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Bae WC, Malis V, Vucevic D, Yamamoto A, Nakamura K, Lane J, Miyazaki M. Non-contrast MRI of micro-vascularity of the feet and toes. Jpn J Radiol 2024; 42:785-797. [PMID: 38536557 DOI: 10.1007/s11604-024-01553-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE This study aimed to develop novel non-contrast MR perfusion techniques for assessing micro-vascularity of the foot in human subjects. METHODS All experiments were performed on a clinical 3 T scanner using arterial spin labeling (ASL). Seven healthy subjects (30-72 years old, 5 males and 2 females) were enrolled and bilateral feet were imaged with tag-on and tag-off alternating inversion recovery spin labeling for determining micro-vascularity. We compared an ASL technique with 1-tag against 4-tag pulses. For perfusion, we determined signal increase ratio (SIR) at varying inversion times (TI) from 0.5 to 2 s. SIR versus TI data were fit to determine perfusion metrics of peak height (PH), time to peak (TTP), full width at half maximum (FWHM), area under the curve (AUC), and apparent blood flow (aBF) in the distal foot and individual toes. Using analysis of variance (ANOVA), effects of tag pulse and region of interest (ROI) on the mean perfusion metrics were assessed. In addition, a 4-tag pulse perfusion experiment was performed on patients with peripheral artery disease (PAD) and Raynaud's disease. RESULTS Using our MR perfusion techniques, SIR versus TI data showed well-defined leading and trailing edges, with a peak near TI of 0.75-1.0 s and subsiding quickly to near zero by TI of 2 s, particularly when 4-tag pulses were used. When imaged with 4-tag pulse, we found significantly greater values in perfusion metrics, as compared to 1-tag pulse. The patients with PAD and Raynaud's disease showed a reduced or scattered perfusion curves compared to the healthy control. CONCLUSION MR perfusion imaging of the distal foot shows greater SIR and perfusion metrics with the 4-tag pulse compared to the 1-tag pulse technique. This will likely benefit those with low perfusion due to aging, PAD, diabetic foot, and other vascular diseases.
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Affiliation(s)
- Won C Bae
- Department of Radiology, University of California-San Diego, La Jolla, CA, USA
- Department of Radiology, VA San Diego Healthcare System, San Diego, CA, USA
| | - Vadim Malis
- Department of Radiology, University of California-San Diego, La Jolla, CA, USA
| | - Diana Vucevic
- Department of Radiology, University of California-San Diego, La Jolla, CA, USA
| | - Asako Yamamoto
- Department of Radiology, Teikyo University, Tokyo, Japan
| | | | - John Lane
- Department of Surgery, University of California-San Diego, La Jolla, CA, USA
| | - Mitsue Miyazaki
- Department of Radiology, University of California-San Diego, La Jolla, CA, USA.
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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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3
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Prior SJ, Chrencik MT, Christensen E, Kundi R, Ryan AS, Addison O, Lal BK. An exercise stress test for contrast-enhanced duplex ultrasound assessment of lower limb muscle perfusion in patients with peripheral arterial disease. J Vasc Surg 2024; 79:397-404. [PMID: 37844848 PMCID: PMC10969459 DOI: 10.1016/j.jvs.2023.10.005] [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: 08/01/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The aim of the present study was to develop a standardized contrast-enhanced duplex ultrasound (CE-DUS) protocol to assess lower-extremity muscle perfusion before and after exercise and determine relationships of perfusion with clinical and functional measures. METHODS CE-DUS (EPIQ 5G, Philips) was used before and immediately after a 10-minute, standardized bout of treadmill walking to compare microvascular perfusion of the gastrocnemius muscle in older (55-82 years) patients with peripheral arterial disease (PAD) (n = 15, mean ankle-brachial index, 0.78 ± 0.04) and controls (n = 13). Microvascular blood volume (MBV) and microvascular flow velocity (MFV) were measured at rest and immediately following treadmill exercise, and the Modified Physical Performance Test (MPPT) was used to assess mobility function. RESULTS In the resting state (pre-exercise), MBV in patients with PAD was not significantly different than normal controls (5.17 ± 0.71 vs 6.20 ± 0.83 arbitrary units (AU) respectively; P = .36); however, after exercise, MBV was ∼40% lower in patients with PAD compared with normal controls (5.85 ± 1.13 vs 9.53 ± 1.31 AU, respectively; P = .04). Conversely, MFV was ∼60% higher in patients with PAD compared with normal controls after exercise (0.180 ± 0.016 vs 0.113 ± 0.018 AU, respectively; P = .01). There was a significant between-group difference in the exercise-induced changes in both MBV and MFV (P ≤ .05). Both basal and exercise MBV directly correlated with MPPT score in the patients with PAD (r = 0.56-0.62; P < .05). CONCLUSIONS This standardized protocol for exercise stress testing of the lower extremities quantifies calf muscle perfusion and elicits perfusion deficits in patients with PAD. This technique objectively quantifies microvascular perfusion deficits that are related to reduced mobility function and could be used to assess therapeutic efficacy in patients with PAD.
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Affiliation(s)
- Steven J Prior
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD; Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Matthew T Chrencik
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Eric Christensen
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Rishi Kundi
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Alice S Ryan
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Medicine, Division of Gerontology, Geriatrics and Palliative Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Odessa Addison
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), Baltimore, MD; Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
| | - Brajesh K Lal
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, Baltimore, MD.
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Sabeti S, Nayak R, McBane RD, Fatemi M, Alizad A. Contrast-free ultrasound imaging for blood flow assessment of the lower limb in patients with peripheral arterial disease: a feasibility study. Sci Rep 2023; 13:11321. [PMID: 37443250 PMCID: PMC10345143 DOI: 10.1038/s41598-023-38576-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Abstract
While being a relatively prevalent condition particularly among aging patients, peripheral arterial disease (PAD) of lower extremities commonly goes undetected or misdiagnosed due to its symptoms being nonspecific. Additionally, progression of PAD in the absence of timely intervention can lead to dire consequences. Therefore, development of non-invasive and affordable diagnostic approaches can be highly beneficial in detection and treatment planning for PAD patients. In this study, we present a contrast-free ultrasound-based quantitative blood flow imaging technique for PAD diagnosis. The method involves monitoring the variations of blood flow in the calf muscle in response to thigh-pressure-cuff-induced occlusion. Four quantitative metrics are introduced for analysis of these variations. These metrics include post-occlusion to baseline flow intensity variation (PBFIV), total response region (TRR), Lag0 response region (L0RR), and Lag4 (and more) response region (L4 + RR). We examine the feasibility of this method through an in vivo study consisting of 14 PAD patients with abnormal ankle-brachial index (ABI) and 8 healthy volunteers. Ultrasound data acquired from 13 legs in the patient group and 13 legs in the healthy group are analyzed. Out of the four utilized metrics, three exhibited significantly different distributions between the two groups (p-value < 0.05). More specifically, p-values of 0.0015 for PBFIV, 0.0183 for TRR, and 0.0048 for L0RR were obtained. The results of this feasibility study indicate the diagnostic potential of the proposed method for the detection of PAD.
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Affiliation(s)
- Soroosh Sabeti
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Rohit Nayak
- Department of Radiology, Mayo Clinic College of Medicine and Science, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Robert D McBane
- Department of Cardiovascular, Division of Vascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mostafa Fatemi
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Azra Alizad
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Department of Radiology, Mayo Clinic College of Medicine and Science, 200 1st Street SW, Rochester, MN, 55905, USA.
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Miyazaki M, Yamamoto A, Malis V, Statum S, Chung CB, Sozanski J, Bae WC. Time-Resolved Noncontrast Magnetic Resonance Perfusion Imaging of Paraspinal Muscles. J Magn Reson Imaging 2022; 56:1591-1599. [PMID: 35191562 PMCID: PMC9393201 DOI: 10.1002/jmri.28123] [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: 06/10/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND While evaluation of blood perfusion in lumbar paraspinal muscles is of interest in low back pain, it has not been performed using noncontrast magnetic resonance (MR) techniques. PURPOSE To introduce a novel application of a time-resolved, noncontrast MR perfusion technique for paraspinal muscles and demonstrate effect of exercise on perfusion parameters. STUDY TYPE Longitudinal. SUBJECTS Six healthy subjects (27-48 years old, two females) and two subjects with acute low back pain (46 and 65 years old females, one with diabetes/obesity). FIELD STRENGTH/SEQUENCE 3-T, MR perfusion sequence. ASSESSMENT Lumbar spines of healthy subjects were imaged axially at L3 level with a tag-on and tag-off alternating inversion recovery arterial spin labeling technique that suppresses background signal and acquires signal increase ratio (SIR) from the in-flow blood at varying inversion times (TI) from 0.12 seconds to 3.5 seconds. SIR vs. TI data were fit to determine the perfusion metrics of peak height (PH), time to peak (TTP), mean transit time, apparent muscle blood volume (MBV), and apparent muscle blood flow (MBF) in iliocostal, longissimus, and multifidus. Imaging was repeated immediately after healthy subjects performed a 20-minute walk, to determine the effect of exercise. STATISTICAL TESTS Repeated measures analysis of variance. RESULTS SIR vs. TI data showed well-defined leading and trailing edges, with sharply increasing SIR to TI of approximately 500 msec subsiding quickly to near zero around TI of 1500 msec. After exercise, the mean SIR at every TI increased markedly, resulting in significantly higher PH, MBV, and MBF (each P < 0.001 and F > 28.9), and a lower TTP (P < 0.05, F = 4.5), regardless of the muscle. MBF increased 2- to 2.5-fold after exercise, similar to the expected increase in cardiac output, given the intensity of the exercise. DATA CONCLUSIONS Feasibility of an MR perfusion technique for muscle perfusion imaging was demonstrated, successfully detecting significantly increased perfusion after exercise. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 1.
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Affiliation(s)
- Mitsue Miyazaki
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Asako Yamamoto
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Vadim Malis
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Sheronda Statum
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
- Department of Radiology, VA San Diego Healthcare System, San Diego, California, USA
| | - Christine B. Chung
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
- Department of Radiology, VA San Diego Healthcare System, San Diego, California, USA
| | - Jesse Sozanski
- Department of Family Medicine, University of California, San Diego, La Jolla, California, USA
| | - Won C. Bae
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
- Department of Radiology, VA San Diego Healthcare System, San Diego, California, USA
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Rogers S, Carreira J, Phair A, Olech C, Ghosh J, McCollum C. Comparison Between Below Knee Contrast Enhanced Tomographic 3D Ultrasound and CT, MR or Catheter Angiography for Peripheral Artery Imaging. Eur J Vasc Endovasc Surg 2020; 61:440-446. [PMID: 33229220 DOI: 10.1016/j.ejvs.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/20/2020] [Accepted: 10/13/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Clear imaging of below knee and foot arteries is essential to plan distal reconstructions. Contrast enhanced tomographic 3D ultrasound (CEtUS) is novel and entirely safe with no exposure to ionising radiation or nephrotoxic contrast. In the present study, inter- and intra-observer agreement of CEtUS was calculated, and compared with below knee angiography. METHODS In the same week as computed tomography, magnetic resonance or catheter angiography, CEtUS was performed using intravenous 1.2 mL bolus injections of Sonovue with a maximum of 5 mL administered per patient. CEtUS was reported by a vascular scientist blinded to the angiograms reported by a consultant radiologist. Images were compared using a modified Society of Vascular Surgery (SVS) runoff score. RESULTS Of the 181 patients recruited with peripheral arterial disease, 20 were excluded from analysis as they withdrew consent, could not be cannulated, or their images were non-diagnostic. In the remaining 161 patients, there were 175 comparative patient images split into two groups: 81 had calf imaging and 94 had pedal imaging representing 405 and 198 imaged arteries, respectively. Weighted quadratic kappa/ICC values for intra- and inter-observer agreement were excellent (κ/ICC = 0.83 to 0.95) and had narrow confidence intervals in both groups. When comparing angiography and CEtUS, weighted quadratic κ/ICC agreement was moderate with acceptable confidence intervals in both groups (Calf κ/ICC = 0.54; Pedal κ/ICC = 0.53). Agreement decreased from popliteal to pedal vessels as diameter decreased. Agreement between CEtUS and digital subtraction angiography was best, and computed tomography angiography the weakest. CONCLUSION CEtUS is a novel imaging modality with strong observer agreement that achieves clear peripheral and foot images without ionising radiation exposure or nephrotoxic X-ray contrast media. CEtUS enhances visualisation of runoff vessels, which may play a role in planning of limb salvage or targeted assessment.
