Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial

BACKGROUND

The prevalence of pulmonary embolism (PE) is approximately 11-17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined.

AIMS

To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD.

METHOD

Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy.

RESULTS

740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %-1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (-10.1 % to -32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %-3.4 %).

CONCLUSION

Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.

Assessment of using ultrasonography to teach abdominal and cervical anatomy in French medical curricula

PURPOSE

The objective of this work was to assess, in a quantitative and qualitative way, the teaching of cervical and abdominal anatomy via ultrasound for medical students.

METHODS

For several years, tutorials on the study of anatomy through use of ultrasound on the living organism have been given at the Medical School of Brest. These sessions have focused on cervical anatomy and abdominal anatomy. Students were invited to quantitatively assess these lessons by taking two tests containing questions on both cervical and abdominal anatomy and ultrasound technique: a pre-test administered at the beginning of the year and a post-test at the end of the year. In addition, a qualitative assessment was carried out at the end of the year. Ten statements were presented, and students were asked to indicate their agreement or disagreement to a four-point Likert scale.

RESULTS

One hundred and twelve students answered all the questions on the pre-test with an average of 13.4 correct answers out of 20. Forty-eight students answered all the questions on the post-test with an average of 14.6/20. Twenty-six students who benefited from the courses gave positive feedback about the workshops on the qualitative assessment at the end of the year (median scores >  = 3/4).

CONCLUSION

The results of this work suggest that the use of ultrasound makes a positive contribution to the teaching of anatomy. The students interviewed think this type of tutorial should be an integral part of the anatomy curriculum at our university. In addition, this type of instruction can serve to introduce the use of ultrasound itself in a practical learning setting.

Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication of a pulmonary embolism (PE) whose incidence and predictors are not precisely determined.

OBJECTIVE

To determine the frequency and predictors for CTEPH after a first unprovoked PE.

PATIENTS/METHODS

In a randomized trial comparing an additional 18-month warfarin versus placebo in patients after a first unprovoked PE initially treated with vitamin K antagonist for 6 months, we applied recommended CTEPH screening strategies through an 8-year follow-up to determine cumulative incidence of CTEPH. CTEPH predictors were estimated using Cox models. Pulmonary vascular obstruction (PVO) and systolic pulmonary arterial pressure (sPAP) at PE diagnosis and 6 months were studied by receiver operating curves analysis. All CTEPH cases and whether they were incident or prevalent were adjudicated.

RESULTS

During a median follow-up of 8.7 years, nine CTEPH cases were diagnosed among 371 patients, with a cumulative incidence of 2.8% (95% confidence interval [CI] 0.95-4.64), and of 1.31% (95% CI 0.01-2.60) after exclusion of five cases adjudicated as prevalent. At PE diagnosis, PVO > 45% and sPAP > 56 mmHg were associated with CTEPH with a hazard ratio (HR) of 33.00 (95% CI 1.64-667.00, p = .02) and 12.50 (95% CI 2.10-74.80, p < .01), respectively. Age > 65 years, lupus anticoagulant antibodies and non-O blood groups were also predictive of CTEPH. PVO > 14% and sPAP > 34 mmHg at 6 months were associated with CTEPH (HR 63.90 [95% CI 3.11-1310.00, p < .01]and HR 17.2 [95% CI 2.75-108, p < .01]).

CONCLUSION

After a first unprovoked PE, CTEPH cumulative incidence was 2.8% during an 8-year follow-up. PVO and sPAP at PE diagnosis and at 6 months were the main predictors for CTEPH diagnosis.

Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial

OBJECTIVE

The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.

METHODS

Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.

RESULTS

From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%).

CONCLUSIONS

Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

Safety and Efficacy of Cangrelor Among Three Antiplatelet Regimens During Stent-Assisted Endovascular Treatment of Unruptured Intracranial Aneurysm: A Single-Center Retrospective Study

Introduction

Thromboembolic events represent the most frequent complications of endovascular treatment of unruptured intracranial aneurysm using stent-assisted coilling or flow diverter stents. Dual antiplatelet therapy has become the standard to prevent these but remains unstandardized. We present here a single center experience of 3 standardized antiplatelet regimens during brain aneurysm treatment, while emphasizing the use of the Cangrelor.

Method

We retrospectively reviewed data from patients treated using stent-assisted coilling or flow diverter stents from 2016 to 2021. We collected and compared safety and efficacy data within 6 months of three groups of patients corresponding to three antiplatelet standardized regimens: group T with Ticagrelor, with preprocedural preparation; group E with Eptifibatide, injected during procedure; group C with Cangrelor, injected during procedure.

Results

Data of 112 patients were analyzed and 76 belonged to group T, 21 to group E, and 15 to group C. Eleven events over the 14 recorded were adjudicated to be related to antiplatelets, their repartition did not differ between the 3 groups (p = 0.43). All symptomatic events (N = 8) were not distributed significantly differently between the 3 groups (p = 0.11) and asymptomatic events were also balanced (p = 1.00). Of these, 6 subjects had a change in the mRS score at 3–6 months. Thrombo-embolic events represented the most encountered events in the sample: 2 acute ischemic strokes were recorded in group E and 1 in group T; 1 transient ischemic stroke was noted in group E; 4 silent infarcts were found on control MRI (2 belonged to group T, 1 to group E and 1 to group C). Among 3 intracranial bleeding events, 1 was symptomatic in group C, 2 were asymptomatic in group T. On the control evaluation performed at 6 months, there was no significant difference on aneurysmal occlusion (p = 0.67).

Conclusion

This single-center retrospective study compared 3 antiplatelet regimens, finding no significant difference in the safety and efficacy in the context of endovascular treatments of unruptured aneurysm using stent or flow diverters. This study adds data for the Cangrelor use and suggests its usefulness in the field of neuro-endovascular intervention. Randomized controlled studies are warranted to confirm these results.

