Left atrial appendage occluder detachment treated with transthoracic ultrasound combined with digital subtraction angiography guided catcher:A case report

BACKGROUND There are very few cases of cardiac occluder detachment,and it is rare to completely remove the occluder using interventional methods without undergoing thoracotomy surgery after detachment.This case innovatively used ultrasound guidance combined with digital subtraction angiography(DSA)to completely remove the occluder,accumulating some experience.CASE SUMMARY The patient underwent left atrial appendage occlusion surgery in our hospital due to atrial fibrillation.After the surgery,the occluder fell off and became free in the left ventricle,which is very dangerous.We innovatively used ultrasound guidance,combined with DSA,and interventional surgery to successfully capture the free occluder using a catcher,completely remove it,and then re implant a new left atrial appendage occluder.After the surgery,the patient recovered very well.CONCLUSION The size selection of the occluder is slightly conservative,and the shape of the left atrial appendage opening is irregular.

Enhancing transjugular intrahepatic portosystemic shunt procedure efficiency with digital subtraction angiography image overlay technology in esophagogastric variceal bleeding

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a pivotal intervention for managing esophagogastric variceal bleeding in patients with chronic hepatic schistosomiasis.AIM To evaluate the efficacy of digital subtraction angiography image overlay tech-nology(DIT)in guiding the TIPS procedure.METHODS We conducted a retrospective analysis of patients who underwent TIPS at our hospital,comparing outcomes between an ultrasound-guided group and a DIT-guided group.Our analysis focused on the duration of the portosystemic shunt puncture,the number of punctures needed,the total surgical time,and various clinical indicators related to the surgery.RESULTS The study included 52 patients with esophagogastric varices due to chronic hepatic schistosomiasis.Results demonstrated that the DIT-guided group expe-rienced significantly shorter puncture times(P<0.001)and surgical durations(P=0.022)compared to the ultrasound-guided group.Additionally,postoperative assessments showed significant reductions in aspartate aminotransferase,B-type natriuretic peptide,and portal vein pressure in both groups.Notably,the DIT-guided group also showed significant reductions in total bilirubin(P=0.001)and alanine aminotransferase(P=0.023).CONCLUSION The use of DIT for guiding TIPS procedures highlights its potential to enhance procedural efficiency and reduce surgical times in the treatment of esophagogastric variceal bleeding in patients with chronic hepatic schistoso-miasis.

Modified magnetic resonance angiography of the liver using sensitivity encoding in comparison with digital subtraction angiography and CT arterial portography

BACKGROUND: Over 355 patients have received ortho- topic liver transplantation ( OLT) at this hospital since 1993. Preoperative imaging studies of both hepatic vessels and parenchyma in these recipients bettered surgical plan- ning or even precluded the necessity of surgery. Here we report our preliminary results of modified magnetic reso- nance angiography ( MRA ) using sensitivity encoding ( SENSE) through comparative study with conventional digital subtraction angiography (DSA) and CT arterial por- tography (CTAP). METHODS: Sixteen patients with suspected liver diseases were included in the study. All of them received both dy- namic MRI of the liver using SENSE and digital DSA with CTAP within a two-week interval. The four-phase MRA was reconstructed from source images of the coronal dy- namic study. The arterial phase of the modified MRA was compared with DSA in the evaluation of hepatic arteries and the portal phase compared with CT portography recon- structed from source images of CTAP. In dynamic study of the liver, a fixed dose (20 ml) of contrast medium and scan timing were used. RESULTS: The main branches and variations of the hepatic arterial system were well shown on the modified MRA, al- though the marginal branches of hepatic arteries were of poor quality. The figures of portal veins on MRA were as clear as or superior to those of CTAP. In addition, the su- prarenal inferior vena cava (IVC) was well demonstrated on MRA and/or non contrast-enhanced coronal balanced fast-field echo (b-FFE) scan sequence in most cases. MRI detected most parenchymal lesions of the liver and hemo- dynamics of these lesions could be evaluated on source ima- ges of the modified MRA. MRI/MRA also serendipitously revealed several extrahepatic disease entities or variations that were not found on DSA/CTAP. CONCLUSIONS: The modified MRA using SENSE is a cost-effective modality of examination for the demonstra- tion of the whole hepatic vascular system. Combined with MRI, it has the potential as a one-stop imaging modality in the preoperative evaluation in fields such as OLT.