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Affiliation(s)
- Steven Rogers
- Academic Surgery Unit, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Joao Carreira
- Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alison Phair
- Academic Surgery Unit, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Christabel Olech
- Academic Surgery Unit, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jonathan Ghosh
- Department of Vascular and Endovascular Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charles McCollum
- Academic Surgery Unit, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Jeon S, Jang J, Lee G, Park S, Lee SK, Kim H, Choi J. Assessment of neovascularization during bone healing using contrast-enhanced ultrasonography in a canine tibial osteotomy model: a preliminary study. J Vet Sci 2020; 21:e10. [PMID: 31940689 PMCID: PMC7000898 DOI: 10.4142/jvs.2020.21.e10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/16/2019] [Accepted: 11/09/2019] [Indexed: 01/08/2023] Open
Abstract
Blood perfusion of skeletal muscle and callus was evaluated using contrast-enhanced ultrasonography (CEUS) in a canine osteotomy model to determine the applicability of CEUS in the assessment of neovascularization during fracture healing and to compare the vascular signals on CEUS between external skeletal fixation and cast-applied dogs. In 6 Beagle dogs, a simple transverse osteotomy was performed at the left tibial shaft and external skeletal fixation (n = 3) or a cast (n = 3) was applied. Radiography, power Doppler ultrasonography (power Doppler), and CEUS were performed until complete union was achieved. On CEUS, vascular changes were quantitatively evaluated by measuring peak intensity (PI) and time to PI in the soft tissue and callus and by counting the vascular signals. Vascular signals from the soft tissue were detected on power Doppler and CEUS on day 2. Significantly more vascular signals were detected by CEUS than by power Doppler. On CEUS, PI in the surrounding soft tissue was markedly increased after the fracture line appeared indistinctively changed on radiography in all dogs. In the cast-applied dogs, vascular signals from the periosteal and endosteal callus were detected on CEUS before mineralized callus was observed on radiography. CEUS was useful in assessing the vascularity of soft tissue and callus, particularly in indirect fracture healing, and provided indications of a normally healing fracture.
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Affiliation(s)
- Sunghoon Jeon
- College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju 61186, Korea
| | - Jaeyoung Jang
- Haemaru Referral Animal Hospital, Seongnam 13590, Korea
| | - Gahyun Lee
- College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju 61186, Korea
| | - Seungjo Park
- College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju 61186, Korea
| | - Sang Kwon Lee
- College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju 61186, Korea
| | - Hyunwook Kim
- Haemaru Referral Animal Hospital, Seongnam 13590, Korea
| | - Jihye Choi
- College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju 61186, Korea.
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Abnormal Microvascular Architecture, Fibrosis, and Pericyte Characteristics in the Calf Muscle of Peripheral Artery Disease Patients with Claudication and Critical Limb Ischemia. J Clin Med 2020; 9:jcm9082575. [PMID: 32784470 PMCID: PMC7464726 DOI: 10.3390/jcm9082575] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/05/2023] Open
Abstract
Work from our laboratory documents pathological events, including myofiber oxidative damage and degeneration, myofibrosis, micro-vessel (diameter = 50–150 μm) remodeling, and collagenous investment of terminal micro-vessels (diameter ≤ 15 µm) in the calf muscle of patients with Peripheral Artery Disease (PAD). In this study, we evaluate the hypothesis that the vascular pathology associated with the legs of PAD patients encompasses pathologic changes to the smallest micro-vessels in calf muscle. Biopsies were collected from the calf muscle of control subjects and patients with Fontaine Stage II and Stage IV PAD. Slide specimens were evaluated by Quantitative Multi-Spectral and Fluorescence Microscopy. Inter-myofiber collagen, stained with Masson Trichrome (MT), was increased in Stage II patients, and more substantially in Stage IV patients in association with collagenous thickening of terminal micro-vessel walls. Evaluation of the Basement Membrane (BM) of these vessels reveals increased thickness in Stage II patients, and increased thickness, diameter, and Collagen I deposition in Stage IV patients. Coverage of these micro-vessels with pericytes, key contributors to fibrosis and BM remodeling, was increased in Stage II patients, and was greatest in Stage IV patients. Vascular pathology of the legs of PAD patients extends beyond atherosclerotic main inflow arteries and affects the entire vascular tree—including the smallest micro-vessels.
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Lin HC, Wang SH. Window-Modulated Compounding Nakagami Parameter Ratio Approach for Assessing Muscle Perfusion with Contrast-Enhanced Ultrasound Imaging. SENSORS (BASEL, SWITZERLAND) 2020; 20:E3584. [PMID: 32599928 PMCID: PMC7348981 DOI: 10.3390/s20123584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022]
Abstract
The assessment of microvascular perfusion is essential for the diagnosis of a specific muscle disease. In comparison with the current available medical modalities, the contrast-enhanced ultrasound imaging is the simplest and fastest means for probing the tissue perfusion. Specifically, the perfusion parameters estimated from the ultrasound time-intensity curve (TIC) and statistics-based time-Nakagami parameter curve (TNC) approaches were found able to quantify the perfusion. However, due to insufficient tolerance on tissue clutters and subresolvable effects, these approaches remain short of reproducibility and robustness. Consequently, the window-modulated compounding (WMC) Nakagami parameter ratio imaging was proposed to alleviate these effects, by taking the ratio of WMC Nakagami parameters corresponding to the incidence of two different acoustic pressures from an employed transducer. The time-Nakagami parameter ratio curve (TNRC) approach was also developed to estimate perfusion parameters. Measurements for the assessment of muscle perfusion were performed from the flow phantom and animal subjects administrated with a bolus of ultrasound contrast agents. The TNRC approach demonstrated better sensitivity and tolerance of tissue clutters than those of TIC and TNC. The fusion image with the WMC Nakagami parameter ratio and B-mode images indicated that both the tissue structures and perfusion properties of ultrasound contrast agents may be better discerned.
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Affiliation(s)
- Huang-Chen Lin
- Department of Computer Science and Information Engineering, Institute of Medical Informatics, National Cheng Kung University, No. 1, University Road, East District, Tainan City 70101, Taiwan;
| | - Shyh-Hau Wang
- Department of Computer Science and Information Engineering, Institute of Medical Informatics, National Cheng Kung University, No. 1, University Road, East District, Tainan City 70101, Taiwan;
- Intelligent Manufacturing Research Center, National Cheng Kung University, No. 1, University Road, East District, Tainan City 70101, Taiwan
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10
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Quantitative Analysis of Lower Leg Muscle Enhancement Measured From Dynamic Computed Tomographic Angiography for Diagnosis of Peripheral Arterial Occlusive Disease. J Comput Assist Tomogr 2020; 44:20-25. [PMID: 31939877 DOI: 10.1097/rct.0000000000000971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether quantitative analysis of lower leg muscle enhancement measured from dynamic computed tomographic angiography (dyn-CTA) could be used for diagnosis of peripheral arterial occlusive disease. METHODS Patients (N = 35) with known peripheral arterial occlusive disease underwent the dyn-CTA of calves first. Five minutes later, standard CTA of the peripheral runoff from the diaphragm to the toes was performed. A runoff score was assigned by radiologists as a reference standard for each of 4 lower leg artery segments. The lower leg muscle enhancement measured from the dyn-CTA was analyzed by using quantitative kinetic parameters, including initial enhancement (E1), peak enhancement (Epeak), and enhancement ratio (ER) calculated from average time attenuation curves. In addition, histogram of lower leg muscle enhancement was evaluated by using the first enhanced phase images. RESULTS Lower extremities were diagnosed as a normal group (n = 22) with each vessel segment score equals to 1 or lower and runoff score, 7 or lower, and otherwise as an ischemia group (n = 48). Average ± SD E1 is 91.4% ± 8.5% and 82.3% ± 10.7%, Epeak is 122.7% ± 10.4% and 115.6% ± 11.1%, and ER is 0.75 ± 0.05 and 0.72 ± 0.09 for normal and ischemia group, respectively. Statistical analysis showed that average E1 and Epeak for the ischemia group were significantly lower (P < 0.05) than the normal group. The histogram analysis demonstrated that mean and median of muscle enhancement in the ischemia group were significantly smaller (P < 0.05), and coefficient of variation (CV) was significantly larger (P < 0.05) than the normal group. There were weak negative correlations (r = -0.42, P < 0.05) between runoff scores and E1 and Epeak, and weak positive correlation (r = 0.40, P < 0.05) between runoff scores and CV. The receiver operating characteristics analysis between the 2 groups had area under the curve of 0.77 and 0.76 for E1 and CV, respectively. CONCLUSIONS Lower leg muscle enhancement measured from the dyn-CTA could be assessed quantitatively to assist diagnosis of ischemia in clinical practice.
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Thakrar DB, Sultan MJ. The Role of Contrast-Enhanced Ultrasound in Managing Vascular Pathologies. J Med Imaging Radiat Sci 2019; 50:590-595. [PMID: 31706878 DOI: 10.1016/j.jmir.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 07/24/2019] [Accepted: 08/08/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Ultrasound is a useful first-line imaging modality for diagnosing and monitoring vascular pathologies. Compared with other modalities, it is relatively low cost, requires no ionizing radiation, is often available at bedside, and is noninvasive. However, the modality can have limitations when differentiating normal from pathologic tissues. In this review, we discuss the role of contrast-enhanced ultrasound (CEUS) in carotid, aortic, and peripheral vascular conditions. DISCUSSION CEUS is a developing modality that supersedes standard vascular ultrasound imaging and complements other modalities such as computed topography and magnetic resonance angiograms. Administered intravenously, the contrast are microbubbles filled with gas, surrounded by a stabilizing shell. They have the ability to enhance the quality of images and quantify vascular pathologies by acting as intravascular tracers of ultrasound energy. Based on these properties, CEUS has the potential to play a pivotal role in the management of vascular pathologies through its utility in detection, diagnosis, risk-stratification, follow-up, and monitoring. CONCLUSION Studies have suggested that CEUS is superior compared with standard ultrasound and on-par with computed topography angiograms in the detection of vascular pathologies, concluding that CEUS should be part of standardized routine practice.
