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Spiliopoulos S, Giannikouris IE, Katsanos K, Filippou P, Efthymiou E, Reppas L, Kitrou P, Palialexis K, Filippiadis D, Brountzos E. VOLume flow assistance for optimizing outcomes of dysfunctional autologous arteriovenous fistula Angioplasty: the VOLA Pilot Study. Eur Radiol 2022; 32:368-376. [PMID: 34195887 DOI: 10.1007/s00330-021-08139-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/01/2021] [Accepted: 06/06/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the feasibility of VF-assisted angioplasty (VFA) in dysfunctional AVF using sequential intraprocedural duplex ultrasound (DUS), to utilize intraprocedural VF as a quantifiable, functional endpoint in endovascular treatment. METHODS This prospective study included 20 consecutive patients (23 lesions; 16 men; mean age 67 ± 16 years) with dysfunctional AVF undergoing fluoroscopically guided balloon angioplasty between June 2019 and May 2020. Primary endpoints were quantification of outcome using sequential DUS VF analysis following each dilation, 6-month target lesion re-intervention (TLR)-free rate, standard technical success, procedural success (achievement of a postprocedural VF value equal (or 10% less) or superior to the baseline steady-state access), and correlation between procedural success and TLR-free rate. Secondary endpoints included 6-month lesion late lumen loss (LLL), correlation between balloon diameter used and intraprocedural VF values, and correlation between VF and LLL at 6 months follow-up. RESULTS Mean VF increase was 168.5% ± 102.5% (range: 24.24-493.33%). Procedural success was 80% (16/20 cases). VFA improved procedural success by 20% (4/20 cases) compared to standard assessment (< 30% residual stenosis and palpable thrill). TLR-free rate was 78.3% and 67.3% at 6 and 12 months. Significantly less TLR was noted in cases of procedural success (82.4% vs. 66.7% 6 months; p = 0.041). Unweighted linear regression showed a significant positive relationship between diameter of balloon and VF (146.9 ± 42.3 mL/min VF gain per mm of balloon diameter; p = 0.001, R2 = 0.23) and a significant negative relationship between LLL and VF decline at follow-up (102.0 ± 34.6 mL/min loss per mm of LLL; p = 0.01, R2 = 0.35). Optimal VF cutoff value and percentile increase to predict access failure were 720 mL/min (sensitivity 58.3%, specificity 71.4%) and 153% (sensitivity 66.7%, specificity 85.7%), respectively. CONCLUSION Intraprocedural VF assessment could be used to optimize AVF angioplasty. KEY POINTS • A newly proposed functional endpoint of angioplasty in dysfunctional dialysis fistula was evaluated and angioplasty outcome was quantified using volume flow (VF) assessment with sequential intraprocedural DUS. • Intraprocedural VF assessment improved immediate procedural success; increased balloon diameter was correlated with VF gain and late lumen loss with VF decline. • Intraprocedural VF values ≥ to baseline steady-state values were correlated with less re-interventions.
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Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece.
| | | | - Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Panagiotis Filippou
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Evgenia Efthymiou
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Lazaros Reppas
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Panagiotis Kitrou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Konstantinos Palialexis
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Dimitrios Filippiadis
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
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Koirala N, McLennan G. Blood flow quantification in dialysis access using digital subtraction angiography: A retrospective study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 190:105379. [PMID: 32050137 DOI: 10.1016/j.cmpb.2020.105379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Vascular access is the "lifeline" of end-stage renal disease patients, which is surgically constructed to remove blood-waste and return artificially filtered blood into circulation. The arteriovenous shunting causes an abrupt change in blood flow and results in increased fluidic stress, which predisposes to access stenosis and thrombosis. While access flow is crucial to evaluate interventional endpoint, application to measure flow using digital angiogram is not yet available. The goal of this study was to determine the feasibility of flow quantification in dialysis access using a software tool and to guide the design of an imaging protocol. METHODS 173 digital subtraction angiographic (DSA) images were retrospectively analyzed to evaluate access flow in a custom-programming environment. Four bolus transit time algorithms and a distance calculation method were assessed for flow computation. Gamma variate function was applied to remove secondary flow and intensity outliers in the bolus time-intensity curves and evaluated for enhancement in computational accuracy. The percent deviations of flow rates computed from dilution of iodinated radio-contrast material were compared with in situ catheter-based flow measurement. RESULTS Among the implemented bolus transit time algorithms, quantification error (mean ± standard error) of cross-correlation algorithm without and with gamma variate curve fitting was 35 ± 1% and 22 ± 1%, respectively. All other algorithms had quantification error >27%. The bias and limits of agreement of the cross-correlation algorithm with gamma variate curve fit was -94 ml/min and [-353, 165] mL/min, respectively. CONCLUSIONS The cross-correlation algorithm with gamma variate curve fit had the best accuracy and reproducibility for image-based blood flow computation. To further enhance accuracy, images may need to be acquired with a dedicated injection protocol with predetermined parameters such as the duration, rate and mode of bolus injection, and the acquisition frame rate.
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Affiliation(s)
- Nischal Koirala
- Department of Chemical and Biomedical Engineering, Cleveland State University, Cleveland, OH, USA; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gordon McLennan
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA.
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