CT attenuation values of blood and myocardium: rationale for accurate coronary artery calcifications detection with multi-detector CT.

OBJECTIVES: To determine inter-session and intra/inter-individual variations of the attenuations of aortic blood/myocardium with MDCT in the context of calcium scoring. To evaluate whether these variations are dependent on patients' characteristics. METHODS: Fifty-four volunteers were evaluated with calcium scoring non-enhanced CT. We measured attenuations (inter-individual variation) and standard deviations (SD, intra-individual variation) of the blood in the ascending aorta and of the myocardium of left ventricle. Every volunteer was examined twice to study the inter-session variation. The fat pad thickness at the sternum and noise (SD of air) were measured too. These values were correlated with the measured aortic/ventricular attenuations and their SDs (Pearson). Historically fixed thresholds (90 and 130 HU) were tested against different models based on attenuations of blood/ventricle. RESULTS: The mean attenuation was 46 HU (range, 17-84 HU) with mean SD 23 HU for the blood, and 39 HU (10-82 HU) with mean SD 18 HU for the myocardium. The attenuation/SD of the blood were significantly higher than those of the myocardium (p < 0.01). The inter-session variation was not significant. There was a poor correlation between SD of aortic blood/ventricle with fat thickness/noise. Based on existing models, 90 HU threshold offers a confidence interval of approximately 95% and 130 HU more than 99%. CONCLUSIONS: Historical thresholds offer high confidence intervals for exclusion of aortic blood/myocardium and by the way for detecting calcifications. Nevertheless, considering the large variations of blood/myocardium CT values and the influence of patient's characteristics, a better approach might be an adaptive threshold

Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndrome: Rationale for the Triple Rule-out Concept.

BACKGROUND: The aims of the study were to evaluate the prevalence of acute coronary syndrome (ACS) among patients presenting with atypical chest pain who are evaluated for acute aortic syndrome (AAS) or pulmonary embolism (PE) with computed tomoangiography (CTA) and discuss the rationale for the use of triple rule-out (TRO) protocol for triaging these patients. METHODS: This study is a retrospective analysis of patients presenting with atypical chest pain and evaluated with thoracic (CTA), for suspicion of AAS/PE. Two physicians reviewed patient files for demographic characteristics, initial CT and final clinical diagnosis. Patients were classified according to CTA finding into AAS, PE and other diagnoses and according to final clinical diagnosis into AAS, PE, ACS and other diagnoses. RESULTS: Four hundred and sixty-seven patients were evaluated: 396 (84.8%) patients for clinical suspicion of PE and 71 (15.2%) patients for suspicion of AAS. The prevalence of ACS and AAS was low among the PE patients: 5.5% and 0.5% respectively (P = 0.0001), while the prevalence of ACS and PE was 18.3% and 5.6% among AAS patients (P = 0.14 and P = 0.34 respectively). CONCLUSION: The prevalence of ACS and AAS among patients suspected clinically of having PE is limited while the prevalence of ACS and PE among patients suspected clinically of having AAS is significant. Accordingly patients suspected for PE could be evaluated with dedicated PE CTA while those suspected for AAS should still be triaged using TRO protocol

Structured team-oriented program to follow patients after vena cava filter placement: a step forward in improving quality for filter retrieval.

To reduce inferior vena cava filter (IVCF) related complications, retrieval is recommended whenever possible. Nevertheless, IVCF retrieval rates remain lower than expected, likely due to insufficient follow-up after placement. We evaluated the value of a structured program designed to follow patients by the interventional radiology team up to 5 months after IVCF placement. We prospectively enrolled 366 consecutive patients (mean age 64 ± 17 years; 201 men and 165 women) who benefited from IVCF between March 2015 and February 2020. The program consisted of advising the patient and clinicians to consider IVCF retrieval as soon as possible (standard workflow) and systematically planning an additional follow-up visit at 5-month. Clinical and technical eligibility, as well as technical success for retrieval (TSR) were evaluated. At 5-months, 38 (10.4%) patients were lost to follow-up, and 47 (12.8%) had died. Among survivors, the overall retrieval rate was 58%. The retrieval rates were 83% and 97% for the clinically eligible and technically eligible patients for retrieval, respectively. The 5-month visit enabled 89 additional retrievals (47.8%) compared to the standard workflow. No significant difference was seen in TSR before and after 5 months (p = 0.95). Improved patient tracking with a dedicated IVCF program results in an effective process to identify suitable patients for retrieval and drastically improves retrieval rates in eligible patients. Involving interventionalists in the process improved IVCF patient management

Virtually Augmented Self-Hypnosis in Peripheral Vascular Intervention: A Randomized Controlled Trial.

