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Wang X, Nai YH, Gan J, Lian CPL, Ryan FK, Tan FSL, Chan DYS, Ng JJ, Lo ZJ, Chong TT, Hausenloy DJ. Multi-Modality Imaging of Atheromatous Plaques in Peripheral Arterial Disease: Integrating Molecular and Imaging Markers. Int J Mol Sci 2023; 24:11123. [PMID: 37446302 DOI: 10.3390/ijms241311123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/14/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral artery disease (PAD) is a common and debilitating condition characterized by the narrowing of the limb arteries, primarily due to atherosclerosis. Non-invasive multi-modality imaging approaches using computed tomography (CT), magnetic resonance imaging (MRI), and nuclear imaging have emerged as valuable tools for assessing PAD atheromatous plaques and vessel walls. This review provides an overview of these different imaging techniques, their advantages, limitations, and recent advancements. In addition, this review highlights the importance of molecular markers, including those related to inflammation, endothelial dysfunction, and oxidative stress, in PAD pathophysiology. The potential of integrating molecular and imaging markers for an improved understanding of PAD is also discussed. Despite the promise of this integrative approach, there remain several challenges, including technical limitations in imaging modalities and the need for novel molecular marker discovery and validation. Addressing these challenges and embracing future directions in the field will be essential for maximizing the potential of molecular and imaging markers for improving PAD patient outcomes.
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Affiliation(s)
- Xiaomeng Wang
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
| | - Ying-Hwey Nai
- Clinical Imaging Research Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Julian Gan
- Siemens Healthineers, Singapore 348615, Singapore
| | - Cheryl Pei Ling Lian
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Fraser Kirwan Ryan
- Infocomm Technology Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Forest Su Lim Tan
- Infocomm Technology Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Dexter Yak Seng Chan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Jun Jie Ng
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of Surgery, Woodlands Health, Singapore 258499, Singapore
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore 168752, Singapore
- Surgical Academic Clinical Programme, Singapore General Hospital, Singapore 169608, Singapore
- Vascular SingHealth Duke-NUS Disease Centre, Singapore 168752, Singapore
| | - Derek John Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore 169609, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore 117597, Singapore
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
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Chou TH, Wynveen MK, Rimmerman ET, Patel S, Go MR, Stacy MR. Detection of Multi-Vessel Calcific Disease Progression in a Patient with Chronic Limb-Threatening Ischemia Using 18F-Sodium Fluoride Positron Emission Tomography Imaging. J Vasc Surg Cases Innov Tech 2023; 9:101137. [PMID: 37139350 PMCID: PMC10149389 DOI: 10.1016/j.jvscit.2023.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Vascular calcification contributes to morbidity and poor clinical outcomes for patients with peripheral artery disease; however, the traditional assessment of the calcium burden using computed tomography (CT) imaging or angiography represents already established disease. In the present report, we describe a 69-year-old man with chronic limb-threatening ischemia who had undergone positron emission tomography/CT imaging with fluorine-18 sodium fluoride to evaluate the relationship between baseline levels of positron emission tomography-detectable active vascular microcalcification and CT-detectable calcium progression 1.5 years later. CT imaging at follow-up identified progression of existing lesions and the formation of new calcium in multiple arteries that had demonstrated elevated fluorine-18 sodium fluoride uptake 1.5 years earlier.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Molly K. Wynveen
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eleanor T. Rimmerman
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
- Interdisciplinary Biophysics Graduate Program, The Ohio State University College of Medicine, Columbus, OH
| | - Surina Patel
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Michael R. Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Mitchel R. Stacy
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
- Interdisciplinary Biophysics Graduate Program, The Ohio State University College of Medicine, Columbus, OH
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
- Correspondence: Mitchel R. Stacy, PhD, Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, 575 Children's Crossroad, WB4133, Columbus, OH 43215
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Chou TH, Rimmerman ET, Patel S, Wynveen MK, Eisert SN, Musini KN, Janse SA, Bobbey AJ, Sarac TP, Atway SA, Go MR, Stacy MR. Vessel-by-vessel analysis of lower extremity 18F-NaF PET/CT imaging quantifies diabetes- and chronic kidney disease-induced active microcalcification in patients with peripheral arterial disease. EJNMMI Res 2023; 13:3. [PMID: 36648583 PMCID: PMC9845537 DOI: 10.1186/s13550-023-00951-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Positron emission tomography (PET)/computed tomography (CT) imaging with fluorine-18 (18F)-sodium fluoride (NaF) provides assessment of active vascular microcalcification, but its utility for evaluating diabetes mellitus (DM)- and chronic kidney disease (CKD)-induced atherosclerosis in peripheral arterial disease (PAD) has not been comprehensively evaluated. This study sought to use 18F-NaF PET/CT to quantify and compare active microcalcification on an artery-by-artery basis in healthy subjects, PAD patients with or without DM, and PAD patients with or without CKD. Additionally, we evaluated the contributions of DM, CKD, statin use and established CT-detectable calcium to 18F-NaF uptake for each lower extremity artery. METHODS PAD patients (n = 48) and healthy controls (n = 8) underwent lower extremity 18F-NaF PET/CT imaging. Fused PET/CT images guided segmentation of arteries of interest (i.e., femoral-popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, and peroneal) and quantification of 18F-NaF uptake. 18F-NaF uptake was assessed for each artery and compared between subject groups. Additionally, established calcium burden was quantified for each artery using CT calcium mass score. Univariate and multivariate analyses were performed to evaluate DM, CKD, statin use, and CT calcium mass as predictors of 18F-NaF uptake in PAD. RESULTS PAD patients with DM or CKD demonstrated significantly higher active microcalcification (i.e., 18F-NaF uptake) for all arteries when compared to PAD patients without DM or CKD. Univariate and multivariate analyses revealed that concomitant DM or CKD was associated with increased microcalcification for all arteries of interest and this increased disease risk remained significant after adjusting for patient age, sex, and body mass index. Statin use was only associated with decreased microcalcification for the femoral-popliteal artery in multivariate analyses. Established CT-detectable calcium was not significantly associated with 18F-NaF uptake for 4 out of 5 arteries of interest. CONCLUSIONS 18F-NaF PET/CT imaging quantifies vessel-specific active microcalcification in PAD that is increased in multiple lower extremity arteries by DM and CKD and decreased in the femoral-popliteal artery by statin use. 18F-NaF PET imaging is complementary to and largely independent of established CT-detectable arterial calcification. 18F-NaF PET/CT imaging may provide an approach for non-invasively quantifying vessel-specific responses to emerging anti-atherogenic therapies or CKD treatment in patients with PAD.
