Pulse Wave Imaging Coupled With Vector Flow Mapping: A Phantom, Simulation, and In Vivo Study

Pulse wave imaging (PWI) is an ultrasound imaging modality that estimates the wall stiffness of an imaged arterial segment by tracking the pulse wave propagation. The aim of the present study is to integrate PWI with vector flow imaging, enabling simultaneous and co-localized mapping of vessel wall mechanical properties and 2-D flow patterns. Two vector flow imaging techniques were implemented using the PWI acquisition sequence: 1) multiangle vector Doppler and 2) a cross-correlation-based vector flow imaging (CC VFI) method. The two vector flow imaging techniques were evaluated in vitro using a vessel phantom with an embedded plaque, along with spatially registered fluid structure interaction (FSI) simulations with the same geometry and inlet flow as the phantom setup. The flow magnitude and vector direction obtained through simulations and phantom experiments were compared in a prestenotic and stenotic segment of the phantom and at five different time frames. In most comparisons, CC VFI provided significantly lower bias or precision than the vector Doppler method ( ) indicating better performance. In addition, the proposed technique was applied to the carotid arteries of nonatherosclerotic subjects of different ages to investigate the relationship between PWI-derived compliance of the arterial wall and flow velocity in vivo. Spearman's rank-order test revealed positive correlation between compliance and peak flow velocity magnitude ( rs = 0.90 and ), while significantly lower compliance ( ) and lower peak flow velocity magnitude ( ) were determined in older (54-73 y.o.) compared with young (24-32 y.o.) subjects. Finally, initial feasibility was shown in an atherosclerotic common carotid artery in vivo. The proposed imaging modality successfully provided information on blood flow patterns and arterial wall stiffness and is expected to provide additional insight in studying carotid artery biomechanics, as well as aid in carotid artery disease diagnosis and monitoring.

Interstitial fluid velocity is decreased around cortical bone vascular pores and depends on osteocyte position in a rat model of disuse osteoporosis

Muscle paralysis induced with botulinum toxin (Botox) injection increases vascular porosity and reduces osteocyte lacunar density in the tibial cortical bone of skeletally mature rats. These morphological changes potentially affect interstitial fluid flow in the lacunar-canalicular porosity, which is thought to play a role in osteocyte mechanotransduction. The aim of this study was to investigate the effects of disuse-induced morphological changes on interstitial fluid velocity around osteocytes in the bone cortex. Micro-CT images from a previous study that quantified the effects of Botox-induced muscle paralysis on bone microarchitecture in skeletally mature rats were used to create high-resolution, animal-specific finite element models that included the vascular pores and osteocyte lacunae within the tibial metaphysis of Botox-injected (BTX, n = 8) and saline-injected control (CTRL, n = 8) groups. To quantify fluid flow, lacunar and canalicular porosities were modeled as fluid-saturated poroelastic materials, and boundary conditions were applied to simulate physiological loading. This modeling approach allowed a detailed quantification of the fluid flow velocities around osteocytes in a relatively large volume of bone tissue. The analysis demonstrated that interstitial fluid velocity at the vascular pore surfaces was significantly lower in BTX compared to CTRL because of the decreased vascular canal separation. No significant differences in average fluid velocity were observed at the osteocyte lacunae and no correlation was found between the fluid velocity and the lacunar density, which was significantly lower in BTX. Instead, the lacunar fluid velocity was dependent on the osteocyte's specific position in the bone cortex and its proximity to a vascular pore.

Modeling Pulse Wave Propagation Through a Stenotic Artery With Fluid Structure Interaction: A Validation Study Using Ultrasound Pulse Wave Imaging

Pulse wave imaging (PWI) is an ultrasound-based method that allows spatiotemporal mapping of the arterial pulse wave propagation, from which the local pulse wave velocity (PWV) can be derived. Recent reports indicate that PWI can help the assessment of atherosclerotic plaque composition and mechanical properties. However, the effect of the atherosclerotic plaque's geometry and mechanics on the arterial wall distension and local PWV remains unclear. In this study, we investigated the accuracy of a finite element (FE) fluid-structure interaction (FSI) approach to predict the velocity of a pulse wave propagating through a stenotic artery with an asymmetrical plaque, as quantified with PWI method. Experiments were designed to compare FE-FSI modeling of the pulse wave propagation through a stenotic artery against PWI obtained with manufactured phantom arteries made of polyvinyl alcohol (PVA) material. FSI-generated spatiotemporal maps were used to estimate PWV at the plaque region and compared it to the experimental results. Velocity of the pulse wave propagation and magnitude of the wall distension were correctly predicted with the FE analysis. In addition, findings indicate that a plaque with a high degree of stenosis (>70%) attenuates the propagation of the pulse pressure wave. Results of this study support the validity of the FE-FSI methods to investigate the effect of arterial wall structural and mechanical properties on the pulse wave propagation. This modeling method can help to guide the optimization of PWI to characterize plaque properties and substantiate clinical findings.