Hypnosis is useful for diminishing distress during medical procedures. This study investigated the efficacy of virtually augmented self-hypnosis as an adjunctive non-pharmacological method for procedural pain and anxiety relief during endovascular interventions (EVI). We compared an immersive distraction experience (clinicaltrials.gov identifier NCT04561596) featuring virtual reality (VR) using a head-mounted display versus treatment as usual (TAU). Patients followed the "Aqua" module (Oncomfort™) consisting of a scuba dive and breathing exercises. They experienced a self-induced dissociative state similar to clinical hypnosis without direct intervention of a professional. Enrollment followed a 1:1 randomized open study (VR or TAU). Patients' feelings were evaluated just before and after the procedure, and 3 months following intervention. Anxiety was evaluated using the State Trait Anxiety Inventory (STAI) and pain (sensory, emotional, and memory) with a visual analogue scale (VAS). This study included 100 patients. Mean anxiety (pre-post) was significantly reduced within groups and between groups (difference of 4.2 points, p = 0.016). The percentage of responders to anxiety lowering were 76 and 46% for VR and TAU, respectively (p = 0.004). The two groups did not significantly differ in mean sensory-intensity and affective emotional pain (pre-post) using VAS, in negative memories concerning remembered pain at 3 months (difference > 1 from immediate post-procedural reported pain intensity), mean procedural time, or the need for analgesic or sedative drugs. VR self-hypnosis has the potential to improve the management of patients' distress during radiological procedures. It is safe and effective for reducing anxiety during EVI

A New Clinically Driven Classification for Acute Aortic Dissection.

Objectives: To report a new classification scheme for acute aortic dissection (AAD) that considers the aortic arch as a separate entity and integrates patterns of malperfusion syndrome (MPS). The proposed classification was evaluated retrospectively in a large population. Materials and Methods: We retrospectively reviewed pre-therapy CT angiograms of 226 consecutive patients (mean ± SD age: 64 ± 12 years) with AAD. AADs were reclassified with a new classification scheme that included three aortic dissection types (A, involving at least the ascending aorta; B, involving exclusively the descending aorta; and C, involving the aortic arch with/without the descending aorta) and four malperfusion grades (0: no MPS; 1: dynamic MPS; 2: static MPS; 3: static and dynamic MPS). AAD features were assessed and correlated to patient outcomes. Results: According to the new classification, we identified 152 type A dissections (92 A0, 11 A1, 38 A2, 11 A3); 50 type B (38 B0, 5 B1, 6 B2, 1 B3); and 24 type C (17 C0, 6 C2, 1 C3). Type C represented 11% of all AADs. MPS occurred in 39, 24, and 29% in type A, B, and C, respectively. Type C was treated with significantly more endovascular or hybrid interventions (37%) than in types A (3%) and B (20%) (p < 0.001). Conclusion: The new AAD classification was feasible, and type C was easily identified ("non-A, non-B"). Preliminary findings supported the usefulness of this classification for the decision-making process and subsequent treatments

Virtually Augmented Self-Hypnosis applied to endovascular interventions (VA-HYPO): Randomized Controlled Trial Protocol.

Endovascular interventions (EVI) are increasingly performed as minimally-invasive alternatives to surgery and have many advantages, including a decreased need for general anesthesia. However, EVI can be stressful for patients and often lead to anxiety and pain related to the procedure. The use of local anesthetics, anxiolytics, and analgesic drugs can help avoid general anesthesia. Nevertheless, these drugs have potential side effects. Alternative nonpharmacological therapies can improve patients' experience during conscious interventions and reduce the need for additional medications. The added value of virtually augmented self-hypnosis (VA-HYPO) and its potential to reduce pain and anxiety during peripheral and visceral arterial and venous EVI is unknown. This is a prospective two-arm trial designed to randomize 100 patients in two groups according to the use or not of VA-HYPO during peripheral EVI as a complementary nonpharmacological technique to improve patient comfort. The main objective is to compare per-procedural anxiety, and the secondary aim is to compare the rated per-procedural pain in both groups. The potential significance is that VA-HYPO may improve patients' experience during peripheral and visceral arterial and venous EVI and other minimally invasive interventions performed under local anesthesia. Trial registration: Our study is registered on clinicaltrials.gov, with trial registration number: NCT04561596

Computer Aided Detection and Measurement of Peripheral Artery Disease

Computer-Aided Tomography Angiography (CTA) images are the standard for assessing Peripheral artery disease (PAD). This paper presents a Computer Aided Detection (CAD) and Computer Aided Measurement (CAM) system for PAD. The CAD stage detects the arterial network using a 3D region growing method and a fast 3D morphology operation. The CAM stage aims to accurately measure the artery diameters from the detected vessel centerline, compensating for the partial volume effect using Expectation Maximization (EM) and a Markov Random field (MRF). The system has been evaluated on phantom data and also applied to fifteen (15) CTA datasets, where the detection accuracy of stenosis was 88% and the measurement accuracy was with an 8% error

Investigating the Influence of High-Speed Gantry Rotation in Cardiac CT on Motion Artifacts in Aortic Stenosis Patients Not Premedicated with β-Blockers: The FAST-CCT Randomized Trial Protocol.

