1
|
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] [Grants] [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.
Collapse
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
| |
Collapse
|
2
|
Chou T, Nabavinia M, Tram NK, Rimmerman ET, Patel S, Musini KN, Eisert SN, Wolfe T, Wynveen MK, Matsuzaki Y, Kitsuka T, Iwaki R, Janse SA, Bobbey AJ, Breuer CK, Goodchild L, Malbrue R, Shinoka T, Atway SA, Go MR, Stacy MR. Quantification of Skeletal Muscle Perfusion in Peripheral Artery Disease Using 18F-Sodium Fluoride Positron Emission Tomography Imaging. J Am Heart Assoc 2024; 13:e031823. [PMID: 38353265 PMCID: PMC11010069 DOI: 10.1161/jaha.123.031823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/07/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Perfusion deficits contribute to symptom severity, morbidity, and death in peripheral artery disease (PAD); however, no standard method for quantifying absolute measures of skeletal muscle perfusion exists. This study sought to preclinically test and clinically translate a positron emission tomography (PET) imaging approach using an atherosclerosis-targeted radionuclide, fluorine-18-sodium fluoride (18F-NaF), to quantify absolute perfusion in PAD. METHODS AND RESULTS Eight Yorkshire pigs underwent unilateral femoral artery ligation and dynamic 18F-NaF PET/computed tomography imaging on the day of and 2 weeks after occlusion. Following 2-week imaging, calf muscles were harvested to quantify microvascular density. PET methodology was validated with microspheres in 4 additional pig studies and translated to patients with PAD (n=39) to quantify differences in calf perfusion across clinical symptoms/stages and perfusion responses in a case of revascularization. Associations between PET perfusion, ankle-brachial index, toe-brachial index, and toe pressure were assessed in relation to symptoms. 18F-NaF PET/computed tomography quantified significant deficits in calf perfusion in pigs following arterial occlusion and perfusion recovery 2 weeks after occlusion that coincided with increased muscle microvascular density. Additional studies confirmed that PET-derived perfusion measures agreed with microsphere-derived perfusion measures. Translation of imaging methods demonstrated significant decreases in calf perfusion with increasing severity of PAD and quantified perfusion responses to revascularization. Perfusion measures were also significantly associated with symptom severity, whereas traditional hemodynamic measures were not. CONCLUSIONS 18F-NaF PET imaging quantifies perfusion deficits that correspond to clinical stages of PAD and represents a novel perfusion imaging strategy that could be partnered with atherosclerosis-targeted 18F-NaF PET imaging using a single radioisotope injection. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03622359.
Collapse
Affiliation(s)
- Ting‐Heng Chou
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Mahboubeh Nabavinia
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Nguyen K. Tram
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Eleanor T. Rimmerman
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
- Biophysics Graduate ProgramOhio State UniversityColumbusOH
| | - Surina Patel
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Kumudha Narayana Musini
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Susan Natalie Eisert
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Tatiana Wolfe
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Molly K. Wynveen
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Yuichi Matsuzaki
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Takahiro Kitsuka
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Ryuma Iwaki
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | | | - Adam J. Bobbey
- Department of RadiologyNationwide Children’s HospitalColumbusOH
| | - Christopher K. Breuer
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Laurie Goodchild
- Animal Resources CoreResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Raphael Malbrue
- Animal Resources CoreResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Toshiharu Shinoka
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
| | - Said A. Atway
- Department of OrthopaedicsOhio State University College of MedicineColumbusOH
| | - Michael R. Go
- Division of Vascular Diseases & Surgery, Department of SurgeryOhio State University College of MedicineColumbusOH
| | - Mitchel R. Stacy
- Center for Regenerative MedicineResearch Institute at Nationwide Children’s HospitalColumbusOH
- Biophysics Graduate ProgramOhio State UniversityColumbusOH
- Division of Vascular Diseases & Surgery, Department of SurgeryOhio State University College of MedicineColumbusOH
| |
Collapse
|
3
|
Chou TH, Stacy MR. Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia. Mol Imaging Biol 2019; 22:245-255. [PMID: 31482412 DOI: 10.1007/s11307-019-01425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.
