1
|
Matthaiou N, Klontzas ME, Kakkos GA, Tsetis K, Maris TG, Ioannou CV, Tsetis D, Kehagias E. Utility of Dual-Energy Computed Tomography in lesion characterization and treatment planning for peripheral Chronic Total Occlusions: A comprehensive analysis of crossing difficulty. Eur J Radiol 2024; 176:111539. [PMID: 38833769 DOI: 10.1016/j.ejrad.2024.111539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/18/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE To investigate whether Dual-Energy Computed Tomography (DECT) could be useful in the lesion characterization and endovascular treatment planning of symptomatic patients with peripheral arterial disease (PAD) due to Chronic Total Occlusions (CTO). MATERIALS AND METHODS Between 2018 and 2022, 60 symptomatic patients (52 male, age 71 years) with peripheral arterial CTO underwent DECT angiography before percutaneous endovascular treatment. Patients were classified, according to guidewire crossing difficulty into four categories, which were subsequently correlated with DECT values, including Dual Energy Index (DEI) and Effective Z (Zeff). DECT values were also corelated with crossing time. The crossing difficulty was further correlated with the Trans-Atlantic Inter-Society Consensus Document (TASC II) classification. RESULTS Technical success, defined as perceived antegrade true lumen or subintimal crossing, was achieved in 76.7 %. Among the cases, 20 were deemed easy, 14 moderate, 12 hard and 14 were failed attempts. Statistical analysis revealed a significant correlation between DEI, Zeff values, and the crossing difficulty categories (p < 0.001). Additionally, there was also a correlation between crossing time and DECT values. However, no significant correlation was recorded between difficulty categories and TASC II classification. CONCLUSION Pre-procedural DECT angiography provides valuable information for patient selection and planning of the revascularization strategy. Moreover, it is helpful in the selection of the appropriate PTA materials, based on the lesion characteristics. Further research should be invested in this important field, to determine the optimal treatment approach in patients suffering from PAD due to CTOs.
Collapse
Affiliation(s)
- Nikolas Matthaiou
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece.
| | - Michail E Klontzas
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece.
| | - George A Kakkos
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Konstantinos Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece
| | - Thomas G Maris
- Department of Medical Physics, University Hospital Heraklion, University of Crete Medical School, Voutes, 71110 Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital Heraklion, University of Crete Medical School, Voutes, 71110 Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece
| |
Collapse
|
2
|
Matthaiou N, Galanakis N, Papadakis AE, Kehagias E, Kontopodis N, Charalambous S, Perisinakis K, Maris TG, Ioannou CV, Tsetis D. Dual-Energy Computed Tomography as an Adjunct in the Evaluation of Peripheral Chronic Total Occlusions: A Feasibility Study. J Vasc Interv Radiol 2022; 33:1531-1535. [PMID: 36100065 DOI: 10.1016/j.jvir.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 07/07/2022] [Accepted: 09/03/2022] [Indexed: 11/25/2022] Open
Abstract
This study investigated the role of dual-energy computed tomography (CT) for lesion characterization in patients with peripheral arterial disease manifesting with chronic total occlusions (CTOs). Forty-one symptomatic patients with CTOs underwent dual-energy CT angiography before endovascular treatment. The lesions were subsequently analyzed in a dedicated workstation, and 2 indexes-dual-energy index (DEI) and effective Z (Zeff)-were calculated, ranging from 0.0027 to 0.321 and from 6.89 to 13.02, respectively. Statistical analysis showed a significant correlation between the DEI and Zeff values (P < .001). The interobserver intraclass correlation coefficient was 0.91 for the mean Zeff values and 0.86 for the mean DEI values. This technique could potentially provide useful information regarding the composition of a CTO.
