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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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Elsaid NMH, Peters DC, Galiana G, Sinusas AJ. Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease. Am J Physiol Heart Circ Physiol 2024; 326:H1304-H1323. [PMID: 38517227 DOI: 10.1152/ajpheart.00533.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024]
Abstract
Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.
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Affiliation(s)
- Nahla M H Elsaid
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Gigi Galiana
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Albert J Sinusas
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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3
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Rahman H, Leutzinger T, Hassan M, Schieber M, Koutakis P, Fuglestad MA, DeSpiegelaere H, Longo GM, Malcolm P, Johanning JM, Casale GP, Pipinos II, Myers SA. Peripheral artery disease causes consistent gait irregularities regardless of the location of leg claudication pain. Ann Phys Rehabil Med 2024; 67:101793. [PMID: 38118246 PMCID: PMC11009086 DOI: 10.1016/j.rehab.2023.101793] [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: 08/09/2022] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND The most common symptom of peripheral artery disease (PAD) is intermittent claudication that involves the calf, thigh, and/or buttock muscles. How the specific location of this leg pain is related to altered gait, however, is unknown. OBJECTIVES We hypothesized that because the location of claudication symptoms uniquely affects different leg muscle groups in people with PAD, this would produce distinctive walking patterns. METHODS A total of 105 participants with PAD and 35 age-matched older volunteers without PAD (CTRL) were recruited. Participants completed walking impairment questionnaires (WIQ), Gardner-Skinner progressive treadmill tests, the six-minute walk test, and we performed an advanced evaluation of the biomechanics of their overground walking. Participants with PAD were categorized into 4 groups according to their stated pain location(s): calf only (C, n = 43); thigh and calf (TC, n = 18); buttock and calf (BC, n = 15); or buttock, thigh, and calf (BTC, n = 29). Outcomes were compared between CTRL, C, TC, BC and BTC groups using a one-way ANOVA with post-hoc comparisons to identify and assess statistically significant differences. RESULTS There were no significant differences between CTRL, C, TC, BC and BTC groups in distances walked or walking speed when either pain-free or experiencing claudication pain. Each participant with PAD had significantly dysfunctional biomechanical gait parameters, even when pain-free, when compared to CTRL (pain-free) walking data. During pain-free walking, out of the 18 gait parameters evaluated, we only identified significant differences in hip power generation during push-off (in C and TC groups) and in knee power absorption during weight acceptance (in TC and BC groups). There were no between-group differences in gait parameters while people with PAD were walking with claudication pain. CONCLUSIONS Our data demonstrate that PAD affects the ischemic lower extremities in a diffuse manner irrespective of the location of claudication symptoms. DATABASE REGISTRATION ClinicalTrials.gov NCT01970332.
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Affiliation(s)
- Hafizur Rahman
- School of Podiatric Medicine, University of Texas Rio Grande Valley, Harlingen, TX, USA; Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA; Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA
| | - Todd Leutzinger
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
| | - Mahdi Hassan
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA; Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA
| | - Molly Schieber
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Matthew A Fuglestad
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Holly DeSpiegelaere
- Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA
| | - G Matthew Longo
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Philippe Malcolm
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
| | - Jason M Johanning
- Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - George P Casale
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Iraklis I Pipinos
- Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sara A Myers
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA; Department of Surgery and Research Service, Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE, USA.
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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.
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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
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El Masry MS, Gnyawali SC, Sen CK. Robust critical limb ischemia porcine model involving skeletal muscle necrosis. Sci Rep 2023; 13:11574. [PMID: 37463916 DOI: 10.1038/s41598-023-37724-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/27/2023] [Indexed: 07/20/2023] Open
Abstract
This work sought to develop a robust and clinically relevant swine model of critical limb ischemia (CLI) involving the onset of ischemic muscle necrosis. CLI carries about 25-40% risk of major amputation with 20% annual mortality. Currently, there is no specific treatment that targets the ischemic myopathy characteristic of CLI. Current swine models of CLI, with tolerable side-effects, fail to achieve sustained ischemia followed by a necrotic myopathic endpoint. Such limitation in experimental model hinders development of effective interventions. CLI was induced unilaterally by ligation-excision of one inch of the common femoral artery (CFA) via infra-inguinal minimal incision in female Yorkshire pigs (n = 5). X-ray arteriography was done pre- and post-CFA transection to validate successful induction of severe ischemia. Weekly assessment of the sequalae of ischemia on limb perfusion, and degree of ischemic myopathy was conducted for 1 month using X-ray arteriography, laser speckle imaging, CTA angiography, femoral artery duplex, high resolution ultrasound and histopathological analysis. The non-invasive tissue analysis of the elastography images showed specific and characteristic pattern of increased muscle stiffness indicative of the fibrotic and necrotic outcome expected with associated total muscle ischemia. The prominent onset of skeletal muscle necrosis was evident upon direct inspection of the affected tissues. Ischemic myopathic changes associated with inflammatory infiltrates and deficient blood vessels were objectively validated. A translational model of severe hindlimb ischemia causing ischemic myopathy was successfully established adopting an approach that enables long-term survival studies in compliance with regulatory requirements pertaining to animal welfare.
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Affiliation(s)
- Mohamed S El Masry
- McGowan Institute for Regenerative Medicine, Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
| | - Surya C Gnyawali
- McGowan Institute for Regenerative Medicine, Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Chandan K Sen
- McGowan Institute for Regenerative Medicine, Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
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Ling Z, Li X, Wu G, Fadoul H. Radiomics of CTA is feasible in identifying muscle ischemia. Acta Radiol 2022; 64:1469-1475. [PMID: 36050936 DOI: 10.1177/02841851221119884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advanced models based on computed tomography angiography (CTA) radiomics features in discriminating muscle ischemia from normal condition are lacking. PURPOSE To investigate the feasibility of radiomics of CTA in discriminating ischemic muscle from normal muscle. MATERIAL AND METHODS A total of 102 patients (51 ischemia and 51 non-ischemia) were analyzed using a CTA radiomics method. The radiomics features of muscle were compared between ischemic and normal cases. The maximum relevance minimum redundancy (mRMR) algorithm and least absolute shrinkage and selection operator (LASSO) logistic regression model were used. The receiver operating characteristic (ROC) curve was used to determine the performance of radiomics signature. RESULTS Thirty-nine CTA radiomics features were significantly different between the two groups (P < 0.05). By LASSO, six features were used to construct a model. The signature area under the curve was 0.92 and 0.91 in the training and validation cohorts, respectively. The sensitivity and specificity of the signature were 92% and 86% for the training cohort, and 80% and 94% for the validation cohort, respectively. CONCLUSION CTA radiomics signature is useful in identifying ischemic muscle in selected patients.
