ACR Appropriateness Criteria® pulsatile abdominal mass, suspected abdominal aortic aneurysm

Patients with Polyvascular Disease: A Very High-risk Group

Polyvascular disease (PolyvascDis) with atherosclerosis occurring in >2 vascular beds (coronary, carotid, aortic, visceral and/or peripheral arteries) is encountered in 15-30% of patients who experience greater rates of major adverse cardiovascular (CV) events. Every patient with multiple CV risk factors or presenting with CV disease in one arterial bed should be assessed for PolyvascDis clinically and noninvasively prior to invasive angiography. Peripheral arterial disease (PAD) can be readily diagnosed in routine practice by measuring the ankle-brachial index. Carotid disease can be diagnosed by duplex ultrasound showing % stenosis and/or presence of plaques. Coronary artery disease (CAD) can be screened by determining coronary artery calcium score using coronary computed tomography angiography; further, non-invasive testing includes exercise stress and/or myocardial perfusion imaging or dobutamine stress test, prior to coronary angiography. Abdominal ultrasound can reveal an abdominal aortic aneurysm. Computed tomography angiography will be needed in patients with suspected mesenteric ischemia to assess the mesenteric arteries. Patients with the acute coronary syndrome and concomitant other arterial diseases have more extensive CAD and poorer CV outcomes. Similarly, PolyvascDis in patients with carotid disease and/or other PAD is independently associated with an increased risk for all-cause and CV mortality during long-term follow-up. Treatment of patients with PolyvascDis should include aggressive management of all modifiable risk factors by lifestyle changes and drug therapy, with particular attention to patients who are commonly undertreated, such as those with PAD. Revascularization should be reserved for symptomatic vascular beds, using the least aggressive strategy in a multidisciplinary vascular team approach.

Abdominal aortic aneurysm screening during transthoracic echocardiography in asymptomatic patients in Guilan province

Background: The prevalence of detected abdominal aortic aneurysm (AAA) during transthoracic echocardiography (TTE) has been different in previous studies based on the study population, and no data are available on AAA in the population of north of Iran. The aim of this study was to investigate the prevalence of AAA in individuals aged 50 and over in the north of Iran who were a candidate for TTE. Methods: This cross sectional study was conducted on all individuals aged 50 and over who referred to our cardiovascular center for TTE evaluation from October 2016 to October 2017. The maximum diameter of the whole abdominal aorta was accepted as abdominal aortic size and a diameter ≥ 30 mm as AAA. All statistical analyses were conducted using SPSS Version 22.0. Also, Mann-Whitney and chi-squared tests were used to compare variables. A p<0.05 was considered significant. Results: In total, 1411 patients underwent TTE in this study and abdominal aorta was visualized in 1329 patients (93.9%) successfully. The prevalence of AAA was 0.5% (7 patients, 95% CI: 0.496-0.503) during the study period. Patients with AAA were significantly older (p=0.002), with a mean age of 74.4±7.7 years, and 85.7% (6 patients) had hypertension, which was significantly higher (p=0.022) than patients without AAA. Conclusion: This study showed that the AAA prevalence during standard TTE in the northern population of Iran aged 50 and over was 0.5%, which was lower than a previous study in Tehran that found AAA on 3.8% of screened patients. Patients with AAA in this population were significantly older and more hypertensive.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.

Non-contrast MR angiography using three-dimensional balanced steady-state free-precession imaging for evaluation of stenosis in the celiac trunk and superior mesenteric artery: a preliminary comparative study with computed tomography angiography

OBJECTIVE

Although non-contrast MR angiography (NC-MRA) is well established for the evaluation of renal artery stenosis, its usefulness in the evaluation of other abdominal aortic branches remains to be studied. This study aimed at evaluating the image quality and diagnostic accuracy of NC-MRA using a three-dimensional balanced steady-state free-precession sequence in identifying stenosis in the celiac trunk (CTR) and superior mesenteric artery (SMA) as compared with CT angiography (CTA) as the reference standard.