Three-dimensional dispersion entropy for uterine fibroid texture quantification and post-embolization evaluation

BACKGROUND AND OBJECTIVE

Uterine fibroids are benign tumors that could lead to symptoms complicating a patient's daily life. Those fibroids can be treated using uterine fibroid embolization (UFE), an effective non-surgical procedure. However, objectively quantifying the benefits of such a procedure, and the patient's quality of life, is rather challenging.

METHODS

With a novel multiscale three-dimensional (3D) entropy-based texture analysis, the multiscale 3D dispersion entropy (MDispEn_3D), this work aims to objectively quantify the evolution -  after UFE  -  of patients' health in terms of quality of life, symptoms severity, and sexual function. For this purpose, clinical data and magnetic resonance imaging (MRI) scans of fibroids are analyzed before UFE (D0), ten days after (D10), and six months after (M6).

RESULTS

An inverse correlation is observed between MDispEn_3D entropy values and both size and volume of fibroids. An inverse correlation is also observed between MDispEn_3D at M6 and the scores of symptoms severity. Moreover, the patient age is found to be related to the relative difference of DispEn_3D and MDispEn_3D values, between D0 and M6, translating into an increasing entropy value. Furthermore, we show that history of fibroma plays a role in determining the obtained DispEn_3D values at D0. Finally, we observe that the lower MDispEn_3D values at D0, the larger the size of the fibroid at M6.

CONCLUSIONS

The proposed MDispEn_3D method - by quantifying fibroid texture - could assist the medical doctors in the prognosis of uterine fibroids and the patients' quality of life assessment post-UFE. It could therefore favor the choice of this treatment compared to other more invasive surgical treatments.

Long-term recurrence risk after a first venous thromboembolism in men and women under 50 years old: A French prospective cohort

BACKGROUND

Data on long-term venous thromboembolism (VTE) recurrence risk according to gender are conflicting.

OBJECTIVE

To evaluate long-term VTE recurrence risk after a first VTE in men and women under 50 years old.

METHODS

Since May 2000, 875 consecutive patients (315 men, 560 women) with a first symptomatic VTE under 50 years old were enrolled in a French prospective multicentre cohort study and were followed up as long as possible. The primary outcome was symptomatic recurrent VTE during follow-up.

RESULTS

At baseline, men were older and had more comorbidities than women. First VTE was mainly unprovoked in men (80.6%) and hormone-related in women (84.3%). During a median follow-up of 7.0 years (inter-quartile range, 5.0-11.0), recurrent VTE occurred in 97 men (30.8%) and in 72 women (12.9%) (annual incidence rates of recurrent VTE of 4.8% versus 1.8%-person-years, P<0.001). However, there was no difference according to gender in subgroups of patients with a first unprovoked VTE (5.8% versus 3.8%-person-years, P = 0.09). In women, duration of hormonal treatment before first VTE did not influence recurrence risk. In multivariable analysis, unprovoked VTE and family history of VTE were independently associated with recurrence (hazard ratio of 2.50 (95% confidence interval, 1.61 to 3.85) and 1.52 (1.11 to 2.09) respectively).

LIMITATIONS

Number of women with unprovoked VTE was low.

CONCLUSIONS

In patients with a first VTE under 50 years old, a first unprovoked episode and a family history of VTE, but not gender, were associated with a high risk of long-term recurrence.

The Impact of Pulmonary Vascular Obstruction on the Risk of Recurrence of Pulmonary Embolism: A French Prospective Cohort

BACKGROUND

 We aimed to assess whether high pulmonary vascular obstruction index (PVOI) measured at the time of pulmonary embolism (PE) diagnosis is associated with an increased risk of recurrent venous thromboembolism (VTE).

STUDY DESIGN AND METHODS

 French prospective cohort of patients with a symptomatic episode of PE diagnosed with spiral computerized tomography pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) lung scan and a follow-up of at least 6 months after anticoagulation discontinuation. PVOI was assessed based on the available diagnostic exam (V/Q lung scan or CTPA). All patients had standardized follow-up and independent clinicians adjudicated all deaths and recurrent VTE events. Main outcome was recurrent VTE after stopping anticoagulation.

RESULTS

 A total of 418 patients with PE were included. During a median follow-up period of 3.6 (1.2-6.0) years, 109 recurrences occurred. In multivariate analysis, PVOI ≥ 40% was an independent risk factor for recurrence (hazard ratio 1.77, 95% confidence interval 1.20-2.62, p < 0.01), whether PE was provoked by a major transient risk factor or not. A threshold at 41% was identified as the best value associated with the risk of recurrence 6 months after stopping anticoagulation (area under curve = 0.64).

CONCLUSION

 PVOI ≥ 40% at PE diagnosis was an independent risk factor for recurrence VTE. Further prospective validation studies are needed.

Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms

IMPORTANCE

The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain.

OBJECTIVE

To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017.

EXPOSURES

Acutely worsening respiratory symptoms in patients with COPD.

MAIN OUTCOMES AND MEASURES

The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not.

RESULTS

Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441).

CONCLUSIONS AND RELEVANCE

Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

Evaluation of Venous Thromboembolism Recurrence Scores in an Unprovoked Pulmonary Embolism Population: A Post-hoc Analysis of the PADIS-PE trial

BACKGROUND

We aimed to validate the Men Continue and HERDOO2 (HERDOO2), D-dimer, age, sex, hormonal therapy (DASH), and updated Vienna recurrent venous thromboembolism prediction models in a population composed entirely of first unprovoked pulmonary embolism, and to analyze the impact of the addition of the pulmonary vascular obstruction index (PVOI) on score accuracy.

METHODS

Analyses were based on the double-blind, randomized PADIS-PE trial, which included 371 unprovoked pulmonary embolism patients initially treated for 6 months, successively randomized to receive an additional 18 months of warfarin or placebo, and subsequently followed-up for 2 years.