Detection of hypervascular hepatocellular carcinoma: Comparison of multi-detector CT with digital subtraction angiography and Lipiodol CT

AIM: The purpose of this study was to compare the diagnostic accuracy of biphasic multi-detector row helical computed tomography (MDCT), digital subtraction angiography (DSA)and Lipiodol computed tomography (CT) in detection of hypervascular hepatocellular carcinoma (HCC).METHODS: Twenty-eight patients with nodular HCC underwent biphasic MDCT examination: hepatic arterial phase (HAP) 25 s and portal venous phase (PVP) 70 s after injection of the contrast medium (1.5 mL/kg). They also underwent hepatic angiography and intra-arterial infusion of iodized oil. Lipiodol CT was performed 3-4 wk after infusion. MDCT images were compared with DSA and Lipiodol CT images for detection of hepatic nodules.RESULTS: The three imaging techniques had the same sensitivity in detecting nodules ＞20 mm in diameter. There was no significant difference in the sensitivity among HAP-MDCT, Lipiodol CT and DSA for nodules of 10-20 mm in diameter. For the nodules ＜10 mm in diameter, HAP-MDCT identified 47, Lipiodol CT detected 27 (X2= 11.3, P= 0.005＜0.01, HAP-MDCT vs Lipiodol CT) and DSA detected 16(X2= 9.09, P= 0.005＜0.01 vs Lipiodol CT and X2= 29.03,P = 0.005＜0.01 vs HAP-MDCT). However, six nodules ＜10 mm in diameter were detected only by Lipiodol CT.CONCLUSION: MDCT and Lipiodol CT are two complementary modalities. At present, MDCT does not obviate the need for DSA and subsequent Lipiodol CT as a preoperative examination for HCC.

Interventional digital subtraction angiography for small bowel gastrointestinal stromal tumors with bleeding

AIM: To retrospectively evaluate the diagnostic efficacy of interventional digital subtraction angiography (DSA) for bleeding small bowel gastrointestinal stromal tumors (GISTs).

Carbon dioxide digital subtraction angiography manifestations of hepa-tocellular carcinoma

Objective: To investigate the imaging features and clinical significance of carbon dioxide digital subtraction angiography (CO2-DSA) in the diagnosis and treatment of hepatocellular carcinoma (HCC). Methods: Both CO2-DSA and conventional DSA were performed in all 47 patients with HCC, and the angio-graphic manifestations of CO2-DSA were compared with those of conventional DSA in the same patients. Results: Peripheral arterial and capillary imaging by CO2-DSA was inferior to that by conventional DSA, although blood pools were well visualized with CO2. Improved visualization of arterioportal shunting (APS) was obtained with CO2-DSA compared with that by conventional angiography. APS was observed in 33 cases by CO2-DSA and in 12 cases by conventional angiography (P<0. 001). Retrograde visualization of the portal vein (PV) trunk and its large branches was demonstrated in 16 cases by CO2-DSA and in 1 case by conventional DSA (P<0. 001). The manifestation of lipiodol retention in the tumors was consistent with CO2-DSA images after TAE in 38 cases, and with those of conventional DSA in 23 cases (P<0. 01). Conclusion: CO2-DSA was superior to conventional DSA in the detection of APS and retrograde visualization of PV system, and the former can provide usefulness information for the treatment planning (chemoembolization) and patient prognosis. Demonstration of APS by CO2-DSA may suggest the presence of intrahepatic metastases.

Value of digital subtraction angiography in endovascular graft exclusion for abdominal aortic aneurysms

Objective: To evaluate the value of digital subtraction angiography (DSA) in management of endovascular graft exclusion (EVGE) for abdominal aortic aneurysms. Methods: Monitored by DSA and fluoroscopy, stent-graft complex were introduced into the aneurysm sac via femoral arteries and were deployed at the proximal and distal necks to exclude the sac from circulation. Results: The success rate of deployment was 94. 74% (36/38). Endoleaks occurred in 4 cases. One converted to open surgery because of sac rupture 4 days after deployment. Thrombosis and stenosis occurred in 2 cases. Three patients died shortly after the operation (< 3 months). Conclusion: DSA can monitor EVCE on real-time throughout the whole procedure. It can meet the needs of measurement, location, evaluating, detecting, and also can be much helpful in correcting complications. Moreover, it provides large visual field and operating space, and is a very important monitoring method for EVGE.