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Affiliation(s)
- Zhiyu Ling
- Department of Radiology, The first People's Hospital of Yongkang, Yongkang, Zhejiang, PR China
| | - Xiaoming Li
- Department of Radiology, 66375Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, PR China
| | - Gang Wu
- Department of Radiology, 66375Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, PR China
| | - Hissein Fadoul
- Department of Radiology, 66375Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, PR China
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Leutzinger TJ, Koutakis P, Fuglestad MA, Rahman H, Despiegelaere H, Hassan M, Schieber M, Johanning JM, Stergiou N, Longo GM, Casale GP, Myers SA, Pipinos II. Peripheral artery disease affects the function of the legs of claudicating patients in a diffuse manner irrespective of the segment of the arterial tree primarily involved. PLoS One 2022; 17:e0264598. [PMID: 35830421 PMCID: PMC9278728 DOI: 10.1371/journal.pone.0264598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Different levels of arterial occlusive disease (aortoiliac, femoropopliteal, multi-level disease) can produce claudication symptoms in different leg muscle groups (buttocks, thighs, calves) in patients with peripheral artery disease (PAD). We tested the hypothesis that different locations of occlusive disease uniquely affect the muscles of PAD legs and produce distinctive patterns in the way claudicating patients walk. Ninety-seven PAD patients and 35 healthy controls were recruited. PAD patients were categorized to aortoiliac, femoropopliteal and multi-level disease groups using computerized tomographic angiography. Subjects performed walking trials both pain-free and during claudication pain and joint kinematics, kinetics, and spatiotemporal parameters were calculated to evaluate the net contribution of the calf, thigh and buttock muscles. PAD patients with occlusive disease affecting different segments of the arterial tree (aortoiliac, femoropopliteal, multi-level disease) presented with symptoms affecting different muscle groups of the lower extremity (calves, thighs and buttocks alone or in combination). However, no significant biomechanical differences were found between PAD groups during the pain-free conditions with minimal differences between PAD groups in the claudicating state. All statistical differences in the pain-free condition occurred between healthy controls and one or more PAD groups. A discriminant analysis function was able to adequately predict if a subject was a control with over 70% accuracy, but the function was unable to differentiate between PAD groups. In-depth gait analyses of claudicating PAD patients indicate that different locations of arterial disease produce claudication symptoms that affect different muscle groups across the lower extremity but impact the function of the leg muscles in a diffuse manner generating similar walking impairments.
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Affiliation(s)
- Todd J. Leutzinger
- Department of Biomechanics and Center for Research in Human Movement Variability, University of Nebraska at Omaha, Omaha, Nebraska, United States of America
| | - Panagiotis Koutakis
- Department of Biology, Baylor University, Wako, Texas, United States of America
| | - Matthew A. Fuglestad
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Hafizur Rahman
- Department of Biomechanics and Center for Research in Human Movement Variability, University of Nebraska at Omaha, Omaha, Nebraska, United States of America
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
| | - Holly Despiegelaere
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
| | - Mahdi Hassan
- Department of Biomechanics and Center for Research in Human Movement Variability, University of Nebraska at Omaha, Omaha, Nebraska, United States of America
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
| | - Molly Schieber
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Jason M. Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
| | - Nick Stergiou
- Department of Biomechanics and Center for Research in Human Movement Variability, University of Nebraska at Omaha, Omaha, Nebraska, United States of America
- Department of Environmental Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - G. Matthew Longo
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - George P. Casale
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sara A. Myers
- Department of Biomechanics and Center for Research in Human Movement Variability, University of Nebraska at Omaha, Omaha, Nebraska, United States of America
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
- * E-mail: (SAM); (IIP)
| | - Iraklis I. Pipinos
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
- Department of Surgery and Research Service, Nebraska and Western Iowa Veterans Affairs Medical Center, Omaha, Nebraska, United States of America
- * E-mail: (SAM); (IIP)
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Stacy MR. Molecular Imaging of Lower Extremity Peripheral Arterial Disease: An Emerging Field in Nuclear Medicine. Front Med (Lausanne) 2022; 8:793975. [PMID: 35096884 PMCID: PMC8789656 DOI: 10.3389/fmed.2021.793975] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic disorder of non-coronary arteries that is associated with vascular stenosis and/or occlusion. PAD affecting the lower extremities is characterized by a variety of health-related consequences, including lifestyle-limiting intermittent claudication, ulceration of the limbs and/or feet, increased risk for lower extremity amputation, and increased mortality. The diagnosis of lower extremity PAD is typically established by using non-invasive tests such as the ankle-brachial index, toe-brachial index, duplex ultrasound, and/or angiography imaging studies. While these common diagnostic tools provide hemodynamic and anatomical vascular assessments, the potential for non-invasive physiological assessment of the lower extremities has more recently emerged through the use of magnetic resonance- and nuclear medicine-based approaches, which can provide insight into the functional consequences of PAD-related limb ischemia. This perspectives article specifically highlights and discusses the emerging applications of clinical nuclear medicine techniques for molecular imaging investigations in the setting of lower extremity PAD.
