Heiko Uthoff

Correlation of Carotid Artery Atherosclerotic Lesion Echogenicity and Severity at Standard US with Intraplaque Neovascularization Detected at Contrast-enhanced US

PURPOSEnTo correlate echogenicity and severity of atherosclerotic carotid artery lesions at standard ultrasonography (US) with the degree of intraplaque neovascularization at contrast material-enhanced (CE) US.nnnMATERIALS AND METHODSnThis HIPAA-compliant study was approved by the local ethics committee, and all patients provided informed consent. A total of 175 patients (113 [65%] men, 62 [35%] women; mean age, 67 years ± 10 [standard deviation]) underwent standard and CE US of the carotid artery. Lesion echogenicity (class I to IV), degree of stenosis, and maximal lesion thickness were evaluated for each documented atherosclerotic lesion. The degree of intraplaque neovascularization at CE US was categorized as absent (grade 1), moderate (grade 2), or extensive (grade 3). Correlation of neovascularization with echogenicity, degree of stenosis, and maximal lesion thickness was made by using Spearman ρ and χ(2) test for trend.nnnRESULTSnIn a total of 293 atherosclerotic lesions, echogenicity was inversely correlated with grade of intraplaque neovascularization (ρ = -0.199, P < .001). More echolucent lesions had a higher degree of neovascularization compared with more echogenic ones (P < .001). The degree of stenosis was significantly correlated with grade of intraplaque neovascularization (ρ = 0.157, P = .003). Lesions with higher degree of stenosis had higher grade of neovascularization (P = .008), and maximal lesion thickness increased with the grade of neovascularization (P < .001) and was significantly correlated with grade of neovascularization (ρ = 0.233, P < .001).nnnCONCLUSIONnNeovascularization visualized with CE US correlates with lesion severity and with morphologic features of plaque instability, contributing to the concept that more vulnerable plaques are more likely to have a greater degree of neovascularization. Therefore, CE US may be a valuable tool for further risk stratification of echolucent atherosclerotic lesions and carotid artery stenosis of different degrees.nnnSUPPLEMENTAL MATERIALnhttp://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10101008/-/DC1.

Central venous pressure and impaired renal function in patients with acute heart failure

To determine the relationship between central venous pressure (CVP) and renal function in patients with acute heart failure (AHF) presenting to the emergency department.

Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium-induced nephropathy: A randomized controlled trial

AIMSnThe most effective regimen for the prevention of contrast-induced nephropathy (CIN) remains uncertain. Our purpose was to compare two regimens of sodium bicarbonate with 24 h sodium chloride 0.9% infusion in the prevention of CIN.nnnMETHODS AND RESULTSnWe performed a prospective, randomized trial between March 2005 and December 2009, including 258 consecutive patients with renal insufficiency undergoing intravascular contrast procedures. Patients were randomized to receive intravenous volume supplementation with either (A) sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure or (B) sodium bicarbonate (166 mEq/L) 3 mL/kg for 1 h before and 1 mL/kg/h for 6 h after the procedure or (C) sodium bicarbonate (166 mEq/L) 3 mL/kg over 20 min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). The primary endpoint was the change in estimated glomerular filtration rate (eGFR) within 48 h after contrast. Secondary endpoints included the development of CIN. The maximum change in eGFR was significantly greater in Group B compared with Group A {mean difference -3.9 [95% confidence interval (CI), -6.8 to -1] mL/min/1.73 m2, P = 0.009} and similar between groups C and B [mean difference 1.3 (95% CI, -1.7-4.3) mL/min/1.73 m(2), P = 0.39]. The incidence of CIN was significantly lower in Group A (1%) vs. Group B (9%, P = 0.02) and similar between Groups B and C (10%, P = 0.9).nnnCONCLUSIONnVolume supplementation with 24 h sodium chloride 0.9% is superior to sodium bicarbonate for the prevention of CIN. A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen. ClinicalTrials.gov Identifier: NCT00130598.

