1
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Rimmerman ET, Stacy MR. Applications of SPECT and PET Imaging for the Physiological Evaluation of Lower Extremity Peripheral Artery Disease. Int J Mol Sci 2024; 25:7474. [PMID: 39000580 PMCID: PMC11242786 DOI: 10.3390/ijms25137474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
Peripheral artery disease (PAD) is classified as the narrowing or complete occlusion of the lower extremity arteries due to atherosclerosis. The risk of developing PAD increases with increased age and risk factors such as smoking, diabetes, hypertension, and hypercholesterolemia. Current treatment for PAD involves lifestyle and symptom management, statin and antiplatelet therapy, and/or surgical interventions to improve quality of life with varying efficacy. PAD affects approximately 5 to 6 percent of the global population, with this global burden continuing to increase. Despite the increase in disease prevalence, no gold standard functional diagnostic tool has been established for enabling early detection of the disease, appropriate medical management, and prediction of adverse outcomes for PAD patients. The visualization and quantification of the physiological consequences of PAD are possible by way of nuclear imaging: specifically, via scintigraphy, single-photon emission computed tomography (SPECT), and positron emission tomography (PET) imaging. These non-invasive modalities, when combined with targeted radionuclides, possess utility for detecting functional perfusion deficits and provide unique insight into muscle tissue- and vascular-level characteristics of PAD patients. This review discusses the past, present, and emerging applications of hybrid nuclear imaging modalities in the evaluation and monitoring of patients with PAD.
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Affiliation(s)
- Eleanor T. Rimmerman
- Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH 43210, USA
- Center for Regenerative Medicine, Research Institute at Nationwide Children’s Hospital, Columbus, OH 43215, USA
| | - Mitchel R. Stacy
- Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH 43210, USA
- Center for Regenerative Medicine, Research Institute at Nationwide Children’s Hospital, Columbus, OH 43215, USA
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA
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2
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Zannoni EM, Sankar P, Jin Y, Liu C, Sinusas AJ, Metzler SD, Meng LJ. Design and development of the DE-SPECT system: a clinical SPECT system for broadband multi-isotope imaging of peripheral vascular disease. Phys Med Biol 2024; 69:125016. [PMID: 38815617 PMCID: PMC11167601 DOI: 10.1088/1361-6560/ad5266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 05/05/2024] [Accepted: 05/30/2024] [Indexed: 06/01/2024]
Abstract
Objective. Peripheral Vascular Disease (PVD) affects more than 230 million people worldwide and is one of the leading causes of disability among people over age 60. Nowadays, PVD remains largely underdiagnosed and undertreated, and requires the development of tailored diagnostic approaches. We present the full design of the Dynamic Extremity SPECT (DE-SPECT) system, the first organ-dedicated SPECT system for lower extremity imaging, based on 1 cm thick Cadmium Zinc Telluride (CZT) spectrometers and a dynamic dual field-of-view (FOV) synthetic compound-eye (SCE) collimator.Approach. The proposed DE-SPECT detection system consists of 48 1 cm thick 3D-position-sensitive CZT spectrometers arranged in a partial ring of 59 cm in diameter in a checkerboard pattern. The detection system is coupled with a compact dynamic SCE collimator that allows the user to select between two different FOVs at any time during an imaging study: a wide-FOV (28 cm diameter) configuration for dual-leg or scout imaging or a high-resolution and high-sensitivity (HR-HS) FOV (16 cm diameter) for single-leg or focused imaging.Main results.The preliminary experimental data show that the CZT spectrometer achieves a 3D intrinsic spatial resolution of <0.75 mm FWHM and an excellent energy resolution over a broad energy range (2.6 keV FWHM at 218, 3.3 keV at 440 keV). From simulations, the wide-FOV configuration offers a 0.034% averaged sensitivity at 140 keV and <8 mm spatial resolution, whereas the HR-HS configuration presents a peak central sensitivity of 0.07% at 140 keV and a ∼5 mm spatial resolution. The dynamic SCE collimator enables the capability to perform joint reconstructions that would ensure an overall improvement in imaging performance.Significance. The DE-SPECT system is a stationary and high-performance SPECT system that offers an excellent spectroscopic performance with a unique computer-controlled dual-FOV imaging capability, and a relatively high sensitivity for multi-tracer and multi-functional SPECT imaging of the extremities.