Duodenal ulcer caused by coil wiggle after digital subtraction angiography-guided embolization: A case report

BACKGROUND Acute gastrointestinal bleeding(GIB)is a life-threatening medical emergency with high morbidity and mortality.Transcatheter embolization with endovascular coils under digital subtraction angiography guidance is a common and effective method for the treatment of GIB with high technical success rates.Duodenal ulcers caused by coils wiggled from the branch of the gastroduodenal artery,which is a rare complication,have not previously been reported in a patient with right intrathoracic stomach.CASE SUMMARY A 62-year-old man had undergone thoracoscopy-assisted radical resection of esophageal cancer and gastroesophageal anastomosis 3 years ago,resulting in right intrathoracic stomach.He was admitted to the hospital 15 mo ago for dizziness and suffered acute GIB during his stay.Interventional surgery was urgently performed to embolize the branch of the gastroduodenal artery with endovascular coils.After 15 mo,the patient was re-admitted with a chief complaint of melena for 2 d,esophagogastroduodenoscopy and abdominal computed tomography revealed that some endovascular coils had migrated into the duodenal bulb,leading to a deep ulcer.Bleeding was controlled after conservative treatment.Seven months later,duodenal balloon dilatation was performed to relieve the stenosis after the removal of a few coils,and the patient was safely discharged with only one coil retained in the duodenum due to difficulties in complete removal and risk of bleeding.Mild melena recurred once during the long-term follow-up.CONCLUSION Although rare,coil wiggle after interventional therapy requires careful attention,effective precautionary measures,and more secure alternative treatment methods.

Observation on 108 Normal Ophthalmic Arteries in 80 Patients by Digital Subtraction Angiography

By digital subtraction angiography(DSA), the authors made observations on 108 normal ophthalmic arteries in 80 patients with regard to the origins, courses, branching, morphology and anastomoses of the vessels. The merits and demerits of DSA in observing the ophthalmic artery were discussed. Eye Science 1994; 10: 157- 162.

Head dual energy-computed tomography angiography versus neuro-digital subtraction angiography

Dual-energy X-ray absorptiometry provides two modes of head computed tomography （CT） angiography scanning： neuro-digital subtraction angiography and dual-energy CT angiography （DE-CTA）. Previous studies have compared image quality, radiation exposure, and bone removal between neuro-digital subtraction angiography and DE-CTA. However, the number of cases was relatively small. The present study examined 300 suspected cases of cerebrovascular disease and observed the methods and duration of post-processing, examination time, and data volume. Results demonstrated similar image quality between the two methods, but lower radiation doses and shorter examination time in DE-CTA. DE-CTA allowed for faster and more stable scanning performance and post-processing methods, facilitating accurate and direct diagnosis of cerebrovascular disease.

Digital subtraction angiography for the analysis of supraaortic vessels: What is its role nowadays?

For about 50 years, angiography represented the only imaging method for studying carotid arteries in order to detect the presence of pathological stenosis due to atherosclerotic plaque. Recently, thanks to the use of non-invasive methods, physicians are able to study and quantify the presence of carotid atherosclerosis in vivo These procedures have enabled the introduction of new concepts: (1) the degree of carotid stenosis is approxi- mate to the volume and extension of carotid plaque; and (2) a set of parameters, easily identifiable by com- puted tomography angiography, magnetic resonance angiogram and ultra-sound echo-color Doppler, are closely linked to the development of ischemic symptoms and can significantly increase the risk of stroke regard- less of the degree of stenosis. In light of these findings vulnerable plaques should be identified early, and the role of Digital Subtraction Angiography which is a purely technical luminal technique should be determined.