METHODS

41 patients underwent both NC-MRA and CTA of the abdominal aorta. Two radiologists analyzed the quality of the images (diagnostic vs non-diagnostic) and the performance (accuracy, sensitivity and specificity) of NC-MRA for the identification of arterial stenosis. Kappa tests were used to determine the interobserver agreement and the intermethod agreement between NC-MRA and CTA.

RESULTS

NC-MRA provided diagnostic quality images of the CTR and SMA in 87.8% and 90.2% of cases, respectively, with high interobserver agreement (kappa 0.95 and 0.80, respectively). For stenosis assessment, NC-MRA had a sensitivity of 100%, a positive-predictive value of 50% and a negative-predictive value of 100% for both segments, with accuracies of 88.8% for the CTR and 94.5% for the SMA.

CONCLUSION

NC-MRA is an accurate method for detecting stenosis in the CTR and SMA. Advances in knowledge: Data from this study suggest that MR angiography with balanced steady-state free-precession sequence is a viable non-contrast alternative for stenosis evaluation of these branches in patients for whom a contrast-enhanced examination is contraindicated.

A graphical clinical decision aid for managing imaging report information

OBJECTIVE

The purpose of this article is to propose a graphical decision aid for managing radiology report information to assist learners in developing clinical decision-making skills through a structured approach.

METHODS

A graphical decision aid informed by learning theories was constructed to manage radiology report information by identifying an overall strategy, specific decision-making steps, and decision goals. A review of radiology reports was performed to demonstrate the rich source of complex information requiring clinical decision making. Radiology report data were descriptively analyzed, and findings were described as definite or indefinite, while recommendations were reported as required or optional.

RESULTS

The graphical decision aid involves 4 stages. The 1st 2 stages interpret report information and consider data obtained during the clinical encounter. The following 2 stages guide decisions by answering questions to ensure patient safety and/or to confirm diagnosis and to address broader case management questions. The mean (SD) age of participants whose imaging reports were reviewed was 73.4 (7.0) years. Of 170 reports, common findings included degenerative disc disease (98%), soft tissue or vascular calcification (94%), bone demineralization (92%), and zygapophyseal joint degeneration (86%). Common indefinite findings were spinal stenosis (15%), compression fracture (12%), bony abnormality (12%), radiodensity (12%), and disc degeneration (10%). One hundred twenty-one recommendations suggested follow-up actions.

CONCLUSIONS

Information within imaging reports requires identification and interpretation to inform complex clinical decisions. The graphical decision aid proposed in this article is designed to facilitate the development of decision-making skills by providing a structured and evidence-based information management process.

Contrast inhomogeneity in CT angiography of the abdominal aortic aneurysm

BACKGROUND

If undetected, infrarenal Abdominal Aortic Aneurysm (AAA) growth can lead to rupture, a high-mortality complication. Some AAA patients exhibit inhomogeneous luminal contrast attenuation at first-pass CT angiography (CTA). This study assesses the association between this observation and aneurysm growth.

METHODS

Sixty-seven consecutive pre-repair AAA CTAs were included in this retrospective study. The "Gravitational Gradient" (GG), defined as the ratio of the mean attenuation in a region-of-interest placed posteriorly to that in a region-of-interest placed anteriorly within the lumen of the aortic aneurysm on a single axial slice, and the maximum aneurysm diameter were measured from each CT data set. "AAA Contrast Inhomogeneity" was defined as the absolute value of the difference between the GG and 1.0. Univariate and multivariate logistic regression was used to assess the association of aneurysm growth >0.4 and >1.0 cm/year to AAA Contrast Inhomogeneity, aneurysm diameter, patient characteristics and cardiovascular co-morbidities.

RESULTS

AAA Contrast Inhomogeneity was not correlated to aneurysm diameter (p = 0.325). In multivariable analysis that included initial aneurysm diameter and AAA Contrast Inhomogeneity, both factors were significantly associated with rapid aneurysm growth (initial diameter: p = 0.029 and 0.011, and, AAA Contrast Inhomogeneity: p = 0.045 and 0.048 for growth >0.4 cm/year and >1 cm/year respectively).

CONCLUSIONS

AAA Contrast Inhomogeneity is a common observation in first-pass CTA. It is associated with rapid aneurysm growth, independent of aneurysm diameter.