Collapse
Affiliation(s)
- Nikolas Matthaiou
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital Heraklion, Heraklion, Greece; Department of Radiology, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital Heraklion, Heraklion, Greece
| | - Antonios E Papadakis
- Department of Medical Physics, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital Heraklion, Heraklion, Greece; Department of Radiology, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Stavros Charalambous
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital Heraklion, Heraklion, Greece; Department of Radiology, University of Crete Medical School, Heraklion, Greece
| | - Konstantinos Perisinakis
- Department of Medical Physics, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Thomas G Maris
- Department of Medical Physics, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital Heraklion, Heraklion, Greece; Department of Radiology, University of Crete Medical School, Heraklion, Greece.
| |
Collapse
|
3
|
Blitzer DN, Rolle NP, Abdou H, Berg L, Nagarsheth KH. Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity Revascularization. Vasc Endovascular Surg 2022; 57:5-10. [PMID: 35968814 DOI: 10.1177/15385744221120203] [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: 11/15/2022]
Abstract
BACKGROUND Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients. METHODS We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1 year, and amputation-free survival at 1 year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1 year were calculated. RESULTS Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1 year, and overall LBP was 67% at 1 year. CONCLUSION Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.
Collapse
Affiliation(s)
- David N Blitzer
- Division of Vascular Surgery, Department of Surgery, 21668University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas P Rolle
- 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hossam Abdou
- 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lars Berg
- 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khanjan H Nagarsheth
- Division of Vascular Surgery, Department of Surgery, 21668University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
4
|
Huillca MAR, Moreno-Loaiza M, Tipacti-Rodríguez F, Briceño-Alvarado M, Llalle WSC. Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique. J Vasc Bras 2021; 20:e20200126. [PMID: 34093686 PMCID: PMC8147880 DOI: 10.1590/1677-5449.200126] [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] [Indexed: 12/03/2022] Open
Abstract
The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.
Collapse
Affiliation(s)
- Miguel Alonso-Rojas Huillca
- Hospital Nacional Edgardo Rebagliati Martins - HNERM, Departamento de Cirugía de Tórax y Cardiovascular, Vascular and Endovascular Surgery Service, Lima, Peru
| | - Milagros Moreno-Loaiza
- Hospital Nacional Edgardo Rebagliati Martins - HNERM, Departamento de Cirugía de Tórax y Cardiovascular, Vascular and Endovascular Surgery Service, Lima, Peru
| | - Félix Tipacti-Rodríguez
- Hospital Nacional Edgardo Rebagliati Martins - HNERM, Departamento de Cirugía de Tórax y Cardiovascular, Vascular and Endovascular Surgery Service, Lima, Peru
| | - Manolo Briceño-Alvarado
- Hospital Nacional Edgardo Rebagliati Martins - HNERM, Departamento de Cirugía de Tórax y Cardiovascular, Vascular and Endovascular Surgery Service, Lima, Peru
| | - Wildor Samir Cubas Llalle
- Hospital Nacional Edgardo Rebagliati Martins - HNERM, Departamento de Cirugía de Tórax y Cardiovascular, Vascular and Endovascular Surgery Service, Lima, Peru
| |
Collapse
|
5
|
Weissler EH, Gutierrez JA, Patel MR, Swaminathan RV. Successful Peripheral Vascular Intervention in Patients with High-risk Comorbidities or Lesion Characteristics. Curr Cardiol Rep 2021; 23:32. [PMID: 33666765 DOI: 10.1007/s11886-021-01465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Certain comorbidities and lesion characteristics are associated with increased risk for procedural complications, limb events, and cardiovascular events following peripheral vascular intervention (PVI) in patients with peripheral arterial disease (PAD). The purpose of this review is to provide an overview of high-risk modifiable and unmodifiable patient characteristics and its relative impact on clinical outcomes such as amputation risk and mortality. Furthermore, general approaches to potentially mitigating these risks through pre-intervention planning and use of modern devices and techniques are discussed. RECENT FINDINGS Diabetes, tobacco use, and older age remain strong risk factors for the development of peripheral arterial disease. Recent data highlight the significant risk of polyvascular disease on major limb and cardiac events in advanced PAD, and ongoing studies are assessing this risk specifically after PVI. Challenging lesion characteristics such as calcified disease and chronic total occlusions can be successfully treated with PVI by utilizing novel devices (e.g., intravascular lithotripsy, re-entry devices) and techniques (e.g., subintimal arterial "flossing" with antegrade-retrograde intervention). Understanding high-risk patient comorbidities and lesion characteristics will improve our ability to counsel and manage patients with advanced PAD. Continued device innovation and novel techniques will aid in procedural planning for successful interventions to improve clinical outcomes.