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Affiliation(s)
- Dixa B Thakrar
- Department of Vascular Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
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12
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Misra S, Shishehbor MH, Takahashi EA, Aronow HD, Brewster LP, Bunte MC, Kim ESH, Lindner JR, Rich K. Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e657-e672. [PMID: 31401843 PMCID: PMC7372288 DOI: 10.1161/cir.0000000000000708] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are >12 million patients with peripheral artery disease in the United States. The most severe form of peripheral artery disease is critical limb ischemia (CLI). The diagnosis and management of CLI is often challenging. Ethnic differences in comorbidities and presentation of CLI exist. Compared with white patients, black and Hispanic patients have higher prevalence rates of diabetes mellitus and chronic renal disease and are more likely to present with gangrene, whereas white patients are more likely to present with ulcers and rest pain. A thorough evaluation of limb perfusion is important in the diagnosis of CLI because it can not only enable timely diagnosis but also reduce unnecessary invasive procedures in patients with adequate blood flow or among those with other causes for ulcers, including venous, neuropathic, or pressure changes. This scientific statement discusses the current tests and technologies for noninvasive assessment of limb perfusion, including the ankle-brachial index, toe-brachial index, and other perfusion technologies. In addition, limitations of the current technologies along with opportunities for improvement, research, and reducing disparities in health care for patients with CLI are discussed.
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Abstract
METHODICAL ISSUE Contrast-enhanced ultrasound (CEUS) offers easily accessible visualization and quantification of the skeletal muscle microcirculation and other tissues in vivo and in real-time with almost no side effects. AIM The aim of this review is to present the increasing number of musculoskeletal CEUS applications. METHODICAL INNOVATIONS/PERFORMANCE CEUS applications regarding the musculoskeletal system include applications at bone and joints extending beyond the visualization of only the muscular microcirculation. Besides basic muscle physiology, impaired microcirculation in patients with peripheral artery disease or diabetes mellitus and the diagnosis of inflammatory myopathies have been the subject of previous CEUS studies. More recent studies in orthopedics and traumatology have focused on osseous and muscular perfusion characteristics, e. g., in differentiating infected and aseptic non-unions or the impact of different types of implants and prostheses on muscular microcirculation as a surrogate marker of clinical success. PRACTICAL RECOMMENDATIONS CEUS of the musculoskeletal system is used in clinical trials or off-label. Therefore, it is not well established in clinical routine. However, considering the increasing number of musculoskeletal CEUS applications, this could change in the future.
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14
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Nguyen T, Davidson BP. Contrast Enhanced Ultrasound Perfusion Imaging in Skeletal Muscle. J Cardiovasc Imaging 2019; 27:163-177. [PMID: 31161755 PMCID: PMC6669180 DOI: 10.4250/jcvi.2019.27.e31] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/21/2019] [Indexed: 12/14/2022] Open
Abstract
The ability to accurately evaluate skeletal muscle microvascular blood flow has broad clinical applications for understanding the regulation of skeletal muscle perfusion in health and disease states. Contrast-enhanced ultrasound (CEU) perfusion imaging, a technique originally developed to evaluate myocardial perfusion, is one of many techniques that have been applied to evaluate skeletal muscle perfusion. Among the advantages of CEU perfusion imaging of skeletal muscle is that it is rapid, safe and performed with equipment already present in most vascular medicine laboratories. The aim of this review is to discuss the use of CEU perfusion imaging in skeletal muscle. This article provides details of the protocols for CEU imaging in skeletal muscle, including two predominant methods for bolus and continuous infusion destruction-replenishment techniques. The importance of stress perfusion imaging will be highlighted, including a discussion of the methods used to produce hyperemic skeletal muscle blood flow. A broad overview of the disease states that have been studied in humans using CEU perfusion imaging of skeletal muscle will be presented including: (1) peripheral arterial disease; (2) sickle cell disease; (3) diabetes; and (4) heart failure. Finally, future applications of CEU imaging in skeletal muscle including therapeutic CEU imaging will be discussed along with technological developments needed to advance the field.
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Affiliation(s)
- TheAnh Nguyen
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.,Veterans Affairs Portland Health Care System, Portland, OR, USA.
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15
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Meneses AL, Nam MCY, Bailey TG, Magee R, Golledge J, Hellsten Y, Keske MA, Greaves K, Askew CD. Leg blood flow and skeletal muscle microvascular perfusion responses to submaximal exercise in peripheral arterial disease. Am J Physiol Heart Circ Physiol 2018; 315:H1425-H1433. [DOI: 10.1152/ajpheart.00232.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peripheral arterial disease (PAD) is characterized by stenosis and occlusion of the lower limb arteries. Although leg blood flow is limited in PAD, it remains unclear whether skeletal muscle microvascular perfusion is affected. We compared whole leg blood flow and calf muscle microvascular perfusion after cuff occlusion and submaximal leg exercise between patients with PAD ( n = 12, 69 ± 9 yr) and healthy age-matched control participants ( n = 12, 68 ± 7 yr). Microvascular blood flow (microvascular volume × flow velocity) of the medial gastrocnemius muscle was measured before and immediately after the following: 1) 5 min of thigh-cuff occlusion, and 2) a 5-min bout of intermittent isometric plantar-flexion exercise (400 N) using real-time contrast-enhanced ultrasound. Whole leg blood flow was measured after thigh-cuff occlusion and during submaximal plantar-flexion exercise using strain-gauge plethysmography. Postocclusion whole leg blood flow and calf muscle microvascular perfusion were lower in patients with PAD than control participants, and these parameters were strongly correlated ( r = 0.84, P < 0.01). During submaximal exercise, total whole leg blood flow and vascular conductance were not different between groups. There were also no group differences in postexercise calf muscle microvascular perfusion, although microvascular blood volume was higher in patients with PAD than control participants (12.41 ± 6.98 vs. 6.34 ± 4.98 arbitrary units, P = 0.03). This study demonstrates that the impaired muscle perfusion of patients with PAD during postocclusion hyperemia is strongly correlated with disease severity and is likely mainly determined by the limited conduit artery flow. In response to submaximal leg exercise, microvascular flow volume was elevated in patients with PAD, which may reflect a compensatory mechanism to maintain muscle perfusion and oxygen delivery during recovery from exercise. NEW & NOTEWORTHY This study suggests that peripheral arterial disease (PAD) has different effects on the microvascular perfusion responses to cuff occlusion and submaximal leg exercise. Patients with PAD have impaired microvascular perfusion after cuff occlusion, similar to that previously reported after maximal exercise. In response to submaximal exercise, however, the microvascular flow volume response was elevated in patients with PAD compared with control. This finding may reflect a compensatory mechanism to maintain perfusion and oxygen delivery during recovery from exercise.
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Affiliation(s)
- Annelise L. Meneses
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Michael C. Y. Nam
- Department of Cardiology, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Tom G. Bailey
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Rebecca Magee
- Department of Surgery, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University and Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sport, University of Copenhagen, Copenhagen, Denmark
| | - Michelle A. Keske
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Kim Greaves
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Department of Cardiology, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Christopher D. Askew
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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16
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Stoner L, Hanson ED, Gram M, Allen JD, Malin SK. Research Toolbox for Peripheral Arterial Disease - Minimally Invasive Assessment of the Vasculature and Skeletal Muscle. Circ J 2018; 82:2462-2469. [PMID: 30058605 DOI: 10.1253/circj.cj-18-0283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In 2010, more than 200 million people were afflicted with peripheral arterial disease (PAD). Because it is atherosclerotic in etiology, it is not surprising that PAD is a leading cause of cardiovascular morbidity. Cardiovascular disease (CVD) risk can be decreased if ambulatory physical function is improved. However, physical function is limited by a mismatch between oxygen supply and demand in the legs, which results in exertional pain, leg weakness, and balance problems. Therefore, a key factor for improving physical function, and decreasing CVD outcomes, is ensuring oxygen supply meets the oxygen demand. The purpose of this review is to highlight and evaluate practical and minimally invasive tools for assessing PAD etiology, with a specific focus on tools suited to studies focusing on improving physical function and CVD outcomes. Specifically, the macrovascular, microvascular, and skeletal muscle pathology of PAD is briefly outlined. Subsequently, the tools for assessing each of these components is discussed, including, where available, the evidence to contextualize these tools to PAD pathology as well as physical function and CVD outcomes. The goal of this review is to guide researchers to the appropriate tools with respect to their methodological design.
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Affiliation(s)
- Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Erik D Hanson
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Martin Gram
- School of Sport and Exercise, Massey University
| | - Jason D Allen
- Department of Kinesiology, University of Virginia.,Division of Cardiovascular Medicine, University of Virginia
| | - Steven K Malin
- Department of Kinesiology, University of Virginia.,Division of Endocrinology & Metabolism, University of Virginia.,Robert M. Berne Cardiovascular Research Center, University of Virginia
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17
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Hou XX, Chu GH, Yu Y. Prospects of Contrast-Enhanced Ultrasonography for the Diagnosis of Peripheral Arterial Disease: A Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1081-1090. [PMID: 29064120 DOI: 10.1002/jum.14451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/03/2017] [Accepted: 07/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Contrast-enhanced ultrasonography (CEUS) is a modern diagnostic method that can also be used to study microperfusion. This study compared the time to peak intensity measured by CEUS in patients with peripheral arterial disease (PAD) and healthy control participants. METHODS After a comprehensive literature search in multiple electronic databases and study selection, a random-effect meta-analysis was performed to compare the time to peak intensity measured by CEUS in patients with PAD and healthy controls, which followed meta-regression analyses for identification of factors affecting the outcomes. RESULTS Fourteen studies (data for 322 patients with PAD and 314 healthy individuals) were used for the meta-analysis. The age of this sample of patients with PAD was 64.92 (95% confidence interval, 62.53, 67.31) years, and that of the healthy controls was 55.32 (51.67, 58.98) years. The times to peak intensity were 18.55 (15.62, 21.48) seconds in healthy controls, 33.40 (27.65, 39.15) seconds in patients with PAD, and 76.22 (36.23, 116.22) seconds in patients with PAD and diabetes mellitus. The difference between patients with PAD and healthy controls in the time to peak intensity was statistically significant (mean difference, 24.80 [10.16, 39.44] seconds; P < .00009). The ABI was not significantly associated with the time to peak intensity in patients with PAD. Age and sex were also not significantly associated with the time to peak intensity. CONCLUSIONS Contrast-enhanced ultrasonography is a valuable tool for the diagnosis of PAD based on its ability to differentiate the time to peak intensity between patients with PAD and healthy individuals, but little data are yet available to assess its diagnostic ability in clinical practice.
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Affiliation(s)
- Xiao-Xia Hou
- Department of Medical Ultrasound Center, Northwest Women and Children's Hospital, Xi'an, China
| | - Guang-Hua Chu
- Department of Gynecology, Northwest Women and Children's Hospital, Xi'an, China
| | - Yuan Yu
- Department of Hand and Foot Micro-Surgery, Ankang Central Hospital of Shaanxi Province, Ankang, China
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18
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Kummer T, Oh L, Phelan MB, Huang RD, Nomura JT, Adhikari S. Emergency and critical care applications for contrast-enhanced ultrasound. Am J Emerg Med 2018; 36:1287-1294. [PMID: 29716799 DOI: 10.1016/j.ajem.2018.04.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/19/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography. METHODS We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications. RESULTS The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite. CONCLUSIONS CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.