Harmonic motion imaging of human breast masses: an in vivo clinical feasibility

Non-invasive diagnosis of breast cancer is still challenging due to the low specificity of the imaging modalities that calls for unnecessary biopsies. The diagnostic accuracy can be improved by assessing the breast tissue mechanical properties associated with pathological changes. Harmonic motion imaging (HMI) is an elasticity imaging technique that uses acoustic radiation force to evaluate the localized mechanical properties of the underlying tissue. Herein, we studied the in vivo feasibility of a clinical HMI system to differentiate breast tumors based on their relative HMI displacements, in human subjects. We performed HMI scans in 10 female subjects with breast masses: five benign and five malignant masses. Results revealed that both benign and malignant masses were stiffer than the surrounding tissues. However, malignant tumors underwent lower mean HMI displacement (1.1 ± 0.5 µm) compared to benign tumors (3.6 ± 1.5 µm) and the adjacent non-cancerous tissue (6.4 ± 2.5 µm), which allowed to differentiate between tumor types. Additionally, the excised breast specimens of the same patients (n = 5) were imaged post-surgically, where there was an excellent agreement between the in vivo and ex vivo findings, confirmed with histology. Higher displacement contrast between cancerous and non-cancerous tissue was found ex vivo, potentially due to the lower nonlinearity in the elastic properties of ex vivo tissue. This preliminary study lays the foundation for the potential complementary application of HMI in clinical practice in conjunction with the B-mode to classify suspicious breast masses.

Atherosclerotic plaque mechanical characterization coupled with vector Doppler imaging in atherosclerotic carotid arteries in-vivo

Methods used in clinical practice to diagnose and monitor atherosclerosis present limitations. Imaging the mechanical properties of the arterial wall has demonstrated the potential evaluate plaque vulnerability and assess the risk for stroke. Adaptive Pulse Wave Imaging (PWI) is a non-invasive ultrasound imaging technique, which automatically detects points of spatial mechanical inhomogeneity along the imaged artery and provides piecewise stiffness characterization. The aims of the present study are to: 1) demonstrate the initial feasibility of adaptive PWI to image the mechanical properties of an atherosclerotic plaque 2) demonstrate the feasibility to combine adaptive PWI with vector Doppler in a single imaging modality in order to simultaneously obtain information plaque mechanical properties and plaque hemodynamics. The common carotid arteries of 1 healthy subject and 2 carotid artery disease patients were scanned in vivo. One of the patients underwent carotid endarterectomy and a plaque sample was retrieved. In this patient, a higher compliance value of the stenotic segment was estimated by Adaptive PWI as compared with the adjacent arterial wall, and the healthy carotid artery. This was corroborated by histological staining of the plaque sample, which revealed the presence of a large necrotic core and a thrombus, characteristics associated with reduced stiffness. Moreover, the same sequence demonstrated the feasibility to obtain both stiffness maps and vector flow information, showing promise in atherosclerosis diagnosis and patient care.

Arterial wall mechanical inhomogeneity detection and atherosclerotic plaque characterization using high frame rate pulse wave imaging in carotid artery disease patients in vivo

Pulse wave imaging (PWI) is a non-invasive, ultrasound-based technique, which provides information on arterial wall stiffness by estimating the pulse wave velocity (PWV) along an imaged arterial wall segment. The aims of the present study were to: (1) utilize the PWI information to automatically and optimally divide the artery into the segments with most homogeneous properties and (2) assess the feasibility of this method to provide arterial wall mechanical characterization in normal and atherosclerotic carotid arteries in vivo. A silicone phantom consisting of a soft and stiff segment along its longitudinal axis was scanned at the stiffness transition, and the PWV in each segment was estimated through static testing. The proposed algorithm detected the stiffness interface with an average error of 0.98  ±  0.49 mm and 1.04  ±  0.27 mm in the soft-to-stiff and stiff-to-soft pulse wave transmission direction, respectively. Mean PWVs estimated in the case of the soft-to-stiff pulse wave transmission direction were 2.47 [Formula: see text] 0.04 m s^-1 and 3.43 [Formula: see text] 0.08 m s^-1 for the soft and stiff phantom segments, respectively, while in the case of stiff-to-soft transmission direction PWVs were 2.60 [Formula: see text] 0.18 m s^-1 and 3.72 [Formula: see text] 0.08 m s^-1 for the soft and stiff phantom segments, respectively, which were in good agreement with the PWVs obtained through static testing (soft segment: 2.41 m s^-1, stiff segment: 3.52 m s^-1). Furthermore, the carotid arteries of N  =  9 young subjects (22-32 y.o.) and N  =  9 elderly subjects (60-73 y.o.) with no prior history of carotid artery disease were scanned, in vivo, as well as the atherosclerotic carotid arteries of N  =  12 (59-85 y.o.) carotid artery disease patients. One-way ANOVA with Holm-Sidak correction showed that the number of most homogeneous segments in which the artery was divided was significantly higher in the case of carotid artery disease patients compared to young (3.25 [Formula: see text] 0.86 segments versus 1.00 [Formula: see text] 0.00 segments, p -value  <  0.0001) and elderly non-atherosclerotic subjects (3.25 [Formula: see text] 0.86 segments versus 1.44 [Formula: see text] 0.51 segments p -value  <  0.0001), indicating increased wall inhomogeneity in atherosclerotic arteries. The compliance provided by the proposed algorithm was significantly higher in non-calcified/high-lipid plaques as compared with calcified plaques (3.35 [Formula: see text] 2.45 *[Formula: see text] versus 0.22 [Formula: see text] 0.18 * [Formula: see text], p -value  <  0.01) and the compliance estimated in elderly subjects (3.35 [Formula: see text] 2.45 * [Formula: see text] versus 0.79 [Formula: see text] 0.30 * [Formula: see text], p -value  <  0.01). Moreover, lower compliance was estimated in cases where vulnerable plaque characteristics were present (i.e. necrotic lipid core, thrombus), compared to stable plaque components (calcification), as evaluated through plaque histological examination. The proposed algorithm was thus capable of evaluating arterial wall inhomogeneity and characterize wall mechanical properties, showing promise in vascular disease diagnosis and monitoring.