Midregional pro-Adrenomedullin in addition to b-type natriuretic peptides in the risk stratification of patients with acute dyspnea: an observational study

IntroductionThe identification of patients at highest risk for adverse outcome who are presenting with acute dyspnea to the emergency department remains a challenge. This study investigates the prognostic value of the newly described midregional fragment of the pro-Adrenomedullin molecule (MR-proADM) alone and combined to B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) in patients with acute dyspnea.MethodsWe conducted a prospective, observational cohort study in the emergency department of a University Hospital and enrolled 287 unselected, consecutive patients (48% women, median age 77 (range 68 to 83) years) with acute dyspnea.ResultsMR-proADM levels were elevated in non-survivors (n = 77) compared to survivors (median 1.9 (1.2 to 3.2) nmol/L vs. 1.1 (0.8 to 1.6) nmol/L; P < 0.001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.81 (95% CI 0.73 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for MR-proADM, NT-proBNP and BNP, respectively (MRproADM vs. NTproBNP P = 0.38; MRproADM vs. BNP P = 0.009). For one-year mortality the AUC were 0.75 (95% CI 0.69 to 0.81), 0.75 (95% CI 0.68 to 0.81), 0.69 (95% CI 0.62 to 0.76) for MR-proADM, NT-proBNP and BNP, respectively without any significant difference. Using multivariate linear regression analysis, MR-proADM strongly predicted one-year all-cause mortality independently of NT-proBNP and BNP levels (OR = 10.46 (1.36 to 80.50), P = 0.02 and OR = 24.86 (3.87 to 159.80) P = 0.001, respectively). Using quartile approaches, Kaplan-Meier curve analyses demonstrated a stepwise increase in one-year all-cause mortality with increasing plasma levels (P < 0.0001). Combined levels of MR-proADM and NT-proBNP did risk stratify acute dyspneic patients into a low (90% one-year survival rate), intermediate (72 to 82% one-year survival rate) or high risk group (52% one-year survival rate).ConclusionsMR-proADM alone or combined to NT-proBNP has a potential to assist clinicians in risk stratifying patients presenting with acute dyspnea regardless of the underlying disease.

Novel applications of contrast-enhanced ultrasound imaging in vascular medicine

The use of contrast-enhanced ultrasound (CEUS) for vascular imaging indications has increased dramatically during the last decade. Ultrasound contrast agents are gas-filled microbubbles that are injected into the bloodstream and serve as strict intravascular reflectors of ultrasound waves. Numerous studies have addressed the potential clinical use of CEUS in different vascular fields including the carotid arteries, the abdominal aorta, renal arteries and the kidneys. In this review article we discuss the clinical value of contrast agents in vascular ultrasound by enhancing the vascular lumen, and more important, their role as a tool to deliver high resolution, real-time images of microvascular perfusion. Specifically, CEUS imaging of the carotid artery provides a novel, non-invasive method not only to improve the delineation of the vessel wall, but also for the assessment of the vasa vasorum and the ectopic vascularization of the atherosclerotic plaque (intraplaque neovascularization); probably providing a window to risk stratify atherosclerotic lesions and individuals by identifying vulnerable plaques prone to rupture causing vascular events. CEUS imaging has also emerged as a novel diagnostic tool in various aortic pathologies and particularly for the detection of endoleaks following endovascular treatment of abdominal aortic aneurysms. It is also a valuable tool for the assessment of the tissue perfusion in native and transplanted kidneys providing information on perfusion deficits of the parenchyma. Furthermore, a real-time CEUS method has recently been developed to assess the skeletal muscle microcirculation which could be used to study patients with peripheral arterial occlusive disease or diabetic microangiopathy. In the future, the use of targeted microbubbles could further enhance and expand the diagnostic capabilities of current vascular ultrasound imaging by detecting specific molecular processes that play a role in the pathophysiology of vascular disease.

Ultrasound-accelerated vs Standard Catheter-directed Thrombolysis—A Comparative Study in Patients with Iliofemoral Deep Vein Thrombosis

PURPOSEnTo compare the thrombolytic efficacy and safety of standard catheter-directed thrombolysis (CDT) and ultrasound (US)-accelerated thrombolysis (UAT) for the treatment of iliofemoral deep vein thrombosis (DVT).nnnMATERIALS AND METHODSnAll medical records of patients who underwent CDT or UAT for DVT between June 2004 and October 2011 at a single tertiary care center were reviewed. Target vein patency was graded according to a reporting standard by an independent interventional radiologist.nnnRESULTSnCDT was performed in 19 patients and UAT in 64 patients. The baseline parameters and DVT characteristics, including the duration of symptoms, the location, and the extension did not differ significantly between groups. Both treatment modalities were associated with a similar substantial resolution of thrombus load (CDT = 89%; interquartile range [IQR], 70%-100%; UAT = 82%; IQR, 55%-92% (P = .560). No significant differences in the lytic drug infusion rates, the total lytic doses, the total infusion time, and the use of adjunctive procedures were observed between groups. Major and minor bleeding complications were observed in 8.4% and 4.8% of the patients, with no difference between the treatment groups (P = .709 and P = .918, respectively). During a median follow-up of 35 months (20-55 months), three deaths and 16 cases of repeated thrombosis were observed. The estimated mean event-free survival time was longer after CDT (69 mo) compared with UAT (33 mo) (log-rank test P = .310).nnnCONCLUSIONSnThe present study failed to prove any substantial clinical benefit provided by UAT with regard to effectiveness or safety compared with standard CDT. Given the added costs of the US delivery device, prospective randomized data are needed to justify its widespread use for DVT treatment.

