Alison Wilcox

High-Dose B Vitamin Supplementation and Progression of Subclinical Atherosclerosis A Randomized Controlled Trial

Background and Purpose— Although plasma total homocysteine (tHcy) levels are associated with cardiovascular disease, it remains unclear whether homocysteine is a cause or a marker of atherosclerotic vascular disease. We determined whether reduction of tHcy levels with B vitamin supplementation reduces subclinical atherosclerosis progression. Methods— In this double-blind clinical trial, 506 participants 40 to 89 years of age with an initial tHcy >8.5 &mgr;mol/L without diabetes and cardiovascular disease were randomized to high-dose B vitamin supplementation (5 mg folic acid+0.4 mg vitamin B12+50 mg vitamin B6) or matching placebo for 3.1 years. Subclinical atherosclerosis progression across 3 vascular beds was assessed using high-resolution B-mode ultrasonography to measure carotid artery intima media thickness (primary outcome) and multidetector spiral CT to measure aortic and coronary artery calcium (secondary outcome). Results— Although the overall carotid artery intima media thickness progression rate was lower with B vitamin supplementation than with placebo, statistically significant between-group differences were not found (P=0.31). However, among subjects with baseline tHcy ≥9.1 &mgr;mol/L, those randomized to B vitamin supplementation had a statistically significant lower average rate of carotid artery intima media thickness progression compared with placebo (P=0.02); among subjects with a baseline tHcy <9.1 &mgr;mol/L, there was no significant treatment effect (probability value for treatment interaction=0.02). B vitamin supplementation had no effect on progression of aortic or coronary artery calcification overall or within subgroups. Conclusion— High-dose B vitamin supplementation significantly reduces progression of early-stage subclinical atherosclerosis (carotid artery intima media thickness) in well-nourished healthy B vitamin “replete” individuals at low risk for cardiovascular disease with a fasting tHcy ≥9.1 &mgr;mol/L.

Identifying, Characterizing, and Classifying Congenital Anomalies of the Coronary Arteries

The clinical manifestations of coronary artery anomalies vary in severity, with some anomalies causing severe symptoms and cardiovascular sequelae and others being benign. Cardiovascular computed tomography (CT) has emerged as the standard of reference for identification and characterization of coronary artery anomalies. Therefore, it is important for the reader of cardiovascular CT images to be thoroughly familiar with the spectrum of coronary artery anomalies. Hemodynamically significant anomalies include atresia, origin from the pulmonary artery, interarterial course, and congenital fistula. Non-hemodynamically significant anomalies include duplication; high origin; a prepulmonic, transseptal, or retroaortic course; shepherds crook right coronary artery; and systemic termination. In general, coronary arteries with an interarterial course are associated with an increased risk of sudden cardiac death. Coronary artery anomalies that result in shunting, including congenital fistula and origin from the pulmonary artery, are also commonly symptomatic and may cause steal of blood from the myocardium. Radiologists should be familiar with each specific variant and its specific constellation of potential implications.

Arch and visceral/renal debranching combined with endovascular repair for thoracic and thoracoabdominal aortic aneurysms

OBJECTIVE We report a single-center experience using the hybrid procedure, consisting of open debranching, followed by endovascular aortic repair, for treatment of arch/proximal descending thoracic/thoracoabdominal aortic aneurysms (TAAA). METHODS From 2005 to 2010, 51 patients (33 men; mean age, 70 years) underwent a hybrid procedure for arch/proximal descending thoracic/TAAA. The 30-day and in-hospital morbidity and mortality rates, and late endoleak, graft patency, and survival were analyzed. Graft patency was assessed by computed tomography, angiography, or duplex ultrasound imaging. RESULTS Hybrid procedures were used to treat 27 thoracic (16 arch, 11 proximal descending thoracic) and 24 TAAA (Crawford/Safi types I to III: 3; type IV: 12; type V: 9). The hybrid procedure involved debranching 47 arch vessels or 77 visceral/renal vessels using bypass grafts, followed by endovascular repair. Seventy-five percent of debranching and endovascular repair procedures were staged, with an average interval of 28 days. Major 30-day and in-hospital complications occurred in 39% of patients and included bypass graft occlusion in four, endoleak reintervention in two, and paraplegia in one. Mortality was 3.9%. During a mean follow-up of 13 months, three additional type II endoleaks required intervention, and one bypass graft occluded. No aneurysm rupture occurred during follow-up. Primary bypass graft patency was 95.3%. Actuarial survival was 86% at 1 year and 67% at 3 years. CONCLUSION The hybrid procedure is associated with acceptable rates of mortality and paraplegia when used for treatment of arch/proximal descending thoracic/TAAA. These results support this procedure as a reasonable approach to a difficult surgical problem; however, longer follow-up is required to appraise its ultimate clinical utility.

High-resolution CT pulmonary findings in adults with gaucher’s disease

The purpose of this study was to illustrate high-resolution computed tomography (HRCT) findings in symptomatic adult Gauchers disease patients. Five adult patients with Gauchers disease experienced dyspnea. These patient were first evaluated by chest X-ray (CXR) followed by HRCT. The chest X-ray on one patient demonstrated a calcified granuloma. Two patients had interstitial disease only seen on HRCT, and two patients had a combination of interstitial and alveolar disease giving a mosaic pattern better illustrated on HRCT. HRCT can be used following CXR to evaluate lung pathology in symptomatic adult Gauchers disease patients.

