Kurt A. Jäger

Blood Oxygenation Level–Dependent Magnetic Resonance Imaging of the Skeletal Muscle in Patients With Peripheral Arterial Occlusive Disease

Background— Blood oxygenation level–dependent (BOLD) magnetic resonance imaging (MRI) has been used to measure T2* changes in skeletal muscle tissue of healthy volunteers. The BOLD effect is assumed to primarily reflect changes in blood oxygenation at the tissue level. We compared the calf muscle BOLD response of patients with peripheral arterial occlusive disease (PAOD) to that of an age-matched non-PAOD group during postischemic reactive hyperemia. Methods and Results— PAOD patients (n=17) with symptoms of intermittent calf claudication and an age-matched non-PAOD group (n=11) underwent T2*-weighted single-shot multiecho planar imaging on a whole-body magnetic resonance scanner at 1.5 T. Muscle BOLD MRI of the calf was performed during reactive hyperemia provoked by a cuff-compression paradigm. T2* maps were generated with an automated fitting procedure. Maximal T2* change (&Dgr;T2*max) and time to peak to reach &Dgr;T2*max for gastrocnemius, soleus, tibial anterior, and peroneal muscle were evaluated. Compared with the non-PAOD group, patients revealed significantly lower &Dgr;T2*max-values, with a mean of 7.3±5.3% versus 13.1±5.6% (P<0.001), and significantly delayed time-to-peak values, with a mean of 109.3±79.3 versus 32.2±13.3 seconds (P<0.001). Conclusions— T2* time courses of the muscle BOLD MRI signal during postocclusive reactive hyperemia revealed statistically significant differences in the key parameters (&Dgr;T2*max; time to peak) in PAOD patients compared with age-matched non-PAOD controls.

Late acute thrombotic occlusion after endovascular brachytherapy and stenting of femoropopliteal arteries

OBJECTIVESnThe aim of this article is to underline the importance of this complication after endovascular brachytherapy (EVBT) and intravascular stenting of the femoropopliteal arteries occurring in a running randomized trial.nnnBACKGROUNDnEndovascular brachytherapy has been proposed as a promising treatment modality to reduce restenosis after angioplasty. However, the phenomenon of late acute thrombotic occlusion (LATO) in patients receiving EVBT after stenting is of major concern.nnnMETHODSnIn an ongoing prospective multicenter trial, patients were randomized to undergo EVBT (iridium 192; 14 Gy at a depth of the radius of the vessel +2 mm) after percutaneous recanalization of femoropopliteal obstructions. Of the 204 patients who completed the six months follow-up, 94 were randomized to EVBT.nnnRESULTSnLate acute thrombotic occlusion occurred exclusively in 6 of 22 patients (27%) receiving EVBT after intravascular stenting and always in concomitance with reduction of antithrombotic drug prevention (clopidogrel). Conversely, none of the 13 patients with stents and without EVBT (0%; p < 0.05) and none of the 72 patients (0%; p < 0.01) undergoing EVBT after simple balloon angioplasty presented LATO.nnnCONCLUSIONSnLate thrombotic occlusion occurs not only in patients undergoing EVBT after percutaneous coronary recanalization but also after stenting of the femoropopliteal arteries and may compromise the benefits of endovascular radiation. The fact that all our cases with LATO occurred concomitantly with stopping clopidogrel may indicate a possible rebound mechanism. An intensive and prolonged antithrombotic prevention is probably indicated in these patients.

Contrast-enhanced ultrasound for assessing carotid atherosclerotic plaque lesions

OBJECTIVEnContrast-enhanced ultrasound that is used to assess atherosclerotic carotid plaques improves visualization of vessel wall irregularities and provides direct visualization of intraplaque neovascularization. This article illustrates the use of contrast-enhanced ultrasound in the assessment of carotid atherosclerotic lesions.nnnCONCLUSIONnContrast-enhanced ultrasound is a new, noninvasive, and safe procedure for imaging carotid atherosclerotic lesions. It is a valuable tool for evaluating the vulnerable plaque at risk for rupture and for evaluating both the development and severity of systemic atherosclerotic disease.