Central venous pressure at emergency room presentation predicts cardiac rehospitalization in patients with decompensated heart failure

To investigate the relationship between central venous pressure (CVP) at presentation to the emergency room (ER) and the risk of cardiac rehospitalization and mortality in patients with decompensated heart failure (DHF).

Auricular Cartilage Calcification and Adrenal Insufficiency

A healthy 60-year-old man presented to the emergency department with profound hypotension 1 day after sustaining a minor hand laceration with minimal blood loss. Physical examination revealed stiffness in both ears, and calcification of the ears was subsequently revealed on computed tomography (Panel A, arrows) and radiography (Panel B, arrows). The patients hemodynamic status improved promptly after administration of antibiotics and glucocorticoids, and he recovered with support from the intensive care unit. Throughout his 20-day hospital stay, bacterial cultures remained negative. Subsequent detailed investigations showed adrenal insufficiency resulting from autoimmune hypophysitis, with isolated failure to secrete corticotropin. Long-term glucocorticoid-replacement therapy .xa0.xa0.

Revascularization for renal-artery stenosis

To the Editor: The ASTRAL (Angioplasty and Stenting for Renal Artery Lesions) Investigators (Nov. 12 issue)1 found substantial risk but no clinical benefit from revascularization as compared with medical management in patients with atherosclerotic renovascular disease. A total of 806 patients at 57 hospitals were enrolled over the course of 7 years. On average, 2 patients per center per year underwent randomization, which indicates serious selection bias or inexperienced staff at centers with very low intervention rates. This concern is supported by a low rate of technical success (317 of 403 patients [79%] in the revascularization group) and a high rate of serious complication in 23 of 280 patients (8%) as compared with reports in the literature of 98% and 2%, respectively.2 In addition, the study design implies that optimal medical therapy was used to achieve normalized blood pressure in both groups. Thus, not only the blood pressure values but also the number of antihypertensive drugs used to achieve this goal should be taken into account. The issue of selection bias and the significantly lower number of antihypertensive drugs administered in the revascularization group (P = 0.03) preclude the definitive conclusion that renal-artery revascularization provides no clinical benefit.

How accurate is clinical assessment of neck veins in the estimation of central venous pressure in acute heart failure? Insights from a prospective study: How accurate is clinical assessment of neck veins in the estimation of central venous pressure in acute heart failure? Insights from a prospective stu

Medical history and physical examination are the primary diagnostic tools when assessing emergency department (ED) patients with suspected acute heart failure (AHF). Among physical signs, positive hepato-jugular reflux (HJR) and jugular vein distention (JVD) are considered to indicate elevated central venous pressure (CVP). Both are major Framingham heart failure criteria and evaluated with priority in dyspnoeic patients presenting to the ED. Unfortunately and in contrast to common perception, the accuracy of clinical neck vein assessment in estimating CVP in AHF patients presenting to the ED is largely unknown. This is a dilemma as treatment decisions are commonly based on estimating CVP from assessing neck veins in AHF. The recent development and validation of a non-invasive forearm vein compression ultrasound technique to reliably measure CVP1,2 allowed us to address this gap in knowledge and to evaluate the diagnostic accuracy of clinical neck vein examination for the detection of elevated CVP in AHF patients at ED presentation. This sub-study of the Basics in Acute Shortness of Breath Evaluation Study ( ClinicalTrials .gov identifier: NCT01831115) prospectively enrolled adult AHF patients at the time of ED presentation. Only patients with a final adjudicated diagnosis of AHF were included in this analysis. The study was approved by the local ethics committee, and patients gave written informed consent. At the time of presentation a physical examination was performed and documented by the treating ED physician using the standardized case report form used universally at the University Hospital Basel. Findings of the examination of the jugular veins were categorized as: normal (HJR–/JVD–), distended Figure 1 Box plots displaying central venous pressure (CVP) levels according to clinical neck vein examination. Comparison between groups by Jonckheere–Terpstra test. HJR+, patients with distended neck veins after provocation with maintained abdominal pressure; JVD+, patients with distended neck veins without provocation; JVD–/HJR–, patients with normal neck veins. HJR, hepato-jugular reflux; JVD, jugular vein distention.