RESULTS

The HERDOO2, DASH, and updated Vienna scores displayed C-statistics of 0.61 (95% CI 0.54-0.68), 0.60 (95% CI 0.53-0.66), and 0.58 (95% CI 0.51-0.66), respectively. Only the HERDOO2 score identified low recurrence risk patients (<3%/year) after anticoagulation was stopped. When added to either of the prediction models, PVOI measured at pulmonary embolism diagnosis, after 6 months of anticoagulation, or both, improved scores' C-statistics between +0.06 and +0.11 points and consistently led to identifying at least 50% of patients who experienced recurrence but in whom the scores would have indicated against extended anticoagulation.

CONCLUSIONS

In patients with a first unprovoked pulmonary embolism, the HERDOO2 score is able to identify patients with a low recurrence risk after treatment discontinuation. Addition of PVOI improves accuracy of all scores.

CLINICAL TRIALS REGISTRATION

URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

Volume variation may be a relevant metric in the study of aneurysm pulsatility: a study using ECG-gated 4D-CTA (PULSAN)

​Background and purpose

Intracranial aneurysms are a frequently occurring disease, with an estimated prevalence of 2–5% in the general population. They usually remain silent until rupture occurs, with a mortality rate of 35–50% and a high rate of morbidity, including long-term disability. However, preventative treatments have their own risk of complications and morbi-mortality rates, including stroke and hemorrhage. ECG-gated four-dimensional CT angiography (4D-CTA) allows the acquisition of time-resolved three-dimensional reconstructions. The aim of our study was to evaluate different intracranial aneurysm metrics over the cardiac cycle using ECG-gated 4D-CTA.

​Materials and methods

ECG-gated 4D-CTA datasets were acquired in patients presenting with intracranial aneurysms. Seven aneurysm metrics, including aneurysm height, aneurysm length, ostium width, aspect ratio, ostium area, volume, and volume-to-ostium ratio, were analysed over different cardiac phases. Intra-reader agreement, inter-reader agreement, and inter-cycle agreement were calculated through the intraclass correlation coefficient.

​Results

Twenty-one aneurysms from 11 patients were considered for inclusion. Post-processing failed for three aneurysms, and 18 aneurysms were finally analysed. There was good intra-reader agreement for each metric (ICC >0.9). Agreements among three consecutive cardiac cycles were calculated for six aneurysms and were especially good for the volume metric (ICC >0.9). Volume variation appears to be the most relevant metric and seems especially perceptible for aneurysms larger than 5 mm.

​Conclusions

Quantification of aneurysm volume changes during the cardiac cycle seems quantitatively possible and reproducible, especially for aneurysms larger than 5 mm. Further studies need to be conducted to validate this parameter for intracranial aneurysm assessment.

Predictors for Residual Pulmonary Vascular Obstruction after Unprovoked Pulmonary Embolism: Implications for Clinical Practice—The PADIS-PE Trial

Background We aimed to identify risk factors for residual pulmonary vascular obstruction after a first unprovoked pulmonary embolism (PE).

Methods Analyses were based on data from the double-blind randomized “PADIS-PE” trial that included 371 patients with a first unprovoked PE initially treated during 6 uninterrupted months; all patients underwent baseline ventilation–perfusion lung scanning at inclusion (i.e., after 6 months of anticoagulation). Each patient's pulmonary vascular obstruction indexes (PVOIs) at PE diagnosis and at inclusion were centrally assessed.

Results Among the 371 included patients, residual PVOI was available in 356 patients, and 150 (42.1%) patients had PVOI ≥ 5%. At multivariable analysis, age > 65 years (odds ratio [OR], 2.81, 95% confidence interval [CI], 1.58–5.00), PVOI ≥ 25% at PE diagnosis (OR, 3.53, 95% CI, 1.94–6.41), elevated factor VIII (OR, 3.89, 95% CI, 1.41–10.8), and chronic respiratory disease (OR, 2.18, 95% CI, 1.11–4.26) were independent predictors for residual PVOI ≥ 5%. Patients with ≥ 1 of these factors represented 94.5% (123 patients) of all patients with residual PVOI ≥ 5%.

Conclusion Six months after a first unprovoked PE, age > 65 years, PVOI ≥ 25% at PE diagnosis, elevated factor VIII, or chronic respiratory disease were found to be independent predictors for residual pulmonary vascular obstruction.

Clinical Trials Registration URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

Normal sonoanatomy of small joints in healthy children: changes in cartilage and vascularisation according to age and gender

OBJECTIVES

The metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints may be involved in juvenile idiopathic arthritis. Our goal was to describe their normal sonoanatomy in healthy children, according to age and gender.

METHODS

We studied 41 consecutive healthy children (20 girls, 21 boys; age 2-15 years) divided into four age groups: 2-4 years (n=9), 5-7 years (n=11), 8-12 years (n=12), and 13-15 years (n=9). Longitudinal ultrasound axis of the MCP and MTP joints were obtained. The evolution of the cartilage thickness and vascularisation of these joints were studied according to age and gender. The MCP or MTP joints were the statistical unit.

RESULTS

At all sites, on B-mode images, cartilage thickness was associated with age (p<0.0001). Cartilage thickness at different sites was significantly greater in boys than in girls (p≤0.05). Blood vessels were seen within the cartilage, with differences across age groups.

CONCLUSIONS

This study provides children's age- and gender-specific sonoanatomy data of MCP and MTP and confirms the importance of using colour Doppler or Power Doppler to study cartilage vascularisation.