Collapse
Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA. .,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Thomassen SA, Kjærgaard B, Olsen Alstrup AK, Munk OL, Frøkiær J, Larsson A, Rasmussen BS. Muscle Tissue Saturation Compared With Muscle Tissue Perfusion During Low Blood Flows: An Experimental Study. J Cardiothorac Vasc Anesth 2017; 31:2065-2071. [DOI: 10.1053/j.jvca.2017.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Indexed: 01/09/2023]
|
6
|
Abstract
Peripheral vascular disease (PVD) is a progressive atherosclerotic disease that leads to stenosis or occlusion of blood vessels supplying the lower extremities. Current diagnostic imaging techniques commonly focus on evaluation of anatomy or blood flow at the macrovascular level and do not permit assessment of the underlying pathophysiology associated with disease progression or treatment response. Molecular imaging with radionuclide-based approaches can offer novel insight into PVD by providing noninvasive assessment of biological processes such as angiogenesis and atherosclerosis. This article discusses emerging radionuclide-based imaging approaches that have potential clinical applications in the evaluation of PVD progression and treatment.
Collapse
Affiliation(s)
- Mitchel R Stacy
- Department of Internal Medicine, Yale University School of Medicine, PO Box 208017, Dana-3, New Haven, CT 06520, USA.
| | - Albert J Sinusas
- Department of Internal Medicine, Yale University School of Medicine, PO Box 208017, Dana-3, New Haven, CT 06520, USA; Department of Diagnostic Radiology, Yale University School of Medicine, PO Box 208042, New Haven, CT 06520, USA
| |
Collapse
|
7
|
Simons M, Alitalo K, Annex BH, Augustin HG, Beam C, Berk BC, Byzova T, Carmeliet P, Chilian W, Cooke JP, Davis GE, Eichmann A, Iruela-Arispe ML, Keshet E, Sinusas AJ, Ruhrberg C, Woo YJ, Dimmeler S. State-of-the-Art Methods for Evaluation of Angiogenesis and Tissue Vascularization: A Scientific Statement From the American Heart Association. Circ Res 2015; 116:e99-132. [PMID: 25931450 DOI: 10.1161/res.0000000000000054] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
8
|
Koga S, Rossiter HB, Heinonen I, Musch TI, Poole DC. Dynamic heterogeneity of exercising muscle blood flow and O2 utilization. Med Sci Sports Exerc 2014; 46:860-76. [PMID: 24091989 DOI: 10.1249/mss.0000000000000178] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Resolving the bases for different physiological functioning or exercise performance within a population is dependent on our understanding of control mechanisms. For example, when most young healthy individuals run or cycle at moderate intensities, oxygen uptake (VO2) kinetics are rapid and the amplitude of the VO2 response is not constrained by O2 delivery. For this to occur, muscle O2 delivery (i.e., blood flow × arterial O2 concentration) must be coordinated superbly with muscle O2 requirements (VO2), the efficacy of which may differ among muscles and distinct fiber types. When the O2 transport system succumbs to the predations of aging or disease (emphysema, heart failure, and type 2 diabetes), muscle O2 delivery and O2 delivery-VO2 matching and, therefore, muscle contractile function become impaired. This forces greater influence of the upstream O2 transport pathway on muscle aerobic energy production, and the O2 delivery-VO2 relationship(s) assumes increased importance. This review is the first of its kind to bring a broad range of available techniques, mostly state of the art, including computer modeling, radiolabeled microspheres, positron emission tomography, magnetic resonance imaging, near-infrared spectroscopy, and phosphorescence quenching to resolve the O2 delivery-VO2 relationships and inherent heterogeneities at the whole body, interorgan, muscular, intramuscular, and microvascular/myocyte levels. Emphasis is placed on the following: 1) intact humans and animals as these provide the platform essential for framing and interpreting subsequent investigations, 2) contemporary findings using novel technological approaches to elucidate O2 delivery-VO2 heterogeneities in humans, and 3) future directions for investigating how normal physiological responses can be explained by O2 delivery-VO2 heterogeneities and the impact of aging/disease on these processes.