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Affiliation(s)
- E M Zannoni
- Department of Nuclear, Plasma, and Radiological Engineering, University of Illinois at Urbana Champaign, Urbana, IL, United States of America
| | - P Sankar
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Y Jin
- Department of Nuclear, Plasma, and Radiological Engineering, University of Illinois at Urbana Champaign, Urbana, IL, United States of America
| | - C Liu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States of America
| | - A J Sinusas
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States of America
- Department of Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - S D Metzler
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - L J Meng
- Department of Nuclear, Plasma, and Radiological Engineering, University of Illinois at Urbana Champaign, Urbana, IL, United States of America
- Beckman Institute for Advance Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, United States of America
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3
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Callegari S, Feher A, Smolderen KG, Mena-Hurtado C, Sinusas AJ. Multi-modality imaging for assessment of the microcirculation in peripheral artery disease: Bench to clinical practice. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100400. [PMID: 38779485 PMCID: PMC11108852 DOI: 10.1016/j.ahjo.2024.100400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
Peripheral artery disease (PAD) is a highly prevalent disorder with a high risk of mortality and amputation despite the introduction of novel medical and procedural treatments. Microvascular disease (MVD) is common among patients with PAD, and despite the established role as a predictor of amputations and mortality, MVD is not routinely assessed as part of current standard practice. Recent pre-clinical and clinical perfusion and molecular imaging studies have confirmed the important role of MVD in the pathogenesis and outcomes of PAD. The recent advancements in the imaging of the peripheral microcirculation could lead to a better understanding of the pathophysiology of PAD, and result in improved risk stratification, and our evaluation of response to therapies. In this review, we will discuss the current understanding of the anatomy and physiology of peripheral microcirculation, and the role of imaging for assessment of perfusion in PAD, and the latest advancements in molecular imaging. By highlighting the latest advancements in multi-modality imaging of the peripheral microcirculation, we aim to underscore the most promising imaging approaches and highlight potential research opportunities, with the goal of translating these approaches for improved and personalized management of PAD in the future.
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Affiliation(s)
- Santiago Callegari
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
| | - Attila Feher
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
| | - Albert J. Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
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4
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Elsaid NMH, Peters DC, Galiana G, Sinusas AJ. Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease. Am J Physiol Heart Circ Physiol 2024; 326:H1304-H1323. [PMID: 38517227 DOI: 10.1152/ajpheart.00533.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024]
Abstract
Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.
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Affiliation(s)
- Nahla M H Elsaid
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Gigi Galiana
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Albert J Sinusas
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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5
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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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6
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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: 6] [Impact Index Per Article: 3.0] [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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7
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Ebenhan T, Kleynhans J, Zeevaart JR, Jeong JM, Sathekge M. Non-oncological applications of RGD-based single-photon emission tomography and positron emission tomography agents. Eur J Nucl Med Mol Imaging 2020; 48:1414-1433. [PMID: 32918574 DOI: 10.1007/s00259-020-04975-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/23/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Non-invasive imaging techniques (especially single-photon emission tomography and positron emission tomography) apply several RGD-based imaging ligands developed during a vast number of preclinical and clinical investigations. The RGD (Arg-Gly-Asp) sequence is a binding moiety for a large selection of adhesive extracellular matrix and cell surface proteins. Since the first identification of this sequence as the shortest sequence required for recognition in fibronectin during the 1980s, fundamental research regarding the molecular mechanisms of integrin action have paved the way for development of several pharmaceuticals and radiopharmaceuticals with clinical applications. Ligands recognizing RGD may be developed for use in the monitoring of these interactions (benign or pathological). Although RGD-based molecular imaging has been actively investigated for oncological purposes, their utilization towards non-oncology applications remains relatively under-exploited. METHODS AND SCOPE This review highlights the new non-oncologic applications of RGD-based tracers (with the focus on single-photon emission tomography and positron emission tomography). The focus is on the last 10 years of scientific literature (2009-2020). It is proposed that these imaging agents will be used for off-label indications that may provide options for disease monitoring where there are no approved tracers available, for instance Crohn's disease or osteoporosis. Fundamental science investigations have made progress in elucidating the involvement of integrin in various diseases not pertaining to oncology. Furthermore, RGD-based radiopharmaceuticals have been evaluated extensively for safety during clinical evaluations of various natures. CONCLUSION Clinical translation of non-oncological applications for RGD-based radiopharmaceuticals and other imaging tracers without going through time-consuming extensive development is therefore highly plausible. Graphical abstract.
