Pulmonary Artery Embolization in the Management of Hemoptysis Related to Lung Tumors

(1) Background: Bronchial artery embolization has been shown to be effective in the management of neoplastic hemoptysis. However, knowledge of pulmonary artery embolization is lacking. The aim of this study was to evaluate the safety and efficacy of pulmonary artery embolization in patients presenting with hemoptysis related to lung tumors. (2) Methods: This retrospective study reviewed all consecutive patients with cancer and at least one episode of hemoptysis that required pulmonary artery embolization from December 2008 to December 2020. The endpoints of the study were technical success, clinical success, recurrence of hemoptysis and complications. (3) Results: A total of 92 patients were treated with pulmonary artery embolization (63.1 years ± 9.9; 70 men). Most patients had stage III or IV advanced disease. Pulmonary artery embolization was technically successful in 82 (89%) patients and clinically successful in 77 (84%) patients. Recurrence occurred in 49% of patients. Infectious complications occurred in 15 patients (16%). The 30-day mortality rate was 31%. At 3 years, the survival rate was 3.6%. Tumor size, tumor cavitation and necrosis and pulmonary artery pseudoaneurysm were significantly associated with recurrence and higher mortality. (4) Conclusions: Pulmonary artery embolization is an effective treatment to initially control hemoptysis in patients with lung carcinoma, but the recurrence rate remains high and overall survival remains poor.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

[Contribution of the maximal exercise test to diagnosis the vascular origin of leg pain in athletes]

Leg pain is a common debilitating symptom in athletes. Vascular disease is not often proposed as a possible cause. Maximal exercise with measure of the ankle-brachial index after exercise can be an interesting diagnostic test. We report an illustrative case where an athlete presented leg pain revealing arterial disease disclosed by exercise. Interestingly, sub-maximal exercise did not cause pain, causing a delay in diagnosis. The vascular origin of leg pain can be detected with a maximal exercise test that induces the symptomatic pain or at least clinical discomfort.

Performance of noninvasive laser Doppler flowmetry and laser speckle contrast imaging methods in diagnosis of Buerger disease: A case report

RATIONALE

Buerger disease (BD) is a nonatherosclerotic, inflammatory, segmental vascular occlusive disease, which affects small and medium-sized arteries and veins and is triggered by substantial tobacco exposure. Angiographic findings consistent with BD are required for diagnosis. Laser Doppler flowmetry (LDF) and laser speckle contrast imaging (LSCI) could represent potential noninvasive alternative techniques to angiography.

PATIENT CONCERNS

We report the case of a 49-year-old smoker who developed an ischemic ulcer in the distal segment of the second finger of the left hand. He had no medical history.

DIAGNOSES

In our vascular center, LDF and LSCI are conducted routinely for digital artery disease diagnosis. LDF was indicative of digital obstructive artery disease (DOAD). Postocclusive reactive hyperemia, assessed by LCSI, demonstrated no skin blood flow (SBF) perfusion in the distal phalanx of the thumb, index, middle, and auricular fingers. Angiography confirmed BD, showing distally located multisegmental vessel occlusion and corkscrew collaterals in this patient's hands.

INTERVENTIONS

Ilomedine treatment was initiated and smoking cessation was definitive.

OUTCOMES

Recently, the patient had an improvement in clinical condition despite the persistence of a small zone of necrosis of the left index finger 28 days post-treatment.

LESSONS

Our observation suggests that where suspicion of BD is based on clinical criteria, combining LDF and LSCI could represent a noninvasive, safe means of reaching BD diagnosis. Further clinical trials are necessary to confirm this novel observation.

Adherence to Antihypertensive Treatment and the Blood Pressure–Lowering Effects of Renal Denervation in the Renal Denervation for Hypertension (DENERHTN) Trial

Background:

The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure–lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control.

Methods:

One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients.

Results:

The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively ( P =0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was –6.7 mm Hg ( P =0.0461) in fully adherent and –7.8 mm Hg ( P =0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients.

Conclusions:

In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Diagnostic contributions of cardiac magnetic resonance imaging in patients presenting with elevated troponin, acute chest pain syndrome and unobstructed coronary arteries

AIMS

Myocardial infarction with unobstructed coronary artery disease represents a serious diagnostic challenge. The role of cardiac magnetic resonance in the management of cardiomyopathies is increasing. We examined the diagnostic contributions of cardiac magnetic resonance in patients presenting with acute chest pain syndrome, elevated serum cardiac troponin concentrations and no significant coronary artery stenoses.