Effects of probucol versus aspirin and versus brachytherapy on restenosis after femoropopliteal angioplasty: the PAB randomized multicenter trial.

Purpose: To evaluate the effect of probucol and/or of endovascular brachytherapy (EVBT) on restenosis after percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries. Methods: A total of 335 patients (206 men; mean age 72±9 years) with intermittent claudication were randomized according to a 2×2 factorial design to 1 of the 4 groups: probucol, placebo, EVBT, and EVBT+probucol. Probucol (1 g/d) or placebo were given in double-blinded fashion 1 month before and for 6 months after PTA. Gamma irradiation (192Iridium, 14 Gy, 5-mm reference depth) was randomly applied in an unblinded manner from a noncentered endoluminal catheter. All patients received aspirin (100 mg/d). Primary endpoint was restenosis (>50% diameter reduction) detected by duplex ultrasound 6 months after PTA. Secondary endpoints included clinical and hemodynamic assessment. Results: Restenosis in patients undergoing EVBT was 17% (23/133) versus 35% (50/142) in patients without EVBT (p<0.001); in patients treated with probucol versus placebo, the rates were 23% (31/135) and 30% (43/140, p<0.001). Three quarters (77%, 102/133) of patients were free of claudication after EVBT therapy versus 61% (87/142) without EVBT (p<0.05). Need for target vessel revascularization was 6% (8/133) with EVBT versus 14% (20/142) without EVBT (p<0.01). Late thrombotic occlusions occurred in 4% (6/133), exclusively in patients treated with EVBT after stent implantation. Conclusions: Endovascular brachytherapy significantly reduces restenosis, improves symptoms, and reduces reinterventions after PTA of femoropopliteal arteries. Probucol reduces restenosis but has no additive effect when combined with brachytherapy.

Distinct hemodynamic and gastric effects of human CGRP I and II in man.

The human calcitonin gene-related peptides I and II (or alpha and beta) (CGRP I and II) are encoded by two different genes, but they have 34 of the 37 amino acid residues in common. Human CGRP I more potently stimulated blood flow through the skin and carotid artery (p less than 0.01), and the heart rate (p less than 0.05), and plasma renin activity and aldosterone secretion than human CGRP II (p less than 0.02). Inhibition of pentagastrin-stimulated gastric acid output, on the other hand, was only obtained with CGRP II. The separate effects of human CGRP I and II on the cardiovascular and gastric systems are presumably mediated by different receptors or receptor pathways recognized by the two closely related neuropeptides.

Impaired skeletal muscle microcirculation in systemic sclerosis

IntroductionMuscle symptoms in systemic sclerosis (SSc) may originate from altered skeletal muscle microcirculation, which can be investigated by means of blood oxygenation level dependent (BOLD) magnetic resonance imaging (MRI).MethodsAfter ethics committee approval and written consent, 11 consecutive SSc patients (5 men, mean age 52.6 years, mean SSc disease duration 5.4 years) and 12 healthy volunteers (4 men, mean age 45.1 years) were included. Subjects with peripheral arterial occlusive disease were excluded. BOLD MRI was performed on calf muscles during cuff-induced ischemia and reactive hyperemia, using a 3-T whole-body scanner (Verio, Siemens, Erlangen, Germany) and fat-suppressed single-short multi-echo echo planar imaging (EPI) with four different effective echo times. Muscle BOLD signal time courses were obtained for gastrocnemius and soleus muscles: minimal hemoglobin oxygen saturation (T2*min) and maximal T2* values (T2*max), time to T2* peak (TTP), and slopes of oxygen normalization after T2* peaking.ResultsThe vast majority of SSc patients lacked skeletal muscle atrophy, weakness or serum creatine kinase elevation. Nevertheless, more intense oxygen desaturation during ischemia was observed in calf muscles of SSc patients (mean T2*min -15.0%), compared with controls (-9.1%, P = 0.02). SSc patients also had impaired oxygenation during hyperemia (median T2*max 9.2% vs. 20.1%, respectively, P = 0.007). The slope of muscle oxygen normalization was significantly less steep and prolonged (TTP) in SSc patients (P<0.001 for both). Similar differences were found at a separate analysis of gastrocnemius and soleus muscles, with most pronounced impairment in the gastrocnemius.ConclusionsBOLD MRI demonstrates a significant impairment of skeletal muscle microcirculation in SSc.

