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In patients with a patent foramen ovale, use of air filters during intravenous infusions is common, but they are not compatible with power injection. Therefore we aimed to assess the incidence of paradoxical air embolism on CT of the chest and brain following contrast material injection through a power injector in patients with a patent foramen ovale, without the use of a filter. In this IRB approved, HIPAA compliant retrospective study, two independent radiologists reviewed 289 CT scans of the chest (n = 233) and brain (n = 56) for vascular air embolism following contrast material injection through a power injector in 93 subjects (43 men, mean age 66 y) with a known patent foramen ovale. The location and amount of the air were assessed. The medical records were reviewed for embolic symptoms. The prevalence and location of right sided and systemic luminal air were determined and inter-observer agreement for detection of intraluminal vascular air was calculated. Vascular air embolism was observed in 19.3% (56/289) of the studies; small in 52 and moderate in 4. In 42 studies, intravascular air was seen in a single territory and 14 studies had intravascular air in multiple territories. None had air in the left side of the heart or brain to suggest paradoxical air embolism. The inter-observer agreement for detection of vascular air was moderate (k = 0.6). Paradoxical air embolism in patients with a patent foramen ovale following contrast material injection with a power injector is rare. [ABSTRACT FROM AUTHOR]

Sandeep S Hedgire,1 Mari Mino-Kenudson,2 Azadeh Elmi,1 Sarah Thayer,3 Carlos Fernandez-del Castillo,3 Mukesh G Harisinghani11Department of Abdominal Imaging and Intervention, 2Department of Pathology, 3Department of Surgery, Massachusetts General Hospital, Boston, MA, USAPurpose: To evaluate the role of ferumoxytol-enhanced magnetic resonance imaging (MRI) in delineating primary pancreatic tumors in patients undergoing preoperative neoadjuvant therapy.Materials and methods: Eight patients with pancreatic adenocarcinoma were enrolled in this study, and underwent MRI scans at baseline, immediate post, and at the 48 hour time point after ferumoxytol injection with quantitative T2* sequences. The patients were categorized into two groups; group A received preoperative neoadjuvant therapy and group B did not. The T2* of the primary pancreatic tumor and adjacent parenchyma was recorded at baseline and the 48 hour time point. After surgery, the primary tumors were assessed histopathologically for fibrosis and inflammation.Results: The mean T2* of the primary tumor and adjacent parenchyma at 48 hours in group A were 22.11 ms and 16.34 ms, respectively; in group B, these values were 23.96 ms and 23.26 ms, respectively. The T2* difference between the tumor and adjacent parenchyma in group A was more pronounced compared to in group B. The tumor margins were subjectively more distinct in group A compared to group B. Histopathologic evaluation showed a rim of dense fibrosis with atrophic acini at the periphery of the lesion in group A. Conversely, intact tumor cells/glands were present at the periphery of the tumor in group B.Conclusion: Ferumoxytol-enhanced MRI scans in patients receiving preoperative neoadjuvant therapy may offer enhanced primary tumor delineation, contributing towards achieving disease-free margin at the time of surgery, and thus improving the prognosis of pancreatic carcinomas.Keywords: pancreatic cancer, tumor margin, neoadjuvant therapy, borderline resectable pancreatic cancer

Sandeep S Hedgire,1 Shaunagh McDermott,1 Gregory R Wojtkiewicz,1 Seyed Mahdi Abtahi,1 Mukesh Harisinghani,1 Jason L Gaglia21Center for Systems Biology, Massachusetts General Hospital, Richard B Simches Research Center, 2Joslin Diabetes Center, Boston, MA, USAPurpose: To evaluate the time-dependent changes in regional quantitative T2* maps of the kidney following intravenous administration of ferumoxytol.Materials and methods: Twenty-four individuals with normal kidney function underwent T2*-weighted MRI of the kidney before, immediately after, and 48 hours after intravenous administration of ferumoxytol at a dose of 4 mg/kg (group A, n=12) or 6 mg/kg (group B, n=12). T2* values were statistically analyzed using two-tailed paired t-tests.Results: In group A, the percentage changes from baseline to immediate post and baseline to 48 hours were 85.3% and 64.2% for the cortex and 90.8% and 64.6% for the medulla, respectively. In group B, the percentage changes from baseline to immediate post and baseline to 48 hours were 85.2% and 73.4% for the cortex and 94.5% and 74% for the medulla, respectively. This difference was significant for both groups (P

Bronchial artery embolization may be the only life-saving procedure available in a patient presenting with massive hemoptysis. Rarely, selective catheterization of these vessels may be rendered difficult due to a stenotic ostium. This may result in closure of the vessel or absence of forward flow after the stenotic segment is crossed with a diagnostic catheter or a microcatheter. Further, it may also lead to recurrence of hemoptysis if the distal vessel and the prearteriolar bed are inadequately embolized. We describe a technique of selective cannulation of the stenotic vessel, dilatation of the stenosis and then successful embolization.

Medical imaging is essential for the proper diagnosis and treatment of many diseases. The literature has found that medical imaging generally accounts for a significant percentage of total healthcare spending. We analyzed a national database between 2013 and 2021, with more than 19 million patients on average, to review which health conditions account for the highest spending on medical imaging in the Colombian health system. We segmented the analysis by type of medical imaging, life cycles, health condition and sex. Our findings indicate that cardiac and mental illnesses account for the highest per capita spending on medical imaging, especially for the elderly. As a proportion of total expenditure, hypertension and tuberculosis are added, with special emphasis on the infancy-childhood life cycle., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this research., (Copyright © 2024 Elsevier Inc. All rights reserved.)