Feasibility of Subtraction Coronary Computed Tomographic Angiography and Influencing Factor Analysis: a Retrospective Study

Objective To investigate the feasibility of subtraction coronary computed tomographic(CT)angiography(SubCCTA)to decline calcium artifacts and improve diagnostic accuracy in the presence of coronary calcification and analyze the factors that influence SubCCTA.Methods A total of 294 patients suspected of having coronary artery diseases underwent coronary computed tomographic angiography(CCTA)and SubCCTA.Coronary stenoses were blindly evaluated by two experienced radiologists,which were compared with invasive coronary angiography(ICA).Multiple statistical indexes were adopted to analyze the value of SubCCTA for the diagnosis of calcium stenoses.Results The diagnosable rate of SubCCTA was 67.2%(n=197),and the non-diagnosable rate was 32.8%(n=97).Using SubCCTA,the false positive rate decreased from 56.5%to 17.4%,and the corresponding diagnostic accuracy was increased from 83.6%to 92.9%.Univariate logistic regression analysis showed that height(OR=1.029,95%CI=1.001–1.058),weight(OR=1.025,95%CI=1.004–1.046),left ventricular size(OR=1.018,95%CI=1.007–1.030),cardiothoracic ratio(OR=39.917,95%CI=1.244–1281.098),the average heart rate(OR=0.866,95%CI=0.836–0.896)and heart rate range(OR=0.882,95%CI=0.853–0.912)might be the factors influencing SubCCTA.Conclusion This study suggested that SubCCTA could help improve diagnostic accuracy in the presence of calcium plaques.Moreover,several factors were discovered for the first time to possibly influence SubCCTA,which will be helpful in improving the subtracted image quality.

Manifestations of hepatic cavernous hemangioma in carbon dioxidedigi-tal subtraction angiography

Objective: To describe the characteristic appearance of cavernous hemangioma of the liver (CHL) presented in carbon dioxide digital subtraction angiography (CO2-DSA) and to evaluate the significance of CO2-DSA in the diagnosis of CHL. Methods: Both CO2-DSA and iodinated contrast DSA (IC-DSA) were performed in all 16 patients with CHL, and the angiographic manifestations in the same patients were compared. The image quality was rated by three experienced angiographers, and the complications were also assessed. Results: There was good correlation between angiographers on image quality (R = 0. 73). Diagnostic images were obtained with both CO2-DSA and IC-DSA in all CHL patients. No difference was noted between IC-DSA and CO2-DSA in visualizing the proper hepatic arteries and its branches (P>0. 05). CO2-DSA produced better images that clearly described the tumor size, shape and margination than those by IC-DSA (P< 0. 05), but both demonstrated characteristic appearances of early opacification and persistent contrast enhancement of the tumors. The portal vein branches near the tumors were constantly demonstrated by CO2-DSA in 15 cases (15/16) but only in 2 cases (2/16) by IC-DSA. Conclusion: CO2-DSA is sensitive in CHL diagnosis, and in patients with contraindications to IC or with unsatisfactory imaging results by IC-DSA, CO2-DSA is a good alternative. As show in most cases by CO2-DSA, the portal veins might act as the main drainage vein of CHLs.

Use of digital subtraction angiography for assessment of digital replantation

Objective: To assess the blood flow of the proper digital artery using digital subtraction angiography (DSA) in the early stage after replantation. Methods: From January 2006 to October 2010, 27 anastomosed arteries in 27 replanted digits were included in the study. The patients included nine males and four females. The patients received DSA at 48 to 96 h after digital replantation. Based on DSA image, the blood flow was classified into normal, slow-running, and flow-stopping types. The patients with normal digital blood flow were given continuous routine treatments; the patients with slow-running flow were given the conservative treatments, such as release of the tight dressings, removal of stitches, keeping warm, the use of massage, and the use of anticoagulants and anti-inflammatory drugs; the patients with flow-stopping received immediate surgical re-exploration. Results: In this series, 23 digits in 11 patients showed a normal blood flow, and these digits all survived. In one of 13 patients, two digits which displayed slow-running flow also survived after conservative treatments. In two of 13 patients, two digits showed flow stopping, with one surviving and one failing after re-exploration and arterial revision. Conclusions: The DSA can be used to assess the blood flow of the proper digital artery in the early stage after replantation. It provides essential information for salvaging the replanted finger.