Collapse
Affiliation(s)
- Shunsaku Koga
- 1Applied Physiology Laboratory, Kobe Design University, JAPAN; 2Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, and School of Biomedical Sciences, University of Leeds, Leeds, UNITED KINGDOM; 3Turku PET Centre and Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku and Turku University Hospital, Turku, FINLAND; Division of Experimental Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, Rotterdam, THE NETHERLANDS; and 4Departments of Kinesiology and Anatomy and Physiology, Kansas State University, Manhattan, KS
| | | | | | | | | |
Collapse
|
9
|
Bajwa A, Wesolowski R, Patel A, Saha P, Ludwinski F, Smith A, Nagel E, Modarai B. Assessment of tissue perfusion in the lower limb: current methods and techniques under development. Circ Cardiovasc Imaging 2014; 7:836-43. [PMID: 25227236 DOI: 10.1161/circimaging.114.002123] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Adnan Bajwa
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Roman Wesolowski
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Ashish Patel
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Prakash Saha
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Francesca Ludwinski
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Alberto Smith
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Eike Nagel
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Bijan Modarai
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.).
| |
Collapse
|
10
|
Abstract
Peripheral vascular disease (PVD) is an atherosclerotic disease affecting the lower extremities, resulting in skeletal muscle ischemia, intermittent claudication, and, in more severe stages of disease, limb amputation and death. The evaluation of therapy in this patient population can be challenging, as the standard clinical indices are insensitive to assessment of regional alterations in skeletal muscle physiology. Radiotracer imaging of the lower extremities with techniques such as PET and SPECT can provide a noninvasive quantitative technique for the evaluation of the pathophysiology associated with PVD and may complement clinical indices and other imaging approaches. This review discusses the progress in radiotracer-based evaluation of PVD and highlights recent advancements in molecular imaging with potential for clinical application.
Collapse
Affiliation(s)
- Mitchel R. Stacy
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Wunan Zhou
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Albert J. Sinusas
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
11
|
Xu H, Yu YM, Ma H, Carter EA, Fagan S, Tompkins RG, Fischman AJ. Glucose metabolism during the early "flow phase" after burn injury. J Surg Res 2012; 179:e83-90. [PMID: 22459295 DOI: 10.1016/j.jss.2012.02.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/06/2012] [Accepted: 02/17/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Burn injury (BI) is associated with insulin resistance (IR) and hyperglycemia which complicate clinical management. We investigated the impact of BI on glucose metabolism in a rabbit model of BI using a combination of positron emission tomography (PET) and stable isotope studies under euglycemic insulin clamp (EIC) conditions. MATERIALS AND METHODS Twelve male rabbits were subjected to either full-thickness BI (B) or sham burn. An EIC condition was established by constant infusion of insulin, concomitantly with a variable rate of dextrose infusion 3 d after treatment. PET imaging of the hind limbs was conducted to determine the rates of peripheral O(2) and glucose utilization. Each animal also received a primed constant infusion of [6,6-(2)H(2)] glucose to determine endogenous glucose production. RESULTS The fasting blood glucose in the burned rabbits was higher than that in the sham group. Under EIC conditions, the sham burn group required more exogenous dextrose than the B group to maintain blood glucose at physiological levels (22.2 ± 2.6 versus 13.3 ± 2.9 mg/min, P < 0.05), indicating a state of IR. PET imaging demonstrated that the rates of O(2) consumption and (18)F 2-fluoro-2-deoxy-D-glucose utilization by skeletal muscle remained at similar levels in both groups. Hepatic gluconeogenesis determined by the stable isotope tracer study was found significantly increased in the B group. CONCLUSIONS These findings demonstrated that hyperglycemia and IR develop during the early "flow phase" after BI. Unsuppressed hepatic gluconeogenesis, but not peripheral skeletal muscular utilization of glucose, contributes to hyperglycemia at this stage.