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Affiliation(s)
- Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
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Deppen JN, Ginn SC, Kim NH, Wang L, Voll RJ, Liang SH, Goodman MM, Oshinski JN, Levit RD. A Swine Hind Limb Ischemia Model Useful for Testing Peripheral Artery Disease Therapeutics. J Cardiovasc Transl Res 2021; 14:1186-1197. [PMID: 34050499 PMCID: PMC8627534 DOI: 10.1007/s12265-021-10134-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/03/2021] [Indexed: 01/27/2023]
Abstract
Currently, there is no large animal model of sustained limb ischemia suitable for testing novel angiogenic therapeutics for peripheral artery disease (PAD) such as drugs, genes, materials, or cells. We created a large animal model suitable for efficacy assessment of these therapies by testing 3 swine hind limb ischemia (HLI) variations and quantifying vascular perfusion, muscle histology, and limb function. Ligation of the ipsilateral external and bilateral internal iliac arteries produced sustained gait dysfunction compared to isolated external iliac or unilateral external and internal iliac artery ligations. Hyperemia-dependent muscle perfusion deficits, depressed limb blood pressure, arteriogenesis, muscle atrophy, and microscopic myopathy were quantifiable in ischemic limbs 6 weeks post-ligation. Porcine mesenchymal stromal cells (MSCs) engineered to express a reporter gene were visualized post-administration via positron emission tomography (PET) in vivo. These results establish a preclinical platform enabling better optimization of PAD therapies, including cellular therapeutics, increasing bench-to-bedside translational success. A preclinical platform for porcine studies of peripheral artery disease therapies including (1) a hind limb ischemia model and (2) non-invasive MSC viability and retention assessment via PET.
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Affiliation(s)
- Juline N Deppen
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sydney C Ginn
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Na Hee Kim
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Lanfang Wang
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ronald J Voll
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven H Liang
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark M Goodman
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - John N Oshinski
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca D Levit
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW, Kwan TW, McDermott MM, Misra S, Ujueta F. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e171-e191. [PMID: 34315230 PMCID: PMC9847212 DOI: 10.1161/cir.0000000000001005] [Citation(s) in RCA: 243] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.
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Johnson LL, Johnson J, Ober R, Holland A, Zhang G, Backer M, Backer J, Ali Z, Tekabe Y. Novel Receptor for Advanced Glycation End Products-Blocking Antibody to Treat Diabetic Peripheral Artery Disease. J Am Heart Assoc 2020; 10:e016696. [PMID: 33327730 PMCID: PMC7955479 DOI: 10.1161/jaha.120.016696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Expression of receptor for advanced glycation end products (RAGE) plays an important role in diabetic peripheral artery disease. We proposed to show that treatment with an antibody blocking RAGE would improve hind limb perfusion and muscle viability in diabetic pig with femoral artery (FA) ligation. Methods and Results Purpose‐bred diabetic Yucatan minipigs with average fasting blood sugar of 357 mg/dL on insulin to maintain a glucose range of 300 to 500 mg/dL were treated with either a humanized monoclonal anti‐RAGE antibody (CR‐3) or nonimmune IgG. All pigs underwent intravascular occlusion of the anterior FA. Animals underwent (201Tl) single‐photon emission computed tomography/x‐ray computed tomography imaging on days 1 and 28 after FA occlusion, angiogenesis imaging with [99mTc]dodecane tetra‐acetic acid–polyethylene glycol–single chain vascular endothelial growth factor (scVEGF), muscle biopsies on day 7, and contrast angiogram day 28. Results showed greater increases in perfusion to the gastrocnemius from day 1 to day 28 in CR‐3 compared with IgG treated pigs (P=0.0024), greater uptake of [99mTc]dodecane tetra‐acetic acid‐polyethylene glycol‐scVEGF (scV/Tc) in the proximal gastrocnemius at day 7, confirmed by tissue staining for capillaries and vascular endothelial growth factor A, and less muscle loss and fibrosis at day 28. Contrast angiograms showed better reconstitution of the distal FA from collaterals in the CR‐3 versus IgG treated diabetic pigs (P=0.01). The gastrocnemius on nonoccluded limb at necropsy had higher 201Tl uptake (percentage injected dose per gram) and reduced RAGE staining in arterioles in CR‐3 treated compared with IgG treated animals (P=0.04). Conclusions A novel RAGE‐blocking antibody improved hind limb perfusion and angiogenesis in diabetic pigs with FA occlusion. Contributing factors are increased collaterals and reduced vascular RAGE expression. CR‐3 shows promise for clinical treatment in diabetic peripheral artery disease.
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Affiliation(s)
- Lynne L Johnson
- Department of Medicine Columbia University Medical Center New York NY
| | - Jordan Johnson
- Department of Medicine Columbia University Medical Center New York NY
| | - Rebecca Ober
- Department of Medicine Columbia University Medical Center New York NY
| | - April Holland
- Department of Medicine Columbia University Medical Center New York NY
| | - Geping Zhang
- Department of Medicine Columbia University Medical Center New York NY
| | | | | | - Ziad Ali
- Department of Medicine Columbia University Medical Center New York NY
| | - Yared Tekabe
- Department of Medicine Columbia University Medical Center New York NY
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Chou TH, Alvelo JL, Janse S, Papademetris X, Sumpio BE, Mena-Hurtado C, Sinusas AJ, Stacy MR. Prognostic Value of Radiotracer-Based Perfusion Imaging in Critical Limb Ischemia Patients Undergoing Lower Extremity Revascularization. JACC Cardiovasc Imaging 2020; 14:1614-1624. [PMID: 33221224 DOI: 10.1016/j.jcmg.2020.09.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the prognostic value of single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of angiosome foot perfusion for predicting amputation outcomes in patients with critical limb ischemia (CLI) and diabetes mellitus (DM). BACKGROUND Radiotracer imaging can assess microvascular foot perfusion and identify regional perfusion abnormalities in patients with critical limb ischemia CLI and DM, but the relationship between perfusion response to revascularization and subsequent clinical outcomes has not been evaluated. METHODS Patients with CLI, DM, and nonhealing foot ulcers (n = 25) were prospectively enrolled for SPECT/CT perfusion imaging of the feet before and after revascularization. CT images were used to segment angiosomes (i.e., 3-dimensional vascular territories) of the foot. Relative changes in radiotracer uptake after revascularization were evaluated within the ulcerated angiosome. Incidence of amputation was assessed at 3 and 12 months after revascularization. RESULTS SPECT/CT detected a significantly lower microvascular perfusion response for patients who underwent amputation compared with those who remained amputation free at 3 (p = 0.01) and 12 (p = 0.01) months after revascularization. The cutoff percent change in perfusion for predicting amputation at 3 months was 7.55%, and 11.56% at 12 months. The area under the curve based on the amputation outcome was 0.799 at 3 months and 0.833 at 12 months. The probability of amputation-free survival was significantly higher at 3 (p = 0.002) and 12 months (p = 0.03) for high-perfusion responders than low-perfusion responders to revascularization. CONCLUSIONS SPECT/CT imaging detects regional perfusion responses to lower extremity revascularization and provides prognostic value in patients with CLI (Radiotracer-Based Perfusion Imaging of Patients With Peripheral Arterial Disease; NCT03622359).
