and both prolonged intraoperative hypotension
(PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous
closure of at least 2 independent spinal cord vascular territories (PPV
0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a
single vascular territory was not associated with an increased risk of
symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16,
p=0.56). The combination of prolonged hypotension and simultaneous
closure of at least 2 territories exhibited the strongest association (PPV
0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to
the entire EuREC cohort found an almost perfect agreement between the
predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to
0.90).
Conclusion
Extensive coverage of intercostal arteries alone by a thoracic stent-graft is
not associated with symptomatic SCI; however, simultaneous closure of at
least 2 vascular territories supplying the spinal cord is highly relevant,
especially in combination with prolonged intraoperative hypotension. As
such, these results further emphasize the need to preserve the left
subclavian artery during TEVAR.
The severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2) pandemic currently constitutes a significant burden on worldwide health care systems, with important implications on many levels, ...including radiology departments. Given the established fundamental role of cardiovascular imaging in modern healthcare, and the specific value of cardiopulmonary radiology in COVID-19 patients, departmental organisation and imaging programs need to be restructured during the pandemic in order to provide access to modern cardiovascular services to both infected and non-infected patients while ensuring safety for healthcare professionals. The uninterrupted availability of cardiovascular radiology services remains, particularly during the current pandemic outbreak, crucial for the initial evaluation and further follow-up of patients with suspected or known cardiovascular diseases in order to avoid unnecessary complications. Suspected or established COVID-19 patients may also have concomitant cardiovascular symptoms and require further imaging investigations. This statement by the European Society of Cardiovascular Radiology (ESCR) provides information on measures for safety of healthcare professionals and recommendations for cardiovascular imaging during the pandemic in both non-infected and COVID-19 patients.
Background
Sympathetic reinnervation after heart transplantation (HTX) is a known phenomenon, which has an impact on patient heart rate variability and exercise capacity. The impact of reinnervation ...on myocardial structure has not been evaluated yet.
Propose
To evaluate the feasibility of simultaneous imaging of cardiac reinnervation and cardiac structure using a hybrid PET/MRI system.
Study type
Prospective / pilot study.
Subjects
Ten patients, 4–21 years after cardiac transplantation.
Field Strength/Sequence
3 T hybrid PET/MRI system. Cine SSFP, T1 mapping (modified Look–Locker inversion recovery sequence) pre/postcontrast as well as dynamic 11Cmeta‐hydroxyephedrine (11CmHED) PET.
Assessment
All MRI and PET parameters were evaluated by experienced readers using dedicated postprocessing software packages for cardiac MRI and PET. For all parameters a 16‐segment model for the left ventricle was applied.
Statistical Tests
Mann–Whitney U‐test; Spearman correlations.
Results
Thirty‐six of 160 myocardial segments showed evidence of reinnervation by PET. On a segment‐based analysis, mean native T1 relaxation times were nonsignificantly altered in segments with evidence of reinnervation (1305 ± 151 msec vs. 1270 ± 112 msec; P = 0.1), whereas mean extracellular volume (ECV) was significantly higher in segments with evidence of reinnervation (35.8 ± 11% vs. 30.9 ± 7%; P = 0.019). There were no significant differences in wall motion (WM) and wall thickening (WT) between segments with or without reinnervation (mean WM: 7.6 ± 4 mm vs. group B: 9.3 ± 7 mm P = 0.13; WT: 79 ± 63% vs. 94 ± 74% P = 0.27) under resting conditions.
Data Conclusion
The assessment of cardiac reinnervation using a hybrid PET/MRI system is feasible. Segments with evidence of reinnervation by PET showed nonsignificantly higher T1 relaxation times and a significantly higher ECV, suggesting a higher percentage of diffuse fibrosis in these segments, without impairment of rest WM and WT.
Level of Evidence: 3
Technical Efficacy: Stage 3
J. Magn. Reson. Imaging 2019;50:1326–1335.
Abstract
Objective: Pregnancy has been reported to be an independent risk factor for 50% of acute aortic dissections recorded in women younger than 45 years of age. The present epidemiologic study ...aimed to identify whether this putative association of pregnancy and acute type A dissection could be an artifact of selective reporting. Methods: This population-based study was conducted in the City of Vienna, Austria, Europe, in an average female population of 341 381 women in the age range of 15-45 years who were followed up between 1994 and 2004 (total of 3755.195 person-years of observation). During this study, the incidence, management, and outcome of acute type A dissection were determined. Results: Fifteen patients (mean age: 38.8 years, SD: 4.8) with acute aortic dissection were identified, and an overall incidence of 0.4 case per 100 000 person-years was estimated. The prehospital mortality rate was recorded to be 53%. Six patients, including two women in late pregnancy (incidence: 0.05 cases per 100 000 person-years), were treated successfully by surgical repair during deep hypothermic circulatory arrest (in-hospital mortality rate: 6.6%). Pregnancy and aortic dissection were identified as events that were not related (RR: 3.27; 95% confidence interval (CI): 0.82-12.95; P = 0.14). Observation during long-term follow-up was uneventful. Conclusions: Acute aortic dissection represents a rare pathology in women younger than 45 years of age; however, it is associated with a high rate of sudden death. Pregnancy may not be a risk factor for this life-threatening vascular emergency. Immediate referral to surgery, even during pregnancy, will result in a prognosis of favorable outcome.
The aim of this study was to determine the technical success after endovascular treatment of acute type B aortic dissections and to evaluate true and false lumen diameter changes at long-term ...follow-up.
Twenty-eight patients with acute type B-dissection who were treated by stent graft repair presented with rupture (n = 1), contained rupture (n = 2), compromised branch vessels (n = 14), pleural effusion (n = 11), rapid aortic diameter progression (n = 5), persistent pain (n = 3), refractory hypertension (n = 10), and an aortic diameter of more than 4 cm (n = 4). Taking into account the perfusion status of the false lumen, diameter changes were monitored in the thoracic aorta at the level of the stented segment (L1), distal to the stent graft (L2), and at the level of the celiac trunk (L3).
Severe complications in 9 patients (32%) resulted in 3 deaths for a 30-day mortality rate of 10.7%. Primary sealing of the entry tear was achieved in 86%. At all levels, the true lumen diameter increased significantly after stent graft placement. At the 1-year follow-up, the false lumen in L1 was thrombosed in 90% and the mean difference of diameter reduction was highly significant. In L2, complete false lumen thrombosis occurred in 60% with a significant diameter decrease. In L3, the false lumen thrombosed in only 22%, and the mean difference of false lumen diameter increase reached significance at the 2-year follow-up.
Ninety percent of patients were treated successfully with thrombosis of the false lumen in the stented segment. False lumen perfusion distal to the stent graft resulted in diameter increase in several patients leaving these segments an area of concern.
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