Single injection dual phase CBCT technique ameliorates results of trans-arterial chemoembolization for hepatocellular cancer

Cone-beam CT (CBCT) application to the field of trans-arterial chemoembolization has been recently the focus of several researches. This imaging modality is performed with a rotation of the C-arm around the patient, without needs of patient repositioning. Datasets are immediately processed, obtaining volumetric CT-like images with the possibility of post-processing and reconstruction of images. Dual phase CBCT recently introduced in clinical practice consists in a first arterial acquisition followed by a delayed acquisition corresponding to a venous phase. The introduction of this feature has overcome the limit of single-phase acquisitions, allowing lesions characterization. Moreover these recent advantages have several intra-procedural implications. Detailed technical and acquisition parameters will be widely exposed in this review with particular attention to: catheter positioning, acquisition delay, injection parameters, patient positioning and contrast dilution. Comparison with standard of practice second line imaging [multidetector computer tomography (MDCT) and MDCT/arteriography] demonstrate the capability of detecting occult nodules providing some clinical implications thus potentially identifying a sub set of patients with aggressive disease behaviour. Other intra-procedural advantages of dual phase CBCT usage consist in a better tumor feeder visualization, reduction of proper DSA and fluoroscopic time, suggestion the presence of an extrahepatic parasitic feeder thus resulting in a more accurate treatment. Finally, the volumetrical intraprocedural evaluation of accumulation of embolic agent has proved to be correlate with treatment response if compared with MRI

Combination of high-resolution cone beam computed tomography and metal artefact reduction software: a new image fusion technique for evaluating intracranial stent apposition after aneurysm treatment.

We introduce a new imaging technique to improve visualisation of stent apposition after endovascular treatment of brain aneurysms employing high-resolution cone beam CT and three-dimensional digital subtraction angiography. After performing a stent-assisted coil embolisation of brain aneurysm, the image datasets were processed with a metal artefact reduction software followed by the automated image fusion programmes. Two patients who underwent aneurysm coiling using a Neuroform stent were evaluated. The reconstructed 3D images showed a detailed structure of the stent struts and identified malappositions of the deployed stents. Case 1 showed good apposition on the outer curvature side of the carotid siphon, while the inner curvature side showed prominent malapposition. Case 2, with multiple aneurysms, showed good apposition on both outer and inner curvature sides, although inward prolapse of the struts was observed. This new imaging technique may help evaluate stent apposition after the endovascular aneurysm treatment

Volumetric analysis of arteriovenous malformation using computed tomographic angiography

Thesis (M.A.)--Boston UniversityAn arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. It is an important and growing public healthcare problem affecting millions of Americans and many more people internationally. There are several potential treatment options for the AVM, and the best treatment depends on the maximum length of nidus based on the Spetzler- Martin grading system. However, this grading system is insensitive to volume, because it was designed on the basis of two dimensional digital subtraction angiography images. Here, we report a method using computed tomographic angiography to measure the volume of AVM nidus, as a means for noninvasively assessment. The initial results show statistically significant differences between healthy and AVM subject groups in the direct comparisons of the volume (cm3) through the method we suggested (2.456 ± 1.482, 12.478 ± 5.743 and 53.963 ± 9.338 (mean ± stdev.); Normal (No AVM), Small (< 3cm), Medium (3 ~ 6 cm) respectively; P < 0.005 for all), and they also show the exponential correlation between the AVM volume and the maximum length of a nidus (trend-line: y = 4.4183e0.536x with R2 = 0.945). These results provide more accurate volumetric information. Therefore, this noninvasive imaging-based method is a promising means to measure the volume of AVM using clinically available imaging tools

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography.

BACKGROUND:A three-dimensional (3D) cardiovascular magnetic resonance (CMR) vessel wall imaging (VWI) technique based on 3D T1 weighted (T1w) Sampling Perfection with Application-optimized Contrast using different flip angle Evolutions (SPACE) has recently been used as a promising CMR imaging modality for evaluating extra-cranial and intra-cranial vessel walls. However, this technique is yet to be validated against the current diagnostic imaging standard. We therefore aimed to evaluate the diagnostic performance of 3D CMR VWI in characterizing carotid disease using intra-arterial digital subtraction angiography (DSA) as a reference. METHODS:Consecutive patients with at least unilateral &gt; 50% carotid stenosis on ultrasound were scheduled to undergo interventional therapy were invited to participate. The following metrics were measured using 3D CMR VWI and DSA: lumen diameter of the common carotid artery (CCA) and segments C1-C7, stenosis diameter, reference diameter, lesion length, stenosis degree, and ulceration. We assessed the diagnostic sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curve of 3D CMR VWI, and used Cohen's kappa, the intraclass correlation coefficient (ICC), and Bland-Altman analyses to assess the diagnostic agreement between 3D CMR VWI and DSA. RESULTS:The ICC (all ICCs ≥0.96) and Bland-Altman plots indicated excellent inter-reader agreement in all individual morphologic measurements by 3D CMR VWI. Excellent agreement in all individual morphologic measurements were also found between 3D CMR VWI and DSA. In addition, 3D CMR VWI had high sensitivity (98.4, 97.4, 80.0, 100.0%), specificity (100.0, 94.5, 99.1, 98.0%), and Cohen's kappa (0.99, 0.89, 0.84, 0.96) for detecting stenosis &gt; 50%, stenosis &gt; 70%, ulceration, and total occlusion, respectively, using DSA as the standard. The AUC of 3D CMR VWI for predicting stenosis &gt; 50 and &gt; 70% were 0.998 and 0.999, respectively. CONCLUSIONS:The 3D CMR VWI technique enables accurate diagnosis and luminal feature assessment of carotid artery atherosclerosis, suggesting that this imaging modality may be useful for routine imaging workups and provide comprehensive information for both the vessel wall and lumen

Accuracy of Length of Virtual Stents in Treatment of Intracranial Wide-Necked Aneurysms.