People with human immunodeficiency virus (HIV, PWH) face an increased risk of cardiovascular disease (CVD) compared to the general population. We previously demonstrated that people with (versus without) HIV have higher macrophage-specific arterial infiltration in relation to systemic monocyte activation. We now show that select T lymphocyte subpopulations (naïve CD4+, effector memory CD4+, and central memory CD8+) are differentially associated with macrophage-specific arterial infiltration among participants with versus without HIV, with evidence of interaction by HIV status. Our results suggest that among PWH, circulating T lymphocytes associate with macrophage-specific arterial infiltration, of relevance to atherogenesis and CVD risk., Clinical Trials Registration: NCT02542371., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The visceral vasculature is inextricably intertwined with abdominopelvic disease staging, spread, and management in routine and emergent cases. Comprehensive evaluation requires specialized imaging techniques for abnormality detection and characterization. Vascular pathology is often encountered on nondedicated routine imaging examinations, which may obscure, mimic, or confound many vascular diagnoses. This review highlights normal arterial, portal venous, and systemic venous anatomy and clinically relevant variants; diagnostic pitfalls related to image-acquisition technique and disease mimics; and characteristics of common and rare vascular diseases to empower radiologists to confidently interpret the vascular findings and avoid misdiagnosis., Competing Interests: Disclosure Dr T.T. Pierce discloses equity and a consultant agreement with AutonomUS Medical Technologies Inc.; ongoing research support from General Electric, United States, the US Department of Defense, United States, and the National Institutes of Health, United States; prior research support from the Society of Abdominal Radiology, United States and American Roentgen Ray Society, United States; honoraria from the Massachusetts Society of Radiologic Technologists and Zhejiang Medical Association; and royalties from Elsevier Inc. No funding was received to assist with the preparation of the article. Dr V. Prabhu, Dr V. Baliyan, and Dr S. Hedgire have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time., Competing Interests: Disclosure The other authors declare no conflict of interest related to this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Heart transplantation is a pivotal treatment of end-stage heart failure, and recent advancements have extended median posttransplant life expectancy. However, despite the progress in surgical techniques and medical treatment, heart transplant patients still face complications such as rejection, infections, and drug toxicity. CT is a reliable tool for detecting most of these complications, whereas MR imaging is particularly adept at identifying pericardial pathologies and signs of rejection. Awareness of these nuances by radiologists, cardiologists, and surgeons is desired to optimize care, reduce morbidities, and enhance survival., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose This special report outlines a retrospective observational study of CT fractional flow reserve (CT-FFR) analysis using dual-source coronary CT angiography (CTA) scans performed without heart rate control and its impact on clinical outcomes. Materials and Methods All patients who underwent clinically indicated coronary CTA between August 2020 and August 2021 were included in this retrospective observational study. Scans were performed in the late systolic to early diastolic period without heart rate control and analyzed at the interpreting physician's discretion. Demographics, coronary CTA features, and rates of invasive coronary angiography (ICA), percutaneous coronary intervention (PCI), myocardial infarction, and all-cause death at 3 months were assessed by chart review. Results During the study period, 3098 patients underwent coronary CTA, of whom 113 with coronary bypass grafting were excluded. Of the remaining 2985 patients, 292 (9.7%) were referred for CT-FFR analysis. Two studies (0.7%) were rejected from CT-FFR analysis, and six (2.1%) analyses did not evaluate the lesion of concern. A total of 160 patients (56.3%) had CT-FFR greater than 0.80. Among patients with significant stenosis at coronary CTA, patients who underwent CT-FFR analysis presented with lower rates of ICA (74.5% vs 25.5%, P = .04) and PCI (78.9% vs 21.1%, P = .05). Conclusion CT-FFR was implemented in patients not requiring heart rate control by using dual-source coronary CTA acquisition and showed the potential to decrease rates of ICA and PCI without compromising safety in patients with significant stenosis and an average heart rate of 65 beats per minute. Keywords: Angiography, CT, CT-Angiography, Fractional Flow Reserve, Cardiac, Heart, Arteriosclerosis Supplemental material is available for this article. © RSNA, 2024.