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Affiliation(s)
- Thomas Ebenhan
- Nuclear Medicine, University of Pretoria, Pretoria, 0001, South Africa. .,Nuclear Medicine Research Infrastructure, NPC, Pretoria, 0001, South Africa.
| | - Janke Kleynhans
- Nuclear Medicine, University of Pretoria, Pretoria, 0001, South Africa.,Nuclear Medicine Research Infrastructure, NPC, Pretoria, 0001, South Africa
| | - Jan Rijn Zeevaart
- Nuclear Medicine Research Infrastructure, NPC, Pretoria, 0001, South Africa.,DST/NWU Preclinical Drug Development Platform, North-West University, Potchefstroom, 2520, South Africa
| | - Jae Min Jeong
- Department of Nuclear Medicine, Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehangno Jongno-gu, Seoul, 110-744, South Korea
| | - Mike Sathekge
- Nuclear Medicine, University of Pretoria, Pretoria, 0001, South Africa
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8
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Divakaran S, Sobieszczyk PS, Di Carli MF. The Potential of PET in the Management of Peripheral Arterial Disease. JACC Cardiovasc Imaging 2020; 13:1018-1020. [PMID: 31422132 PMCID: PMC7384373 DOI: 10.1016/j.jcmg.2019.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/SanjayDivakaran
| | - Piotr S Sobieszczyk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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9
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Dynamic Volume Perfusion CT of the Foot in Critical Limb Ischemia: Response to Percutaneous Revascularization. AJR Am J Roentgenol 2020; 214:1398-1408. [PMID: 32097028 DOI: 10.2214/ajr.19.21520] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE. The purpose of this study was to assess the reproducibility and validity of quantitative perfusion parameters derived from dynamic volume perfusion CT in patients with critical limb ischemia (CLI) and to evaluate perfusion parameter changes before and after endovascular revascularization. SUBJECTS AND METHODS. Patients with CLI referred for unilateral extremity endovascular arterial recanalization were enrolled in this study. CT examinations obtained 1-3 days before the procedure and then within 1 week after the treatment were evaluated at two reading sessions. Blood flow (BF), blood volume (BV), and time to peak (TTP) were measured on color-coded maps and compared statistically. Intraobserver agreement was assessed using intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS. Endovascular treatment was technically successful for all 16 patients. The posttreatment BF and BV showed a statistically significant increase in both dermal and muscle areas (p < 0.05). The posttreatment TTP shortened at a statistically significant level (p < 0.05). In the 3-month clinical follow-up period, the limb salvage rate was 81% and the percentage change in BF and BV of patients with poor response to treatment had no statistically significant increase after treatment, consistent with the clinical assessment. The percentage change in BF and BV correlated well with the improvement of the clinical condition (r = 0.673-0.901). ICC values showed excellent agreement in the range of 0.95-0.98. CONCLUSION. As a reproducible method, dynamic volume perfusion CT of the foot may enable quantitative evaluation of the perfusion of soft tissues and also provide a novel approach to assessing response to endovascular recanalization in CLI.