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jessica L Alvelo
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Janse
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Xenophon Papademetris
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Bauer E Sumpio
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Albert J Sinusas
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA.
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S Zaitseva T, Yang G, Dionyssiou D, Zamani M, Sawamura S, Yakubov E, Ferguson J, Hallett RL, Fleischmann D, Paukshto MV, Huang NF. Delivery of hepatocyte growth factor mRNA from nanofibrillar scaffolds in a pig model of peripheral arterial disease. Regen Med 2020; 15:1761-1773. [PMID: 32772903 PMCID: PMC7787177 DOI: 10.2217/rme-2020-0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Chemical modification of mRNA (mmRNA) substantially improves their stability and translational efficiency within cells. Nanofibrillar collagen scaffolds were previously shown to enable the spatially localized delivery and temporally controlled release of mmRNA encoding HGF both in vitro and in vivo. Materials & methods: Herein we developed an improved slow-releasing HGF mmRNA scaffold and tested its therapeutic efficacy in a porcine model of peripheral arterial disease. Results & conclusion: The HGF mmRNA was released from scaffolds in a temporally controlled fashion in vitro with preserved transfection activity. The mmRNA scaffolds improved vascular regeneration when sutured to the ligated porcine femoral artery. These studies validate the therapeutic potential of HGF mmRNA delivery from nanofibrillar scaffolds for treatment of peripheral arterial disease.
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Affiliation(s)
| | - Guang Yang
- Stanford Cardiovascular Institute, Stanford, CA 94305, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304,USA
| | - Dimitris Dionyssiou
- Fibralign Corporation, Union City, CA 94587, USA
- Department of Plastic Surgery, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Maedeh Zamani
- Stanford Cardiovascular Institute, Stanford, CA 94305, USA
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
| | | | | | | | - Richard L Hallett
- Stanford Cardiovascular Institute, Stanford, CA 94305, USA
- Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | - Dominik Fleischmann
- Stanford Cardiovascular Institute, Stanford, CA 94305, USA
- Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | | | - Ngan F Huang
- Stanford Cardiovascular Institute, Stanford, CA 94305, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304,USA
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA
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Johnson LL, Johnson J, Ali Z, Tekabe Y, Ober R, Geist G, McLuckie A, Safarov A, Holland A, Zhang G, Backer M, Backer J. VEGF receptor targeted imaging of angiogenic response to limb ischemia in diabetic vs. non-diabetic Yucatan minipigs. EJNMMI Res 2020; 10:48. [PMID: 32399850 PMCID: PMC7218044 DOI: 10.1186/s13550-020-00626-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background New therapies to treat diabetic peripheral artery disease (PAD) require target-specific non-invasive imaging modalities to follow efficacy. As a translational study, we performed targeted imaging of receptors for vascular endothelial growth factor (VEGF) in response to anterior femoral artery occlusion (FAO) in Yucatan minipigs and compare the normal response to response in diabetic Yucatan minipigs. Methods Eleven Yucatan minipigs, 6 non-diabetic (non-D) and 5 purpose bred diabetic (D) (Sinclair, Auxvasse MO), underwent intravascular total occlusion of the anterior femoral artery (FA). At days 1 and 28, pigs underwent SPECT/CT 201Tl hindlimb perfusion imaging and at day 7 were injected with [99mTc]DOTA-PEG-scVEGF (scV/Tc) tracer targeting VEGF receptor, and underwent biopsies of the hindlimb muscles for gamma counting and histology, followed by imaging. One day after the final scan, pigs underwent contrast angiography of the lower extremities. Counts from scans were converted to percentage injected activity (%IA). Results Perfusion was lower in the occluded hindlimb compared to non-occluded on day 1 in both the D and non-D pigs. At day 7, scV/Tc count ratio of counts from ROIs drawn in proximal gastrocnemius muscle for the occluded over non-occluded limb was significantly higher in non-D vs. D pigs (1.32 ± 0.06 vs. 1.04 ± 0.13, P = 0.02) reflecting higher level of angiogenesis. Perfusion increased between days 1 and 28 in the muscles in the occluded limb for the non-diabetic pigs while the diabetic pig showed no increase (+ 0.13 ± 0.08 %IA vs. − 0.13 ± 0.11, P = 0.003). The anterior FA showed poor contrast filling beyond occluder and qualitatively fewer bridging collaterals compared to non-D pigs at 28 days. Conclusion VEGF receptor targeted imaging showed the effects of diabetes to suppress angiogenesis in response to occlusion of the anterior femoral artery of purpose bred diabetic Yucatan minipigs and indicates potential applicability as a marker to follow efficacy of novel therapies to improve blood flow by stimulating angiogenesis in diabetic PAD.
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Affiliation(s)
- Lynne L Johnson
- Department of Medicine, Columbia University Medical Center, 622 West 168th St., PH 10-203, New York, NY, 10032, USA.