Purpose: To identify associations between computed tomography (CT)-based lower-extremity calcium score (LECS) across different anatomic segments and the presence, severity, and clinical outcomes of peripheral artery disease (PAD)., Materials and Methods: In a mixed retrospective and prospective cohort study, 139 patients without prior lower-extremity intervention who underwent CT angiography of the aorta and lower extremities were identified. Subjects were classified as asymptomatic, claudicants, or having chronic limb-threatening ischemia (CLTI). LECS was measured using the Agatston method. Univariate and multivariate analyses were performed across categories of PAD severity. Receiver operating characteristic (ROC) analysis was performed, and an optimal cutoff point for LECS was identified. Claudicants were followed prospectively for CLTI and mortality., Results: Higher infrapopliteal calcium score (CS) was independently associated with CLTI versus claudication (odds ratio [OR], 3.24 per unit increase in log 10 -transformed CS; P < .001) in addition to hemodialysis dependence and poor functional status. One hundred eighty-eight Agatston units was identified as the optimal cutoff for infrapopliteal CS in assessing the risk of CLTI versus claudication (area under the ROC curve, 0.84 [SD ± 0.049]). This cutoff was validated in an independent cohort to be associated with progression to CLTI (OR, 12.8; P = .0039). In the claudicant group followed prospectively, infrapopliteal CS ≥188 predicted increased risk of CLTI or death after adjusting for functional status and hemodialysis dependence (Cox hazard ratio, 4.92; P = .0202)., Conclusions: Higher infrapopliteal CS was associated with CLTI among those with symptomatic PAD. An infrapopliteal CS cutoff of 188 Agatston units may serve as a useful tool to identify patients with increased risk of CLTI and mortality., (Copyright © 2023 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Type 2 myocardial infarction (MI) results from coronary supply and demand imbalance and has a poor prognosis. It is crucial to identify potential sex-based differences in the prevalence and nature of coronary artery disease (CAD) within this population., Objectives: The purpose of this study was to evaluate sex-based disease differences in type 2 MI among patients evaluated with coronary computed tomography angiography and fractional flow reserve., Methods: In a single-center, prospective study, patients with strictly adjudicated type 2 MI underwent coronary computed tomography angiography with fractional flow reserve., Results: Among 50 study participants enrolled, 50% were women. A similar mix of MI precipitants was present in both sexes. ST-segment depression was more common in women (64% vs 32%), while men were more likely to have T wave inversion (68% vs 36%). Women and men had comparable coronary artery calcium scores (median: 152 [Q1, Q3: 45, 762] vs 234 [Q1, Q3: 56, 422]). Prevalence of any CAD (84% vs 100%), obstructive CAD (24% vs 28%), and hemodynamically significant focal stenosis (20% vs 32%) were similar between sexes. Total plaque volume was similar between sexes, but women had significantly lower levels of low-attenuation plaque (median: 3 [Q1, Q3: 1, 7] vs 9 [Q1, Q3: 3, 14])., Conclusions: Among patients with type 2 MI, prevalence of any CAD and obstructive CAD did not differ according to sex. Total plaque volume was similar between sexes, but women had a lower volume of low-attenuation plaque (DEFINing the PrEvalence and Characteristics of Coronary Artery Disease Among Patients With TYPE 2 Myocardial Infarction Using CT-FFR [DEFINE TYPE2MI]; NCT04864119)., Competing Interests: Dr Wasfy is supported by 10.13039/100000968American Heart Association (18 CDA 34110215); is chair of the New England Comparative Effectiveness Public Affairs Council (CEPAC); has received grant support from the American Heart Association and the National Institutes of Health; and has received past consulting fees from Pfizer and Biotronik. Dr Januzzi is supported by the Hutter Family Professorship. Dr McCarthy has received consulting income from Abbott Laboratories and Roche Diagnostics. Dr Ghoshhajra is on the Executive Committee of the Society of Cardiovascular Computed Tomography (President); has received grant support from 10.13039/501100011699Siemens Healthineers and the 10.13039/100000002National Institutes of Health; and received consulting fees from Siemens Healthineers, Philips Healthcare, and 3DR Labs (all unrelated to this work). Dr Rogers is an employee and shareholder of HeartFlow, Inc. Dr Blankstein has received research support from 10.13039/100002429Amgen Inc and 10.13039/100004336Novartis Inc; and has served as a consultant/advisory board for Caristo Inc, Elucid Inc, Hearflow Inc, Beren Therapeutics, Nanox AI. Dr Januzzi is a Trustee of the American College of Cardiology; a Director at Imbria Pharmaceuticals; an Advisor at Jana Care; has received grant support from 10.13039/100001316Abbott, Applied Therapeutics, 10.13039/100020588HeartFlow Inc, Innolife, and 10.13039/100016545Roche Diagnostics; consulting income from Abbott, Janssen, Novartis, Merck, and Roche Diagnostics; and participates in clinical endpoint committees/data safety monitoring boards for Abbott, AbbVie, Bayer, CVRx, Intercept, Pfizer, and Takeda. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Type 2 myocardial infarction (T2MI) related to a supply/demand imbalance of coronary blood flow is common and associated with poor prognosis. Coronary artery disease (CAD) may predispose some individuals to T2MI and contribute to its high rate of recurrent cardiovascular events. Little is known about the presence and extent of CAD in this population., Objectives: The goal of this study was to evaluate the presence and characteristics of CAD among patients with T2MI., Methods: In this prospective study, consecutive eligible individuals with Fourth Universal Definition of Myocardial Infarction criteria for T2MI were enrolled. Participants underwent coronary computed tomography angiography (CTA), fractional flow reserve derived with coronary CTA (FFR CT ), and plaque volume analyses., Results: Among 50 participants, 25 (50%) were female, and the mean age was 68.0 ± 11.4 years. Atherosclerotic risk factors were common. Coronary CTA revealed coronary plaque in 46 participants (92%). A moderate or greater stenosis (≥50%) was identified in 42% of participants, and obstructive disease (≥50% left main stenosis or ≥70% stenosis in any other epicardial coronary artery) was present in 26%. Prevalence of obstructive CAD did not differ according to T2MI cause (P = 0.54). A hemodynamically significant focal stenosis identified by FFR CT was present in 13 participants (26%). Among participants with a stenosis ≥50% (n = 21), FFR CT excluded lesion-specific hemodynamically significant stenosis in 8 cases (38%)., Conclusions: Among individuals with adjudicated T2MI, CAD was prevalent, but the majority of patients had nonobstructive CAD. Mediators of ischemia are likely multifactorial in this population. (Defining the Prevalence and Characteristics of Coronary Artery Disease Among Patients with Type 2 Myocardial Infarction using CT-FFR [DEFINE TYPE 2 MI]; NCT04864119)., Competing Interests: Funding Support and Author Disclosures This work was supported by a grant from HeartFlow Inc. Dr McCarthy was supported by a National Heart, Lung, and Blood Institute T32 postdoctoral training grant (5T32HL094301-12); and has received consulting income from Abbott Laboratories and Roche Diagnostics. Dr Mohebi is supported by the Barry Fellowship. Dr Wasfy is supported by the American Heart Association (18 CDA 34110215); is chair of the New England Comparative Effectiveness Public Affairs Council (CEPAC); has received grant support from the American Heart Association and the National Institutes of Health; and has received consulting fees from Pfizer and Biotronik. Dr Januzzi is supported by the Hutter Family Professorship; is a Trustee of the American College of Cardiology; is a Director at Imbria Pharmaceuticals; is an advisor at Jana Care; has received grant support from Abbott, Applied Therapeutics, HeartFlow Inc, Innolife, and Roche Diagnostics; has received consulting income from Abbott, Janssen, Novartis, Merck, and Roche Diagnostics; and participates in clinical endpoint committees/data safety monitoring boards for Abbott, AbbVie, Bayer, CVRx, Intercept, Pfizer, and Takeda. Dr Ghoshhajra is on the Executive Committee of the Society of Cardiovascular Computed Tomography (President); has received grant support from Siemens Healthineers and the National Institutes of Health; and has received consulting fees from Siemens Healthineers, Philips Healthcare, and 3DR Labs (all unrelated to this work). Dr Rogers is an employee and shareholder of HeartFlow Inc. Dr Blankstein has received research support from Amgen Inc and Novartis Inc; and has served as a consultant/advisory board member for Caristo Inc, Elucid Inc, HeartFlow Inc, Beren Therapeutics, and Nanox.AI. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The COVID-19 pandemic disrupted the delivery of preventative care and management of acute diseases. This study assesses the effect of the COVID-19 pandemic on coronary calcium score and coronary CT angiography imaging volume., Materials and Methods: A single institution retrospective review of consecutive patients presenting for coronary calcium score or coronary CT angiography examinations between January 1, 2020 to January 4, 2022 was performed. The weekly volume of calcium score and coronary CT angiogram exams were compared., Results: In total, 1,817 coronary calcium score CT and 5,895 coronary CT angiogram examinations were performed. The average weekly volume of coronary CTA and coronary calcium score CT exams decreased by up to 83% and 100%, respectively, during the COVID-19 peak period compared to baseline (P < 0.0001). The post-COVID recovery through 2020 saw weekly coronary CTA volumes rebound to 86% of baseline (P = 0.024), while coronary calcium score CT volumes remained muted at only a 53% recovery (P < 0.001). In 2021, coronary CTA imaging eclipsed pre-COVID rates (P = 0.012), however coronary calcium score CT volume only reached 67% of baseline (P < 0.001)., Conclusions: A significant decrease in both coronary CTA and coronary calcium score CT volume occurred during the peak-COVID-19 period. In 2020 and 2021, coronary CTA imaging eventually superseded baseline rates, while coronary calcium score CT volumes only reached two thirds of baseline. These findings highlight the importance of resumption of screening exams and should prompt clinicians to be aware of potential undertreatment of patients with coronary artery disease., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To describe the design and methodological approach of a multicenter, retrospective study to externally validate a clinical and imaging-based model for predicting the risk of late adverse events in patients with initially uncomplicated type B aortic dissection (uTBAD)., Materials and Methods: The Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) is a collaboration between 10 academic aortic centers in North America and Europe. Two centers have previously developed and internally validated a recently developed risk prediction model. Clinical and imaging data from eight ROADMAP centers will be used for external validation. Patients with uTBAD who survived the initial hospitalization between January 1, 2001, and December 31, 2013, with follow-up until 2020, will be retrospectively identified. Clinical and imaging data from the index hospitalization and all follow-up encounters will be collected at each center and transferred to the coordinating center for analysis. Baseline and follow-up CT scans will be evaluated by cardiovascular imaging experts using a standardized technique., Results: The primary end point is the occurrence of late adverse events, defined as aneurysm formation (≥6 cm), rapid expansion of the aorta (≥1 cm/y), fatal or nonfatal aortic rupture, new refractory pain, uncontrollable hypertension, and organ or limb malperfusion. The previously derived multivariable