Collapse
Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC, USA
| | - J Antonio Gutierrez
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke University Medical Center, Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27705, USA
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke University Medical Center, Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27705, USA
| | - Rajesh V Swaminathan
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
- Duke University Medical Center, Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27705, USA.
| |
Collapse
|
6
|
Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
Collapse
Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
| |
Collapse
|
7
|
Gahide G, Bui BT, Beland M. The Cupidon's Strike Technique: How to Never Miss a Rendezvous While Going on SAFARI. Ann Vasc Surg 2020; 70:555-558. [PMID: 32800886 DOI: 10.1016/j.avsg.2020.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 12/09/2022]
Abstract
One of the difficulties of the subintimal arterial flossing with antegrade-retrograde intervention technique (SAFARI) technique is to properly achieve a rendezvous between both antegrade and retrograde accesses. We propose a new technique to overcome this difficulty. It consists of directly percutaneously puncturing 2 loop snares, placed via each access, which are then both used to snare an externally introduced guidewire introduced through the needle. The snares are then moved en bloc, bringing both snares and the wire into the same channel.
Collapse
Affiliation(s)
- Gérald Gahide
- Service d'Angioradiologie. Département d'Imagerie Médicale, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
| | - Bao T Bui
- Service d'Angioradiologie. Département d'Imagerie Médicale, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Mathieu Beland
- Département de Radiologie, Centre Hospitalier Universitaire de Québec, Québec, Québe, Canada
| |
Collapse
|
8
|
Younes N, Al-Sadeq DW, AL-Jighefee H, Younes S, Al-Jamal O, Daas HI, Yassine HM, Nasrallah GK. Challenges in Laboratory Diagnosis of the Novel Coronavirus SARS-CoV-2. Viruses 2020; 12:E582. [PMID: 32466458 PMCID: PMC7354519 DOI: 10.3390/v12060582] [Citation(s) in RCA: 248] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
The recent outbreak of the Coronavirus disease 2019 (COVID-19) has quickly spread worldwide since its discovery in Wuhan city, China in December 2019. A comprehensive strategy, including surveillance, diagnostics, research, clinical treatment, and development of vaccines, is urgently needed to win the battle against COVID-19. The past three unprecedented outbreaks of emerging human coronavirus infections at the beginning of the 21st century have highlighted the importance of readily available, accurate, and rapid diagnostic technologies to contain emerging and re-emerging pandemics. Real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) based assays performed on respiratory specimens remain the gold standard for COVID-19 diagnostics. However, point-of-care technologies and serologic immunoassays are rapidly emerging with high sensitivity and specificity as well. Even though excellent techniques are available for the diagnosis of symptomatic patients with COVID-19 in well-equipped laboratories; critical gaps still remain in screening asymptomatic people who are in the incubation phase of the virus, as well as in the accurate determination of live viral shedding during convalescence to inform decisions for ending isolation. This review article aims to discuss the currently available laboratory methods and surveillance technologies available for the detection of COVID-19, their performance characteristics and highlight the gaps in current diagnostic capacity, and finally, propose potential solutions. We also summarize the specifications of the majority of the available commercial kits (PCR, EIA, and POC) for laboratory diagnosis of COVID-19.
Collapse
Affiliation(s)
- Nadin Younes
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
| | - Duaa W. Al-Sadeq
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
- College of Medicine, Member of QU Health, Qatar University, P.O. Box 2713 Doha, Qatar
| | - Hadeel AL-Jighefee
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
| | - Salma Younes
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713 Doha, Qatar;
| | - Ola Al-Jamal
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
| | - Hanin I. Daas
- College of Dental Medicine, Member of QU Health, Qatar University, P.O. Box 2713 Doha, Qatar;
| | - Hadi. M. Yassine
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713 Doha, Qatar;
| | - Gheyath K. Nasrallah
- Biomedical Research Center, Qatar University, P.O. Box 2713 Doha, Qatar; (N.Y.); (D.W.A.-S.); (H.A.-J.); (O.A.-J.); (H.M.Y.)
- Department of Biomedical Science, College of Health Sciences, Member of QU Health, Qatar University, P.O. Box 2713 Doha, Qatar;
| |
Collapse
|