Imaging characteristics and ECG distribution of coronary fistulas: The first large-scale study

BACKGROUND

The proportion of abnormal electrocardiogra (ECG) in patients with coronary artery fistula (CAF) is relatively high, but the correlation between CAF and arrhythmia is mostly reported in individual case studies. This paper analyzes the correlation between imaging features and ECG features.

OBJECTIVE

This paper aims to analyze the incidence and distribution characteristics of abnormal ECG in patients with CAF and further explore the difference in ECG characteristics between coronary-cameral fistula (CCF) and coronary-pulmonary artery fistula (CPAF).

METHOD

A total of 144,448 patients who underwent coronary computerized tomography angiography (CTA) examination from January 2016 to December 2022 were included in this study, and 284 patients with CAF (excluding coronary atherosclerosis) were selected for analysis of their ECG and image characteristics. And divided them into the CPAF (221 cases) and CCF (63 cases) groups, the differences in ECG between the two groups was compared. The changes in the ECG after the operation were analyzed.

RESULTS

The incidence of abnormal ECG in patients with CAF was approximately 72.9%. There were significant differences in the proportion of ECG block, myocardial ischemia and structural ECG changes between the CPAF group and CCF group (P < 0.05). CCF was more likely to cause conduction block and ischemic and structural ECG changes. A total of 53 patients with CAF underwent surgical treatment, 28 patients with improved ECG (52%).

CONCLUSION

CCF especially CCF patients often have abnormal ECG findings such as conduction block, myocardial ischemia, and structural changes, which can often be restored to normal through surgery.

Transient ischemic attack due to dynamic evolution of carotid artery web

Carotid artery web (CaW) is a rare focal fibromuscular dysplasia, which is an underappreciated risk factor for transient ischemic attack. This case illustrates the dynamic evolution of secondary thrombus and plaque in CaW, and the importance of carotid doppler ultrasound in early detection and follow-up.

A U-Shaped Network Based on Multi-level Feature and Dual-Attention Coordination Mechanism for Coronary Artery Segmentation of CCTA Images

PURPOSE

Computed tomography coronary angiography (CCTA) images provide optimal visualization of coronary arteries to aid in diagnosing coronary heart disease (CHD). With the deep convolutional neural network, this work aims to develop an intelligent and lightweight coronary artery segmentation algorithm that can be deployed in hospital systems to assist clinicians in quantitatively analyzing CHD.

METHODS

With the multi-level feature fusion, we proposed Dual-Attention Coordination U-Net (DAC-UNet) that achieves automated coronary artery segmentation in 2D CCTA images. The coronary artery occupies a small region, and the foreground and background are extremely unbalanced. For this reason, the more original information can be retained by fusing related features between adjacent layers, which is conducive to recovering the small coronary artery area. The dual-attention coordination mechanism can select valid information and filter redundant information. Moreover, the complementation and coordination of double attention factors can enhance the integrity of features of coronary arteries, reduce the interference of non-coronary arteries, and prevent over-learning. With gradual learning, the balanced character of double attention factors promotes the generalization ability of the model to enhance coronary artery localization and contour detail segmentation.

RESULTS

Compared with existing related segmentation methods, our method achieves a certain degree of improvement in 2D CCTA images for the segmentation accuracy of coronary arteries with a mean Dice index of 0.7920. Furthermore, the method can obtain relatively accurate results even in a small sample dataset and is easy to implement and deploy, which is promising. The code is available at: https://github.com/windfly666/Segmentation .

CONCLUSION

Our method can capture the coronary artery structure end-to-end, which can be used as a fundamental means for automatic detection of coronary artery stenosis, blood flow reserve fraction analysis, and assisting clinicians in diagnosing CHD.

The Role of Triple Rule-out CT in an Indian Emergency Setting

Background

Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way.

Materials and methods

Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings.

Results

Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv).

Conclusion

Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases.

How to cite this article

Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

Radiological classification of azygos anterior cerebral artery and evaluation of the accompanying vascular anomalies

PURPOSE

There is not a classification of azygos anterior cerebral artery (ACA) based on anatomical branching levels in the literature. In the present study, a classification of azygos ACA was made based on radiological imaging for a common terminology, and frequency, accompanying vascular anomalies and malformations were investigated.

METHODS

A total of 4913 cases who had brain CTA, MRA, contrast-enhanced MRI and DSA in January 2010-January 2020 period were screened for the study. Based on anatomical branching level, azygos ACAs were classified into four groups. Aneurysms, anomalies and malformations accompanying azygos ACA were identified. The associations of azygos ACA types with the presence of aneurysm or ACA A1 segment anomalies were investigated.