model will be externally validated by using Cox proportional hazards regression modeling., Conclusion: This study will show whether a recent clinical and imaging-based risk prediction model for patients with uTBAD can be generalized to a larger population, which is an important step toward individualized risk stratification and therapy. Keywords: CT Angiography, Vascular, Aorta, Dissection, Outcomes Analysis, Aortic Dissection, MRI, TEVAR© RSNA, 2022See also the commentary by Rajiah in this issue., Competing Interests: Disclosures of conflicts of interest: D.M. Research grant from the National Institute of Biomedical Imaging and Bioengineering (no. 5T32EB009035); consulting fees from Segmed; stock or stock options in Segmed; member of Radiology: Cardiothoracic Imaging trainee editorial board. M.J.W. Postdoctoral Fellowship Award (no. 18POST34030192) from the American Heart Association, payments to author’s institution; consulting fees from Segmed; payment from GLG, AlphaInsight, and Guidepoint for expert testimony; leadership or fiduciary role in the Society of Cardiovascular Computed Tomography, unpaid; stock or stock options in Segmed. V.L.T. Shareholder of Segmed stock or stock options. V.H. No relevant relationships. M.C. Postdoctoral Fellowship Award (no. 826389) from the American Heart Association; payment or honoraria from FASTeR as lecturer for research methodology course; owner of stock options in Arterys; employee of Arterys. K.H. Payment or honoraria from Sanofi Genzyme and Amicus for lectures, presentations, speakers bureaus, manuscript writing, or educational events; participation on a Data Safety Monitoring Board or Advisory Board for Sanofi Genzyme; associate editor for Radiology: Cardiothoracic Imaging. M.O. No relevant relationships. D.O.T. No relevant relationships. R.O.A. Consultant for Medtronic and EndoRon; member of the Society for Vascular Surgery (SVS) Diversity Equity and Inclusion Committee and council member of the SVS Young Surgeon Section; shareholder for EndoRon and Voythus. S.H. No relevant relationships. N.S.B. Radiological Society of North America Research Scholar Grant (no. RSCH1801); entitled to royalties related to licensure of intellectual property to Imbio; patents planned, issued, or pending for U.S. patent number 10,896,507, Techniques of Deformation Analysis for Quantification of Vascular Enlargement in Aneurysmal Disease. B.Y. Honoraria from seminar hosted by Medtronic. J.M.L. Honoraria from Cardiovascular Institute of Philadelphia. T.G.G. No relevant relationships. D.P. No relevant relationships. G.F. No relevant relationships. L.L. Participation on the Medtronic Thoracic Hostile Neck Club Advisory Board, Barcelona, December 20, 2021. R.H. No relevant relationships. H.A. No relevant relationships. A.E.S. Member of Radiology: Cardiothoracic Imaging editorial board. E.C. No relevant relationships. S.M.J.v.K. No relevant relationships. G.W.H.S. No relevant relationships. A.M.S. No relevant relationships. K.B. No relevant relationships. D.C.M. No relevant relationships. M.P.F. No relevant relationships. D.F. Deputy editor for Radiology: Cardiothoracic Imaging., (© 2022 by the Radiological Society of North America, Inc.)

Background: Collaboration among cardiac surgeons and radiologists is essential to fully leverage advanced imaging technologies and improve the care of cardiac surgery patients. In this review, a cardiac surgeon and cardiovascular radiologist discuss imaging pearls and considerations in aortic dissection cases., Methods: The surgeon and the radiologist discuss imaging considerations in two aortic dissection cases., Results: It is essential to obtain and review all phases of a CTA when diagnosing acute aortic pathology. Optimizing scan parameters and careful multiplanar image review is necessary for adept interpretation. Current CT technology allows ECG gating to eliminate motion artifact and allow for dynamic assessment of the aortic pathology. Concurrent evaluation of thoracic aorta and coronary arteries is feasible. A systematic review of the scan using landmarks is critical for appropriate diagnosis and reporting. As TEVAR is increasingly used for arch repair, collaboration with radiologists is essential for preoperative planning in redo cases., Conclusions: Collaboration among cardiac surgeons and radiologists is mutually beneficial for surgeons, radiologists, and their patients., (© 2022 Wiley Periodicals LLC.)

Background: Persistent immune activation is thought to contribute to heightened atherosclerotic cardiovascular disease (ASCVD) risk among people with human immunodeficiency virus (PWH)., Methods: Participants (≥18 years) with or without human immunodeficiency virus (HIV) and without history of clinical ASCVD were enrolled. We hypothesized that increased macrophage-specific arterial infiltration would relate to plaque composition and systemic immune activation among PWH. We applied a novel targeted molecular imaging approach (technetium-99m [99mTc]-tilmanocept single photon emission computed tomography [SPECT]/CT) and comprehensive immune phenotyping., Results: Aortic 99mTc-tilmanocept uptake was significantly higher among PWH (n = 20) than participants without HIV (n = 10) with similar 10-year ASCVD risk (P = .02). Among PWH, but not among participants without HIV, noncalcified aortic plaque volume related directly to aortic 99mTc-tilmanocept uptake at different uptake thresholds. An interaction (P = .001) was seen between HIV status and noncalcified plaque volume, but not calcified plaque (P = .83). Systemic levels of caspase-1 (P = .004), CD14-CD16+ (nonclassical/patrolling/homing) monocytes (P = .0004) and CD8+ T cells (P = .005) related positively and CD4+/CD8+ T-cell ratio (P = .02) inversely to aortic 99mTc-tilmanocept uptake volume., Conclusions: Macrophage-specific arterial infiltration was higher among PWH and related to noncalcified aortic plaque volume only among PWH. Key systemic markers of immune activation relating to macrophage-specific arterial infiltration may contribute to heightened ASCVD risk among PWH., Clinical Trials Registration: NCT02542371., Competing Interests: Potential conflicts of interest. M. T. L. reports grant funding to his institution from AstraZeneca/MedImmune and Kowa Pharmaceuticals and consulting fees from PQBypass, unrelated to the present project. T. L. S. reports unrelated grant funding to her institution from Pfizer and Novo Nordisk. M. V. Z. is principal investigator of an industry-sponsored research grant from Gilead Sciences to her institution, unrelated to the present project. S. K. G. has grant funding to his institution from Gilead Sciences, KOWA Pharmaceuticals, and Theratechnologies, unrelated to the present project, and serves as a consultant for Theratechnologies, Regeneron, and ViiV Healthcare. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The purpose of this study was to identify the significant imaging predictors of transmural intestinal necrosis in patients with acute mesenteric ischemia (AMI)., Methods: The medical records and CT imaging of 48 patients between 2011 and 2019 suspected of having AMI that underwent exploratory laparotomy with bowel resection and pathological confirmation of ischemic bowel injury were retrospectively reviewed. Using histopathology as a gold standard, various parameters related to vascular insufficiency and bowel injury were analyzed and correlated with outcome of ischemic bowel necrosis using nonparametric tests. Univariate analysis was performed using Fisher's exact test followed by binary logistic regression test for multivariate analysis., Results: 48 Patients (19 females, 40%) with a median age of 68.5 years (IQR of 17 years) built our retrospective cohort. 26 (54%) patients were found to have transmural intestinal necrosis on histopathology (case group) whereas 22 (46%) patients had partial mucosal injury (control group). Pneumatosis intestinalis (p = 0.005, odd's ratio of 2.07-63.14) and severity (> 70% or complete occlusion) of vascular narrowing (p = 0.019, odd's ratio of 1.39-42.30) were identified as the most significant predictors of transmural ischemic necrosis on imaging. Dilatation of bowel did not approach the statistical significance on multivariate analysis although it was found significant on univariate analysis (p = 0.041)., Conclusion: Pneumatosis intestinalis and severity of vascular luminal narrowing are the most important imaging predictors of transmural ischemic bowel necrosis in patients presenting with AMI. The presence of these findings on CT scan should raise high index of suspicion for irreversible transmural ischemic necrosis. In the absence of these factors, endovascular management might be beneficial., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To develop and validate a deep learning-based system that predicts the largest ascending and descending aortic diameters at chest CT through automatic thoracic aortic segmentation and identifies aneurysms in each segment., Materials and Methods: In this retrospective study conducted from July 2019 to February 2021, a U-Net and a postprocessing algorithm for thoracic aortic segmentation and measurement were developed by using a dataset (dataset A) that included 315 CT studies split into training, hyperparameter-tuning, and testing sets. The U-Net and postprocessing algorithm were associated with a Digital Imaging and Communications in Medicine series filter and visualization interface and were further validated by using a dataset (dataset B) that included 1400 routine CT studies. In dataset B, system-predicted measurements were compared with annotations made by two independent readers as well as radiology reports to evaluate system performance., Results: In dataset B, the mean absolute error between the automatic and reader-measured diameters was equal to or less than 0.27 cm for both the ascending aorta and the descending aorta. The intraclass correlation coefficients (ICCs) were greater than 0.80 for the ascending aorta and equal to or greater than 0.70 for the descending aorta, and the ICCs between readers were 0.91 (95% CI: 0.90, 0.92) and 0.82 (95% CI: 0.80, 0.84), respectively. Aneurysm detection accuracy was 88% (95% CI: 86, 90) and 81% (95% CI: 79, 83) compared with reader 1 and 90% (95% CI: 88, 91) and 82% (95% CI: 80, 84) compared with reader 2 for the ascending aorta and descending aorta, respectively., Conclusion: Thoracic aortic aneurysms were accurately predicted at CT by using deep learning. Keywords: Aorta, Convolutional Neural Network, Machine Learning, CT, Thorax, Aneurysms Supplemental material is available for this article .© RSNA, 2022., Competing Interests: Disclosures of conflicts of interest: F.B.C.M. Work was sponsored by Nuance Communications (Montreal, Quebec, Canada) who had a relationship with the institution in which this work was developed, but not directly with the co-authors from the Center for Clinical Data Science or from the MGH. C.L. Institutional support from NVIDIA, GE, and Nuance Communications. J.S. Work was performed while at the Center for Clinical Data Science and was sponsored by Nuance Communications. A.T. Nuance Communications sponsored MGH & BWH Center for Clinical Data Science (CCDS) to perform the study. Author collaborated with the study but didn’t have any financial benefit or interaction with Nuance Communications. R.B. Support from Nuance Communications; stock/stock options in Nuance Communications. S.D. Payments made to CCDS/Partners Healthcare from Nuance Communications. M.Y. Work was sponsored by Nuance Communications, who had a relationship with CCDS, but not directly to this author. V.B. Nuance Communications partly sponsored this work at the MGH & BWH Center of Clinical Data Science, where author was employed. Author did not have a direct relationship with Nuance. S.H. No relevant relationships. B.G. Grants/contracts from Siemens Healthineers and National Institutes of Health (unrelated to current work); support from Siemens Healthineers for attending meetings/travel (unrelated to current work); executive committee (treasurer) of Society of Cardiovascular Computed Tomography., (2022 by the Radiological Society of North America, Inc.)