Background and purposePrecise stent deployment is important for successful treatment of intracranial aneurysms by stent-assisted coiling (SAC). We evaluated the accuracy of virtual stents generated using commercial stent planning software by comparing the length of virtual and actually deployed intracranial laser cut stents on three-dimensional digital subtraction angiography (3D-DSA) images.MethodsWe retrospectively analyzed the data of 75 consecutive cases of intracranial wide-necked aneurysms treated with the SAC technique using laser cut stents. Based on 3D-DSA images acquired by C-arm CT, stent sizing and placement were intraoperatively simulated by a commercial software application. The difference in length of the stents was estimated by measuring proximal discrepancies between the end points of the virtual and actually deployed stents on fused pre-procedural and post-procedural 3D-DSA images. Discrepancies between distal stent end points were manually minimized. The Kruskal-Wallis test was applied to test whether stent location, type, and length had an effect on difference in length between virtual and real stent.ResultsThe median difference in length between virtual and real stents was 1.58 mm with interquartile range 1.12-2.12 mm. There was no evidence for an effect of stent location (p = 0.23), stent type (p = 0.33), or stent length (p = 0.53) on difference in length between virtual and real stents.ConclusionsStent planning software allows 3D simulation of laser cut stents overlain on 3D-DSA images of vessels and may thus be useful for stent selection and deployment of laser cut stents during stent-assisted coiling of intracranial aneurysms

Use of magnetic resonance angiography to select candidates with recently symptomatic carotid stenosis for surgery: systematic review

Objective To determine if sufficient evidence exists to support the use of magnetic resonance angiography as a means of selecting patients with recently symptomatic high grade carotid stenosis for surgery. Design Systematic review of published research on the diagnostic performance of magnetic resonance angiography, 1990-9. Main outcome measures Performance characteristics of diagnostic test. Results 126 potentially relevant articles were identified, but many articles failed to examine die performance of magnetic resonance angiography as a diagnostic test at the surgical decision thresholds used in major clinical trials on endarterectomy. 26 articles were included in a meta-analysis that showed a maximal joint sensitivity and specificity of 99% (95% confidence interval 98% to 100%) for identifying 70-99% stenosis and 90% (81% to 99%) for identifying 50-99% stenosis. Only four articles evaluated contrast enhanced magnetic resonance angiography. Conclusions Magnetic resonance angiography is accurate for selecting patients for carotid endarterectomy at the surgical decision thresholds established in the major endarterectomy trials, but the evidence is not very robust because of the heterogeneity of the studies included. Research is to determine the diagnostic performance of the most recent developments in magnetic resonance angiography, including contrast enhanced techniques, as well as to assess the impact of magnetic resonance angiography on surgical decision making and outcomes

Ferumoxytol-enhanced magnetic resonance angiography for the assessment of potential kidney transplant recipients

Objectives: Traditional contrast-enhanced methods for scanning blood vessels using magnetic resonance imaging (MRI) or CT carry potential risks for patients with advanced kidney disease. Ferumoxytol is a superparamagnetic iron oxide nanoparticle preparation that has potential as an MRI contrast agent in assessing the vasculature. Methods: Twenty patients with advanced kidney disease requiring aorto-iliac vascular imaging as part of pre-operative kidney transplant candidacy assessment underwent ferumoxytol-enhanced magnetic resonance angiography (FeMRA) between December 2015 and August 2016. All scans were performed for clinical indications where standard imaging techniques were deemed potentially harmful or inconclusive. Image quality was evaluated for both arterial and venous compartments. Results: First-pass and steady-state FeMRA using incremental doses of up to 4 mg/kg body weight of ferumoxytol as intravenous contrast agent for vascular enhancement was performed. Good arterial and venous enhancements were achieved, and FeMRA was not limited by calcification in assessing the arterial lumen. The scans were diagnostic and all patients completed their studies without adverse events. Conclusions: Our preliminary experience supports the feasibility and utility of FeMRA for vascular imaging in patients with advanced kidney disease due for transplant listing, which has the advantages of obtaining both arteriography and venography using a single test without nephrotoxicity

Hemodynamic evaluation using four-dimensional flow magnetic resonance imaging for a patient with multichanneled aortic dissection

The hemodynamic function of multichanneled aortic dissection (MCAD) requires close monitoring and effective management to avoid potentially catastrophic sequelae. This report describes a 47-year-old man who underwent endovascular repair based on findings from four-dimensional (4D) flow magnetic resonance imaging of an MCAD. The acquired 4D flow data revealed complex, bidirectional flow patterns in the false lumens and accelerated blood flow in the compressed true lumen. The collapsed abdominal true lumen expanded unsatisfactorily after primary tear repair, which required further remodeling with bare stents. This case study demonstrates that hemodynamic analysis using 4D flow magnetic resonance imaging can help understand the complex pathologic changes of MCAD

Esophagopulmonary fistula causing pulmonary arterial pseudoaneurysms and massive hemoptysis.

An esophagopulmonary fistula (EPF) may occur in patients with esophageal carcinoma and result in pulmonary abscess formation. Lung abscesses may in turn cause pulmonary artery (PA) pseudoaneurysms and life-threatening hemoptysis. We report a 59-year-old man with past medical history of metastatic distal esophageal adenocarcinoma who presented with fever, cough, and massive hemoptysis. Imaging evaluation demonstrated an EPF, associated lung abscess, and PA pseudoaneurysms. The presented case illustrates that embolization of PA pseudoaneurysms to prevent bleeding, and endoscopic esophageal covered stent graft placement to divert esophageal contents from the abscess, may facilitate a favorable outcome