| | - Jordan Johnson
- Department of Medicine, Columbia University Medical Center, 622 West 168th St., PH 10-203, New York, NY, 10032, USA
| | - Ziad Ali
- Department of Medicine, Columbia University Medical Center, 622 West 168th St., PH 10-203, New York, NY, 10032, USA
| | - Yared Tekabe
- Department of Medicine, Columbia University Medical Center, 622 West 168th St., PH 10-203, New York, NY, 10032, USA
| | - Rebecca Ober
- Department of Veterinary Medicine, Columbia University, New York, NY, USA
| | - Gail Geist
- Department of Veterinary Medicine, Columbia University, New York, NY, USA
| | - Alicia McLuckie
- Department of Veterinary Medicine, Columbia University, New York, NY, USA
| | - Aram Safarov
- Department of Veterinary Medicine, Columbia University, New York, NY, USA
| | - April Holland
- Department of Medicine, Columbia University Medical Center, 622 West 168th St., PH 10-203, New York, NY, 10032, USA
| | - Geping Zhang
- Department of Veterinary Medicine, Columbia University, New York, NY, USA
| | - Marina Backer
- Department of Pathology, Columbia University, New York, NY, USA
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15
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Chou TH, Atway SA, Bobbey AJ, Sarac TP, Go MR, Stacy MR. SPECT/CT Imaging: A Noninvasive Approach for Evaluating Serial Changes in Angiosome Foot Perfusion in Critical Limb Ischemia. Adv Wound Care (New Rochelle) 2020; 9:103-110. [PMID: 31993252 PMCID: PMC6985768 DOI: 10.1089/wound.2018.0924] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/07/2019] [Indexed: 12/19/2022] Open
Abstract
Objective: To investigate the feasibility of serial radiotracer-based imaging as a noninvasive approach for quantifying volumetric changes in microvascular perfusion within angiosomes of the foot following lower extremity revascularization in the setting of critical limb ischemia (CLI). Approach: A CLI patient with a nonhealing foot ulcer underwent single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of the feet before and after balloon angioplasty of the superficial femoral artery (SFA) and popliteal artery. SPECT/CT imaging was used to evaluate serial changes in angiosome perfusion, which was compared to quantitative changes in peripheral vascular anatomy and hemodynamics, as assessed by standard clinical tools that included digital subtraction angiography (DSA), ankle-brachial index (ABI), and toe-brachial index (TBI). Results: Following revascularization, upstream quantitative improvements in stenosis of the SFA (pre: 35.4% to post: 11.9%) and popliteal artery (pre: 59.1% to post: 21.7%) shown by DSA were associated with downstream angiosome-dependent improvements in SPECT microvascular foot perfusion that ranged from 2% to 16%. ABI measurement was not possible due to extensive arterial calcification, while TBI values decreased from 0.26 to 0.16 following revascularization. Innovation: This is the first study to demonstrate the feasibility of assessing noninvasive volumetric changes in angiosome foot perfusion in response to lower extremity revascularization in a patient with CLI by utilizing radiotracer-based imaging. Conclusion: SPECT/CT imaging allows for quantification of serial perfusion changes within angiosomes containing nonhealing ulcers and provides physiological assessment that is complementary to conventional anatomical (DSA) and hemodynamic (ABI/TBI) measures in the evaluation of lower extremity revascularization.
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Affiliation(s)
- Ting-Heng Chou
- The Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Said A. Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Adam J. Bobbey
- Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Timur P. Sarac
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Michael R. Go
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mitchel R. Stacy
- The Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
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16
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Chou TH, Stacy MR. Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia. Mol Imaging Biol 2019; 22:245-255. [PMID: 31482412 DOI: 10.1007/s11307-019-01425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA. .,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
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17
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Alvelo JL, Papademetris X, Mena-Hurtado C, Jeon S, Sumpio BE, Sinusas AJ, Stacy MR. Radiotracer Imaging Allows for Noninvasive Detection and Quantification of Abnormalities in Angiosome Foot Perfusion in Diabetic Patients With Critical Limb Ischemia and Nonhealing Wounds. Circ Cardiovasc Imaging 2019; 11:e006932. [PMID: 29748311 PMCID: PMC5951395 DOI: 10.1161/circimaging.117.006932] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
Abstract
Background: Single photon emission computed tomography (SPECT)/computed tomography (CT) imaging allows for assessment of skeletal muscle microvascular perfusion but has not been quantitatively assessed in angiosomes, or 3-dimensional vascular territories, of the foot. This study assessed and compared resting angiosome foot perfusion between healthy subjects and diabetic patients with critical limb ischemia (CLI). Additionally, the relationship between SPECT/CT imaging and the ankle–brachial index—a standard tool for evaluating peripheral artery disease—was assessed. Methods and Results: Healthy subjects (n=9) and diabetic patients with CLI and nonhealing ulcers (n=42) underwent SPECT/CT perfusion imaging of the feet. CT images were segmented into angiosomes for quantification of relative radiotracer uptake, expressed as standardized uptake values. Standardized uptake values were assessed in ulcerated angiosomes of patients with CLI and compared with whole-foot standardized uptake values in healthy subjects. Serial SPECT/CT imaging was performed to assess uptake kinetics of technetium-99m-tetrofosmin. The relationship between angiosome perfusion and ankle–brachial index was assessed via correlational analysis. Resting perfusion was significantly lower in CLI versus healthy subjects (P=0.0007). Intraclass correlation coefficients of 0.95 (healthy) and 0.93 (CLI) demonstrated excellent agreement between serial perfusion measurements. Correlational analysis, including healthy and CLI subjects, demonstrated a significant relationship between ankle–brachial index and SPECT/CT (P=0.01); however, this relationship was not significant for diabetic CLI patients only (P=0.2). Conclusions: SPECT/CT imaging assesses regional foot perfusion and detects abnormalities in microvascular perfusion that may be undetectable by conventional ankle–brachial index in patients with diabetes mellitus. SPECT/CT may provide a novel approach for evaluating responses to targeted therapies.
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Affiliation(s)
- Jessica L Alvelo
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.)
| | - Xenophon Papademetris
- Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.).,Department of Biomedical Engineering (X.P.)
| | | | | | - Bauer E Sumpio
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.).,Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.).,and Department of Surgery (B.E.S.) Yale University School of Medicine, New Haven, CT
| | - Albert J Sinusas
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.).,Department of Radiology and Biomedical Imaging (X.P., B.E.S., A.J.S.)
| | - Mitchel R Stacy
- Department of Internal Medicine (J.L.A., C.M.-H., B.E.S., A.J.S., M.R.S.)
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Restoration of brain circulation and cellular functions hours post-mortem. Nature 2019; 568:336-343. [PMID: 30996318 DOI: 10.1038/s41586-019-1099-1] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/01/2019] [Indexed: 11/08/2022]
Abstract
The brains of humans and other mammals are highly vulnerable to interruptions in blood flow and decreases in oxygen levels. Here we describe the restoration and maintenance of microcirculation and molecular and cellular functions of the intact pig brain under ex vivo normothermic conditions up to four hours post-mortem. We have developed an extracorporeal pulsatile-perfusion system and a haemoglobin-based, acellular, non-coagulative, echogenic, and cytoprotective perfusate that promotes recovery from anoxia, reduces reperfusion injury, prevents oedema, and metabolically supports the energy requirements of the brain. With this system, we observed preservation of cytoarchitecture; attenuation of cell death; and restoration of vascular dilatory and glial inflammatory responses, spontaneous synaptic activity, and active cerebral metabolism in the absence of global electrocorticographic activity. These findings demonstrate that under appropriate conditions the isolated, intact large mammalian brain possesses an underappreciated capacity for restoration of microcirculation and molecular and cellular activity after a prolonged post-mortem interval.