An 86-year old asymptomatic male was incidentally found to have a variant of levoatrial cardinal vein (LACV) forming a complete venous ring. This is the first report of this variant. Although rare, the ability to identify LACV in the adult population is clinically significant because it may result in bi-directional shunt and the development of symptoms is an indication for intervention., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Coronavirus disease 2019 (COVID-19) is associated with abnormal inflammatory and coagulation markers, potentially mediating thrombotic events. Our objective was to investigate the incidence, time course, laboratory features, and in-hospital outcomes of COVID-19 patients with suspected venous thromboembolism (VTE)., Methods: A retrospective observational cohort study was conducted of patients hospitalized with COVID-19 who had undergone ultrasound imaging for suspected VTE from March 13 to May 18, 2020. The medical records of the included patients were reviewed for D-dimer, fibrinogen, prothrombin time, partial thromboplastin time, platelet count, C-reactive protein (CRP), and high-sensitivity troponin T at admission and at up to seven time points before and after ultrasound examination. The clinical outcomes included superficial venous thrombosis, deep vein thrombosis, pulmonary embolism, intubation, and death. Mixed effects logistic, linear, and Cox proportional hazards methods were used to evaluate the relationships between the laboratory markers and VTE and other in-hospital outcomes., Results: Of 138 patients who had undergone imaging studies, 44 (31.9%) had evidence of VTE. On univariable analysis, an elevated admission CRP (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; P = .02; per 10-U increase in CRP), platelet count (OR, 1.48; 95% CI, 1.04-2.12; P = .03; per 1000-U increase in platelet count), and male sex (OR, 2.64; 95% CI, 1.19-5.84; P = .02), were associated with VTE. However only male sex remained significant on multivariable analysis (OR, 2.37; 95% CI, 1.01-5.56; P = .048). The independent predictors of death included older age (hazard ratio [HR], 1.04; 95% CI, 1.00-1.07; P = .04), active malignancy (HR, 4.39; 95% CI, 1.39-13.91; P = .01), elevated admission D-dimer (HR, 1.016; 95% CI, 1.003-1.029; P = .02), and evidence of disseminated intravascular coagulation (HR, 4.81; 95% CI, 1.76-13.10; P = .002)., Conclusions: Male sex, elevated CRP, and elevated platelet count at admission were associated with VTE on univariable analysis. However, only male sex remained significant on multivariable analysis. Older age, active malignancy, disseminated intravascular coagulation, and elevated D-dimer at admission were independently associated with death for patients hospitalized with COVID-19., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform a retrospective review of Coronary Artery Disease Reporting and Data System (CAD-RADS) adoption at a high-volume cardiac CT service., Materials and Methods: In this retrospective study, the adoption of CAD-RADS in 6562 coronary CT angiography (CTA) reports from January 1, 2017, to February 13, 2020, was evaluated. Reports without CAD-RADS were classified as opt-outs or exceptions to CAD-RADS. CAD-RADS classifications were retrospectively assigned to the opt-outs and the clinical indications for coronary CTA., Results: CAD-RADS scores were reported in 95% (6264 of 6562) of cases. Among the 5% ( n = 298) of reports not reported according to CAD-RADS, 58% ( n = 172) were considered opt-outs and 42% ( n = 126) were exceptions. Cases with higher degree of stenosis, stents, and coronary artery bypass grafts (CABGs) occurred more often in opt-outs versus reports with CAD-RADS (odds ratio [OR], 8.3 [95% CI: 1.6, 42.1]; P < .001). The quarterly opt-out rate decreased over consecutive quarters in the 1st year (OR, 0.77 [95% CI: 0.61, 0.96]; P = .01), then stabilized. Quarterly opt-out rate for patients with stents decreased over time (OR, 0.82 [95% CI: 0.73, 0.92]; P = .008), as did the opt-out rates in patients with CABG (OR, 0.83 [95% CI: 0.76, 0.91]; P < .001). Exceptions ( n = 126) included coronary dissections (44%), anomalous coronary arteries (41%), coronary artery aneurysms or pseudoaneurysms (10%), vasculitis (2%), stent complications (2%), and extrinsic compression of grafts (2%)., Conclusion: CAD-RADS was adopted rapidly and widely. Readers opted out of its use most often in complex cases of CAD, and the most common exceptions were coronary dissections and anomalous coronary artery. Keywords: Coronary Arteries, CT Angiography© RSNA, 2021., Competing Interests: Disclosures of Conflicts of Interest: A.K.T. disclosed no relevant relationships. V.T. disclosed no relevant relationships. R.J.G. disclosed no relevant relationships. J.D. disclosed no relevant relationships. S. Gupta disclosed no relevant relationships. S. Garrana Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author receives author royalties from Elsevier, unrelated to this study. Other relationships: disclosed no relevant relationships. V.K. disclosed no relevant relationships. A.T.R. disclosed no relevant relationships. M.T.L. disclosed no relevant relationships. N.M. disclosed no relevant relationships. U.H. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author received consultancy fees from Recor and Duke University; author’s institution has grants/grants pending from KOWA, Astra Zeneca, Medimmune, and HeartFlow. Other relationships: disclosed no relevant relationships. S.H. disclosed no relevant relationships. B.G. Activities related to the present article: author’s institution has grant support from Siemens Healthineers for cardiac CT research unrelated to this work; author is on the editorial board of Radiology: Cardiothoracic Imaging (not involved in handling of the article). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships., (2021 by the Radiological Society of North America, Inc.)

