Use of On-Site Digital Subtraction Angiography for Left Subclavian Artery Management During Hybrid Aortic Arch Repair in DeBakey I Dissection

Purpose: A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies. Case Report: We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days. Conclusion: Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

The value of inflow inversion recovery MRI for the diagnosis of transplant renal artery stenosis: comparison with digital subtraction angiography

Background To date, few data on the assessment of transplant renal artery stenosis (TRAS) by using inflow inversion recovery (IFIR) are available. The aims of this study was to evaluate the feasibility of IFIR in the assessment of TRAS using Digital Subtraction Angiography (DSA) as the reference. Results We retrospectively assessed the IFIR of 195 transplant renal arteries. The IFIR images for 194/195 arteries were judged to be of excellent, good, or moderate quality, and 1/195 was not diagnostic. There were 100 arteries with TRAS, of which 27 were subjected to DSA. The stenosis percentages were divided into five grades. Using DSA images, the TRAS in 27 patients were estimated as grade 1 (2, 7.4%), grade 2 (8, 29.6%), grade 3 (10, 37.0%), grade 4 (7, 25.9%) and grade 5 (0, 0%). In comparison, the TRAS was shown to be grade 1 (1, 3.7%), grade 2 (8, 29.6%), grade 3 (9, 33.3%), grade 4 (9, 33%) and grade 5 (0, 0%) in the IFIR images. The nonparametric Wilcoxon signed-rank test was used to compare IFIR with DSA. In addition, a Bland–Altman plot was used to estimate the agreement between IFIR and DSA measurements. There was no significant difference between IFIR and DSA measurements (p < 0.05). Conclusions Relative to the reference DSA, IFIR was shown to be noninvasive, accurate for the diagnosis and evaluation of TRAS.

Anatomical variations of posterior inferior cerebellar artery (PICA) on digital subtraction angiography (DSA)

Introduction: The posterior inferior cerebellar artery (PICA) often exhibits anatomical variations at the craniovertebral junction. Few studies investigated variations of the posterior inferior cerebellar artery, and the prevalence of other variations has not been reported. The study aimed to identify variations of the posterior inferior cerebral artery using cerebral Digital Subtraction Angiography (DSA). Method: 50 patients underwent 64-slice cerebral Digital Subtraction Angiography. Four types of variations were observed. Results: Out of a total of 50 patients, 23 (46%) were males and 27 (54%) females (all age groups). Our study has shown the utility of the 2 sequences - fluoroscopy and cine. All 2 sequences have their significance in evaluating anatomical variations in PICA. Only 20% of the 50 patients had all the posterior inferior cerebellar artery without anatomical variations. Anatomic variations commonly involve the distal segment of the vertebral artery (VA). Most of them are seen arising from the C1, C2, and both C1 and C2 origins. Anatomic variations involve arising from the C1 origin in 9 patients, C2 origin in 11 patients, C1 & C2 origin in 8 patients, and other variations observed in 12 patients. Conclusion: Variations of the posterior inferior cerebellar artery can be easily evaluated by cerebral Digital Subtraction Angiography (CDSA). Recognizing and reporting them at cerebral CDSA may be clinically important. Surgeons should be mindful of this variation during operations.

Evaluation of Tissue Perfusion by Wound Blush and 2D Color-Coded Digital Subtraction Angiography During Endovascular Intervention and Its Impact on Limb Salvage in Critical Limb Ischemia

Purpose: Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI. Materials and Methods: 198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow). Results: 176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001). Conclusions: WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.

Care of Maintenance Hemodialysis Patients through Intelligent Algorithm-Based Low-Dose Digital Subtraction Angiography

Objective. The study aimed to explore the application value of artificial intelligence (AI)-based low-dose digital subtraction angiography (DSA) in the care of maintenance hemodialysis (MHD) patients. Methods. The characteristics of DSA imaging were analyzed, and the refinement efficiency of the AI algorithm was discussed, expected to assist clinicians in the care and treatment of patients. 100 MHD patients who were in the hospital were selected as the research subjects. They were randomly divided into the conventional DSA group (conventional group) and the AI algorithm-based DSA group (AI-based DSA group). The conventional group used conventional DSA images to guide the care of HM patients, and the AI-based DSA group used the AI algorithm to optimize DSA images. Results. It was found that the AI-based DSA group was better than the conventional DSA group in terms of image sharpness and shaded areas, and the image mean square error (MSE) loss value was smaller ( P < 0.05 ). The patients were followed up for 3 months. In the AI-based DAS group, the blood flow of the drainage vein (DV), the blood flow of the proximal vein (PA), and the blood flow of the brachial artery (BA) were greater than those of the conventional group ( P < 0.05 ). During the 3-month follow-up period, in the conventional group, thrombosis occurred in 4 patients, low-flow AVF occurred in 5 patients, high-flow AVF occurred in 3 patients, and heart failure occurred in 5 patients. In the AI-based DSA group, thrombosis occurred in 2 patients, low-flow AVF occurred in 2 cases, high-flow AVF occurred in 1 case, and heart failure occurred in 3 cases. There were no other cardiac complications in both groups. Conclusion. DSA images optimized by the AI algorithm are suitable for clinical diagnosis and have practical application value.