Collapse
Affiliation(s)
- Hongzhi Xu
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School and Shriners Hospitals for Children, Boston, Massachusetts, USA.
| | | | | | | | | | | | | |
Collapse
|
12
|
Autologous bone marrow mononuclear cell therapy is safe and promotes amputation-free survival in patients with critical limb ischemia. J Vasc Surg 2011; 53:1565-74.e1. [PMID: 21514773 DOI: 10.1016/j.jvs.2011.01.074] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 01/27/2011] [Accepted: 01/28/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this Phase I open label nonrandomized trial was to assess the safety and efficacy of autologous bone marrow mononuclear cell (ABMNC) therapy in promoting amputation-free survival (AFS) in patients with critical limb ischemia (CLI). METHODS Between September 2005 and March 2009, 29 patients (30 limbs), with a median age of 66 years (range, 23-84 years; 14 male, 15 female) with CLI were enrolled. Twenty-one limbs presented with rest pain (RP), six with RP and ulceration, and three with ulcer only. All patients were not candidates for surgical bypass due to absence of a patent artery below the knee and/or endovascular approaches to improving perfusion was not possible as determined by an independent vascular surgeon. Patients were treated with an average dose of 1.7 ± 0.7 × 10(9) ABMNC injected intramuscularly in the index limb distal to the anterior tibial tuberosity. The primary safety end point was accumulation of serious adverse events, and the primary efficacy end point was AFS at 1 year. Secondary end points at 12 weeks posttreatment were changes in first toe pressure (FTP), toe-brachial index (TBI), ankle-brachial index (ABI), and transcutaneous oxygen measurements (TcPO(2)). Perfusion of the index limb was measured with positron emission tomography-computed tomography (PET-CT) with intra-arterial infusion of H(2)O(15). RP, using a 10-cm visual analogue scale, quality of life using the VascuQuol questionnaire, and ulcer healing were assessed at each follow-up interval. Subpopulations of endothelial progenitor cells were quantified prior to ABMNC administration using immunocytochemistry and fluorescent-activated cell sorting. RESULTS There were two serious adverse events; however, there were no procedure-related deaths. Amputation-free survival at 1 year was 86.3%. There was a significant increase in FTP (10.2 ± 6.2 mm Hg; P = .02) and TBI (0.10 ± 0.05;P = .02) and a trend in improvement in ABI (0.08 ± 0.04; P = .73). Perfusion index by PET-CT H(2)O(15) increased by 19.3 ± 3.1, and RP decreased significantly by 2.2 ± 0.6 cm (P = .02). The VascuQol questionnaire demonstrated significant improvement in quality of life, and three of nine ulcers (33%) healed completely. KDR(+) but not CD34(+) or CD133(+) subpopulations of ABMNC were associated with improvement in limb perfusion. CONCLUSION This Phase I study has demonstrated safety, and the AFS rates suggest efficacy of ABMNC in promoting limb salvage in "no option" CLI. Based on these results, we plan to test the concept that ABMNCs improve AFS at 1 year in a Phase III randomized, double-blinded, multicenter trial.
Collapse
|
13
|
Laaksonen MS, Björklund G, Heinonen I, Kemppainen J, Knuuti J, Kyröläinen H, Kalliokoski KK. Perfusion heterogeneity does not explain excess muscle oxygen uptake during variable intensity exercise. Clin Physiol Funct Imaging 2010; 30:241-9. [DOI: 10.1111/j.1475-097x.2010.00934.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
14
|
de Langen AJ, van den Boogaart VEM, Marcus JT, Lubberink M. Use of H2(15)O-PET and DCE-MRI to measure tumor blood flow. Oncologist 2008; 13:631-44. [PMID: 18586918 DOI: 10.1634/theoncologist.2007-0235] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Positron emission tomography (PET) with H2(15)O and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) provide noninvasive measurements of tumor blood flow. Both tools offer the ability to monitor the direct target of antiangiogenic treatment, and their use is increasingly being studied in trials evaluating such drugs. Antiangiogenic therapy offers great potential and, to an increasing extent, benefit for oncological patients in a variety of palliative and curative settings. Because this type of targeted therapy frequently results in consolidation of the tumor mass instead of regression, monitoring treatment response with the standard volumetric approach (Response Evaluation Criteria in Solid Tumors) leads to underestimation of the response rate. Monitoring direct targets of anticancer therapy might be superior to indirect size changes. In addition, measures of tumor blood flow contribute to a better understanding of tumor biology. This review shows that DCE-MRI and H2(15)O-PET provide reliable measures of tumor perfusion, provided that a certain level of standardization is applied. Heterogeneity in scan acquisition and data analysis complicates the interpretation of study results. Also, limitations inherent to both techniques must be considered when interpreting DCE-MRI and H2(15)O-PET results. This review focuses on the technical and physiological aspects of both techniques and aims to provide the essential information necessary to critically evaluate the use of DCE-MRI and H2(15)O-PET in an oncological setting.