METHODS

Over a 3-year period, 107 consecutive patients (mean age 43.5 years; 62% men) presented to our institution with acute onset of chest pain, elevated serum troponin concentration and unobstructed coronary arteries, and underwent 3-tesla cardiac magnetic resonance at a mean delay of 6.9 days. A diagnosis was made based on: wall motion abnormalities and pericardial effusion on cine mode; myocardial oedema on T2-weighted imaging; abnormalities on first-pass perfusion imaging; and late gadolinium enhancement on T1-weighted imaging.

RESULTS

Cardiac magnetic resonance was normal in 10.3% of patients and contributed a diagnosis in 89.7%, including myocarditis in 59.9%, stress cardiomyopathy (takotsubo syndrome) in 14% and myocardial infarction in 15.8%. Patients with normal cardiac magnetic resonance had a significantly lower mean peak troponin concentration (2.6ng/mL) than patients with diagnostic cardiac magnetic resonance (9.7ng/mL; P=0.01).

CONCLUSION

Cardiac magnetic resonance contributed a diagnosis in nearly 90% of patients presenting with acute chest pain, elevated serum troponin and unobstructed coronary arteries.

[Surgery of aortic dissection: for which patient?]

In the acute stage (less than two weeks), surgery is indicated for Stanford type A aortic dissections. With respect to the initial work-up, surgery consists in replacing the ascending aorta, sometimes the aortic arch (with supra aortic vessels reimplantation), and aortic valve replacement (valve replacement, Bentall valved tube or valve sparing Tyron David technique). Ischemic visceral complications must be searched for and treated by endovascular techniques or surgery. Aneurismal evolution of chronic dissections must be treated surgically. Replacement can encompass the entire aorta.

[Acute aortic syndrome: CT imaging features]

Acute aortic syndromes include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. These are potentially life-threatening abnormalities of the aorta requiring immediate evaluation by the cardio-thoracic surgery service. CT angiography is the most appropriate imaging modality in the acute setting to detect and diagnose the disease and assess its severity. Precontrast and postcontrast imaging should be obtained of the entire aorta from thorax to pelvis. After aortic rupture, the most severe complication is visceral ischemia from hypoperfusion. Dissections should be systematically searched for and may be amenable to endovascular treatment.

Optimized time-resolved 3D contrast-enhanced MRA at 3T: appreciating the feasibility of assessing cervical paragangliomas

OBJECTIVES

To describe an optimized 3D time-resolved contrast-enhanced MR angiography (3D TR-CE-MRA) at 3T in diagnosing head and neck paragangliomas and assessing their morphology and relation to neighboring vessels.

METHODS

In a prospective study, eight consecutive patients presenting cranial cervical masses suspected to be 10 paragangliomas were examined with 3D TR-CE-MRA at 3T. Two neuroradiologists evaluated the overall image quality, the presence of a paraganglioma, the maximum diameter, as well as the vessel invasion.

RESULTS

In all of the cases, the overall image quality was scored as good. The tumors (n=10) were all visualized and localized. The mean maximum diameter was 32.7mm [range 7-80]. Vessel invasion was assessed as uncertain in one case and improbable in nine cases.

CONCLUSION

3D TR-CE-MRA at 3T associated with conventional sequences facilitates a comprehensive investigation of paragangliomas, thus providing the anatomical and functional information.

Cardiac MRI studies of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy): a systematic review

BACKGROUND

Since its first description in 1991, many cases of transient left ventricular apical ballooning syndrome (TLVABS) have been described, but the use of cardiac MRI in this condition is much more recent.

METHODS AND RESULTS

We performed a systematic review of the present literature in the MEDLINE and EMBASE databases for relevant case series of TLVABS (>or=5 reported original cases, MRI analysis in the acute phase) and summarized the main results in a narrative synthesis. Only 8 studies met the eligible criteria, counting 176 patients (women: 95%; age: 68, stress trigger: 80%). MRI assessed an improvement of mean left ventricular ejection fraction from 39 (in the acute phase) to 64% (in the recovery phase). A right ventricular dysfunction was reported in 38%, a myocardial oedema in 81% and an apical thrombus in 5%.

CONCLUSIONS

Although cardiac MRI is a very useful and inescapable tool in the management of TLVABS, there is no large published study concerning this topic. A systematic and multicentric register of TLVABS studied by cardiac MRI is necessary.

[Contribution of cardiac MRI in the etiologic diagnosis of chest pain syndrome with a normal angiographic aspect of the coronary arteries]

The etiologic diagnosis of chest pain with elevation of specific cardiac enzymes, repolarization abnormalities and a normal angiographic aspect of the coronary arteries is difficult. In this situation, the role of cardiac MRI is growing, frequently allowing to precise the etiology of the chest pain. We present a literature review concerning the semiology of the cardiac MRI in the three main involved etiologies: myocarditis, takotsubo syndrome, and myocardial ischemia with a normal angiographic aspect of the coronary arteries.