The combination of targeted and systematic prostate biopsies is the best protocol for the detection of clinically significant prostate cancer

OBJECTIVE

Compared with standard systematic transrectal ultrasound (TRUS)-guided biopsies (SBx), targeted biopsies (TBx) using magnetic resonance imaging (MRI)/TRUS fusion could increase the detection of clinically significant prostate cancer (PCa-s) and reduce non-significant PCa (PCa-ns). This study aimed to compare the performance of the two approaches.

MATERIALS AND METHODS

A prospective, single-center study was conducted on all consecutive patients with PCa suspicion who underwent prebiopsy multiparametric MRI (mpMRI) using the Prostate Imaging Reporting and Data System (PI-RADS). All patients underwent mpMRI/TRUS fusion TBx (two to four cores/target) using UroStation™ (Koelis, Grenoble, France) and SBx (10-12 cores) during the same session. PCa-s was defined as a maximal positive core length ≥4 mm or Gleason score ≥7.

RESULTS

The study included 191 patients (at least one suspicious lesion: PI-RADS ≥3). PCa was detected in 55.5% (106/191) of the cases. The overall PCa detection rate and the PCa-s detection rate were not significantly higher in TBx alone versus SBx (44.5% vs 46.1%, p = .7, and 38.2% vs 33.5%, p = .2, respectively). Combined TBx and SBx diagnosed significantly more PCa-s than SBx alone (45% vs 33.5%, p = .02). PCa-s was detected only by TBx in 12% of cases (23/191) and only by SBx in 7.3% (14/191). Gleason score was upgraded by TBx in 16.8% (32/191) and by SBx in 13.6% (26/191) of patients (p = .4).

CONCLUSIONS

The combination of TBx and SBx achieved the best results for the detection and prognosis of PCa-s. The use of SBx alone would have missed the detection of PCa-s in 12% of patients.

Risk factors for recurrent venous thromboembolism after unprovoked pulmonary embolism: the PADIS-PE randomised trial

We aimed to identify risk factors for recurrent venous thromboembolism (VTE) after unprovoked pulmonary embolism.

Analyses were based on the double-blind randomised PADIS-PE trial, which included 371 patients with a first unprovoked pulmonary embolism initially treated during 6 months who were randomised to receive an additional 18 months of warfarin or placebo and followed up for 2 years after study treatment discontinuation. All patients had ventilation/perfusion lung scan at inclusion (i.e. at 6 months of anticoagulation).

During a median follow-up of 41 months, recurrent VTE occurred in 67 out of 371 patients (6.8 events per 100 person-years). In main multivariate analysis, the hazard ratio for recurrence was 3.65 (95% CI 1.33–9.99) for age 50–65 years, 4.70 (95% CI 1.78–12.40) for age >65 years, 2.06 (95% CI 1.14–3.72) for patients with pulmonary vascular obstruction index (PVOI) ≥5% at 6 months and 2.38 (95% CI 1.15–4.89) for patients with antiphospholipid antibodies. When considering that PVOI at 6 months would not be available in practice, PVOI ≥40% at pulmonary embolism diagnosis (present in 40% of patients) was also associated with a 2-fold increased risk of recurrence.

After a first unprovoked pulmonary embolism, age, PVOI at pulmonary embolism diagnosis or after 6 months of anticoagulation and antiphospholipid antibodies were found to be independent predictors for recurrence.

A new time-resolved 3D angiographic technique (4D DSA): Description, and assessment of its reliability in Spetzler-Martin grading of cerebral arteriovenous malformations

BACKGROUND AND PURPOSE

The Spetzler and Martin (SM) cerebral arteriovenous malformation (AVM) classification is a widely used 5-tier classification. This common language allows specialists to exchange about AVMs and must be reliably characterized by the imaging methods. We presented an agreement study on a new method of digital subtracted 3D rotational angiography resolved in time (four-dimensional DSA: 4D DSA) compared to the gold standard (two-dimensional DSA: 2D DSA) in AVM grading using the SM classification.

METHODS

Ten patients with AVMs were included during one year, they had an angiographic exploration with both 4D DSA and 2D DSA. Three readers assessed the SM classification. One reader conducted a second reading. The inter-, intra-observer and intermodality agreements were calculated by Kappas. Dose to patient was reported.

RESULTS

Considering the SM grade, the inter-observer agreement between 4D DSA and 2D DSA was equivalent (κ=0.45 and 0.46), and calculated as substantial κ=0.76 between the 2 methods. The agreement between 4D DSA and 2D DSA was calculated as moderate κ=0.46 assessing the size of the nidus, slight κ=0.18 analyzing the drainage and almost perfect κ=0.95 depicting the localization. 4D DSA performed during a standard initial angiographic assessment of AVM represented approximately 6% of the total dose.

CONCLUSION

The addition of this new technique 4D DSA could be performed regularly in addition to the 2D DSA if available, to assess SM grading, with an acceptable exposure to ionizing radiation.

Diagnostic Accuracy of Compression Ultrasonography for the Detection of Asymptomatic Deep Venous Thrombosis in Medical Patients

We assessed the accuracy of venous compression ultrasonography (CUS) for the detection of asymptomatic deep vein thrombosis in 122 consecutive patients, with a mean age of 69 years, who were hospitalised in an internal medicine unit. All included patients had CUS within 48 h of admission. Twelve out of 17 patients with a positive CUS underwent phlebography, as the others withdrew their consent, whereas the remaining 105 patients with a negative serial CUS testing were clinically followed-up at 3 months. We found that CUS had a sensitivity and a specificity of respectively 1 (95% CI, 0.73 to 1) and 1 (95% CI, 0.96 to 1) for the detection of asymptomatic deep vein thrombosis. Kappa-coefficients for intra-observer and inter-observer agreements were respectively 0.88 and 0.56. We concluded that venous compression ultrasonography, performed as described, fulfils requirements of a screening test that could be available for prophylactic clinical trials or epidemiological researches.