Collapse
Affiliation(s)
- Adrianus J de Langen
- Department of Pulmonary Diseases, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
15
|
Heinonen I, Nesterov SV, Kemppainen J, Nuutila P, Knuuti J, Laitio R, Kjaer M, Boushel R, Kalliokoski KK. Role of adenosine in regulating the heterogeneity of skeletal muscle blood flow during exercise in humans. J Appl Physiol (1985) 2007; 103:2042-8. [PMID: 17885025 DOI: 10.1152/japplphysiol.00567.2007] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Evidence from both animal and human studies suggests that adenosine plays a role in the regulation of exercise hyperemia in skeletal muscle. We tested whether adenosine also plays a role in the regulation of blood flow (BF) distribution and heterogeneity among and within quadriceps femoris (QF) muscles during exercise, measured using positron emission tomography. In six healthy young women, BF was measured at rest and then during three incremental low and moderate intermittent isometric one-legged knee-extension exercise intensities without and with theophylline-induced nonselective adenosine receptor blockade. BF heterogeneity within muscles was calculated from 16-mm3voxels in BF images and heterogeneity among the muscles from the mean values of the four QF compartments. Mean BF in the whole QF and its four parts increased, and heterogeneity decreased with workload both without and with theophylline ( P < 0.001). Adenosine receptor blockade did not have any effect on mean bulk BF or BF heterogeneity among the QF muscles, yet blockade increased within-muscle BF heterogeneity in all four QF muscles ( P = 0.03). Taken together, these results show that BF becomes less heterogeneous with increasing exercise intensity in the QF muscle group. Adenosine seems to play a role in muscle BF heterogeneity even in the absence of changes in bulk BF at low and moderate one-leg intermittent isometric exercise intensities.
Collapse
|
16
|
Kalliokoski KK, Knuuti J, Nuutila P. Blood transit time heterogeneity is associated to oxygen extraction in exercising human skeletal muscle. Microvasc Res 2004; 67:125-32. [PMID: 15020203 DOI: 10.1016/j.mvr.2003.11.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2003] [Indexed: 10/26/2022]
Abstract
Capillary transit time and its heterogeneity have a marked impact on oxygen extraction in different tissues. Animal studies have shown that exercise shortens capillary transit time but the effects on capillary transit time heterogeneity have been controversial. We investigated whether exercise changes muscle blood transit time heterogeneity in humans in vivo and whether this heterogeneity correlates to muscle oxygen extraction. Muscle blood flow, blood volume, and oxygen uptake were measured during rest and low-intensity exercise in 12 healthy men using positron emission tomography (PET). Blood transit time was calculated from parametric PET images voxel by voxel by dividing blood volume with blood flow. Oxygen extraction was calculated by nonlinear fitting from dynamic 15O-O2 data. Relative dispersion (=SD/mean) was calculated as an index of heterogeneity of blood volume and blood transit time. As expected, exercise significantly shortened blood transit time and increased oxygen extraction. Furthermore, exercise decreased transit time heterogeneity (from 47 +/- 9% to 39 +/- 10%, P=0.07). Transit time heterogeneity correlated inversely to oxygen extraction in the exercising (r=-0.76, P=0.004) but not in the resting muscle (r=0.04, P=0.89). These results show that even low-intensity exercise shortens blood transit time markedly and decreases its heterogeneity in human skeletal muscle in vivo. Findings in correlation analyses suggest that less heterogeneous blood transit time associates to better muscle oxygen extraction during exercise. This may have effects on muscle oxygenation during exercise.