Coronary CT angiography (CCTA) is increasingly used as a non-invasive tool to assess coronary artery disease (CAD). However, CCTA is subject to motion artifacts, potentially limiting its clinical utility. Despite faster (0.35 and 0.28 s/rot) gantry rotation times, low (60-65 bpm) heartbeat is recommended, and the use of β-blockers is often needed. Technological advancements have resulted in the development of faster rotation speeds (0.23 s/rot). However, their added value in patients not premedicated with β-blockers remains unclear. This prospective single-center, two-arm, randomized, controlled trial aims to assess the influence of fast rotation on coronary motion artifacts, diagnostic accuracy of CCTA for CAD, and patient safety. We will randomize a total of 142 patients aged ≥ 50 scheduled for an aortic stenosis work-up to receive CCTA with either a fast (0.23) or standard (0.28 s/rot) gantry speed. rate of CCTAs with coronary motion artifacts hindering interpretation. assessable coronary segments rate, diagnostic accuracy against invasive coronary angiography (ICA), motion artifact magnitude per segment, contrast-to-noise ratio (CNR), and patient ionizing radiation dose. The local ethics committee has approved the protocol. Potential significance: FAST-CCT may improve motion artifact reduction and diagnosis quality, thus eliminating the need for rate control and β-blocker administration. gov identifier: NCT05709652

Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes : long-term follow-up.

The vast majority of superior vena cava (SVC) syndromes are of malignant causes, but with growing use of indwelling central catheters and implanted cardiac devices, benign SVC syndromes are becoming more frequent. The main objective of this study is to evaluate long term outcome in patients treated for benign SVC syndrome by endovascular techniques. Forty-four patients, 26 men and 18 women, mean age 56, treated for benign SVC syndrome using endovascular techniques between 2002 and 2015 were included. Type of obstruction was classified according to the site of disease and degree of occlusion. Complications and recurrence of symptoms were analyzed. Technical and clinical success were achieved in all but one patient. Four patients (9 %) were treated by angioplasty alone and 40 (91 %) required stent implantation. Mean clinical follow-up was 1275 days. Nine patients had at least one episode of recurrence after a mean of 385 days. Four minor and two major complications were reported. Percutaneous endovascular techniques to treat benign SVC syndrome are safe with good long term patency. Recurrence of symptoms can easily be addressed by repeat procedure. • Malposition of indwelling central catheter can cause superior vena cava obstruction. • Image-guided catheter placement helps prevent superior vena cava obstruction. • Imaging and superior vena cava obstruction classification allows adequate procedure planning. • Endovascular techniques are safe and effective for superior vena cava syndrome treatment

Percutaneous endovascular biopsy of intravascular masses: efficacy and safety in establishing pre-therapy diagnosis.

To evaluate the efficacy and safety of percutaneous endovascular biopsy (PEB) in intravascular filling-defect lesions (IVLs) of the great vessels. We retrospectively reviewed 19 patients (age 65 ± 12 years), 11 men and eight women, who underwent PEB for IVLs, between March 2004 and November 2014. All PEBs were performed for early diagnosis and/or characterization of the IVL, or in case of reasonable doubt about the IVL nature. Pre-intervention imaging work-up included CT, MRI and/or PET-CT. PEBs were obtained with a 7F biopsy forceps device. Clinical profile, procedure technical success and safety, and clinical success were evaluated. PEB was technically successful in all patients (mean of two samples per IVL). No intra- or post-procedural complications were reported. Histopathological analysis provided a diagnosis in all PEBs with a clinical success of 100%. Of the 19 IVLs, 14 were malignant (74%). The most frequent malignant lesion observed was leiomyosarcoma (29%). Benign lesions (26%) included three thrombi (pulmonary artery) and two myxomas. PEB is a safe and efficient procedure providing the most effective technique to obtain a tissue sample of high diagnostic quality, which serves to establish early diagnosis in patients with suspected malignant lesions. • Intravascular filling-defect lesions are related to both benign conditions and malignant tumours. • Endovascular biopsy is indicated in case of doubt about intravascular lesion nature. • Percutaneous endovascular biopsy is a safe technique. • Endovascular biopsy provides tissue samples leading to correct histopathological analysis. • Percutaneous endovascular biopsy provides early diagnosis of malignant intravascular lesions