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Affiliation(s)
- Tobias Kummer
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Laura Oh
- Department of Emergency Medicine, Emory University, Atlanta, GA, United States
| | - Mary Beth Phelan
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Robert D Huang
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care Health System, Newark, DE, United States
| | - Srikar Adhikari
- Department of Emergency Medicine, University of Arizona, Tucson, AZ, United States
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19
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Choi M, James Shapiro AM, Zemp R. Tissue perfusion rate estimation with compression-based photoacoustic-ultrasound imaging. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-7. [PMID: 29349951 DOI: 10.1117/1.jbo.23.1.016010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 12/12/2017] [Indexed: 06/07/2023]
Abstract
Tissue perfusion is essential for transporting blood oxygen and nutrients. Measurement of tissue perfusion rate would have a significant impact in clinical and preclinical arenas. However, there are few techniques to image this important parameter and they typically require contrast agents. A label-free methodology based on tissue compression and imaging with a high-frequency photoacoustic-ultrasound system is introduced for estimating and visualizing tissue perfusion rates. Experiments demonstrate statistically significant differences in depth-resolved perfusion rates in a human subject with various temperature exposure conditions.
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Affiliation(s)
- Min Choi
- University of Alberta, Department of Electrical and Computer Engineering, Faculty of Engineering, Ed, Canada
| | - A M James Shapiro
- University of Alberta, Alberta Diabetes Institute and Alberta Transplant Institute, Division of Gene, Canada
| | - Roger Zemp
- University of Alberta, Department of Electrical and Computer Engineering, Faculty of Engineering, Ed, Canada
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20
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Lucero AA, Addae G, Lawrence W, Neway B, Credeur DP, Faulkner J, Rowlands D, Stoner L. Reliability of muscle blood flow and oxygen consumption response from exercise using near-infrared spectroscopy. Exp Physiol 2017; 103:90-100. [DOI: 10.1113/ep086537] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/13/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Adam A. Lucero
- School of Sport & Exercise; Massey University; Wellington New Zealand
| | - Gifty Addae
- School of Public Health; Harvard; Boston MA USA
| | | | | | | | - James Faulkner
- Department of Sport and Exercise; University of Winchester; Winchester UK
| | - David Rowlands
- School of Sport & Exercise; Massey University; Wellington New Zealand
| | - Lee Stoner
- School of Sport & Exercise; Massey University; Wellington New Zealand
- Department of Exercise and Sport Science; University of North Carolina at Chapel Hill; NC USA
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21
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Davidson BP, Hodovan J, Belcik JT, Moccetti F, Xie A, Ammi AY, Lindner JR. Rest-Stress Limb Perfusion Imaging in Humans with Contrast Ultrasound Using Intermediate-Power Imaging and Microbubbles Resistant to Inertial Cavitation. J Am Soc Echocardiogr 2017; 30:503-510.e1. [PMID: 28238588 PMCID: PMC5573794 DOI: 10.1016/j.echo.2016.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Contrast-enhanced ultrasound (CEU) limb perfusion imaging is a promising approach for evaluating peripheral artery disease (PAD). However, low signal enhancement in skeletal muscle has necessitated high-power intermittent imaging algorithms, which are not clinically feasible. We hypothesized that CEU using a combination of intermediate power and a contrast agent resistant to inertial cavitation would allow real-time limb stress perfusion imaging. METHODS In normal volunteers, CEU of the calf skeletal muscle was performed on separate days with Sonazoid, Optison, or Definity. Progressive reduction in the ultrasound pulsing interval was used to assess the balance between signal enhancement and agent destruction at escalating mechanical indices (MI, 0.1-0.4). Real-time perfusion imaging at MI 0.1-0.4 using postdestructive replenishment kinetics was performed at rest and during 25 W plantar flexion contractile exercise. RESULTS For Optison, limb perfusion imaging was unreliable at rest due to very low signal enhancement generated at all MIs and was possible during exercise-induced hyperemia only at MI 0.1 due to agent destruction at higher MIs. For Definity, signal intensity progressively increased with MI but was offset by microbubble destruction, which resulted in modest signal enhancement during CEU perfusion imaging and distortion of replenishment curves at MI ≥ 0.2. For Sonazoid, there strong signal enhancement at MI ≥ 0.2, with little destruction detected only at MI 0.4. Accordingly, high signal intensity and nondistorted perfusion imaging was possible at MI 0.2-0.3 and detected an 8.0- ± 5.7-fold flow reserve. CONCLUSIONS Rest-stress limb perfusion imaging in humans with real-time CEU, which requires only seconds to perform, is possible using microbubbles with viscoelastic properties that produce strong nonlinear signal generation without destruction at intermediate acoustic pressures.
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Affiliation(s)
- Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon; Portland VA Medical Center, Portland, Oregon
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - J Todd Belcik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Federico Moccetti
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Aris Xie
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Azzdine Y Ammi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon; Oregon National Primate Research Center, Oregon Health and Science University, Portland, Oregon.
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22
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Kundi R, Prior SJ, Addison O, Lu M, Ryan AS, Lal BK. Contrast-Enhanced Ultrasound Reveals Exercise-Induced Perfusion Deficits in Claudicants. ACTA ACUST UNITED AC 2017; 2. [PMID: 28691118 PMCID: PMC5501290 DOI: 10.21767/2573-4482.100041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Contrast-Enhanced Ultrasonography (CEUS) is an imaging modality allowing
perfusion quantification in targeted regions of interest of the lower extremity that has
not been possible with color-flow imaging or with measurement of ankle brachial indices.
We developed a protocol to quantify lower extremity muscle perfusion impairment in PAD
patients in response to exercise. Methods and findings Thirteen patients with Rutherford Class I-III Peripheral Arterial Disease (PAD)
and no prior revascularization procedures were recruited from the Baltimore Veterans
Affairs Medical Center and compared with eight control patients without PAD. CEUS
interrogation of the index limb gastrocnemius muscle was performed using an intravenous
bolus of lipid-stabilized microsphere contrast before and after a standardized treadmill
protocol. Peak perfusion (PEAK) and time to peak perfusion (TTP) were measured before
and after exercise. Between and within group differences were assessed. Control subjects
demonstrated a more rapid TTP (p<0.01) and an increase in peak perfusion (PEAK,
p=0.02) after exercise, when compared to their baseline measures. Patients with
PAD demonstrated TTP and PEAK measures equivalent to controls at baseline
(p=0.39, p=0.71, respectively). However, they exhibited no significant
exercise-induced changes in perfusion (TTP p=0.49 and PEAK 0.67, respectively
compared to baseline). After exercise, normal subjects had significantly shorter TTP
(p=0.04) and greater PEAK (p=0.02) than PAD patients. Conclusion Consistent with their lack of ischemic symptoms at rest, class I to III
claudicant PAD patients showed similar perfusion measures (TTP and PEAK) at rest. PAD
patients, however, were unable to increase perfusion in response to exercise, whereas
controls increased perfusion significantly. This corresponds with claudication and
limited walking capacity observed in PAD. CEUS with bolus injection offers a convenient,
objective, quantitative and visual physiologic assessment of perfusion limitation in
specific muscle groups of PAD patients. This has the potential for substantial clinical
and research utility.
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Affiliation(s)
- Rishi Kundi
- Department of Surgery, Division of Vascular Surgery, Baltimore VA Medical Center, University of Maryland School of Medicine, Baltimore, USA
| | - Steven J Prior
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), USA.,Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Odessa Addison
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), USA.,Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Michael Lu
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), USA.,Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Alice S Ryan
- Department of Veterans Affairs and Baltimore Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center (GRECC), USA.,Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Brajesh K Lal
- Department of Surgery, Division of Vascular Surgery, Baltimore VA Medical Center, University of Maryland School of Medicine, Baltimore, USA
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Calf muscle perfusion as measured with magnetic resonance imaging to assess peripheral arterial disease. Med Biol Eng Comput 2016; 54:1667-1681. [PMID: 26906279 DOI: 10.1007/s11517-016-1457-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Abstract
We hypothesized that skeletal muscle perfusion is impaired in peripheral arterial disease (PAD) patients compared to healthy controls and that perfusion patterns exhibit marked differences across five leg muscle compartments including the anterior muscle group (AM), lateral muscle group (LM), deep posterior muscle group (DM), soleus (SM), and the gastrocnemius muscle (GM). A total of 40 individuals (26 PAD patients and 14 healthy controls) underwent contrast-enhanced magnetic resonance imaging (CE-MRI) utilizing a reactive hyperemia protocol. Muscle perfusion maps were developed for AM, LM, DM, SM, and GM. Perfusion maps were analyzed over the course of 2 min, starting at local pre-contrast arrival, to study early-to-intermediate gadolinium enhancement. PAD patients had a higher fraction of hypointense voxels at pre-contrast arrival for all five muscle compartments compared with healthy controls (p < 0.0005). Among PAD patients, the fraction of hypointense voxels of the AM, LM, and GM were inversely correlated with the estimated glomerular filtration rate (eGFR; r = -0.509, p = 0.008; r = -0.441, p = 0.024; and r = -0.431, p = 0.028, respectively). CE-MRI-based skeletal leg muscle perfusion is markedly reduced in PAD patients compared with healthy controls and shows heterogeneous patterns across calf muscle compartments.
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24
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Wang D, Zhong H, Zhai Y, Hu H, Jin B, Wan M. Influence of Guided Waves in Tibia on Non-linear Scattering of Contrast Agents. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:561-573. [PMID: 26617242 DOI: 10.1016/j.ultrasmedbio.2015.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/21/2015] [Accepted: 10/09/2015] [Indexed: 06/05/2023]
Abstract
The aim of this study was to elucidate the linear and non-linear responses of ultrasound contrast agent (UCA) to frequency-dispersive guided waves from the tibia cortex, particularly two individual modes, S0 (1.23 MHz) and A1 (2.06 MHz). The UCA responses to guided waves were illustrated through the Marmottant model derived from measured guided waves, and then verified by continuous infusion experiments in a vessel-tibia flow phantom. These UCA responses were further evaluated by the enhanced ratio of peak values and the resolutions of UCA backscattered echoes. Because of the individual modes S0 and A1 in the tibia, the peak values of the UCA backscattered echoes were enhanced by 83.57 ± 7.35% (p < 0.05) and 80.77 ± 6.60% (p < 0.01) in the UCA subharmonic frequency and subharmonic imaging, respectively. However, corresponding resolutions were 0.78 ± 0.07 (p < 0.05) and 0.72 ± 0.12 (p < 0.01) times those without guided wave disturbances, respectively. Even though the resolution was partly degenerated, the subharmonic detection sensitivity of UCA was improved by the guided waves. Thus, UCA responses to the double-frequency guided waves should be further explored to benefit the detection of capillary perfusion in tissue layers near the bone cortex, particularly for perfusion imaging in the free flaps and skeletal muscles.
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Affiliation(s)
- Diya Wang
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China
| | - Hui Zhong
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China
| | - Yu Zhai
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China
| | - Hong Hu
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China
| | - Bowen Jin
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China
| | - Mingxi Wan
- Key Laboratory of Biomedical Information Engineering of Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi' an Jiaotong University, Xi' an, China.
