The correlation between computed tomography and duplex evaluation of autogenous vein bypass grafts and their relationship to failure

OBJECTIVE

Duplex ultrasound (DUS) imaging for vein bypass graft (VBG) surveillance is confounded by technical and physiologic factors that reduce the sensitivity for detecting impending graft failure. In contrast, three-dimensional computed tomography angiography (CTA) offers high-fidelity anatomic characterization of VBGs, but its utility in detecting at risk grafts is unknown. The current study analyzed the correlation between DUS and CTA for detection of vein graft stenosis and evaluated the relationship of the observed abnormalities to VBG failure.

METHODS

Consecutive lower extremity VBG patients underwent surveillance with concurrent DUS imaging and CTA at 1 week and at 1, 6, and 12 months postoperatively. A standardized algorithm was used for CT reconstruction and extraction of the lumen geometries at 1-mm intervals. At each interval, CT-derived cross-sectional areas were coregistered and correlated to DUS peak systolic velocities (PSVs) within six predesignated anatomic zones and then analyzed for outcome association. Vein graft failure was defined as pathologic change within a given anatomic zone resulting in thrombosis, amputation, or reintervention within the 6-month period after the observed time point.

RESULTS

The study recruited 54 patients, and 10 (18%) experienced failure ≤18 months of implantation. The expected inverse relationship between cross-sectional area and PSV was only weakly correlated (Spearman rank coefficient = -0.19). Moderate elevations in the PSV ratio (PSVr; 2-3.5) were frequently transient, with 14 of 18 grafts (78%) demonstrating ratio reduction on subsequent imaging. A PSVr ≥3.5 was associated with a 67% failure rate. CT stenosis <50% was highly correlated with success (0 failures); however, high-grade (>80%) CT stenosis was more likely to succeed than to fail (25%). Significant discordance between CT and DUS was found in 18 patients. Although 14 of these patients had CT stenosis >70% with a PSVr <3.5, subsequent failure occurred in only two. Conversely, graft failure occurred in three of four patients with CT stenosis <70% but PSVr >3.5. Focused analysis of these patients using computational fluid dynamic modeling demonstrated that vein side branches, local tortuosity, regional diameter variations, and venovenostomies were the drivers of these discrepancies.

CONCLUSIONS

This analysis demonstrated that a PSVr ≥3.5 is strongly correlated with VBG failure, whereas the natural history of moderately elevated PSVr (2-3.5) is largely clinically benign. Although minimum stenosis on the CT scan was highly predictive of success, high-grade CT stenosis was infrequently associated with failure. The interaction of anatomic features with the local flow dynamics was identified as the primary confounder for a direct correlation between CT and DUS imaging.

Release mode of large and small dense-core vesicles specified by different synaptotagmin isoforms in PC12 cells

Different synaptotagmin isoforms (syt I, VII, and IX) sort to populations of dense-core vesicles with different sizes. These isoforms differ in their sensitivities to divalent cations and trigger different modes of exocytosis. Exocytosis triggered by these isoforms also differs in its sensitivity to inhibition by another isoform, syt IV.

Many cells release multiple substances in different proportions according to the specific character of a stimulus. PC12 cells, a model neuroendocrine cell line, express multiple isoforms of the exocytotic Ca²⁺ sensor synaptotagmin. We show that these isoforms sort to populations of dense-core vesicles that differ in size. These synaptotagmins differ in their Ca²⁺ sensitivities, their preference for full fusion or kiss-and-run, and their sensitivity to inhibition by synaptotagmin IV. In PC12 cells, vesicles that harbor these different synaptotagmin isoforms can be preferentially triggered to fuse by different forms of stimulation. The mode of fusion is specified by the synaptotagmin isoform activated, and because kiss-and-run exocytosis can filter small molecules through a size-limiting fusion pore, the activation of isoforms that favor kiss-and-run will select smaller molecules over larger molecules packaged in the same vesicle. Thus synaptotagmin isoforms can provide multiple levels of control in the release of different molecules from the same cell.