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10
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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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11
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Alvelo JL, Papademetris X, Mena-Hurtado C, Jeon S, Sumpio BE, Sinusas AJ, Stacy MR. Radiotracer Imaging Allows for Noninvasive Detection and Quantification of Abnormalities in Angiosome Foot Perfusion in Diabetic Patients With Critical Limb Ischemia and Nonhealing Wounds. Circ Cardiovasc Imaging 2019; 11:e006932. [PMID: 29748311 PMCID: PMC5951395 DOI: 10.1161/circimaging.117.006932] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
Abstract
Background: Single photon emission computed tomography (SPECT)/computed tomography (CT) imaging allows for assessment of skeletal muscle microvascular perfusion but has not been quantitatively assessed in angiosomes, or 3-dimensional vascular territories, of the foot. This study assessed and compared resting angiosome foot perfusion between healthy subjects and diabetic patients with critical limb ischemia (CLI). Additionally, the relationship between SPECT/CT imaging and the ankle–brachial index—a standard tool for evaluating peripheral artery disease—was assessed. Methods and Results: Healthy subjects (n=9) and diabetic patients with CLI and nonhealing ulcers (n=42) underwent SPECT/CT perfusion imaging of the feet. CT images were segmented into angiosomes for quantification of relative radiotracer uptake, expressed as standardized uptake values. Standardized uptake values were assessed in ulcerated angiosomes of patients with CLI and compared with whole-foot standardized uptake values in healthy subjects. Serial SPECT/CT imaging was performed to assess uptake kinetics of technetium-99m-tetrofosmin. The relationship between angiosome perfusion and ankle–brachial index was assessed via correlational analysis. Resting perfusion was significantly lower in CLI versus healthy subjects (P=0.0007). Intraclass correlation coefficients of 0.95 (healthy) and 0.93 (CLI) demonstrated excellent agreement between serial perfusion measurements. Correlational analysis, including healthy and CLI subjects, demonstrated a significant relationship between ankle–brachial index and SPECT/CT (P=0.01); however, this relationship was not significant for diabetic CLI patients only (P=0.2). Conclusions: SPECT/CT imaging assesses regional foot perfusion and detects abnormalities in microvascular perfusion that may be undetectable by conventional ankle–brachial index in patients with diabetes mellitus. SPECT/CT may provide a novel approach for evaluating responses to targeted therapies.
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Affiliation(s)
- Jessica L Alvelo
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.)
| | - Xenophon Papademetris
- Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.).,Department of Biomedical Engineering (X.P.)
| | | | | | - Bauer E Sumpio
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.).,Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.).,and Department of Surgery (B.E.S.) Yale University School of Medicine, New Haven, CT
| | - Albert J Sinusas
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.).,Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.)
| | - Mitchel R Stacy
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.)
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12
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Boutagy NE, Feher A, Alkhalil I, Umoh N, Sinusas AJ. Molecular Imaging of the Heart. Compr Physiol 2019; 9:477-533. [PMID: 30873600 DOI: 10.1002/cphy.c180007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Multimodality cardiovascular imaging is routinely used to assess cardiac function, structure, and physiological parameters to facilitate the diagnosis, characterization, and phenotyping of numerous cardiovascular diseases (CVD), as well as allows for risk stratification and guidance in medical therapy decision-making. Although useful, these imaging strategies are unable to assess the underlying cellular and molecular processes that modulate pathophysiological changes. Over the last decade, there have been great advancements in imaging instrumentation and technology that have been paralleled by breakthroughs in probe development and image analysis. These advancements have been merged with discoveries in cellular/molecular cardiovascular biology to burgeon the field of cardiovascular molecular imaging. Cardiovascular molecular imaging aims to noninvasively detect and characterize underlying disease processes to facilitate early diagnosis, improve prognostication, and guide targeted therapy across the continuum of CVD. The most-widely used approaches for preclinical and clinical molecular imaging include radiotracers that allow for high-sensitivity in vivo detection and quantification of molecular processes with single photon emission computed tomography and positron emission tomography. This review will describe multimodality molecular imaging instrumentation along with established and novel molecular imaging targets and probes. We will highlight how molecular imaging has provided valuable insights in determining the underlying fundamental biology of a wide variety of CVDs, including: myocardial infarction, cardiac arrhythmias, and nonischemic and ischemic heart failure with reduced and preserved ejection fraction. In addition, the potential of molecular imaging to assist in the characterization and risk stratification of systemic diseases, such as amyloidosis and sarcoidosis will be discussed. © 2019 American Physiological Society. Compr Physiol 9:477-533, 2019.