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Stacy MR, Caracciolo CM, Qiu M, Pal P, Varga T, Constable RT, Sinusas AJ. Comparison of regional skeletal muscle tissue oxygenation in college athletes and sedentary control subjects using quantitative BOLD MR imaging. Physiol Rep 2017; 4:4/16/e12903. [PMID: 27535483 PMCID: PMC5002911 DOI: 10.14814/phy2.12903] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/28/2016] [Indexed: 11/24/2022] Open
Abstract
Blood oxygen level‐dependent (BOLD) magnetic resonance (MR) imaging permits noninvasive assessment of tissue oxygenation. We hypothesized that BOLD imaging would allow for regional evaluation of differences in skeletal muscle oxygenation between athletes and sedentary control subjects, and dynamic BOLD responses to ischemia (i.e., proximal cuff occlusion) and reactive hyperemia (i.e., rapid cuff deflation) would relate to lower extremity function, as assessed by jumping ability. College football athletes (linemen, defensive backs/wide receivers) were compared to sedentary healthy controls. BOLD signal of the gastrocnemius, soleus, anterior tibialis, and peroneus longus was assessed for peak hyperemic value (PHV), time to peak (TTP), minimum ischemic value (MIV), and time to recovery (TTR). Significantly higher PHVs were identified in athletes versus controls for the gastrocnemius (linemen, 15.8 ± 9.1%; defensive backs/wide receivers, 17.9 ± 5.1%; controls, 7.4 ± 3.5%), soleus (linemen, 25.9 ± 11.5%; backs/receivers, 22.0 ± 9.4%; controls, 12.9 ± 5.8%), and anterior tibialis (linemen, 12.8 ± 5.3%; backs/receivers, 12.6 ± 3.9%; controls, 7.7 ± 4.0%), whereas no differences in PHV were found for the peroneus longus (linemen, 14.1 ± 6.9%; backs/receivers, 11.7 ± 4.6%; controls, 9.0 ± 4.9%). In all subject groups, the gastrocnemius and soleus muscles exhibited the lowest MIVs during cuff occlusion. No differences in TTR were found between muscles for any subject group. PHV of the gastrocnemius muscle was significantly and positively related to maximal vertical (r = 0.56, P = 0.002) and broad jump (r = 0.47, P = 0.01). These results suggest that BOLD MR imaging is a useful noninvasive tool for evaluating differences in tissue oxygenation of specific muscles between active and sedentary individuals, and peak BOLD responses may relate to functional capacity.
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Affiliation(s)
- Mitchel R Stacy
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Maolin Qiu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Prasanta Pal
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Tyler Varga
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Robert Todd Constable
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut Department of Neurosurgery, 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 Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
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Hernandez MJ, Christman KL. Designing Acellular Injectable Biomaterial Therapeutics for Treating Myocardial Infarction and Peripheral Artery Disease. JACC Basic Transl Sci 2017; 2:212-226. [PMID: 29057375 PMCID: PMC5646282 DOI: 10.1016/j.jacbts.2016.11.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 02/07/2023]
Abstract
As the number of global deaths attributed to cardiovascular disease continues to rise, viable treatments for cardiovascular events such as myocardial infarction (MI) or conditions like peripheral artery disease (PAD) are critical. Recent studies investigating injectable biomaterials have shown promise in promoting tissue regeneration and functional improvement, and in some cases, incorporating other therapeutics further augments the beneficial effects of these biomaterials. In this review, we aim to emphasize the advantages of acellular injectable biomaterial-based therapies, specifically material-alone approaches or delivery of acellular biologics, in regards to manufacturability and the capacity of these biomaterials to regenerate or repair diseased tissue. We will focus on design parameters and mechanisms that maximize therapeutic efficacy, particularly, improved functional perfusion and neovascularization regarding PAD and improved cardiac function and reduced negative left ventricular (LV) remodeling post-MI. We will then discuss the rationale and challenges of designing new injectable biomaterial-based therapies for the clinic.
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Affiliation(s)
| | - Karen L. Christman
- Department of Bioengineering, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, California
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Hashimoto H, Fukushima Y, Kumita SI, Miyamoto M, Takagi G, Yamazaki J, Ikeda T. Prognostic value of lower limb perfusion single-photon emission computed tomography-computed tomography in patients with lower limb atherosclerotic peripheral artery disease. Jpn J Radiol 2016; 35:68-77. [DOI: 10.1007/s11604-016-0602-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/09/2016] [Indexed: 02/07/2023]
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Long CA, Timmins LH, Koutakis P, Goodchild TT, Lefer DJ, Pipinos II, Casale GP, Brewster LP. An endovascular model of ischemic myopathy from peripheral arterial disease. J Vasc Surg 2016; 66:891-901. [PMID: 27693032 DOI: 10.1016/j.jvs.2016.07.127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/27/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Peripheral arterial disease (PAD) is a significant age-related medical condition with limited pharmacologic options. Severe PAD, termed critical limb ischemia, can lead to amputation. Skeletal muscle is the end organ most affected by PAD, leading to ischemic myopathy and debility of the patient. Currently, there are not any therapeutics to treat ischemic myopathy, and proposed biologic agents have not been optimized owing to a lack of preclinical models of PAD. Because a large animal model of ischemic myopathy may be useful in defining the optimal dosing and delivery regimens, the objective was to create and to characterize a swine model of ischemic myopathy that mimics patients with severe PAD. METHODS Yorkshire swine (N = 8) underwent acute right hindlimb ischemia by endovascular occlusion of the external iliac artery. The effect of ischemia on limb function, perfusion, and degree of ischemic myopathy was quantified by weekly gait analysis, arteriography, hindlimb blood pressures, femoral artery duplex ultrasound scans, and histologic examination. Animals were terminated at 5 (n = 5) and 6 (n = 3) weeks postoperatively. Ossabaw swine (N = 8) fed a high-fat diet were used as a model of metabolic syndrome for comparison of arteriogenic recovery and validation of ischemic myopathy. RESULTS There was persistent ischemia in the right hindlimb, and occlusion pressures were significantly depressed compared with the untreated left hindlimb out to 6 weeks (systolic blood pressure, 31 ± 21 vs 83 ± 15 mm Hg, respectively; P = .0007). The blood pressure reduction resulted in a significant increase of ischemic myopathy in the gastrocnemius muscle in the treated limb. Gait analysis revealed a functional deficit of the right hindlimb immediately after occlusion that improved rapidly during the first 2 weeks. Peak systolic velocity values in the right common femoral artery were severely diminished throughout the entire study (P < .001), and the hemodynamic environment after occlusion was characterized by low and oscillatory wall shear stress. Finally, the internal iliac artery on the side of the ischemic limb underwent significant arteriogenic remodeling (1.8× baseline) in the Yorkshire but not in the Ossabaw swine model. CONCLUSIONS This model uses endovascular technology to produce the first durable large animal model of ischemic myopathy. Acutely (first 2 weeks), this model is associated with impaired gait but no tissue loss. Chronically (2-6 weeks), this model delivers persistent ischemia, resulting in ischemic myopathy similar to that seen in PAD patients. This model may be of use for testing novel therapeutics including biologic therapies for promoting neovascularization and arteriogenesis.