Current incidence of venous thromboembolism and comparison with 1998: a community-based study in Western France

In 1998 we estimated the incidence of venous thromboembolism (VTE) to be 1.8/1,000 per year. The aim of this study was to compare current VTE incidence to that observed in 1998. We prospectively recorded all cases of symptomatic pulmonary embolism (PE) and deep vein thrombosis (DVT) of the lower limbs diagnosed between March 1, 2013 and February 28, 2014 in hospitals and in the community, using the same method and geographic area than in 1998. The 2013 incidence rates of VTE were computed and compared with those of 1998 using age- and sex-specific standardised incidence ratios (SIRs). In 2013, we recorded 576 VTE cases (279 isolated DVT and 297 PE ± DVT). Among 367,911 inhabitants, the overall incidence of VTE was 1.57/1,000 (95 % CI 1.44–1.69). The overall VTE incidence was significantly lower in 2013 as compared with 1998: SIR 0.72 (95 % CI 0.67–0.79) as well as the incidence of isolated DVT: SIR 0.53 (95 % CI 0.47–0.60); conversely, the overall incidence of PE was unchanged: SIR 1.10 (95 % CI, 0.98–1.23) despite an increase in the incidence of isolated PE: SIR 1.29 (95 % CI, 1.10–1.52). In 1998, 4.4 % of PE cases were diagnosed using CTPA as compared with 73.7 % in 2013 (p < 0.001). In conclusion, between 1998 and 2013, the incidence of symptomatic DVT decreased. Conversely, we found no similar reduction in the incidence of symptomatic PE; whether this is due to changes in diagnostic tests and algorithms in the management of suspected PE requires further investigations.

Supplementary Material to this paper is available online at www.thrombosis-online.com.

Six Months vs Extended Oral Anticoagulation After a First Episode of Pulmonary Embolism: The PADIS-PE Randomized Clinical Trial

IMPORTANCE

The optimal duration of anticoagulation after a first episode of unprovoked pulmonary embolism is uncertain.

OBJECTIVES

To determine the benefits and harms of an additional 18-month treatment with warfarin vs placebo, after an initial 6-month nonrandomized treatment period on a vitamin K antagonist.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind trial (treatment period, 18 months; median follow-up, 24 months); 371 adult patients who had experienced a first episode of symptomatic unprovoked pulmonary embolism (ie, with no major risk factor for thrombosis) and had been treated initially for 6 uninterrupted months with a vitamin K antagonist were randomized and followed up between July 2007 and September 2014 in 14 French centers.

INTERVENTIONS

Warfarin or placebo for 18 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months after randomization. Secondary outcomes were the composite at 42 months (treatment period plus 24-month follow-up), as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months.

RESULTS

After randomization, 4 patients were lost to follow-up, all after month 18, and 1 withdrew due to an adverse event. During the 18-month treatment period, the primary outcome occurred in 6 of 184 patients (3.3%) in the warfarin group and in 25 of 187 (13.5%) in the placebo group (hazard ratio [HR], 0.22; 95% CI, 0.09-0.55; P = .001). Recurrent venous thromboembolism occurred in 3 patients in the warfarin group and 25 patients in the placebo group (HR, 0.15; 95% CI, 0.05-0.43); major bleeding occurred in 4 patients in the warfarin group and in 1 patient in the placebo group (HR, 3.96; 95% CI, 0.44 to 35.89). During the 42-month entire study period (including the study treatment and follow-up periods), the composite outcome occurred in 33 patients (20.8%) in the warfarin group and in 42 (24.0%) in the placebo group (HR, 0.75; 95% CI, 0.47-1.18). Rates of recurrent venous thromboembolism, major bleeding, and unrelated death did not differ between groups.

CONCLUSIONS AND RELEVANCE

Among patients with a first episode of unprovoked pulmonary embolism who received 6 months of anticoagulant treatment, an additional 18 months of treatment with warfarin reduced the composite outcome of recurrent venous thrombosis and major bleeding compared with placebo. However, benefit was not maintained after discontinuation of anticoagulation therapy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00740883.

Venous organization in the transverse foramen: dissection, histology, and magnetic resonance imaging

OBJECT

The anatomical arrangement of the venous system within the transverse foramen is controversial; there is disagreement whether the anatomy consists of a single vertebral vein or a confluence of venous plexus. Precise knowledge of this arrangement is necessary in imaging when vertebral artery dissection is suspected, as well as in surgical approaches for the cervical spine. This study aimed to better explain anatomical organization of the venous system within the transverse foramen according to the Trolard hypothesis of a transverse vertebral sinus.

METHODS

This was an anatomical and radiological study. For the anatomical study, 10 specimens were analyzed after vascular injection. After dissection, histological cuts were prepared. For the radiological study, a high-resolution MRI study with 2D time-of-flight segment MR venography sequences was performed on 10 healthy volunteers.

RESULTS

Vertebral veins are arranged in a plexiform manner within the transverse canal. This arrangement begins at the upper part of the transverse canal before the vertebral vein turns into a single vein along with the vertebral artery running from the transverse foramen of the C-6. This venous system runs somewhat ventrolaterally to the vertebral artery. In most cases, this arrangement is symmetrical and facilitates radiological readings. The anastomoses between vertebral veins and ventral longitudinal veins are uniform and arranged segmentally at each vertebra.

CONCLUSIONS

These findings confirm recent or previous anatomical descriptions and invalidate others. It is hard to come up with a common description of the arrangement of vertebral veins. The authors suggest providing clinicians as well as anatomists with a well-detailed description of components essential to the understanding of this organization.

Clinical-radiological correlation after functional endoscopic sinus surgery in patients with chronic rhinosinusitis: interest of a sinonasal aerial volumetry

BACKGROUND

Although a CT scan is often performed after functional endoscopic sinonasal surgery (FESS) in patients with chronic rhinosinusitis, its role hasn`t been firmly established. The goal of this study is to investigate the correlation between symptoms and CT findings before and after FESS for chronic rhinosinusitis. In addition, the interobserver agreement for both sinonasal aerial volumetry and CT score is assessed.