RESULTS

Azygos ACA was observed in 57 cases (29 male and 28 female) and frequency of azygos ACA was 1.16%. Average age of the cases with ACA was 56.19 ± 19.65 years. Forty-eight of the cases had type C azygos ACA, four cases type B, four cases type D and one case type A azygos ACA. A total of nine intracranial aneurysms were identified in seven of the cases (12.28%). Five of the aneurysms were located in MCA and four in distal ACA. Most common vascular anomalies accompanying azygos ACA were unilateral vertebral artery hypoplasia and ACA A1 segment hypoplasia. Azygos types did not have significant correlations with the presence of aneurysms or ACA A1 segmental anomalies (p = 0.683 and p = 0.949, respectively).

CONCLUSION

Azygos ACA is a rare variation, but it could be accompanied by aneurysms or other vascular anomalies.

Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging

Pulmonary contrast enhanced magnetic resonance angiography (CE-MRA) is useful for the primary diagnosis of pulmonary embolism (PE). Many sites have chosen not to use CE-MRA as a first line of diagnostic tool for PE because of the speed and higher efficacy of computerized tomographic angiography (CTA). In this review, we discuss the strengths and weaknesses of CE-MRA and the appropriate imaging scenarios for the primary diagnosis of PE derived from our unique multi-institutional experience in this area. The optimal patient for this test has a low to intermediate suspicion for PE based on clinical decision rules. Patients in extremis are not candidates for this test. Younger women (< 35 years of age) and patients with iodinated contrast allergies are best served by using this modality We discuss the history of the use of this test, recent technical innovations, artifacts, direct and indirect findings for PE, ancillary findings, and the effectiveness (patient outcomes) of CE-MRA for the exclusion of PE. Current outcomes data shows that CE-MRA and NM V/Q scans are effective alternative tests to CTA for the primary diagnosis of PE.

A 3-D ultrasound imaging robotic system to detect and quantify lower limb arterial stenoses: in vivo feasibility

The degree of stenosis is the most common criterion used to assess the severity of lower limb peripheral arterial disease. Two-dimensional ultrasound (US) imaging is the first-line diagnostic method for investigating lesions, but it cannot render a 3-D map of the entire lower limb vascular tree required for therapy planning. We propose a prototype 3-D US imaging robotic system that can potentially reconstruct arteries from the iliac in the lower abdomen down to the popliteal behind the knee. A realistic multi-modal vascular phantom was first conceptualized to evaluate the system's performance. Geometric accuracies were assessed in surface reconstruction and cross-sectional area in comparison to computed tomography angiography (CTA). A mean surface map error of 0.55 mm was recorded for 3-D US vessel representations, and cross-sectional lumen areas were congruent with CTA geometry. In the phantom study, stenotic lesions were properly localized and severe stenoses up to 98.3% were evaluated with -3.6 to 11.8% errors. The feasibility of the in vivo system in reconstructing the normal femoral artery segment of a volunteer and detecting stenoses on a femoral segment of a patient was also investigated and compared with that of CTA. Together, these results encourage future developments to increase the robot's potential to adequately represent lower limb vessels and clinically evaluate stenotic lesions for therapy planning and recurrent non-invasive and non-ionizing follow-up examinations.

Is computerized tomography angiographic surveillance valuable for prevention of tracheoinnominate artery fistula, a life-threatening complication after tracheostomy?

OBJECTIVE

The aim of this study was to evaluate the utility of volume-rendered helical computerized tomography (CT) angiography focusing tracheostomy tube and innominate artery for prevention of tracheoinnominate artery fistula.

METHODS

The authors retrospectively analyzed 22 patients with tracheostomy who had checked CT angiography. To evaluate the relationship between tracheostomy tube and innominate artery, we divided into three categories. First, proximal tube position based on cervical vertebra, named "tracheostomy tube departure level (TTDL)". Second, distal tube position and course of innominate artery, named "tracheostomy tube-innominate artery configuration (TTIC)". Third, the gap between the tube and innominate artery, named "tracheostomy tube to innominate artery gap (TTIG)". The TTDL/TTIC and TTIG are based on 3-dimensional (3D) reconstruction around tracheostomy and enhanced axial slices of upper chest, respectively.

RESULTS

First, mean TTDL was 6.8±0.6. Five cases (23%) were lower than C7 vertebra. Second, TTIC were remote to innominate artery (2 cases; 9.1%), matched with it (14 cases; 63.6%) or crossed it (6 cases; 27.3%). Only 9% of cases were definitely free from innominate artery injury. Third, average TTIG was 4.3±4.6 mm. Surprisingly, in 6 cases (27.3%), innominate artery, trachea wall and tracheostomy tube were tightly attached all together, thus have much higher probability of erosion.

CONCLUSION

If low TTDL, match or crossing type TTIC with reverse-L shaped innominate artery, small trachea and thin TTIG are accompanied all together, we may seriously consider early plugging and tube removal.