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Affiliation(s)
- Chandler A Long
- Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Lucas H Timmins
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga
| | | | - Traci T Goodchild
- Cardiovascular Center of Excellence, Louisiana State University School of Medicine, New Orleans, La
| | - David J Lefer
- Cardiovascular Center of Excellence, Louisiana State University School of Medicine, New Orleans, La
| | | | | | - Luke P Brewster
- Department of Surgery, Emory University School of Medicine, Atlanta, Ga; Surgical and Research Services, Atlanta VA Medical Center, Atlanta, Ga.
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Abstract
Critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is associated with significant morbidity, mortality, and health care resource utilization. It is also associated with physical, as well as psychosocial, consequences such as amputation and depression. Importantly, after a major amputation, patients are at heightened risk of amputation on the contralateral leg. However, despite the technological advances to manage CLI with minimally invasive technologies, this condition often remains untreated, with significant disparities in revascularization and amputation rates according to race, socioeconomic status, and geographic region. Care remains disparate across medical specialties in this rapidly evolving field. Many challenges persist, including appropriate reimbursement for treating complex patients with difficult anatomy. This paper provides a comprehensive summary that includes diagnostic assessment and analysis, endovascular versus open surgical treatment, regenerative and adjunctive therapies, and other important aspects of CLI.
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Rundback JH, Armstrong EJ, Contos B, Iida O, Jacobs D, Jaff MR, Matsumoto AH, Mills JL, Montero-Baker M, Pena C, Tallian A, Uematsu M, Wilkins LR, Shishehbor MH. Key Concepts in Critical Limb Ischemia: Selected Proceedings from the 2015 Vascular Interventional Advances Meeting. Ann Vasc Surg 2016; 38:191-205. [PMID: 27569717 DOI: 10.1016/j.avsg.2016.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/01/2016] [Accepted: 08/03/2016] [Indexed: 01/28/2023]
Abstract
Over 500,000 patients each year are diagnosed with critical limb ischemia (CLI), the most severe form of peripheral artery disease. CLI portends a grim prognosis; half the patients die from a cardiovascular cause within 5 years, a rate that is 5 times higher than a matched population without CLI. In 2014, the Centers for Medicare and Medicaid Services paid approximately $3.6 billion for claims submitted by hospitals for inpatient and outpatient care delivered to patients with CLI. Although significant advances in diagnosis, treatment, and follow-up of patients with CLI have been made, many challenges remain. In this article, we summarize selected presentations from the 2015 Vascular Interventional Advances Conference related to the modern demographics, diagnosis, and management of patients with CLI.
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Affiliation(s)
- John H Rundback
- Interventional Institute, Holy Name Medical Center, Teaneck, NJ.
| | - Ehrin J Armstrong
- Department of Vascular Surgery, VA Eastern Colorado Healthcare System and University of Colorado, Denver, CO
| | | | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Donald Jacobs
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Michael R Jaff
- Department of Vascular Medicine, Massachusetts General Hospital, Boston, MA
| | - Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | - Constantino Pena
- Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL
| | | | - Masaaki Uematsu
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Luke R Wilkins
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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SPECT and PET imaging of angiogenesis and arteriogenesis in pre-clinical models of myocardial ischemia and peripheral vascular disease. Eur J Nucl Med Mol Imaging 2016; 43:2433-2447. [PMID: 27517840 PMCID: PMC5095166 DOI: 10.1007/s00259-016-3480-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/28/2016] [Indexed: 01/03/2023]
Abstract
Purpose The extent of neovascularization determines the clinical outcome of coronary artery disease and other occlusive cardiovascular disorders. Monitoring of neovascularization is therefore highly important. This review article will elaborately discuss preclinical studies aimed at validating new nuclear angiogenesis and arteriogenesis tracers. Additionally, we will briefly address possible obstacles that should be considered when designing an arteriogenesis radiotracer. Methods A structured medline search was the base of this review, which gives an overview on different radiopharmaceuticals that have been evaluated in preclinical models. Results Neovascularization is a collective term used to indicate different processes such as angiogenesis and arteriogenesis. However, while it is assumed that sensitive detection through nuclear imaging will facilitate translation of successful therapeutic interventions in preclinical models to the bedside, we still lack specific tracers for neovascularization imaging. Most nuclear imaging research to date has focused on angiogenesis, leaving nuclear arteriogenesis imaging largely overlooked. Conclusion Although angiogenesis is the process which is best understood, there is no scarcity in theoretical targets for arteriogenesis imaging.