METHODS

Thirty-three patients surgically treated for chronic rhinosinusitis were included in this prospective study. Conventional and modified Lund-Mackay scores and sinonasal volumetry were determined by two radiologists before (M0), at 3 months (M3) and 1 year (M12) after surgery. The symptoms were evaluated by the 22-item SinoNasal Outcome Test (SNOT-22).

RESULTS

Change of SNOT-22 and air volume were significantly correlated between M0 and M12, but not between M0 and M3, for both readers. Compared to other scores, volume had the best intraclass correlation coefficient and reproducibility, according to the Bland-Altman analysis. No correlation was found between SNOT-22 and CT scores before and after surgery, except between M12 and M0 for one reader.

CONCLUSION

The correlation between CT scan and symptoms is low or absent. The measurement of sinonasal air volume is best correlated with the symptoms after surgery, with the best inter-observer agreement.

Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study

PURPOSE

To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis.

METHODS

DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS.

RESULTS

CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%.

CONCLUSION

Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.

[MR angiography of peripheral arterial disease of the distal legs: is time resolved MRA (TRICKS) necessary?]

PURPOSE

To demonstrate the added diagnostic value of time-resolved imaging of contrast kinetics (TRICKS) in the evaluation of lower limb arteries compared to standard 3 level MRA with stepping table method.

PATIENTS AND METHODS

Forty patients (30% diabetics) with lower extremity peripheral arterial disease (87.5% with chronic ischemia) underwent standard contrast MRA including TRICKS of the distal arteries. Five arterial segments were defined per leg, and 395 arterial segments were compared (one patient with amputation). Two reviewers evaluated the quality of arterial imaging, presence of venous return and degree of stenosis per segment. The degree of interobserver agreement for arterial stenosis measurement was calculated.

RESULTS

More arterial segments could be analyzed on the TRICKS sequence (good or excellent analysis in 63.03%-66.32% of arterial segments compared to 41.51%-47.08% on routine MRA). There was less venous contamination on TRICKS images (25.57% to 27.60% gain). The degree of interobserver agreement was superior with TRICKS compared to standard MRA (kappa 0.85 vs 0.69).

CONCLUSION

The TRICKS sequence can be added to standard MRA for pre-therapeutic evaluation of distal arteries in patients with peripheral arterial disease, especially with chronic ischemic with rest pain and/or trophic changes.

Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial

BACKGROUND

Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism.

METHODS

We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169.

FINDINGS

The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken.

INTERPRETATION

The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.

Iodixanol in multidetector-row computed tomography angiography (MDCTA): diagnostic accuracy for abdominal aorta and abdominal aortic major-branch diseases using four-, eight- and 16-detector-row CT scanners

PURPOSE

To compare iodixanol-enhanced multidetector-row computed tomography angiography (MDCTA) with digital subtraction angiography (DSA), perioperative angiography, or surgical findings in the evaluation of the abdominal aorta and its main branches.

MATERIAL AND METHODS

173 patients with known or suspected aortic aneurysms or stenosis/occlusion of the abdominal aorta or its major branches were enrolled. The iso-osmolar contrast medium iodixanol (320 mg Iota/ml) was used, and data were acquired using four-, eight-, or 16-active-detector-row scanners. Reference diagnoses were provided by surgical findings, interventional findings, or DSA. Diagnostic accuracy was estimated with reference to surgery or interventional arteriography or DSA. Image quality was assessed as excellent, good, sufficient, or insufficient, and correlations were made with attenuation values in the aortic lumen. Tolerability of iodixanol was monitored during the injection for discomfort and other adverse events, and for 72 hours after contrast injection.

RESULTS

In 132 of 136 evaluable cases, MDCTA diagnosis matched the reference diagnosis, yielding an agreement rate of 97.1% (95% CI 92.6-99.2%). The quality of most MDCTA scans (147/173) was rated as excellent. Overall mean attenuation was 305.7 HU. MDCTA appeared more accurate than DSA for identification of lesion calcification, thrombus, irregularity, and ulceration. Tolerability of iodixanol was good, and no serious adverse events were reported.

CONCLUSION

MDCTA using iodixanol is a promising, noninvasive alternative for evaluating patients with abdominal aortic disease.

Multi-slice computer tomography of left ventricular function with automated analysis software in comparison with conventional ventriculography

PURPOSE

To evaluate the accuracy of left ventricular volumetric and functional parameters from multi-slice computed tomography using automated analysis software, and to correlate results with those of invasive left ventriculography.

MATERIALS AND METHODS

In 145 consecutive patients (mean age, 61 years+/-12) known or suspected to have coronary artery disease, a 16-channel multi-slice computed tomography (Philips Mx8000 IDT 16) was performed using a standard technique. Using short-axis secondary multi-slice computed tomography reformations, we determined end-diastolic and end-systolic left ventricular volumes and ejection fraction with a commercially available analysis software capable of automated contour detection. Conventional left ventriculography was performed according to standard techniques within the following 24 h. Bland-Altman analysis was performed to calculate the limits of agreement and systematic errors between multi-slice computed tomography and conventional left ventriculography.

RESULTS

As determined by computer tomography, mean end-systolic (53+/-29 mL) left ventricular volumes had an acceptable correlation with conventional ventriculography (67+/-50 mL; r=0.74; p<0.001) and mean end-diastolic (119+/-33 mL) left ventricular volumes a poor correlation with conventional ventriculography measurements (154+/-69 mL; r=0.41). Left ventricular ejection fraction (57%+/-14 versus 55%+/-14 for conventional ventriculography; r=0.79) showed a very good correlation (p<0.001). Bland-Altman analysis showed acceptable limits of agreement (+/-9.2% for ejection fraction) without systematic errors.