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Arici V, Perotti C, Fabrizio C, Del Fante C, Ragni F, Alessandrino F, Viarengo G, Pagani M, Moia A, Tinelli C, Bozzani A. Autologous immuno magnetically selected CD133+ stem cells in the treatment of no-option critical limb ischemia: clinical and contrast enhanced ultrasound assessed results in eight patients. J Transl Med 2015; 13:342. [PMID: 26526721 PMCID: PMC4630831 DOI: 10.1186/s12967-015-0697-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 10/14/2015] [Indexed: 01/10/2023] Open
Abstract
Objectives Demonstrate the safety and effectiveness of highly purified CD133+ autologous stem cells in critical limb ischemia (CLI). Design Prospective single-center not randomized. Clinicaltrials.gov identifier: NCT01595776 Methods Eight patients with a history of stable CLI were enrolled in a period of 2 years. After bone marrow stimulation and single leukapheresis collection, CD133+ immunomagnetic cell selection was performed. CD133+ cells in buffer phosphate suspension was administered intramuscularly. Muscular and arterial contrast enhanced ultra sound (CEUS), lesion evolution and pain management were assessed preoperatively and 3, 6 and 12 months after the implant. Results No patient had early or late complications related to the procedure. Two patients (25 %) didn’t get any relief from the treatment and underwent major amputation. Six patients (75 %) had a complete healing of the wounds, rest pain cessation and walking recovery. An increase in CEUS values was shown in all eight patients at 6 months and in the six clinical healed patients at 12 months and had statistical relevance. Conclusions Highly purified autologous CD133+ cells can stimulate neo-angiogenesis, as based on clinical and CEUS data. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0697-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vittorio Arici
- Vascular Surgery Unit, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
| | - Cesare Perotti
- Haemotransfusional Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Calliada Fabrizio
- Radiology Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Claudia Del Fante
- Haemotransfusional Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Franco Ragni
- Vascular Surgery Unit, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
| | - Francesco Alessandrino
- Radiology Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Gianluca Viarengo
- Haemotransfusional Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Michele Pagani
- Anesthesiology and Intensive Care Unit 2, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Alessia Moia
- Vascular Surgery Unit, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
| | - Carmine Tinelli
- Statistics and Epidemiology Service, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
| | - Antonio Bozzani
- Vascular Surgery Unit, Fondazione IRCCS Policlinico S. Matteo and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
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26
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Seol SH, Davidson BP, Belcik JT, Mott BH, Goodman RM, Ammi A, Lindner JR. Real-time contrast ultrasound muscle perfusion imaging with intermediate-power imaging coupled with acoustically durable microbubbles. J Am Soc Echocardiogr 2015; 28:718-26.e2. [PMID: 25769666 DOI: 10.1016/j.echo.2015.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is growing interest in limb contrast-enhanced ultrasound (CEU) perfusion imaging for the evaluation of peripheral artery disease. Because of low resting microvascular blood flow in skeletal muscle, signal enhancement during limb CEU is prohibitively low for real-time imaging. The aim of this study was to test the hypothesis that this obstacle can be overcome by intermediate- rather than low-power CEU when performed with an acoustically resilient microbubble agent. METHODS Viscoelastic properties of Definity and Sonazoid were assessed by measuring bulk modulus during incremental increases in ambient pressure to 200 mm Hg. Comparison of in vivo microbubble destruction and signal enhancement at a mechanical index (MI) of 0.1 to 0.4 was performed by sequential reduction in pulsing interval from 10 to 0.05 sec during limb CEU at 7 MHz in mice and 1.8 MHz in dogs. Destruction was also assessed by broadband signal generation during passive cavitation detection. Real-time CEU perfusion imaging with destruction-replenishment was then performed at 1.8 MHz in dogs using an MI of 0.1, 0.2, or 0.3. RESULTS Sonazoid had a higher bulk modulus than Definity (66 ± 12 vs 29 ± 2 kPa, P = .02) and exhibited less inertial cavitation (destruction) at MIs ≥ 0.2. On in vivo CEU, maximal signal intensity increased incrementally with MI for both agents and was equivalent between agents except at an MI of 0.1 (60% and 85% lower for Sonazoid at 7 and 1.8 MHz, respectively, P < .05). However, on progressive shortening of the pulsing interval, Definity was nearly completely destroyed at MIs ≥ 0.2 at 1.8 and 7 MHz, whereas Sonazoid was destroyed only at 1.8 MHz at MIs ≥ 0.3. As a result, real-time CEU perfusion imaging demonstrated approximately fourfold greater enhancement for Sonazoid at an MI of 0.3 to 0.4. CONCLUSIONS Robust signal enhancement during real-time CEU perfusion imaging of the limb is possible when using intermediate-power imaging coupled with a durable microbubble contrast agent.
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Affiliation(s)
- Sang-Hoon Seol
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - J Todd Belcik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Brian H Mott
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Reid M Goodman
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Azzdine Ammi
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Division of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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Oh J, Jeon S, Choi J. Contrast-enhanced ultrasonography to assess blood perfusion of skeletal muscles in normal dogs. J Vet Med Sci 2015; 77:783-8. [PMID: 25754794 PMCID: PMC4527499 DOI: 10.1292/jvms.14-0328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study evaluated perfusion of skeletal muscle using contrast enhanced ultrasonography in humerus, radius, femur and tibia in normal dogs. Contrast enhanced ultrasonography for each region was performed after injecting 0.5 mL and 1 mL of contrast medium (SonoVue) in every dog. Blood perfusion was assessed quantitatively by measuring the peak intensity, time to the peak intensity and area under the curve from the time-intensity curve. Vascularization in skeletal muscle was qualitatively graded with a score of 0-3 according to the number of vascular signals. A parabolic shape of time-intensity curve was observed from muscles in normal dogs, and time to the peak intensity, the peak intensity and area under the curve of each muscle were not significantly different according to the appendicular regions examined and the dosage of contrast agent administered. This study reports that feasibility of contrast enhanced ultrasonography for assessment of the muscular perfusion in canine appendicular regions.
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Affiliation(s)
- Juyeon Oh
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Chonnam National University, Gwangju 500-757, South Korea
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Thomas KN, Cotter JD, Lucas SJE, Hill BG, van Rij AM. Reliability of contrast-enhanced ultrasound for the assessment of muscle perfusion in health and peripheral arterial disease. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:26-34. [PMID: 25308937 DOI: 10.1016/j.ultrasmedbio.2014.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 06/08/2014] [Accepted: 06/17/2014] [Indexed: 06/04/2023]
Abstract
We investigated the reliability of contrast-enhanced ultrasound (CEUS) in assessing calf muscle microvascular perfusion in health and disease. Response to a post-occlusive reactive hyperaemia test was repeated on two occasions >48 h apart in healthy young (28 ± 7 y) and elderly controls (70 ± 5 y), and in peripheral arterial disease patients (PAD, 69 ± 7 y; n = 10, 9 and 8 respectively). Overall, within-individual reliability was poor (coefficient of variation [CV] range: 15-87%); the most reliable parameter was time to peak (TTP, 15-48% CV). Nevertheless, TTP was twice as long in elderly controls and PAD compared to young (19.3 ± 10.4 and 22.0 ± 8.6 vs. 8.9 ± 6.2 s respectively; p < 0.01), and area under the curve for contrast intensity post-occlusion (a reflection of blood volume) was ∼50% lower in elderly controls (p < 0.01 versus PAD and young). Thus, CEUS assessment of muscle perfusion during reactive hyperaemia demonstrated poor reliability, yet still distinguished differences between PAD patients, elderly and young controls.
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Affiliation(s)
- Kate N Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - James D Cotter
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - Samuel J E Lucas
- Department of Physiology, University of Otago, Dunedin, New Zealand; School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Brigid G Hill
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - André M van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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Aschwanden M, Partovi S, Jacobi B, Fergus N, Schulte AC, Robbin MR, Bilecen D, Staub D. Assessing the end-organ in peripheral arterial occlusive disease-from contrast-enhanced ultrasound to blood-oxygen-level-dependent MR imaging. Cardiovasc Diagn Ther 2014; 4:165-72. [PMID: 24834413 DOI: 10.3978/j.issn.2223-3652.2014.03.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/26/2014] [Indexed: 11/14/2022]
Abstract
Peripheral arterial occlusive disease (PAOD) is a result of atherosclerotic disease which is currently the leading cause of morbidity and mortality in the western world. Patients with PAOD may present with intermittent claudication or symptoms related to critical limb ischemia. PAOD is associated with increased mortality rates. Stenoses and occlusions are usually detected by macrovascular imaging, including ultrasound and cross-sectional methods. From a pathophysiological view these stenoses and occlusions are affecting the microperfusion in the functional end-organs, such as the skin and skeletal muscle. In the clinical arena new imaging technologies enable the evaluation of the microvasculature. Two technologies currently under investigation for this purpose on the end-organ level in PAOD patients are contrast-enhanced ultrasound (CEUS) and blood-oxygen-level-dependent (BOLD) MR imaging (MRI). The following article is providing an overview about these evolving techniques with a specific focus on skeletal muscle microvasculature imaging in PAOD patients.
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Affiliation(s)
- Markus Aschwanden
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Sasan Partovi
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Bjoern Jacobi
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Nathan Fergus
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Anja-Carina Schulte
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Mark R Robbin
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Deniz Bilecen
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
| | - Daniel Staub
- 1 University Hospital Basel, Department of Angiology, Basel, Switzerland ; 2 University Hospitals Case Medical Center, Case Western Reserve University, Department of Radiology, Cleveland, Ohio, USA ; 3 University Hospital Mainz, Department of Hematology & Oncology, Mainz, Germany ; 4 University Hospital Bruderholz, Department of Radiology, Bruderholz, Switzerland
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Amarteifio E, Wormsbecher S, Demirel S, Krix M, Braun S, Rehnitz C, Delorme S, Kauczor HU, Weber MA. Assessment of skeletal muscle microcirculation in type 2 diabetes mellitus using dynamic contrast-enhanced ultrasound: a pilot study. Diab Vasc Dis Res 2013; 10:468-70. [PMID: 23695824 DOI: 10.1177/1479164113484165] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To investigate muscular micro-perfusion by employing dynamic contrast-enhanced ultrasound (CEUS) and performing transient arterial occlusion in patients with type 2 diabetes mellitus (DM-2). METHODS Twenty DM-2 patients (mean age, 58 ± 8.6 years; duration of diabetes, 15.4 ± 12.1 years) and 20 healthy volunteers (mean age, 54 ± 5.4 years) participated. CEUS was applied to the calf, while 4.8 mL of SonoVue(®) was injected intravenously. At the thigh level, arterial occlusion (60 s) was performed. CEUS parameters (tmax, max, AUCpost and m) were evaluated and Pearson-product-moment correlation coefficients were computed. RESULTS A moderate negative correlation of HbA1c and max was established (-0.53). Max in patients with DM-2 >10 years was 79.89 ± 37.4. Max in patients with DM-2 duration <10 years was 137.62 ± 71.72 (p = 0.04). AUCpost in patients with DM-2 duration >10 years was 3924.01 ± 1630.52. AUCpost in patients with DM-2 duration <10 years was 6453.59 ± 3206.23 (p = 0.04). CONCLUSION Patients with long history of DM-2 present with impaired muscular perfusion. CEUS and transient arterial occlusion may provide appropriate methods for semi-quantitative evaluation of muscular micro-perfusion in patients with DM-2.
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Affiliation(s)
- Erick Amarteifio
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg, Germany.
