Role of Vascular Ultrasonography in Patients with Leg Swelling

There are many causes of leg swelling or edema. Leg edema due to systemic condition or disease demonstrates chronic, bilateral features, whereas leg edema caused by vascular disease shows more complex clinical features including secondary skin changes and ulcerative lesion, resulting in more complicated clinical outcomes with less frequent early diagnosis and appropriate management. Definite differential diagnosis might not be possible by medical history, clinical features, and physical findings. Vascular ultrasonography (Duplex ultrasound) can be used easily as a bedside diagnostic procedure and is a recommended diagnostic tool for differentiation of a non-vascular from vascular etiology in patients with leg swelling.

A case of COVID-19 with superficial thrombophlebitis caused by an indwelling peripheral venous catheter

Background: COVID-19 is caused by SARS-CoV-2 infection, and cytokine storm and microthrombus formation affect the severity of the disease, which is often complicated by venous thrombosis due to a systemic hypercoagulable state. On the other hand, indwelling peripheral venous catheters can cause catheter-related bloodstream infections and venous thrombus formation, albeit less frequently. Case presentation: A 53-year-old man was admitted to the hospital with severe COVID-19. He had bilateral pneumonia and required ventilator management but recovered after steroid and anticoagulation. On the 26th day after onset, redness, swelling, and pain developed around the insertion site of the catheter placed in the cephalic vein of the left forearm. Vascular ultrasonography revealed a thrombus in this vein accompanied by inflammation in the surrounding tissues. Catheter-related bloodstream infection was suspected and vancomycin was administered; however, blood cultures were negative, leading to the diagnosis of non-infectious superficial thrombophlebitis. The skin findings improved after removal of the peripheral venous catheter. Conclusions: This case suggested that catheter placement in peripheral veins during COVID-19 treatment increases the risk of thrombus formation. Although anticoagulant therapy is able to control the systemic hypercoagulable state caused by COVID-19, indwelling catheters can induce a local hypercoagulable state, leading to superficial thrombophlebitis.

Recanalization of the occluded radial artery via distal transradial access in the anatomic snuffbox

Background Radial artery occlusion is a common complication after coronary angiography and percutaneous coronary intervention via the transradial access. In recent years, coronary angiography and percutaneous coronary intervention via the distal transradial access has gradually emerged, but recanalization of the occluded radial artery through the distal transradial access has rarely been reported. Case presentation A 67-year-old female with arterial hypertension and diabetes mellitus was admitted to the hospital due to chest pain for three hours. She was diagnosed with acute myocardial infarction. After admission, the patient successfully underwent emergency coronary angiography and percutaneous coronary intervention through the right transradial access. Radial artery occlusion was found after the operation, and recanalization was successfully performed through the right distal transradial access before discharge. Immediately after the operation and one month later, vascular ultrasonography showed that the antegrade flow was normal. Conclusions This report presents a case of radial artery occlusion after emergency coronary angiography and percutaneous coronary intervention in which recanalization was successfully performed through the right distal transradial access. This case demonstrates that recanalization of a radial artery occlusion via the distal transradial access is safe and feasible.