CONCLUSION

The use of a multi-slice computed tomography with an automatic calculation software has a good correlation with conventional ventriculography findings and could accurately assess left ventricular function, but should not be used for ventricular volumes, because of biased estimations.

Abdominal and iliac arterial stenoses: comparative double-blinded randomized study of diagnostic accuracy of 3D MR angiography with gadodiamide or gadopentetate dimeglumine

PURPOSE

To prospectively evaluate accuracy of gadolinium-enhanced three-dimensional (3D) magnetic resonance (MR) angiography with gadodiamide and gadopentetate dimeglumine (0.1 mmol/kg), with intraarterial DSA as reference standard, for imaging abdominal and iliac arterial stenoses.

MATERIALS AND METHODS

The study was approved by all institutional review boards; informed consent was obtained from each subject before procedures. Two hundred forty-seven subjects were included; 240 received either contrast agent and were available for safety analysis; 222 were available for accuracy analysis. Enhanced 3D MR angiography and DSA were performed; image data were evaluated in a double-blinded randomized study. Stenoses were classified as not relevant (<50% stenosis) or relevant (> or =50%). For detection of main stenosis, accuracy with enhanced 3D MR angiography compared with that with DSA was determined.

RESULTS

The difference in accuracy for imaging with gadodiamide and gadopentetate was 3.6%. Noninferiority was inferred because the lower bound of the exact two-sided 95% confidence interval was -10.1 and was above the noninferiority margin (-15%). Accuracy for detection of the main stenosis was low, 56.4% for gadodiamide and 52.8% for gadopentetate group. Subgroup analysis with exclusion of inferior mesenteric artery and internal iliac arteries and the most false-positive stenosis classifications yielded better results: 76.6% and 71.6%, respectively. Sensitivity, specificity, and negative and positive predictive values did not differ substantially between study groups. In the main analysis, values were 44%, 96%, 35%, and 97% for gadodiamide and 44%, 83%, 30%, and 90% for gadopentetate, respectively. In the subgroup analysis, values were 66%, 95%, 61%, and 96% for gadodiamide and 63%, 86%, 58%, and 88% for gadopentetate, respectively.

CONCLUSION

Noninferiority of gadodiamide versus gadopentetate was verified based on the primary end point, which was accuracy for detection of the main stenosis with enhanced 3D MR angiography compared with DSA.

Plaque density on CT, a potential marker of ischemic stroke

The authors sought to determine in a retrospective analysis whether carotid plaque soft TD on CT is associated with recent ischemic neurologic events. Among 141 patients (99 asymptomatic), 106 plaques with more than 50% stenosis were selected for density measurements. They found an odds ratio for neurologic events associated with a 10-point decrease in density of 1.54 (p = 0.002), showing an association between plaque density and neurologic events.

Swallowing, arterial pulsation, and breathing induce motion artifacts in carotid artery MRI

PURPOSE

To identify and quantify the potential sources of motion in carotid artery imaging.

MATERIALS AND METHODS

Two healthy volunteers and 12 patients (20-75 years old) with atherosclerotic disease were scanned on a Philips Intera 1.5T system. A single-shot balanced-fast field echo (bFFE) sequence was used to acquire real-time axial views of the carotid artery wall (three images per second). A three-step acquisition protocol was performed to analyze the three types of motion (arterial pulsation, breathing, and swallowing) separately. The isocenter carotid artery motion amplitude in either the x or y direction was measured. Radial variation in the carotid lumen between the systolic and diastolic phases was analyzed. Motion frequency was reported for each patient.

RESULTS

Significant motion related to arterial pulsation (amplitude = 0.27-0.93 mm, mean = 0.6, SD = 0.19), breathing (amplitude = 0.5-3.6 mm, mean = 1.56, SD = 0.99)), and swallowing (amplitude = 1.4-9.2 mm, mean = 4.7, SD = 2.4) were visualized.

CONCLUSION

Pulsation, breathing, and swallowing are sources of significant motion in the carotid artery wall. Such motion should be considered in the future to improve carotid artery image quality.

Multi-detector row computed tomography angiography: an alternative imaging method for surgical strategy in lower extremity arterial occlusive disease

In order to show the value of CT angiography in the pretherapeutic assessment of lower leg ischemia, we studied 93 CT angiographies in 85 patients. Two groups were defined according to the level of revascularization: 52 angioscanner were made prior to suprainguinal revascularization and 41 prior to infrainguinal reconstruction. Two decision attitudes were chosen by two different physicians, a radiologist and vascular surgeon, members of the same team. The attitudes where then compared in order to evaluate the value of CT angiography. The first attitude was a pragmatic strategy based on the images as interpreted by the first physician and on the intraoperative information including surgical treatment and, if necessary, angiography. This indicates that the results of this attitude cover the performed revascularizations. The second attitude determined a virtual strategy and was chosen by the second physician a posteriori, based solely on the medical file with the same CT angiography images. These two strategies were compared in order to assess the agreement on the level of the lesion and the choice of revascularization. In 84 CT angiographies (90.3%), the analysis of the lesions and the choice of lesions to be treated were identical. In 9.6% of scans the strategies were not comparable because the lesions were interpreted differently or the scans were difficult to read. The sensitivity of CT angiography in detecting lesions and guiding the therapeutic strategy was 96% and its positive predictive value was 93%. Follow-up was reported according to the life-table method to assess the overall outcome and the results in both groups. The overall survival rate at 12 months for 85 patients was 90%. Secondary patency rates at 12 months in the group of patients who underwent a suprainguinal and infrainguinal revascularization were 98% and 71% respectively. Overall limb salvage at 12 months was 94%. In this setting, CT angiography allowed us to select adequate treatment in the majority of cases. These results obtained after a strategy based on CT angiography images are comparable with the results as published in the literature after the strategy based on conventional angiography.