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Traupe T, Ortmann J, Stoller M, Baumgartner I, de Marchi SF, Seiler C. Direct quantitative assessment of the peripheral artery collateral circulation in patients undergoing angiography. Circulation 2013; 128:737-44. [PMID: 23817577 DOI: 10.1161/circulationaha.112.000516] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the fact that numerous studies have pursued the strategy of improving collateral function in patients with peripheral artery disease, there is currently no method available to quantify collateral arterial function of the lower limb. METHODS AND RESULTS Pressure-derived collateral flow index (CFIp, calculated as (occlusive pressure-central venous pressure)/(aortic pressure-central venous pressure); pressure values in mm Hg) of the left superficial femoral artery was obtained in patients undergoing elective coronary angiography using a combined pressure/Doppler wire (n=30). Distal occlusive pressure and toe oxygen saturation (Sao2) were measured for 5 minutes under resting conditions, followed by an exercise protocol (repetitive plantar-flexion movements in supine position; n=28). In all patients, balloon occlusion of the superficial femoral artery over 5 minutes was painless under resting conditions. CFIp increased during the first 3 minutes from 0.451±0.168 to 0.551±0.172 (P=0.0003), whereas Sao2 decreased from 98±2% to 93±7% (P=0.004). Maximal changes of Sao2 were inversely related to maximal CFIp (r(2)=0.33, P=0.003). During exercise, CFIp declined within 1 minute from 0.560±0.178 to 0.393±0.168 (P<0.0001) and reached its minimum after 2 minutes of exercise (0.347±0.176), whereas Sao2 declined to a minimum of 86±6% (P=0.002). Twenty-five patients (89%) experienced pain or cramps/tired muscles, whereas 3 (11%) remained symptom-free for an occlusion time of 10 minutes. CFIp values were positively related to the pain-free time span (r(2)=0.50, P=0.002). CONCLUSIONS Quantitatively assessed collateral arterial function at rest determined in the nonstenotic superficial femoral artery is sufficient to prevent ischemic symptoms during a total occlusion of 5 minutes. During exercise, there is a decline in CFIp that indicates a supply-demand mismatch via collaterals or, alternatively, a steal phenomenon. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT01742455.
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Affiliation(s)
- Tobias Traupe
- Department of Cardiology, University Hospital, CH-3010 Bern, Switzerland
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Jiji RS, Pollak AW, Epstein FH, Antkowiak PF, Meyer CH, Weltman AL, Lopez D, DiMaria JM, Hunter JR, Christopher JM, Kramer CM. Reproducibility of rest and exercise stress contrast-enhanced calf perfusion magnetic resonance imaging in peripheral arterial disease. J Cardiovasc Magn Reson 2013; 15:14. [PMID: 23343398 PMCID: PMC3562222 DOI: 10.1186/1532-429x-15-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 01/15/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose was to determine the reproducibility and utility of rest, exercise, and perfusion reserve (PR) measures by contrast-enhanced (CE) calf perfusion magnetic resonance imaging (MRI) of the calf in normal subjects (NL) and patients with peripheral arterial disease (PAD). METHODS Eleven PAD patients with claudication (ankle-brachial index 0.67 ±0.14) and 16 age-matched NL underwent symptom-limited CE-MRI using a pedal ergometer. Tissue perfusion and arterial input were measured at rest and peak exercise after injection of 0.1 mM/kg of gadolinium-diethylnetriamine pentaacetic acid (Gd-DTPA). Tissue function (TF) and arterial input function (AIF) measurements were made from the slope of time-intensity curves in muscle and artery, respectively, and normalized to proton density signal to correct for coil inhomogeneity. Perfusion index (PI) = TF/AIF. Perfusion reserve (PR) = exercise TF/ rest TF. Intraclass correlation coefficient (ICC) was calculated from 11 NL and 10 PAD with repeated MRI on a different day. RESULTS Resting TF was low in NL and PAD (mean ± SD 0.25 ± 0.18 vs 0.35 ± 0.71, p = 0.59) but reproducible (ICC 0.76). Exercise TF was higher in NL than PAD (5.5 ± 3.2 vs. 3.4 ± 1.6, p = 0.04). Perfusion reserve was similar between groups and highly variable (28.6 ± 19.8 vs. 42.6 ± 41.0, p = 0.26). Exercise TF and PI were reproducible measures (ICC 0.63 and 0.60, respectively). CONCLUSION Although rest measures are reproducible, they are quite low, do not distinguish NL from PAD, and lead to variability in perfusion reserve measures. Exercise TF and PI are the most reproducible MRI perfusion measures in PAD for use in clinical trials.
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Affiliation(s)
- Ronny S Jiji
- Departments of Medicine and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Amy W Pollak
- Departments of Medicine and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Frederick H Epstein
- Departments of Radiology and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
- Biomedical Engineering and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Patrick F Antkowiak
- Biomedical Engineering and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Craig H Meyer
- Biomedical Engineering and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Arthur L Weltman
- Departments of Medicine and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - David Lopez
- Departments of Medicine and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Joseph M DiMaria
- Departments of Radiology and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Jennifer R Hunter
- Departments of Radiology and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - John M Christopher
- Departments of Radiology and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
| | - Christopher M Kramer
- Departments of Medicine and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
- Departments of Radiology and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
- Departments of Medicine and Radiology, University of Virginia Health System, Lee Street, Box 800170, Charlottesville, VA, 22908, USA
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Dynamic contrast-enhanced ultrasound for assessment of therapy effects on skeletal muscle microcirculation in peripheral arterial disease: pilot study. Eur J Radiol 2012; 82:640-6. [PMID: 23265181 DOI: 10.1016/j.ejrad.2012.11.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 10/19/2012] [Accepted: 11/20/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess with dynamic contrast-enhanced ultrasound (CEUS) and transient arterial occlusion whether the muscular micro-perfusion in patients with peripheral arterial disease (PAD) is improved after angioplasty or surgery. MATERIALS AND METHODS This study had local institutional review board approval. Written informed consent was obtained from all 20 patients with PAD, Fontaine stage IIb (mean age, 64 years), who participated in the study. Low-MI CEUS (7MHz; MI, 0.28) was applied to the mainly affected lower leg after start of a continuous automatic intravenous injection of 4.8mL SonoVue(®). Muscle-perfusion was monitored by CEUS before, during, and after provocation by arterial occlusion at the thigh level lasting for 60s. CEUS examination was performed a second time within 14 days after angioplasty (n=15), thrombendarterectomy (n=2), angioplasty and thrombendarterectomy (n=1), or bypass (n=2). Clinical amelioration was re-evaluated within 6 months after the intervention using a 4-point scale. RESULTS Ankle-brachial-index (ABI) increased from 0.8±0.2 to 0.9±0.3 after treatment (p=0.01). Time to maximum CEUS signal (tmax) shortened from 26±14s to 14±4s (p=0.004). The slope to maximum after transient occlusion (m2) changed to steeper values (6.4±5.8∼mL/s versus 10.2±5.0∼mL/s; p=0.04). Shortened tmax predicted improvement in the patients' intermittent leg pain and therefore successful therapy outcome. CONCLUSION Dynamic CEUS with transient arterial occlusion can visualize the treatment-induced improvement of muscular micro-perfusion in patients with PAD.
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Affiliation(s)
- Brian P Davidson
- Division of Cardiovascular Medicine, Oregon Health & Science University, Portland, 97239, USA
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Dynamic contrast-enhanced ultrasound and transient arterial occlusion for quantification of arterial perfusion reserve in peripheral arterial disease. Eur J Radiol 2012; 81:3332-8. [PMID: 22285606 DOI: 10.1016/j.ejrad.2011.12.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 12/25/2011] [Accepted: 12/26/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To quantify muscular micro-perfusion and arterial perfusion reserve in peripheral arterial disease (PAD) with dynamic contrast-enhanced ultrasound (CEUS) and transient arterial occlusion. MATERIALS AND METHODS This study had local institutional review board approval and written informed consent was obtained from all subjects. We examined the dominant lower leg of 40 PAD Fontaine stage IIb patients (mean age, 65 years) and 40 healthy volunteers (mean age, 54 years) with CEUS (7 MHz; MI, 0.28) during continuous intravenous infusion of 4.8 mL microbubbles. Transient arterial occlusion at mid-thigh level simulated physical exercise. With time-CEUS-intensity curves obtained from regions of interest within calf muscles, we derived the maximum CEUS signal after occlusion (max) and its time (tmax), slope to maximum (m), vascular response after occlusion (AUC(post)), and analysed accuracy, receiver operating characteristic (ROC) curves, and correlations with ankle-brachial index (ABI) and walking distance. RESULTS All parameters differed in PAD and volunteers (p<0.014). In PAD, tmax was delayed (31.2±13.6 vs. 16.7±8.5 s, p<0.0001) and negatively correlated with ankle-brachial-index (r=-0.65). m was decreased in PAD (4.3±4.6 mL/s vs. 13.1±8.4 mL/s, p<0.0001) and had highest diagnostic accuracy (sensitivity/specificity, 75%/93%) for detection of diminished muscular micro-perfusion in PAD (cut-off value, m<5∼mL/s). Discriminant analysis and ROC curves revealed m, and AUC(post) as optimal parameter combination for diagnosing PAD and therefore impaired arterial perfusion reserve. CONCLUSIONS Dynamic CEUS with transient arterial occlusion quantifies muscular micro-perfusion and arterial perfusion reserve. The technique is accurate to diagnose PAD.
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Dynamic contrast-enhanced ultrasound for assessment of skeletal muscle microcirculation in peripheral arterial disease. Invest Radiol 2011; 46:504-8. [PMID: 21487300 DOI: 10.1097/rli.0b013e3182183a77] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE : This feasibility study was performed to assess whether dynamic contrast-enhanced ultrasound (CEUS) and transient arterial occlusion are able to detect alterations in the microvascular perfusion and arterial perfusion reserve in patients suffering from peripheral arterial disease (PAD) in comparison with healthy volunteers. MATERIALS AND METHODS : Twenty patients with PAD, Rutherford classification grade I, category III (mean age, 64 years; mean height, 173 cm; mean weight, 81.8 kg), and 20 volunteers (mean age, 50 years; mean height, 174 cm; mean weight, 77.8 kg) participated in the study. Low-mechanical index CEUS (7 MHz; MI, 0.28) was performed to the dominant lower leg after start of a continuous automatic intravenous injection of 4.8 mL suspension with microbubbles containing sulfur hexafluoride (SonoVue) within 5 minutes. Perfusion of the calf muscle was monitored by CEUS before, during, and after release of arterial occlusion at the thigh level lasting for 60 seconds. Several parameters, especially the time to maximum enhancement after release of occlusion (tmax), the maximum enhancement after release of occlusion (maxenh), the total vascular response after release of occlusion (AUCpost), and the resulting slope (m2) to maximum enhancement were calculated. RESULTS : After release of the occlusion, a significantly delayed increase of the CEUS signal to maxenh was observed in the patients with PAD (32 ± 17 seconds) compared with volunteers (17 ± 8 seconds, P = 0.0009). maxenh was 66.5 ± 36.6 (∼mL) in PAD versus 135.6 ± 75.1 (∼mL) in volunteers (P = 0.0016). AUCpost was 3016.5 ± 1825.8 (∼mL·s) in PAD versus 5906.4 ± 3173.1 (∼mL·s) in volunteers (P = 0.0013), and m2 was significantly lower in PAD (3.8 ± 5.2 vs. 14.8 ± 9.7 [∼mL/s], P = 0.0001). CONCLUSIONS : Microvascular perfusion deficits and reduced arterial perfusion reserve in patients with PAD are clearly detectable with dynamic CEUS after transient arterial occlusion.