Association Between Body Size Phenotypes and Subclinical Atherosclerosis

Context The underlying relationship between body mass index (BMI), cardiometabolic disorders, and subclinical atherosclerosis is poorly understood. Objective To evaluate the association between body size phenotypes and subclinical atherosclerosis. Design Cross-sectional. Setting Cardiovascular disease-free cohort. Participants Middle-aged asymptomatic subjects (n = 3909). A total of 6 cardiometabolic body size phenotypes were defined based on the presence of at least 1 cardiometabolic abnormality (blood pressure, fasting blood glucose, triglycerides, low high-density lipoprotein cholesterol, homeostasis model assessment-insulin resistance index, high-sensitivity C-reactive protein) and based on BMI: normal-weight (NW; BMI <25), overweight (OW; BMI = 25.0-29.9) or obese (OB; BMI >30.0). Main Outcome Measures Subclinical atherosclerosis was evaluated by 2D vascular ultrasonography and noncontrast cardiac computed tomography. Results For metabolically healthy subjects, the presence of subclinical atherosclerosis increased across BMI categories (49.6%, 58.0%, and 67.7% for NW, OW, and OB, respectively), whereas fewer differences were observed for metabolically unhealthy subjects (61.1%, 69.7%, and 70.5%, respectively). When BMI and cardiometabolic abnormalities were assessed separately, the association of body size phenotypes with the extent of subclinical atherosclerosis was mostly driven by the coexistence of cardiometabolic risk factors: adjusted OR = 1.04 (95% confidence interval [CI], 0.90-1.19) for OW and OR = 1.07 (95% CI, 0.88-1.30) for OB in comparison with NW, whereas there was an increasing association between the extent of subclinical atherosclerosis and the number of cardiometabolic abnormalities: adjusted OR = 1.21 (95% CI, 1.05-1.40), 1.60 (95% CI, 1.33-1.93), 1.92 (95% CI, 1.48-2.50), and 2.27 (95% CI, 1.67-3.09) for 1, 2, 3, and >3, respectively, in comparison with noncardiometabolic abnormalities. Conclusions The prevalence of subclinical atherosclerosis varies across body size phenotypes. Pharmacologic and lifestyle interventions might modify their cardiovascular risk by facilitating the transition from one phenotype to another.

Diagnostic Value of Spectral CT Reconstruction Mode for Carotid Atherosclerotic Plaque Lesions

Objective: To investigate the diagnostic value of spectral CT reconstruction mode for carotid atherosclerotic plaque lesions. Methods: From January 2017 to January 2019, 70 patients with carotid atherosclerotic plaque lesions in our hospital were selected as the research object. All patients were diagnosed with cervical vascular color Doppler ultrasound and spectral CT scan under spectral CT reconstruction mode. Taking the results of coronary angiography as the “gold standard”, the clinical value of the two examination methods in the diagnosis of carotid atherosclerotic plaque lesions was compared and analyzed. Results: Coronary angiography diagnosis confirmed that 33 of 70 patients with suspected carotid atherosclerotic plaque lesions had vulnerable plaques and 37 had stable plaques. The accuracy of Spectral CT examination of carotid artery plaque was 87.14% (61/70), sensitivity was 90.91% (30/33), specificity was 83.78% (31/37), and the positive predictive value was 83.33% (30 /36), the negative predictive value is 91.76% (31/34), which is higher than that of cervical vascular ultrasonography (61.43%, 60.61%, 56.76%, 57.89%, 65.63%), the difference is statistically significant (P<0.05). Conclusion: The application of Spectral CT in the clinical diagnosis and treatment of carotid atherosclerotic plaque lesions with higher accuracy, sensitivity and specificity, is more significant and can provide a more reliable and effective imaging basis.

Metabolic syndrome detection with biomarkers in childhood cancer survivors

Purpose: Augmented survival of childhood nephroblastoma and neuroblastoma has increased long-term side effects such as metabolic syndrome (MetS). Risk stratification is difficult after abdominal radiation because waist circumference underestimates adiposity. We aimed to develop a strategy for determining MetS in irradiated survivors using an integrated biomarker profile and vascular ultrasonography. Methods: The NCEP-ATPIII MetS-components, 14 additional serum biomarkers and 9 vascular measurements were assessed in a single-centre cohort of childhood nephroblastoma (n = 67) and neuroblastoma (n = 36) survivors and controls (n = 61). Multivariable regression models were used to study treatment effects. Principal component analysis (PCA) was used to study all biomarkers in a combined analysis, to identify patterns and correlations. Results: After 27.5 years of follow-up, MetS occurred more often in survivors (14%) than controls (3%). Abdominal radiotherapy and nephrectomy, to a lesser extent, were associated with MetS and separate components and with several biomarker abnormalities. PCA of biomarkers revealed a pattern on PC1 from favourable lipid markers (HDL-cholesterol, adiponectin) towards unfavourable markers (triglycerides, LDL-cholesterol, apoB, uric acid). Abdominal radiotherapy was associated with the unfavourable biomarker profile (β = 1.45, P = 0.001). Vascular measurements were not of added diagnostic value. Conclusions: Long-term childhood nephro- and neuroblastoma survivors frequently develop MetS. Additional assessment of biomarkers identified in PCA – adiponectin, LDL, apoB, and uric acid – may be used especially in abdominally irradiated survivors, to classify MetS as alternative for waist circumference. Vascular ultrasonography was not of added value.