Collapse
|
17
|
Laaksonen MS, Kalliokoski KK, Kyröläinen H, Kemppainen J, Teräs M, Sipilä H, Nuutila P, Knuuti J. Skeletal muscle blood flow and flow heterogeneity during dynamic and isometric exercise in humans. Am J Physiol Heart Circ Physiol 2003; 284:H979-86. [PMID: 12446282 DOI: 10.1152/ajpheart.00714.2002] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effects of dynamic and intermittent isometric knee extension exercises on skeletal muscle blood flow and flow heterogeneity were studied in seven healthy endurance-trained men. Regional muscle blood flow was measured using positron emission tomography (PET) and an [(15)O]H(2)O tracer, and electromyographic (EMG) activity was recorded in the quadriceps femoris (QF) muscle during submaximal intermittent isometric and dynamic exercises. QF blood flow was 61% (P = 0.002) higher during dynamic exercise. Interestingly, flow heterogeneity was 13% (P = 0.024) lower during dynamic compared with intermittent isometric exercise. EMG activity was significantly higher (P < 0.001) during dynamic exercise, and the change in EMG activity from isometric to dynamic exercise was tightly related to the change in blood flow in the vastus lateralis muscle (r = 0.98, P < 0.001) but not in the rectus femoris muscle (r = -0.09, P = 0.942). In conclusion, dynamic exercise causes higher and less heterogeneous blood flow than intermittent isometric exercise at the same exercise intensity. These responses are, at least partly, related to the increased EMG activity.
Collapse
Affiliation(s)
- Marko S Laaksonen
- Turku Positron Emission Tomography Centre, University of Turku, FIN-20521 Turku, Finland.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Kalliokoski KK, Kuusela TA, Laaksonen MS, Knuuti J, Nuutila P. Muscle fractal vascular branching pattern and microvascular perfusion heterogeneity in endurance-trained and untrained men. J Physiol 2003; 546:529-35. [PMID: 12527739 PMCID: PMC2342530 DOI: 10.1113/jphysiol.2002.030882] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Less heterogeneous skeletal muscle perfusion has recently been reported in endurance-trained compared to untrained men at macrovascular level. The causes of this difference in perfusion heterogeneity are unknown as is whether the same difference is observed in microvasculature. We hypothesised that the difference could be caused by changes in muscle vascular branching pattern. Perfusion was measured in resting and exercising muscle in 14 endurance-trained and seven untrained men using [(15)O]water and positron emission tomography. Fractal dimension (D) of perfusion distribution was calculated as a measure of fractal characteristics of muscle vascular branching pattern. Perfusion heterogeneity in microvascular units (1 mm(3) samples) was estimated using the measured heterogeneity in voxels of positron emission tomography (PET) images (relative dispersion, RD = S.D./mean) and corresponding D values. D was similar between the groups (exercising muscle 1.11 +/- 0.07 and 1.14 +/- 0.06, resting muscle 1.12 +/- 0.06 and 1.14 +/- 0.03, trained and untrained, respectively). Trained men had lower perfusion (151 +/- 44 vs. 218 +/- 87 ml min(-1) kg(-1), P < 0.05) and macrovascular perfusion heterogeneity (relative dispersion 21 +/- 5 vs. 25 +/- 5 %, P < 0.05) in exercising muscle than untrained men. Furthermore, estimated perfusion heterogeneity in microvascular units in exercising muscle was also lower in trained men (33 +/- 7 vs.48 +/- 19 %, P < 0.05). These results show that fractal vascular branching pattern is similar in endurance-trained and untrained men but perfusion is less heterogeneous at both the macro- and the microvascular level in endurance-trained men. Thus, changes in fractal branching pattern do not explain the differences in perfusion heterogeneity between endurance-trained and untrained men.
Collapse
|