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Eraso LH, Reilly MP, Sehgal C, Mohler ER. Emerging diagnostic and therapeutic molecular imaging applications in vascular disease. Vasc Med 2011; 16:145-56. [PMID: 21310769 DOI: 10.1177/1358863x10392474] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Assessment of vascular disease has evolved from mere indirect and direct measurements of luminal stenosis to sophisticated imaging methods to depict millimeter structural changes of the vasculature. In the near future, the emergence of multimodal molecular imaging strategies may enable robust therapeutic and diagnostic ('theragnostic') approaches to vascular diseases that comprehensively consider structural, functional, biological and genomic characteristics of the disease in individualized risk assessment, early diagnosis and delivery of targeted interventions.This review presents a summary of recent preclinical and clinical developments in molecular imaging and theragnostic applications covering diverse atherosclerosis events such as endothelial activation, macrophage inflammatory activity, plaque neovascularization and arterial thrombosis. The main focus is on molecular targets designed for imaging platforms commonly used in clinical medicine including magnetic resonance, computed tomography and positron emission tomography. A special emphasis is given to vascular ultrasound applications, considering the important role this imaging platform plays in the clinical and research practice of the vascular medicine specialty.
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Affiliation(s)
- Luis H Eraso
- Cardiovascular Division, Vascular Medicine Section, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Success of arterial revascularization determined by contrast ultrasound muscle perfusion imaging. J Vasc Surg 2010; 52:1531-6. [PMID: 20843628 DOI: 10.1016/j.jvs.2010.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 06/29/2010] [Accepted: 07/01/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the early postoperative evaluation of the success of arterial revascularization, ankle-brachial index (ABI) and other noninvasive tests lack reliability, especially in patients with incompressible arteries or local edema. Contrast-enhanced ultrasound (CEUS) imaging of limb muscle perfusion may be an alternative to standard tests if it detects treatment success reliably. METHODS We compared a simplified CEUS method with clinical staging, pulse volume recording (PVR), and ABI in patients with lifestyle-limiting peripheral arterial disease undergoing revascularization by percutaneous transluminal angioplasty (PTA) or bypass surgery. Patients underwent staging, PVR, ABI, and CEUS before, directly after, and 3 to 5 months after successful PTA (n = 20) or successful bypass grafting (n = 14). For CEUS, contrast agent was injected into an antecubital vein, and the time from beginning to peak intensity of contrast enhancement (TTP) in the calf muscle was measured. RESULTS Successful revascularization by both PTA and bypass was associated with a significant improvement in staging, PVR, ABI, and TTP directly after intervention and at follow-up. Median ABI increased from 0.60 to 0.85 (P = .001) after PTA and from 0.36 to 0.76 (P = .003) after bypass surgery. Median TTP decreased from 45 seconds to 24 seconds (P = .015) and from 30 seconds to 27 seconds (P = .041), respectively. McNemar analysis revealed unidirectional changes in both ABI and TTP (P = .625 after PTA and P = 1.000 after bypass surgery), and equivalence analysis showed 95% confidence intervals within clinical indifference, indicating that TTP was equivalent to standard tests in detecting successful revascularization. CONCLUSIONS Contrast ultrasound perfusion imaging of calf muscle after arterial revascularization may be a valuable alternative to standard noninvasive tests such as ABI or PVR to determine the success of an arterial revascularization.
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Wu FTH, Stefanini MO, Mac Gabhann F, Kontos CD, Annex BH, Popel AS. VEGF and soluble VEGF receptor-1 (sFlt-1) distributions in peripheral arterial disease: an in silico model. Am J Physiol Heart Circ Physiol 2010; 298:H2174-91. [PMID: 20382861 DOI: 10.1152/ajpheart.00365.2009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis, the growth of new capillaries from existing microvasculature. In peripheral arterial disease (PAD), lower extremity muscle ischemia develops downstream of atherosclerotic obstruction. A working hypothesis proposed that the maladaptive overexpression of soluble VEGF receptor 1 (sVEGFR1) in ischemic muscle tissues, and its subsequent antagonism of VEGF bioactivity, may contribute to the deficient angiogenic response in PAD, as well as the limited success of therapeutic angiogenesis strategies where exogenous VEGF genes/proteins are delivered. The objectives of this study were to develop a computational framework for simulating the systemic distributions of VEGF and sVEGFR1 (e.g., intramuscular vs. circulating, free vs. complexed) as observed in human PAD patients and to serve as a platform for the systematic optimization of diagnostic tools and therapeutic strategies. A three-compartment model was constructed, dividing the human body into the ischemic calf muscle, blood, and the rest of the body, connected through macromolecular biotransport processes. Detailed molecular interactions between VEGF, sVEGFR1, endothelial surface receptors (VEGFR1, VEGFR2, NRP1), and interstitial matrix sites were modeled. Our simulation results did not support a simultaneous decrease in plasma sVEGFR1 during PAD-associated elevations in plasma VEGF reported in literature. Furthermore, despite the overexpression in sVEGFR1, our PAD control demonstrated increased proangiogenic signaling complex formation, relative to our previous healthy control, due to sizeable upregulations in VEGFR2 and VEGF expression, thus leaving open the possibility that impaired angiogenesis in PAD may be rooted in signaling pathway disruptions downstream of ligand-receptor binding.
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Affiliation(s)
- Florence T H Wu
- Dept. of Biomedical Engineering, Johns Hopkins Univ. School of Medicine, 720 Rutland Ave., 613 Traylor Research Bldg., Baltimore, MD 21205, USA.
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Zimmermann A, Roenneberg C, Wendorff H, Holzbach T, Giunta RE, Eckstein HH. Early postoperative detection of tissue necrosis in amputation stumps with indocyanine green fluorescence angiography. Vasc Endovascular Surg 2010; 44:269-73. [PMID: 20356863 DOI: 10.1177/1538574410362109] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Amputations of the lower extremity due to irreversible ischemic tissue loss are performed as distally as possible. Therefore, oftentimes wound-healing disorders develop, requiring additional surgical treatment. METHODS The amputations stumps of 10 patients with irreversible ischemic tissue loss due to arteriosclerosis were investigated within 72 hours postoperatively with indocyanine green (ICG) fluorescence. RESULTS For 6 of the investigated stumps, no perfusion deficit could be seen through fluorescence angiography. All stumps displayed primary healing. In the fluorescence angiography of 3 amputations, stump perfusions deficits predicted later tissue necrosis and had to be amputated again in a second operation. One amputation wound showed a small ICG perfusion deficit that represented a blood clot. CONCLUSION Indocyanine green fluorescence angiography allows a perfusion analysis of amputation stumps and therefore a prediction of the expected tissue necrosis. This tool may allow reliable prediction of amputation level.
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Affiliation(s)
- Alexander Zimmermann
- Clinic of Vascular Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Krix M, Krakowski-Roosen H, Amarteifio E, Armarteifio E, Fürstenberger S, Delorme S, Kauczor HU, Weber MA. Comparison of transient arterial occlusion and muscle exercise provocation for assessment of perfusion reserve in skeletal muscle with real-time contrast-enhanced ultrasound. Eur J Radiol 2009; 78:419-24. [PMID: 20005060 DOI: 10.1016/j.ejrad.2009.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 11/09/2009] [Accepted: 11/11/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Contrast-enhanced ultrasound (CEUS) is able to quantify muscle perfusion and changes in perfusion due to muscle exercise in real-time. However, reliable measurement of standardized muscle exercise is difficult to perform in clinical examinations. We compared perfusion reserve assessed by CEUS after transient arterial occlusion and exercise to find the most suitable measurement for clinical application. METHODS Contrast pulse sequencing (7 MHz) during continuous IV infusion of SonoVue(®) (4.8 mL/300 s) was used in 8 healthy volunteers to monitor muscle perfusion of the gastrocnemius muscle during transient (1 min) arterial occlusion produced by a thigh cuff of a venous occlusion plethysmograph. Isometric muscle exercise (50% of individual maximum strength for 20s) was subsequently performed during the same examination, and several CEUS parameters obtained from ultrasound-signal-intensity-time curves and its calculation errors were compared. RESULTS The mean maximum local blood volume after occlusion was 13.9 [∼mL] (range, 4.5-28.8 [∼mL]), and similar values were measured after sub-maximum exercise 13.8 [∼mL], (range, 4.6-22.2 [∼mL]. The areas under the curve during reperfusion vs. recovery were also similar (515.2±257.5 compared to 482.2±187.5 [∼mLs]) with a strong correlation (r=0.65), as were the times to maximum (15.3s vs. 15.9s), with a significantly smaller variation for the occlusion method (±2.1s vs. ±9.0s, p=0.03). The mean errors for all calculated CEUS parameters were lower for the occlusion method than for the exercise test. CONCLUSIONS CEUS muscle perfusion measurements can be easily performed after transient arterial occlusion. It delivers data which are comparable to CEUS measurements after muscle exercise but with a higher robustness. This method can be easily applied in clinical examination of patients with e.g. PAOD or diabetic microvessel diseases to assess perfusion reserve.
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Affiliation(s)
- Martin Krix
- German Cancer Research Center, Research Program Imaging and Radiooncology, Department of Radiology, INF 280, D-69120 Heidelberg, Germany.
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Krix M, Krakowski-Roosen H, Kauczor HU, Delorme S, Weber MA. Real-time contrast-enhanced ultrasound for the assessment of perfusion dynamics in skeletal muscle. ULTRASOUND IN MEDICINE & BIOLOGY 2009; 35:1587-1595. [PMID: 19682788 DOI: 10.1016/j.ultrasmedbio.2009.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 03/26/2009] [Accepted: 05/04/2009] [Indexed: 05/28/2023]
Abstract
We developed a real-time low-MI contrast-enhanced ultrasound method (CEUS), compared it with venous occlusion plethysmography (VOP) and evaluated its robustness in the quantification of skeletal muscle perfusion during exercise. Contrast pulse sequencing (7 MHz) during continuous intravenous infusion of SonoVue (4.8 mL/300 s) was used repeatedly in eight healthy volunteers to monitor changes of the muscle perfusion before, during and after isometric exercises (10 to 50% of individual maximum strength for 20 to 30 s) of the gastrocnemius muscle in real time. CEUS was correlated with VOP at different time points, and the exactness of several CEUS parameters obtained from ultrasound-signal-intensity-time curves was evaluated. Real-time CEUS depicted a large variability of the skeletal muscle blood volume at rest (mean, 3.48; range, 0.60 to 9.92 [approximately mL]), with a significant reproducibility (r=0.72, p<0.05) and correlation with VOP (r=0.59, p<0.001). Mean blood volume during exercise was 1.58(approximately mL), increased to a mean maximum after exercise of 8.88 (approximately mL), the mean change of the local blood volume during and directly after the exercise was -0.10 and +1.57(approximately mL/s). The average CEUS signal during exercise decreased (mean area under the curve, -50.4 [approximately mL.s]) and subsequently increased post exercise (mean 118.6 [approximately mL.s]). CEUS parameters could be calculated with mean relative errors between 6 and 36%. Continuous assessment of local muscle microcirculation during exercise is possible with real-time CEUS with an acceptable robustness. Its application may be of particular interest in a better understanding of the role of perfusion during muscle training, and the monitoring of pathological vascular response, such as in diabetic microvessel diseases.