To assess if radiomics can differentiate left atrial appendage (LAA) contrast-mixing artifacts and thrombi on early-phase CT angiography without the need for late-phase images. Our study included 111 patients who underwent early- and late-phase, contrast-enhanced cardiac CT. Of these, 79 patients had LAA filling defects from thrombus (n = 46, mean age: 72  ±  12 years, M:F 26:20) or contrast-mixing artifact (n = 33, mean age: 71  ±  13 years, M:F 21:12) on early-contrast-enhanced phase. The remaining 32 patients (mean age: 66  ±  10 years, M:F 19:13) had homogeneous LAA opacification without filling defects. The entire LAA volume on early-phase CT images was manually segmented to obtain radiomic features (Frontier, Siemens). A radiologist assessed for the presence of LAA filling defects and recorded the size and mean CT attenuation (HU) of filling defects and normal LAA. The data were analyzed using multiple logistic regression with receiver operating characteristics area under the curve (AUC) as an output. The radiologist correctly identified all 32 patients without LAA filling defects, 42/46 LAA with thrombi, and 23/33 contrast mixing artifacts. Although HU of LAA thrombi and contrast mixing artifacts was significantly different, with the lowest AUC (0.66), it was inferior to both radiologist assessment and radiomics (p = 0.05). Combination of radiologist assessment and radiomics (AUC 0.92) was superior to HU (0.66), radiomics (0.85), and radiologist (0.80) alone (p < 0.008). Radiomics can differentiate between LAA filling defects from thrombi and contrast mixing artifacts on early-phase contrast-enhanced CT images without the need for late-phase CT.

BACKGROUND. Coronavirus disease (COVID-19) is known to be associated with a distinct form of coagulopathy. OBJECTIVE. The purpose of this study was to describe the imaging manifestations of COVID-19-associated coagulopathy across anatomic sites and modalities in hospitalized patients and to identify clinical variables associated with positive imaging findings. METHODS. We conducted a retrospective review of consecutive adult patients with COVID-19 admitted to our hospital over a 3-week period. Data on patient demographics, hematologic values, cross-sectional imaging examinations, and clinical outcomes (death and intubation) were collected. Imaging was reviewed for manifestations of coagulopathy. Multivariable logistic regression analyses were performed to assess associations of patient demographics, hematologic markers, and outcomes with the need for imaging and imaging manifestations of coagulopathy. RESULTS. Of 308 hospitalized patients with COVID-19, 142 (46%) underwent 332 cross-sectional imaging examinations. Of these, 37 (26%) had imaging results positive for coagulopathy. The most common imaging manifestations of coagulopathy were pulmonary embolus ( n = 21) on contrast-enhanced CT or CTA, thrombus in the upper- or lower-extremity veins ( n = 13) on Doppler ultrasound, end-organ infarction in the bowel ( n = 4) and kidney ( n = 4) on contrast-enhanced CT, and thrombus or parenchymal infarction in the brain ( n = 2) on contrast-enhanced CTA or MRI with MRA. Among patients with imaging results positive for coagulopathy, eight (22%) had multisite involvement. Thrombi were multifocal in four of five patients with positive upper-extremity and three of eight patients with positive lower-extremity examination results and involved superficial veins, deep veins, or both. In multivariable analysis, intubation ( p < .001) and prolonged prothrombin time ( p = .04) were significantly associated with undergoing imaging. No patient variable was significantly associated with imaging results positive for coagulopathy ( p > .05). CONCLUSION. Imaging commonly shows manifestations of coagulopathy in hospitalized patients with COVID-19. Over one-fifth of patients with such manifestations show multisite involvement. Clinical variables poorly predict which patients have positive imaging results, indicating a complementary role of imaging in detecting COVID-19-associated coagulopathy. CLINICAL IMPACT. In patients with COVID-19 with suspected systemic coagulopathy, pulmonary CTA, extremity Doppler ultrasound, contrast-enhanced abdominal CT, and contrast-enhanced brain MRI and MRA may all be appropriate in the absence of imaging contraindications.

Objective: There are no societal ultrasound (US) guidelines detailing appropriate patient selection for deep vein thrombosis (DVT) imaging in patients with COVID-19, nor are there protocol recommendations aimed at decreasing exposure time for US technologists. We aimed to provide COVID-19-specific protocol optimization recommendations limiting US technologist exposure while optimizing patient selection., Methods: A novel two-pronged algorithm was implemented to limit the DVT US studies on patients with COVID-19 prospectively, which included direct physician communication with the care team and a COVID-19-specific imaging protocol was instated to reduce US technologist exposure. To assess the pretest risk of DVT, the sensitivity and specificity of serum d-dimer in 500-unit increments from 500 to 8000 ng/mL and a receiver operating characteristic curve to assess performance of serum d-dimer in predicting DVT was generated. Rates of DVT, pulmonary embolism, and scan times were compared using t-test and Fisher's exact test (before and after implementation of the protocol)., Results: Direct physician communication resulted in cancellation or deferral of 72% of requested examinations in COVID-19-positive patients. A serum d-dimer of >4000 ng/mL yielded a sensitivity of 80% and a specificity of 70% (95% confidence interval, 0.54-0.86) for venous thromboembolism. Using the COVID-19-specific protocol, there was a significant (50%) decrease in the scan time (P < .0001) in comparison with the conventional protocol., Conclusions: A direct physician communication policy between imaging physician and referring physician resulted in deferral or cancellation of a majority of requested DVT US examinations. An abbreviated COVID-19-specific imaging protocol significantly decreased exposure time to the US technologist., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)