Giá trị của cắt lớp vi tính trong đánh giá mạch máu của ung thư biểu mô tế bào gan có chỉ định nút mạch hóa chất

Mục tiêu: Khảo sát giá trị của cắt lớp vi tính (CLVT) trong đánh giá mạch máu của ung thư biểu mô tế bào gan (UTBMTBG) có chỉ định nút mạch hóa chất (TACE). Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang trên 63 bệnh nhân UTBMTBG được nút mạch hóa chất (TACE) tại Bệnh viện trường Đại học Y Dược Huế từ 9/2018 đến tháng 10/2020. Mô tả đặc điểm hình ảnh mạch máu của UTBMTBG trên CLVT đối chiếu với chụp mạch xóa nền (DSA). Chẩn đoán UTBMTBG và chỉ định TACE dựa vào hướng dẫn của EASL 2018. Kết quả: Tuổi trung bình của nhóm nghiên cứu là 63,2 ± 11,3. Kích thước trung bình của UTBMTBG là 5,7 ± 3,4 cm, (1 - 14,5 cm). Đặc điểm hình ảnh mạch máu của UTBMTBG trên CLVT và DSA là: ngấm thuốc mạnh (87,3% vs. 96,8%), mạch tăng sinh (58,7% vs. 88,9%), mạch tân sinh (65,1% vs. 88,9%), thông động - tĩnh mạch (6,4% vs. 6,4%), mạch nuôi u ngoài gan (25,4% vs. 19%), biến thể giải phẫu (14,3% vs. 15,9%). CLVT và DSA có sự phù hợp thấp trong khảo sát mạch tăng sinh và mạch tân sinh nhưng có độ nhạy và độ đặc hiệu cao trong khảo sát thông động tĩnh mạch, nguồn mạch nuôi u ngoài gan và biến thể giải phẫu. Kích thước u có tương quan thuận với mạch tăng sinh và có ý nghĩa dự báo nguồn mạch nuôi u ngoài gan, mạch tăng sinh, mạch tân sinh và thông động - tĩnh mạch. Kết luận: CLVT có độ nhạy và độ đặc hiệu cao trong đánh giá thông động tĩnh mạch, nguồn mạch nuôi u ngoài gan và biến thể giải phẫu. Phân tích đầy đủ hình ảnh CLVT trước can thiệp là rất cần thiết nhằm tối ưu hóa kỹ thuật và hiệu quả điều trị. Từ khóa: Ung thư biểu mô tế bào gan, cắt lớp vi tính, chụp mạch xóa nền, nút mạch hóa chất. ABSTRACT VALUE OF COMPUTED TOMOGRAPHI IN THE EVALUATION OF VASCULAR PATTERNS OF HEPATOCELLULAR CARCINOMA Aim: To determine the additional value of computed tomography in the evaluation of vascular patterns of hepatocellular carcinoma (HCC). Materials and methods: A cross - sectional study was conducted on 63 HCC patients who underwent transarterial chemoembolization at Hue University of Medicine and Pharmacy Hospital from 9/2018 to 10/2020. Vascular patterns of HCC were documented on CT and correlated with digital subtraction angiography (DSA). Diagnosis and management of HCC were based on the practice guideline of EASL 2018. Results: The mean age was 63.2 ± 11.3 years, the average HCC diameter was 5.7 ± 3.4 cm, (range 1 - 14,5 cm). Vascular patterns of HCC at CT and DSA were hyperattenuating/tumor staining (87.3% vs. 96.8%), hypervascularity (58.7% vs. 88.9%), neovascularity (65.1% vs. 88.9%), arterioportal shunt (6.4% vs. 6.4%), extrahepatic parasitic supplies (25.4% vs. 19%), and anatomical variations (14.3% vs. 15.9%), respectively. There was a low agreement between CT and DSA on hyper and neovascularity. CT had high sensitivity and specificity in detecting arterioportal shunt, extrahepatic supply and anatomical variations. Tumor size had a positive correlation with hypervascularity and was a predictor of hyper/neovascularity, arterioportal shunt, and extrahepatic supply. Conclusion: CT had high sensitivity and specificity in detecting arterioportal shunt, extrahepatic supply and anatomical variations. Careful and comprehensive interpretation of preprocedural computed tomography and angiography is essential to optimize treatment and patient outcomes. Key words: Hepatocellular carcinoma, computed tomography, digital subtraction angiography, transarterial chemoembolization.