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Affiliation(s)
- Martin Krix
- German Cancer Research Center, Research Program Imaging and Radiooncology, Department of Radiology, Heidelberg, Germany.
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Krix M, Weber MA, Kauczor HU, Delorme S, Krakowski-Roosen H. Changes in the micro-circulation of skeletal muscle due to varied isometric exercise assessed by contrast-enhanced ultrasound. Eur J Radiol 2009; 76:110-6. [PMID: 19541442 DOI: 10.1016/j.ejrad.2009.05.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 04/17/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To quantitatively assess local muscle micro-circulation with real-time contrast-enhanced ultrasound (CEUS) during different exercises and compare the results with performed muscle work and global blood flow. MATERIALS AND METHODS Sixteen low mechanical index CEUS examinations of the right lower leg flexors of healthy volunteers were performed using a continuous infusion of SonoVue(®) (4.8 mL/300 s). Several muscle perfusion parameters were extracted from derived CEUS signal intensity time curves during different isometric exercises (10-50% of maximum individual strength for 20-30s) and then correlated with the performed muscle work or force, and the whole lower leg blood flow which we measured simultaneously by venous occlusion plethysmography (VOP). RESULTS The shapes of the CEUS curve during and after exercise differed individually depending on the performed muscle work. The maximum blood volume MAX was observed only after exercise cessation and was significantly correlated with the performed muscle force (r=0.77, p<0.0001). The blood volume over exercise time was inversely correlated with the spent muscle work (r=-0.60, p=0.006). CEUS and VOP measurements correlated only at rest and after the exercise. During exercise, mean CEUS local blood volume decreased (from 3.48 to 2.19 (∼mL)), while mean VOP global blood flow increased (mean, from 3.96 to 7.71 mL/100 mg/min). CONCLUSION Real-time low-MI CEUS provides complementary information about the local muscle micro-circulation compared to established blood flow measures. CEUS may be used for a better understanding of muscle perfusion physiology and in the diagnosis of micro-circulation alterations such as in peripheral arterial occlusive disease or diabetic angiopathy.
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Affiliation(s)
- Martin Krix
- German Cancer Research Center, Research Program Imaging and Radiooncology, Department of Radiology, Heidelberg, Germany.
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Casey DP, Curry TB, Joyner MJ. Measuring muscle blood flow: a key link between systemic and regional metabolism. Curr Opin Clin Nutr Metab Care 2008; 11:580-6. [PMID: 18685453 PMCID: PMC3462349 DOI: 10.1097/mco.0b013e32830b5b34] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW To provide a brief overview of the main techniques to measure muscle blood flow in humans and highlight some of the strengths and weaknesses associated with each technique. RECENT FINDINGS Peak muscle blood flow values of 300 ml/min per 100 g are possible in humans during heavy exercise performed with small muscle mass. This value is far higher than that which appears in most textbooks. Accurate and reliable techniques are therefore essential in measuring muscle blood flow. Current invasive techniques commonly used include indicator dilution (thermodilution and dye dilution) and radiolabel tracer washout (e.g. 133Xe washout) methods. Although invasive techniques have provided valuable insight into tissue blood flow, noninvasive techniques such as venous occlusion plethysmography and Doppler ultrasound are frequently used and provide accurate measurements of blood flow. Newer imaging techniques (MRI, positron emission tomography, and contrast-enhanced ultrasonography) promise increased resolution of measurements of local blood flow, including in discrete tissues in which more classical techniques are not able to be used. SUMMARY Muscle blood flow is a key link in the interplay and regulation of systemic and local muscle metabolism. Recognizing the advantages and limitations of each technique is essential to translational researchers studying the effects of nutrition and metabolism on muscle blood flow.
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Affiliation(s)
- Darren P Casey
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Duerschmied D, Maletzki P, Freund G, Olschewski M, Seufert J, Bode C, Hehrlein C. Analysis of muscle microcirculation in advanced diabetes mellitus by contrast enhanced ultrasound. Diabetes Res Clin Pract 2008; 81:88-92. [PMID: 18417241 DOI: 10.1016/j.diabres.2008.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 03/02/2008] [Indexed: 11/23/2022]
Abstract
AIMS Contrast enhanced ultrasound (CEUS) was recently established to quantify perfusion deficits in peripheral arterial disease (PAD). However, this approach was not suitable to assess microangiopathy of skeletal muscle, a major contributor to PAD in diabetic patients. We hypothesized that an optimized methodology would detect impaired microcirculation. METHODS Ten patients with advanced diabetes mellitus (mean diabetes duration 21 years), 10 PAD patients, and 10 control subjects were enrolled consecutively. The arrival times of the contrast agent Sonovue after intravenous injection were assessed selectively in a small artery, muscle tissue and a muscle vein of the calf muscle. Contrast transit times (CTTs) were calculated as the differences between arrival times. RESULTS The median CTT for artery-vein was significantly higher in the diabetes group (43 s) than in the PAD (22 s, p=0.007) and control groups (11 s, p<0.001, no value overlap). CTTs for artery-muscle and muscle-vein were shorter with highest median values in the diabetes group. CONCLUSIONS We validated improved CEUS as consistent method to detect changes in the microvascular bed. This method may become a valuable tool to quantify impaired microcirculation in diabetes and help to improve patient care.
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Affiliation(s)
- D Duerschmied
- Department of Cardiology and Angiology, University Hospital of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany.
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Duerschmied D, Zhou Q, Rink E, Harder D, Freund G, Olschewski M, Bode C, Hehrlein C. Simplified contrast ultrasound accurately reveals muscle perfusion deficits and reflects collateralization in PAD. Atherosclerosis 2008; 202:505-12. [PMID: 18606414 DOI: 10.1016/j.atherosclerosis.2008.05.046] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 04/30/2008] [Accepted: 05/16/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Simplified contrast-enhanced ultrasound (CEUS) can be used to evaluate muscle perfusion in peripheral arterial disease (PAD). Here, we report its diagnostic accuracy for detecting symptomatic PAD. Additionally, we hypothesize that the extent of collateral formation is reflected by CEUS. METHODS Ultrasound contrast agent was injected into an antecubital vein of 58 control subjects and 52 symptomatic PAD patients and its appearance in the calf muscle was evaluated. Interreader variability was tested using 118 raw data films. Arterial collateralization of PAD patients was assessed by angiographic imaging. RESULTS PAD patients showed a significantly longer median time to peak intensity (TTP, 36.9s) than control subjects (19.4s, p<0.001) with longer TTPs in advanced PAD stages. The area under the receiver operating characteristic curve was 0.942 and the mean TTP difference between two blinded readers was 0.28s. A TTP cut off at 30.5s was associated with 91% positive predictive value. PAD patients with good collateralization showed a significantly shorter TTP (34.1s) than patients with poor collateralization (44.0 s, p=0.008) but not a higher ankle-brachial index (ABI). CONCLUSIONS CEUS accurately displays perfusion deficits of the calf muscle in symptomatic PAD patients. The degree of arterial collateralization is reflected by CEUS and not by ABI.
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Affiliation(s)
- Daniel Duerschmied
- Department of Cardiology and Angiology, University Hospital of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany.
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Lindner JR, Womack L, Barrett EJ, Weltman J, Price W, Harthun NL, Kaul S, Patrie JT. Limb stress-rest perfusion imaging with contrast ultrasound for the assessment of peripheral arterial disease severity. JACC Cardiovasc Imaging 2008; 1:343-50. [PMID: 19356447 PMCID: PMC2651026 DOI: 10.1016/j.jcmg.2008.04.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 03/31/2008] [Accepted: 04/03/2008] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We hypothesized that stress-rest perfusion imaging of skeletal muscle in the lower extremity with contrast-enhanced ultrasound (CEU) could evaluate the severity of peripheral arterial disease (PAD). BACKGROUND Perfusion imaging may provide valuable quantitative information on PAD, particularly in patients with diabetes in whom microvascular functional abnormalities are common. METHODS Study subjects included 26 control subjects and 39 patients with symptomatic PAD, 19 of whom had type 2 diabetes mellitus. A modified treadmill exercise test was performed to determine exercise time to development of claudication. Multilevel pulse-volume recordings and ankle-brachial index (ABI) at rest and post-exercise ABI were measured in both extremities. Microvascular blood flow in the gastrocnemius and soleus muscles was measured at rest and after 2 min of calibrated plantar-flexion exercise. RESULTS During exercise, claudication did not occur in normal subjects and occurred earlier in PAD patients with diabetes than without (median time 1.2 min [95% confidence interval (CI) 0.6 to 2.5] vs. 3.0 min [95% CI 2.1 to 6.0], p < 0.01). Compared to control subjects, patients with PAD had lower skeletal muscle blood flow during plantar-flexion exercise and lower flow reserve on CEU. After adjusting for diabetes, the only diagnostic tests that predicted severity of disease by claudication threshold were CEU exercise blood flow and flow reserve (odds ratios 0.67 [95% CI 0.51 to 0.88; p = 0.003] and 0.64 [95% CI 0.46 to 0.89, p = 0.008], respectively). A quasi-likelihood information analysis incorporating all non-invasive diagnostic tests indicated that the best models for predicting severity of disease were the combination of diabetes and either exercise blood flow or flow-reserve on CEU. CONCLUSIONS Perfusion imaging of limb skeletal during exercise and measurement of absolute flow reserve can provide valuable information on the severity PAD. This strategy may be useful for evaluating the total impact of disease in patients with complex disease or those with coexisting functional abnormalities of flow regulation.
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Affiliation(s)
- Jonathan R Lindner
- Cardiovascular Division, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Rissanen TT, Korpisalo P, Karvinen H, Liimatainen T, Laidinen S, Gröhn OH, Ylä-Herttuala S. High-Resolution Ultrasound Perfusion Imaging of Therapeutic Angiogenesis. JACC Cardiovasc Imaging 2008; 1:83-91. [DOI: 10.1016/j.jcmg.2007.10.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 10/12/2007] [Accepted: 10/18/2007] [Indexed: 11/29/2022]
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Weber MA, Krix M, Delorme S. Quantitative evaluation of muscle perfusion with CEUS and with MR. Eur Radiol 2007; 17:2663-74. [PMID: 17453217 DOI: 10.1007/s00330-007-0641-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 02/20/2007] [Accepted: 03/22/2007] [Indexed: 11/30/2022]
Abstract
Functional imaging might increase the role of imaging in muscular diseases, since alterations of muscle morphology alone are not specific for a particular disease. Perfusion, i.e., the blood flow per tissue and time unit including capillary flow, is an important functional parameter. Pathological changes of skeletal muscle perfusion can be found in various clinical conditions, such as degenerative or inflammatory myopathies or peripheral arterial occlusive disease. This article reviews the theoretical basics of functional radiological techniques for assessing skeletal muscle perfusion and focuses on contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI) techniques. Also, the applications of microvascular imaging, such as in detection of myositis and for discriminating myositis from other myopathies or evaluating peripheral arterial occlusive disease, are presented, and possible clinical indications are discussed. In conclusion, dedicated MR and CEUS methods are now available that visualize and quantify (patho-)physiologic information about microcirculation within skeletal muscles in vivo and hence establish a useful diagnostic tool for muscular diseases.
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Affiliation(s)
- Marc-André Weber
- Department of Radiology, German Cancer Research Centre, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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