SAT0262 PROPOSAL FOR OPTIMIZATION OF DIAGNOSTIC IMAGING FOR GIANT CELL ARTERITIS USING THREE-DIMENSIONAL COMPUTED TOMOGRAPHY ANGIOGRAPHY IMAGE AND CONSTRUCTING VASCULAR MAPPING FROM VASCULAR ULTRASONOGRAPHY AS REFERENCES

Background:The development of rapid and accurate methods of diagnosing giant cell arteritis (GCA) is critical to prevent blindness and stroke, which may develop rapidly in patients with GCA. In 2018, EULAR published recommendations that the first imaging modality for GCA should be vascular ultrasonography without biopsy. However, many institutions still consider biopsy to make an important contribution to the diagnosis of GCA.Objectives:Our purpose is to eliminate blindness and stroke among GCA patients by optimizing diagnostic imaging and method to diagnose GCA employed by vascular ultrasonography (V-US), CT Angiography (CTA), MRI/A, and PET/CT without biopsy.Methods:We evaluated the clinical and serological characteristics of 20 patients who were diagnosed with GCA at our hospital from 2012 to 2018, and compared the image and biopsy findings of these patients. We then evaluated the effect of optimizing diagnostic imaging and methods for patients with suspected GCA who visited our hospital during 2019. Vascular mapping was carried out using V-US for 3DCTA and other imaging methods as references.Results:Table 1 shows the clinical characteristics of the study population. The sensitivity of CTA for GCA was 85.7% (12 of 14 patients), which was the highest of the studied imaging methods. All biopsy-positive cases were diagnosed as GCA, and we compared these cases with cases with positive imaging findings. This revealed that CTA findings were correct (i.e., positive) in 66.7% (four of six patients), MRI/A findings were correct in in 33.3% (three of nine), V-US findings were correct in 50.0% (three of six). Therefore, CTA exhibited the highest sensitivity for positive findings. Comparison of biopsy-positive cases with cases in which imaging findings were negative revealed that CTA findings were correct (negative) in 33.3% (two of six patients), MRI/A findings were correct in 55.6% (five of nine), V-US was correct in 50.0% (three of six). Thus, CTA had the lowest sensitivity for negative findings. Comparison of CTA findings of positive cases with other imaging modalities which reported positive findings revealed MRI/A findings to be correct in 44.4% (four of nine patients), PET/CT findings to be correct in 50.0% (one of two), V-US to be correct in 63.3% (five of eight). Thus, V-US had the highest agreement with CTA. We carried out vascular mapping by V-US using 3DCTA and other imaging methods and produced references to improve the accuracy of diagnosis. Using these references, we diagnosed five cases of GCA among the 20 patients; the positive predictive value of V-US was 80% (four of five patients) and negative predictive value was 86.7% (13 of 15 patients).Table 1.Baseline characteristics of the study sample The number of biopsies performed decreased from 50% (10 of 20 patients) from 2012 to 2018 to 15% (3 of 20 patients) in 2019. Two cases in the present study had positive findings in both biopsy and V-US; in one case, biopsy, CTA, and MRI/A were negative while V-US revealed positive findings. No patients with GCA developed blindness or stroke during 2019.Conclusion:We propose that V-US should be performed as the first examination for the diagnosis of GCA by the creation of vascular mappings when GCA is suspected in order to prevent blindness and stroke.References:[1]Christian Dejaco et al.EULAR recommendations for the use of imaging in large vasculitis in clinical practice.Annals of the Rheumatic Diseases,2018 May;77(5):636-643[2]Kawamoto T et al.Diagnosis of giant cell arthritis by head-contrast three-dimensional computed tomography angiography.Journal of Medical Case Reports2019 Sep 11;13(1):285.Figure 1.Left side is before, right side is after thrapy. (A) 3DCTA finding, (B) determination of V-US arrangement with vascular location to evaluate wall thickening of V-US, compression sign, stenosis and stoppage of vessels.Disclosure of Interests:None declared