Incidental Myocardial Infarct on Conventional Nongated CT: A Review of the Spectrum of Findings With Gated CT and Cardiac MRI Correlation

OBJECTIVE Myocardial infarctions (MIs) are frequently evident on routine chest or abdominal CT, even when studies are not performed for cardiac-specific indications. However, the telltale signs of an MI may be easily overlooked. Herein, we present the spectrum of appearances of MIs, including areas of fat attenuation, myocardial calcifications, focal areas of wall thinning or aneurysm formation, and perfusion abnormalities. Thrombi, especially when present at the apex of the left ventricle, may also suggest an MI. CONCLUSION The increased use of CT in the evaluation of patients for a variety of indications gives the radiologist the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.

Anomalous coronary arteries: cardiovascular computed tomographic angiography for surgical decisions and planning.

Cardiovascular computed tomographic angiography (CCTA) provides an understanding of the three-dimensional (3D) coronary artery anatomy in relation to cardiovascular thoracic structures important to the surgical management of anomalous coronary arteries (ACAs). Although some ACA variants are not clinically significant, others can lead to ischemia/infarction, related acute ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death. The CCTA is important to surgical decision making, as it provides noninvasive visualization of the coronary arteries with (1) assessment of origin, course, and termination of coronary artery anomalies in the context of 3D thoracic anatomy, (2) characterization of anatomy helpful for differentiation of benign versus hemodynamically significant variants, (3) identification of other cardiothoracic anomalies, and (4) detection of coronary artery disease. High-risk ACA anatomy in the appropriate clinical setting can require surgical intervention with decisions including minimally invasive versus open sternotomy approach, correction via reimplantation of a coronary artery, alteration of the ACA course without reimplantation, or bypass of an ACA. Given the rarity of ACA, there is limited data in the literature, and significant controversy related to the management issues. The management of ACA requires comprehensive clinical history, thorough assessment of cardiac function, and detailed anatomic imaging. Future studies will need to address the long-term outcome based on detailed assessment of original anatomy and surgical approach.

Coronary artery ostial atresia: diagnosis of conotruncal anastomotic collateral rings using CT angiography.

In this paper we discuss 2 unprecedented examples of coronary ostial atresia in adults. The first case documents a case of left main ostial agenesis with intercoronary communication through a retroaortic Kugel anastomotic collateral. The second case describes a right coronary artery (RCA) ostial agenesis with a preconal intercoronary anastomosis in association with supravalvular pulmonary stenosis. While atresia of the left coronary artery ostium is a rare anatomic variant of the coronary circulation, atresia of the right coronary ostium is exceedingly rare and not reported in adults (1). Correlative images of coronary computed tomography angiography (CTA) using a 64-slice multidetector computed tomography and coronary catheterization angiograms are presented for both cases, and the arterial collateral pathways between the proximal right and left coronary systems are discussed. We also reviewed the differences between congenital and developmental forms of abnormalities.

Small airway involvement in interstitial lung disease: radiologic evidence

High resolution computed tomography (HRCT) has considerably improved the ability to diagnose and characterize interstitial lung disease (ILD). This paper assesses the role of HRCT in evaluating small airway disease associated with ILD particularly sarcoidosis, hypersensitivity pneumonitis, and interstitial pulmonary fibrosis.

Classic Images: Coronary Computed Tomographic Angiography

A number of congenital and acquired conditions may affect the coronary arteries, ranging from very common entities, such as atherosclerotic disease, to very rare coronary anomalies. Some of the conditions that affect the coronary arteries are unique in the body. As a result, readers of cardiac computed tomography are faced with several unique challenges in classifying and stratifying a wide array of diseases. Herein, we discuss some of the technical aspects of coronary computed tomographic angiography and review the spectrum of coronary abnormalities that may be detected with this modality. The typical imaging findings of common and uncommon coronary disease states will be demonstrated.

Caseous mitral annular calcifications: Multimodality imaging characteristics.

The authors report herein a series of 3 patients with caseous mitral annular calcifications (MAC). One of the patients presented with mass-like, caseous MAC as an incidental finding on a staging computed tomography (CT) for metastatic colorectal carcinoma. Another patient presented with a nodule on a chest radiograph, which was later found on CT to be due to caseous MAC. In the third patient, caseous MAC was initially detected on echocardiography, and was further evaluated with CT and cardiac magnetic resonance imaging. In all three patients, the appearances posed a diagnostic dilemma. The appearance of caseous MAC is dissimilar to non-caseous MAC and is usually seen as an ovoid, mass-like structure, with homogeneous hyperattenuation, representing a liquefied form of calcium and proteinaceous fluid. This homogeneous center is surrounded by peripheral, shell-like calcifications. Caseous MAC is likely an under-recognized entity and may present a diagnostic dilemma at CT, magnetic resonance imaging, or echocardiography.