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Affiliation(s)
- Ting-Heng Chou
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA
| | - Eleanor T. Rimmerman
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA ,grid.261331.40000 0001 2285 7943Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH USA
| | - Surina Patel
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA
| | - Molly K. Wynveen
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA
| | - Susan N. Eisert
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA
| | - Kumudha Narayana Musini
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA
| | - Sarah A. Janse
- grid.261331.40000 0001 2285 7943Center for Biostatistics, The Ohio State University, Columbus, OH USA
| | - Adam J. Bobbey
- grid.240344.50000 0004 0392 3476Department of Radiology, Nationwide Children’s Hospital, Columbus, OH USA
| | - Timur P. Sarac
- grid.261331.40000 0001 2285 7943Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH USA
| | - Said A. Atway
- grid.261331.40000 0001 2285 7943Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH USA
| | - Michael R. Go
- grid.261331.40000 0001 2285 7943Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH USA
| | - Mitchel R. Stacy
- grid.240344.50000 0004 0392 3476Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH WB413343215 USA ,grid.261331.40000 0001 2285 7943Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH USA ,grid.261331.40000 0001 2285 7943Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH USA
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Stacy MR. Molecular Imaging of Lower Extremity Peripheral Arterial Disease: An Emerging Field in Nuclear Medicine. Front Med (Lausanne) 2022; 8:793975. [PMID: 35096884 PMCID: PMC8789656 DOI: 10.3389/fmed.2021.793975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic disorder of non-coronary arteries that is associated with vascular stenosis and/or occlusion. PAD affecting the lower extremities is characterized by a variety of health-related consequences, including lifestyle-limiting intermittent claudication, ulceration of the limbs and/or feet, increased risk for lower extremity amputation, and increased mortality. The diagnosis of lower extremity PAD is typically established by using non-invasive tests such as the ankle-brachial index, toe-brachial index, duplex ultrasound, and/or angiography imaging studies. While these common diagnostic tools provide hemodynamic and anatomical vascular assessments, the potential for non-invasive physiological assessment of the lower extremities has more recently emerged through the use of magnetic resonance- and nuclear medicine-based approaches, which can provide insight into the functional consequences of PAD-related limb ischemia. This perspectives article specifically highlights and discusses the emerging applications of clinical nuclear medicine techniques for molecular imaging investigations in the setting of lower extremity PAD.
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Affiliation(s)
- Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
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Emerging Preclinical and Clinical Applications of Theranostics for Nononcological Disorders. PET Clin 2021; 16:429-440. [PMID: 34053586 DOI: 10.1016/j.cpet.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Studies in nuclear medicine have shed light on molecular imaging and therapeutic approaches for oncological and nononcological conditions. Using the same radiopharmaceuticals for diagnosis and therapeutics of malignancies, the theranostics approach, has improved clinical management of patients. Theranostic approaches for nononcological conditions are recognized as emerging topics of research. This review focuses on preclinical and clinical studies of nononcological disorders that include theranostic strategies. Theranostic approaches are demonstrated as possible in the clinical management of infections and inflammations. There is an emerging need for randomized trials to specify the factors affecting validity and efficacy of theranostic approaches in nononcological diseases.
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Noninvasive Detection of Active Microcalcification in an Occlusive Peripheral Vascular Aneurysm Using 18F-NaF PET/CT Imaging. Clin Nucl Med 2020; 45:1029-1031. [PMID: 33086277 PMCID: PMC7606725 DOI: 10.1097/rlu.0000000000003344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 65-year-old man with an occluded popliteal artery aneurysm and calf claudication underwent PET/CT imaging with 18F-NaF to assess the status of active microcalcification in the aneurysm site and additional lower extremity arteries. CT imaging revealed macrocalcification of the aneurysm that colocalized with elevated retention of 18F-NaF on PET images. PET/CT detected additional distal arterial sites with focal uptake of 18F-NaF that did not coincide with CT-detectable macrocalcification. This report highlights a case of active microcalcification in an occlusive peripheral aneurysm using PET/CT. PET/CT may provide molecular insight into the remodeling of lower extremity aneurysms and atherosclerotic lesions.
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Chou TH, Stacy MR. Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia. Mol Imaging Biol 2019; 22:245-255. [PMID: 31482412 DOI: 10.1007/s11307-019-01425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA. .,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
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