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Affiliation(s)
- Nabil E Boutagy
- Department of Medicine, Yale Translational Research Imaging Center, Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, Connecticut, USA
| | - Attila Feher
- Department of Medicine, Yale Translational Research Imaging Center, Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, Connecticut, USA
| | - Imran Alkhalil
- Department of Medicine, Yale Translational Research Imaging Center, Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, Connecticut, USA
| | - Nsini Umoh
- Department of Medicine, Yale Translational Research Imaging Center, Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, Connecticut, USA
| | - Albert J Sinusas
- Department of Medicine, Yale Translational Research Imaging Center, Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, Connecticut, USA.,Yale University School of Medicine, Department of Radiology and Biomedical Imaging, New Haven, Connecticut, USA
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Haghighat L, Ionescu CN, Regan CJ, Altin SE, Attaran RR, Mena-Hurtado CI. Review of the Current Basic Science Strategies to Treat Critical Limb Ischemia. Vasc Endovascular Surg 2019; 53:316-324. [DOI: 10.1177/1538574419831489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Critical limb ischemia (CLI) is a highly morbid disease with many patients considered poor surgical candidates. The lack of treatment options for CLI has driven interest in developing molecular therapies within recent years. Through these translational medicine studies in CLI, much has been learned about the pathophysiology of the disease. Here, we present an overview of the macrovascular and microvascular changes that lead to the development of CLI, including impairment of angiogenesis, vasculogenesis, and arteriogenesis. We summarize the randomized clinical controlled trials that have used molecular therapies in CLI, and discuss the novel imaging modalities being developed to assess the efficacy of these therapies.
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Affiliation(s)
- Leila Haghighat
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Costin N. Ionescu
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J. Regan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sophia Elissa Altin
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert R. Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos I. Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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14
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Kapanadze T, Bankstahl JP, Wittneben A, Koestner W, Ballmaier M, Gamrekelashvili J, Krishnasamy K, Limbourg A, Ross TL, Meyer GJ, Haller H, Bengel FM, Limbourg FP. Multimodal and Multiscale Analysis Reveals Distinct Vascular, Metabolic and Inflammatory Components of the Tissue Response to Limb Ischemia. Am J Cancer Res 2019; 9:152-166. [PMID: 30662559 PMCID: PMC6332799 DOI: 10.7150/thno.27175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemia triggers a complex tissue response involving vascular, metabolic and inflammatory changes. Methods: We combined hybrid SPECT/CT or PET/CT nuclear imaging studies of perfusion, metabolism and inflammation with multicolor flow cytometry-based cell population analysis to comprehensively analyze the ischemic tissue response and to elucidate the cellular substrate of noninvasive molecular imaging techniques in a mouse model of hind limb ischemia. Results: Comparative analysis of tissue perfusion with [99mTc]-Sestamibi and arterial influx with [99mTc]-labeled albumin microspheres by SPECT/CT revealed a distinct pattern of response to vascular occlusion: an early ischemic period of matched suppression of tissue perfusion and arterial influx, a subacute ischemic period of normalized arterial influx but impaired tissue perfusion, and a protracted post-ischemic period of hyperdynamic arterial and normalized tissue perfusion, indicating coordination of macrovascular and microvascular responses. In addition, the subacute period showed increased glucose uptake by [18F]-FDG PET/CT scanning as the metabolic response of viable tissue to hypoperfusion. This was associated with robust macrophage infiltration by flow cytometry, and glucose uptake studies identified macrophages as major contributors to glucose utilization in ischemic tissue. Furthermore, imaging with the TSPO ligand [18F]-GE180 showed a peaked response during the subacute phase due to preferential labeling of monocytes and macrophages, while imaging with [68Ga]-RGD, an integrin ligand, showed prolonged post-ischemic upregulation, which was attributed to labeling of macrophages and endothelial cells by flow cytometry. Conclusion: Combined nuclear imaging and cell population analysis reveals distinct components of the ischemic tissue response and associated cell subsets, which could be targeted for therapeutic interventions.