Classification and digital subtraction angiography evaluation of carotidcavernous fistulas

Objective To investigate the role of digital subtraction angiography (DSA) in evaluation of carotid cavernous fistulas, and to initiate a new classification for carotid cavernous fistula Methods Cerebral angiography and selective external and internal carotid angiography were carried out in 56 patients who were classified into 5 types according to their hemodynamic features Results The types were A (38 patients), B (4), C (10), D (2), and E (2) One of the 38 direct fistulas was located at C1 of the cavernous segment Fistulas at C2 were observed in 10 patients, at C3 in 4, at C4 in 10 and at C5 in 5 The anterior communicating arteries were patent and well compensated in 33 of the 56 patients The posterior communicating arteries were patent and well compensated in 39 patients Both communicating arteries were well compensated in 31 patients Fifty of the 56 patients were drained by ophthalmic veins, 47 by inferior petrous sinuses, 18 by cortical veins, and 8 to the posterior fossa region Conclusions Digital subtraction angiography was helpful in localization of the rents in carotid cavernous fistulas, in evaluation of function of Willis circles and provided valuable information for treatment of carotid cavernous fistulas Carotid cavernous fistulas were divided into 5 categories: type A, B, C, D and E, among which type E was not previously described elsewhere

Superiority of Digital Subtraction for Analysis of Simultaneously-Acquired Dual-Radiopharmaceutical Parathyroid Scintigraphy

With dual-radiopharmaceutical (DR) parathyroid scintigraphy, imaging with 99mTcO4-or 123I-NaI is combined with 99mTc-sestamibi scintigraphy for localization of parathyroid adenomas. The set images are then either visually compared or digitally subtracted to aid in interpretation. While both EANM and SNMMI guidelines recommend use of digital subtraction over visual interpretation alone, to date, the few formal comparisons performed have not demonstrated superiority. The purpose of this investigation is to rigorously assess the added value of digital subtraction over visual interpretation alone using simultaneously-acquired 123I-NaI and 99mTc-sestamibi images. Materials: 90 consecutive patients with DR parathyroid scintigraphy for primary hyperparathyroidism who underwent successful parathyroidectomy were included. DR planar acquisition was performed 15 minutes post injection using 10% dual energy windows. Digital subtraction was subsequently performed using commercially available software. Images were independently reviewed by 3 nuclear medicine trainees and 2 experienced nuclear medicine physicians with and without digital subtraction. Results were compared with surgical and histopathologic findings, which served as ground truth. Results: 90 patients had a total of 91 confirmed parathyroid lesions. All 5 readers had significantly greater sensitivity with digital subtraction compared with visual interpretation alone while specificity was not significantly diminished. Area under the ROC curve was significantly greater with digital subtraction in 3 of 5 readers. Agreement was greater among trainees and experienced physicians when using digital subtraction. Conclusion: Using an optimized DR planar co-imaging technique, digital subtraction significantly improved inter-observer agreement and confidence of interpretation and increased sensitivity, without diminishing specificity.

Evaluation of Diagnostic Efficacy of Digital Subtraction Radiography in the Diagnosis of Simulated External Root Resorption: An <i>in Vitro</i>Study

External root resorption can induce the degeneration of dental cementum and dentine and may extend towards the pulp reductive. Digital subtraction radiography can function as a useful tool in diagnosing degenerative carious lesions. This study investigated the diagnostic value of digital subtraction radiography in detecting external root resorption. This was a descriptive study conducted using the lab trial method. Artificially-induced external root resorption was created in different sizes at the coronal and apical aspects of 20 premolar teeth. Digital radiographs were obtained of each tooth under standard conditions and these radiographs were subtracted by imaging devices. The subtracted images and the digital radiographs were observed by three radiologists. Chi-square, Kappa test, and Z-test were used to analyze the data. The mean of general sensitivity of digital subtraction radiography and direct digital radiography was low in diagnosing 0.05 mm lesions (Sen = 35%), yet, the accuracy index was good for all lesions (Acc ≥ 65%). Other diagnostic parameters were also acceptable. Both types of radiography worked better in diagnosing coronal than apical lesions (P > 0.05). The interpreters (observers) showed a better performance in diagnosing external root resorption using digital subtraction radiography compared to digital radiography. Both modalities were exact and accurate in detecting 0.05 mm lesions as well as other lesions. However, the results of digital subtraction radiography were not significantly different from those of direct digital radiography.