Management of suspected venous thromboembolism: the impact of a multifaceted intervention

OBJECTIVE

To achieve a common strategy in the event of a suspected venous thromboembolism.

DESIGN

A multifaceted intervention, combining an audit strategy and implementation of local guidelines: phase 1, the first step, consisted of a 6-month audit to identify dysfunction; during phase 2, intervention, local guidelines were formulated by a working group and then implemented; phase 3 consisted of a re-audit over a 6-month period following the intervention.

SETTING

A tertiary hospital, France.

PARTICIPANTS

419 patients with suspected venous thromboembolism in phase 1; 287 patients with suspected pulmonary embolism in phase 3.

RESULTS

First phase: a dysfunction was observed in three of five criteria under study: (i) the diagnostic procedure lasted more than 48 hours in 114 patients (27.2%); (ii) no anticoagulant therapy at the time of suspicion in 116 patients (27.7%); (iii) an inconclusive lung scan without further testing in the event of a suspected pulmonary embolism in 40 patients (14%); the intervention phase was thus restricted to the management of suspected pulmonary embolism; similar results were found during the phase 3 re-audit.

CONCLUSION

No improvement in the diagnostic work-up in the event of a suspected pulmonary embolism was observed following this multifaceted intervention.

Assessment of coronary artery stents by 16 slice computed tomography

OBJECTIVE

To analyse coronary stents with multislice spiral computed tomography (MSCT) in comparison with coronary angiography.

PATIENTS AND METHODS

310 patients referred for conventional coronary angiography underwent MSCT on the next day (16 x 0.75 mm cross section, 420 ms rotation, 110 ml contrast agent intravenously at 4 ml/s). Two independent blinded reviewers analysed the MSCT.

RESULTS

143 patients had previous stenting (232 stents) and 190 (82%) of the 232 stents were detected. Intrastent lumen was interpretable in 126 (64%) of the detected stents. Lumen interpretability depended on stent diameter: for stent diameter > 3 mm, 81% of lumens were interpretable, as against 51% with < or = 3 mm stent diameter (p < 0.001). Restenosis detection likewise depended on stent diameter: with small stents (< or = 3 mm), sensitivity and specificity of MSCT were 54% and 100%, respectively; positive and negative predictive values were 100% and 94%. For stents with > 3 mm diameter, corresponding values were 86%, 100%, 100%, and 99%.

CONCLUSION

16 slice MSCT allows analysis of in-stent lumen in about half of all stented angioplasties. It performs better when stent diameter is more than 3 mm and may offer a non-invasive alternative to conventional coronary angiography for monitoring stented coronary arteries. Technical progress may improve interpretability and hence increase the yield of MSCT in this application.

Duplication droite de la veine cave inférieure

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

[Persistence of the stapedial artery: three cases]

The authors report three cases of persistence of the stapedial artery, discovered by computed tomography examination. For two cases, a clinical symptomatology was present but probably related to the association with an aberrant carotid artery in the middle ear; the only case of isolated persistence of the stapedial artery was asymptomatic. Direct visualisation of the abnormal artery was possible on the C. T. scans in two cases and a collateral sign as a larger tympanic part of the facial canal was found in the third case inducing a MRI. The incidence of this anomaly is 0.48 per cent from 1,045 dissections of temporal bones but it is generally clinically unrecognized. The hyoïdo-stapedial artery appears and develops at the 7-18 mm embryonic stages. Partial or complete persistence have been described associated with no regression or no division of the ventral pharyngeal artery.

Coexistence of annular pancreas with carcinoma in the dorsal part of pancreas divisum: diagnostic value of magnetic resonance cholangiopancreatography

We report on the incidental observation of a pancreas divisum coexistent with an annular pancreas in a 88-year-old woman presenting with jaundice due to a pancreatic carcinoma. This case report discusses the embryologic hypotheses underlying this peculiar association, highlights the capacities of imaging techniques to depict them, and enhances the performance of magnetic resonance imaging.

Concordance rate differences of 3 noninvasive imaging techniques to measure carotid stenosis in clinical routine practice: results of the CARMEDAS multicenter study

BACKGROUND AND PURPOSE

To replace digital subtraction angiography (DSA) in carotid stenosis evaluation, noninvasive imaging techniques have to reach a high concordance rate. Our purpose is to compare the concordance rates of contrast-enhanced MR angiography (CEMRA) and CT angiography (CTA) with Doppler ultrasound (DUS) in clinical routine practice.

METHODS

We evaluated prospectively with DUS, CEMRA, and CTA 150 patients suspected of carotid stenosis. The overall concordance rates of the 3 techniques were calculated for symptomatic stenosis > or =50% and > or =70%, for asymptomatic stenosis > or =60%, and for occlusion. For the carotid arteries treated by surgery (n=97), the results of each method and combined techniques were recorded, and misclassification rates were evaluated from surgical reports.

RESULTS

The overall concordance rates of DUS-CEMRA, DUS-CTA, and CEMRA-CTA were not statistically different. However, the concordance rate of DUS-CEMRA (92.53%) was significantly higher than that for DUS-CTA (79.10%) in the surgical asymptomatic stenosis group (P=0.0258). CTA considered alone would misclassify the stenosis in a significant number of cases (11 of 64) in the surgical asymptomatic group compared with CEMRA (3 of 67) and DUS (1 of 66) (P=0.0186 versus MRA, P=0.0020 versus DUS).

CONCLUSIONS

With the techniques as utilized in our study, the overall concordance rates of combined noninvasive methods are similar for measuring carotid stenosis in clinical routine practice, but in asymptomatic carotid stenosis, the decision making for surgery is significantly altered if DUS and CTA are considered in place of DUS and CEMRA.