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15
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Stacy MR, Dearth CL. Multimodality Imaging Approaches for Evaluating Traumatic Extremity Injuries: Implications for Military Medicine. Adv Wound Care (New Rochelle) 2017; 6:241-251. [PMID: 28736684 DOI: 10.1089/wound.2016.0716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 01/08/2023] Open
Abstract
Significance: Military service members are susceptible to traumatic extremity injuries that often result in limb loss. Tremendous efforts have been made to improve medical treatment that supports residual limb function and health. Despite recent improvements in treatment and novel prosthetic devices, many patients experience a wide range of clinical problems within residual limbs that can negatively impact the progress of rehabilitation programs while also impairing functional capacity and overall quality of life. Recent Advances: In addition to existing standard imaging modalities that are used for clinical evaluation of patients suffering from traumatic extremity injury, novel noninvasive imaging techniques are in development that may facilitate rapid and sensitive assessment of various aspects of traumatic extremity injuries and residual limb health. Critical Issues: Despite recent advances, there remains a clinical need for noninvasive quantitative imaging techniques that are capable of providing rapid objective assessments of residual limb health at the time of initial presentation as well as after various forms of medical treatment. Future Directions: Ongoing development of imaging techniques that allow for assessment of anatomical and physiological characteristics of extremities exposed to traumatic injury should greatly enhance the quality of patient care and assist in optimizing clinical outcomes.
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Affiliation(s)
- Mitchel R. Stacy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher L. Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
- Regenerative Biosciences Laboratory, Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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16
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Woodard PK, Liu Y, Pressly ED, Luehmann HP, Detering L, Sultan DE, Laforest R, McGrath AJ, Gropler RJ, Hawker CJ. Design and Modular Construction of a Polymeric Nanoparticle for Targeted Atherosclerosis Positron Emission Tomography Imaging: A Story of 25% (64)Cu-CANF-Comb. Pharm Res 2016; 33:2400-10. [PMID: 27286872 PMCID: PMC5096390 DOI: 10.1007/s11095-016-1963-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/01/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE To assess the physicochemical properties, pharmacokinetic profiles, and in vivo positron emission tomography (PET) imaging of natriuretic peptide clearance receptors (NPRC) expressed on atherosclerotic plaque of a series of targeted, polymeric nanoparticles. METHODS To control their structure, non-targeted and targeted polymeric (comb) nanoparticles, conjugated with various amounts of c-atrial natriuretic peptide (CANF, 0, 5, 10 and 25%), were synthesized by controlled and modular chemistry. In vivo pharmacokinetic evaluation of these nanoparticles was performed in wildtype (WT) C57BL/6 mice after (64)Cu radiolabeling. PET imaging was performed on an apolipoprotein E-deficient (ApoE(-/-)) mouse atherosclerosis model to assess the NPRC targeting efficiency. For comparison, an in vivo blood metabolism study was carried out in WT mice. RESULTS All three (64)Cu-CANF-comb nanoparticles showed improved biodistribution profiles, including significantly reduced accumulation in both liver and spleen, compared to the non-targeted (64)Cu-comb. Of the three nanoparticles, the 25% (64)Cu-CANF-comb demonstrated the best NPRC targeting specificity and sensitivity in ApoE(-/-) mice. Metabolism studies showed that the radiolabeled CANF-comb was stable in blood up to 9 days. Histopathological analyses confirmed the up-regulation of NPRC along the progression of atherosclerosis. CONCLUSION The 25% (64)Cu-CANF-comb demonstrated its potential as a PET imaging agent to detect atherosclerosis progression and status.
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Affiliation(s)
- Pamela K Woodard
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Yongjian Liu
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Eric D Pressly
- Materials Research Laboratory, University of California, Santa Barbara, California,, USA
| | - Hannah P Luehmann
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Lisa Detering
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Deborah E Sultan
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Richard Laforest
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Alaina J McGrath
- Materials Research Laboratory, University of California, Santa Barbara, California,, USA
| | - Robert J Gropler
- Department of Radiology, Washington University, St. Louis, Missouri, USA
| | - Craig J Hawker
- Materials Research Laboratory, University of California, Santa Barbara, California,, USA.
- Department of Chemistry and Biochemistry, University of California, Santa Barbara, California,, USA.
- Materials Department, University of California, Santa Barbara, California, USA.
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