Evaluation of characteristics of left-sided colorectal perfusion in elderly patients by angiography

BACKGROUND Handling of the inferior mesenteric artery(IMA)and maintaining anastomotic perfusion are important in radical resection of left-sided colorectal cancer.However,the branching of this artery and the drainage patterns of this vein vary among individuals,and the characteristics and perfusion region of this artery in elderly patients remain unclear.AIM To evaluate the characteristics and perfusion region of the IMA in elderly patients using angiography.METHODS We enrolled 154 patients(>65 years old)who underwent digital subtraction angiography of the IMA.The characteristics,bifurcation,and distribution of the IMA and termination of the anastomotic perfusion of the left colon and rectum were examined using digital subtraction angiography.Collateral arterial arches and the IMA hemoperfusion region were also recorded.Perfusion regions were cross-referenced with clinical and anatomical features by the univariate analysis.RESULTS Of 154 patients,25(16.2%)had IMA lesions.The left colic artery arose independently from the IMA in 44.2%of patients,shared a trunk with the sigmoid artery in 35.1%,shared an opening with the sigmoid and superior rectal arteries in 16.9%,and was absent in 5.1%.The IMA perfusion region stopped at the splenic flexure in 50(32.5%)patients.The collateral circulation existed in the colonic perfusion region,including the marginal artery(Drummond’s artery),the ascending branch of the left colonic artery to supply the transverse colon,and the arc of Riolan with a frequency of 100%,22.7%,and 1.9%,respectively.The IMA perfusion region was independently associated with the comorbidity of atherosclerosis,IMA atherosclerotic lesion,branching pattern,collateral circulation,and marginal artery integrity.CONCLUSION The IMA and its branches are prone to arteriosclerosis,and IMA perfusion may be interrupted at the splenic flexure in elderly patients.The applicability and precision of preoperative angiography for evaluating the IMA branching and perfusion patterns could facilitate geriatric laparoscopic left-sided colorectal cancer surgery with suspicion of poor IMA perfusion.

Intracranial aneurysm with neck indistinguishable from surrounding artery branches by cerebral angiography

The aim of this study is to examine morphology of intracranial aneurysm with neck indistinguishable from surrounding artery branches by cerebral angiography and discuss whether such aneurysms can be treated by interventional embolization. 6 patients who had not been treated by embolization due to irregular wide-necked aneurysms indistinguishable from surrounding artery branches by cerebral angiography received craniotomy for aneurysm clipping. The operations succeeded. Morphologically, neck width and location of the aneurysms were carefully observed and photographed from different directions and multi-angles during operation. The intraoperative findings were compared with the preoperative CTA and DSA images. Walls of the 6 patients’ aneurysms tightly clung to or adhered to surrounding branches and oppressed the branches into arcs, similar to the aneurysm walls in shape, and arterial branches and aneurysm walls suffered from segmental adhesion. In addition, abnormalities of communicating arteries to vary degrees were observed in 4 patients. However, after successful surgical clipping, it was revealed that the aneurysms would have been better treated by embolization since they are basically saccular aneurysms with regular sizes. Deformations in preoperative angiography may be due to anatomical variations of surrounding vessels near the aneurysms, aneurysm wall oppression or incomplete adhesion of surrounding arterial branches. Such deformations can be recognized by careful observation in preoperative angiography from different directions and multi-angles.

Carbon dioxide-angiography for patients with peripheral arterial disease at risk of contrast-induced nephropathy

Patients with peripheral arterial disease(PAD)and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow.Patients with PAD often have several comorbidities,including chronic kidney disease,diabetes mellitus,and hypertension.Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy(CIN).The use of carbon dioxide(CO2)as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN.However,CO2 angiography has been underutilized due to concerns regarding safety and image quality.Modern CO2 delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN.Awareness of the need for optimal imaging conditions,contraindications,and potential complications have improved the safety of CO2 angiography.This review aims to highlight current technological advances in the delivery of CO2 in vascular angiography for patients with PAD and critical limb ischemia,which result in limb preservation while preventing kidney damage.