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Hendrikx G, Vries MH, Bauwens M, De Saint-Hubert M, Wagenaar A, Guillaume J, Boonen L, Post MJ, Mottaghy FM. Comparison of LDPI to SPECT perfusion imaging using (99m)Tc-sestamibi and (99m)Tc-pyrophosphate in a murine ischemic hind limb model of neovascularization. EJNMMI Res 2016; 6:44. [PMID: 27234510 PMCID: PMC4883021 DOI: 10.1186/s13550-016-0199-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/20/2016] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to determine the accuracy of laser Doppler perfusion imaging (LDPI) in an animal model for hind limb ischemia. Methods We used a murine (C57Bl/6 mice) ischemic hind limb model in which we compared LDPI with the clinically used 99mTc-sestamibi SPECT perfusion imaging (n = 7). In addition, we used the SPECT tracer 99mTc-pyrophosphate (99mTc-PyP) to image muscular damage (n = 6). Results LDPI indicated a quick and prominent decrease in perfusion immediately after ligation, subsequently recovering to 21.9 and 25.2 % 14 days later in the 99mTc-sestamibi and 99mTc-PyP group, respectively. 99mTc-sestamibi SPECT scans also showed a quick decrease in perfusion. However, nearly full recovery was reached 7 days post ligation. Muscular damage, indicated by the uptake of 99mTc-PyP, was highest at day 3 and recovered to baseline levels at day 14 post ligation. Postmortem histology supported these findings, as a significantly increased collateral diameter was found 7 and 14 days after ligation and peak macrophage infiltration and TUNEL positivity was found on day 3 after ligation. Conclusions Here, we indicate that LDPI strongly underestimates perfusion recovery in a hind limb model for profound ischemia.
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Affiliation(s)
- Geert Hendrikx
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mark H Vries
- Department of Physiology, CARIM, Maastricht University, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Matthias Bauwens
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands
| | - Marijke De Saint-Hubert
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands
| | - Allard Wagenaar
- Department of Physiology, CARIM, Maastricht University, Maastricht, The Netherlands
| | - Joël Guillaume
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands
| | - Levinia Boonen
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands
| | - Mark J Post
- Department of Physiology, CARIM, Maastricht University, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Felix M Mottaghy
- Department of Nuclear Medicine, Maastricht University Medical Centre (MUMC+), Postbox 5800, AZ, 6202, Maastricht, The Netherlands. .,Department of Nuclear Medicine, University hospital, RWTH University, Aachen, Germany.
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Stacy MR, Qiu M, Papademetris X, Caracciolo CM, Constable RT, Sinusas AJ. Application of BOLD Magnetic Resonance Imaging for Evaluating Regional Volumetric Foot Tissue Oxygenation: A Feasibility Study in Healthy Volunteers. Eur J Vasc Endovasc Surg 2016; 51:743-9. [PMID: 26970710 DOI: 10.1016/j.ejvs.2016.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/09/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE/BACKGROUND To evaluate the feasibility and repeatability of applying blood oxygen level-dependent (BOLD) magnetic resonance imaging (MRI) in the feet to quantify regional dynamic changes in tissue oxygenation during proximal cuff occlusion and reactive hyperemia. METHODS Ten healthy male subjects underwent BOLD and T1-weighted imaging of the feet on two separate occasions, using a 3-T scanner. Dynamic changes in BOLD signal intensity were assessed before and during proximal cuff occlusion of the thigh and during reactive hyperemia, and BOLD time course data were evaluated for the time-to-half ischemic minimum, minimum ischemic value, peak hyperemic value, time-to-peak hyperemia, time-to-half peak hyperemia, and end value. T1-weighted images were used for segmentation of volumes of interest (VOI) in anatomical regions of the foot (heel, toes, dorsal foot, medial and lateral plantar foot). Repeatability of vascular responses was assessed for each foot VOI using semiautomated image registration and quantification of serial BOLD images. RESULTS The heel VOI demonstrated a significantly higher peak hyperemic response, expressed as percent change from baseline BOLD signal intensity, compared with all other VOIs of the foot (heel, 7.4 ± 1.2%; toes, 5.6 ± 0.8%; dorsal foot, 5.7 ± 1.6%; medial plantar, 5.6 ± 1.7%; lateral plantar, 5.6 ± 1.5% [p < .05]). Additionally, the lateral plantar VOI had a significantly lower terminal signal intensity value (i.e., end value) when compared with all foot VOIs (p < .05). BOLD MRI was repeatable between visits in all foot VOIs, with no significant differences between study visits for any of the evaluated functional indices. CONCLUSION BOLD MRI offers a repeatable technique for volumetric assessment of regional foot tissue oxygenation. Future application of BOLD imaging in the feet of patients with peripheral vascular disease may permit serial evaluation of regional tissue oxygenation and allow for improved assessment of therapeutic interventions targeting specific sites of the foot.
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Affiliation(s)
- M R Stacy
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - M Qiu
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - X Papademetris
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA; Department of Biomedical Engineering, Yale University School of Medicine, New Haven, CT, USA
| | - C M Caracciolo
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - R T Constable
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA; Department of Biomedical Engineering, Yale University School of Medicine, New Haven, CT, USA; Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - A J Sinusas
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
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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.
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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
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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: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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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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Stacy MR, Paeng JC, Sinusas AJ. The role of molecular imaging in the evaluation of myocardial and peripheral angiogenesis. Ann Nucl Med 2015; 29:217-23. [PMID: 25750124 PMCID: PMC4661208 DOI: 10.1007/s12149-015-0961-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/26/2015] [Indexed: 11/28/2022]
Abstract
Angiogenesis, or the formation of new microvasculature, is a physiological process that may occur in the setting of chronic tissue ischemia and can play an important role in improving tissue perfusion and blood flow following myocardial infarction or in the presence of peripheral vascular disease (PVD). Molecular imaging of angiogenesis within the cardiovascular system is a developing field of study. Targeted imaging of angiogenesis has the potential for non-invasive assessment of the underlying molecular signaling events associated with the angiogenic process and, when applied in conjunction with physiological perfusion imaging, may be utilized to predict and evaluate clinical outcomes in the setting of ischemic heart disease or PVD. This review discusses the developing radiotracer-based imaging techniques and technology currently in use that possess potential for clinical translation, with specific focus on PET and SPECT imaging of myocardial and peripheral angiogenesis.
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Affiliation(s)
- Mitchel R Stacy
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, Dana-3, P.O. Box 208017, New Haven, CT, 06520, USA
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Affiliation(s)
- Scott Kinlay
- Cardiovascular Division, VA Boston Healthcare System, West Roxbury, MA
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