Infragenual cuff-compression reduces venous contamination in contrast-enhanced MR angiography of the calf

To reduce venous contamination at the calf level in three‐dimensional contrast‐enhanced MR angiography (CE‐MRA) by applying continuous infragenual cuff‐compression.

A new rotational thrombectomy catheter: System design and first clinical experiences

AbstractPurpose: To describe a new catheter for the percutaneous mechanical removal of fresh and organized thrombi, and to assess its efficacy and safety in vitro and in vivo.n Methods: The catheter consists of a coated stainless steel spiral that rotates at 40,000 rpm over a guidewire inside the whole length of an 8 Fr, single-lumen, polyurethane catheter, driving a dual-blade cutting crown. Abraded occlusion material is sucked into the catheter head through distal side holes and transported by the spiral into a reservoir at the proximal end. The efficacy of the device was tested in arterial models and fresh bovine carotid arteries (n=72). In a clinical pilot study 10 patients (8 women, 2 men; mean age 70.6 ±10.1 years) with occlusions of the superficial femoral artery (2–12 cm, mean 5.8 cm), not older than 4 weeks, underwent thrombectomy with the new catheter.n Results: In arterial models and bovine cadaver arteries the catheter completely removed fresh thrombi. Occlusion material of higher consistency was cut into particles of 100–500 μm and transported outside. Thrombectomy was successful and vessel patency restored in all 10 patients. The ankle/brachial pressure index significantly (p<0.0005) increased from 0.41±0.18 before intervention to 0.88±0.15 after 48 hr and to 0.84±0.20 after 3 months. Two reocclusions occurred within 14 days after the intervention.n Conclusion: Thrombectomy with the new device appears to be feasible and safe in patients with acute and subacute occlusions of the femoropopliteal artery.

Correlation of skeletal muscle blood oxygenation level‐dependent MRI and skin laser doppler flowmetry in patients with systemic sclerosis

To investigate the origin of skeletal muscle BOLD MRI alterations in patients with systemic sclerosis (SSc) by correlating BOLD MRI T2* signal of calf muscles with microcirculatory blood flow of calf skin measured by laser Doppler flowmetry (LDF).

Comparison of denture models by means of micro computed tomography

The production of dental inlays and crowns requires precise information on patients’ teeth morphology. The conventional method is the preparation of impressions using mold materials, e.g. a silicone impression material. The disadvantage of this technique is the human choke impulse and the flavor of the material. These discomforts can be avoided by methods where a three-dimensional scanner is used for recording the teeth morphology. The present study reveals the accuracy of three model types, namely conventional impression, rapid prototyping using an oral scanner C.O.S., 3M (Schweiz) AG and milling from a proprietary resin using the oral scanner iTero, Straumann Holding AG. For each method five models were fabricated from a steel reference (standard). Using a nanotom m (phoenixǀx-ray, GE Sensing and Inspection Technologies GmbH), three-dimensional micro computed tomography data sets of the standard and the 15 models were recorded and landmark distances within the data sets were measured with sub-pixel accuracy. To verify these results a coordinate measuring machine (Leitz PMM 864, Hexagon Metrology GmbH) based on tactile detection was used for the measurement of the landmark distances, and a correction of the distances measured by the nanotom m was arranged. The nanotom data sets of the 15 models were also compared to the standard by means of a non-rigid registration algorithm. The calculated deformation field exhibited mean pixel displacement values of (0.19 ± 0.09) mm for the C.O.S. models, (0.12 ± 0.07) mm for the gypsum models and (0.19 ± 0.12) mm for the i-Tero models.