Botox-induced muscle paralysis alters intracortical porosity and osteocyte lacunar density in skeletally mature rats

Reduced mechanical loading can lead to disuse osteoporosis, resulting in bone fragility. Disuse models report macroscopic bone loss due to muscle inactivity and immobilization, yet only recently has there been quantification of the effects of disuse on the vascular pores and osteocyte network, which are believed to play an important role in mechanotransduction via interstitial fluid flow. The goal of this study was to perform a high-resolution analysis of the effects of muscle inactivity on intracortical porosity and osteocyte lacunar density in skeletally mature rats. Muscle paralysis was induced in 20-week-old female Sprague Dawley rats by injection of botulinum neurotoxin. Rats were injected in the right hindlimb muscles with either Botox (BTX, n = 8) or saline solution (CTRL, n = 8), with a third group used as baseline controls (n = 8). Four weeks after injection, Botox caused a ∼60% reduction in hindlimb muscle mass. High-resolution micro-CT analysis showed that Botox-induced muscle paralysis increased vascular canal porosity and reduced osteocyte lacunar density within the tibial metaphysis cortex. Cortical thickness and other areal properties were diminished in the proximal tibial metaphysis, whereas no differences were found in the mid-diaphysis. Within the BTX group, the injected limbs showed a lower cancellous bone volume fraction relative to the contralateral limb. These results indicate that diminished muscle activity alters the vascular canal porosity and osteocyte lacunar density in cortical bone, which could alter interstitial fluid flow, affecting molecular transport and the transmission of mechanical signals to osteocytes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

The effects of estrogen deficiency on cortical bone microporosity and mineralization

Recent studies have demonstrated matrix-mineral alterations in bone tissue surrounding osteocytes in estrogen-deficient animals. While cortical bone porosity has been shown to be a contributor to the mechanical properties of bone tissue, little analysis has been done to investigate the effects of estrogen deficiency on bone's microporosities, including the vascular and osteocyte lacunar porosities. In this study we examined alterations in cortical bone microporosity, mineralization, and cancellous bone architecture due to estrogen deficiency in the ovariectomized rat model of postmenopausal osteoporosis. Twenty-week-old female Sprague-Dawley rats were subjected to either ovariectomy or sham surgery. Six weeks post-surgery tibiae were analyzed using high-resolution micro-CT, backscattered electron imaging, nanoindentation, and dynamic histomorphometry. Estrogen deficiency caused an increase in cortical bone vascular porosity, with enlarged vascular pores and little change in tissue mineral density in the proximal tibial metaphysis. Measurements of cancellous architecture corresponded to previous studies reporting a decrease in bone volume fraction, an increase in trabecular separation, and a decrease in trabecular number in the proximal tibia due to estrogen deficiency. Nanoindentation results showed no differences in matrix stiffness in osteocyte-rich areas of the proximal tibia of estrogen-deficient rats, and bone labeling and backscattered electron imaging showed no significant changes in mineralization around the vascular pores. The findings demonstrate local surface alterations of vascular pores due to estrogen deficiency. An increase in cortical vascular porosity may diminish bone strength as well as alter bone mechanotransduction via interstitial fluid flow, both of which could contribute to bone fragility during postmenopausal osteoporosis.

[Ultrasonic videolaparoscopic cholecystectomy: evolution of a revolutionary technique]

AIM

The present retrospective study, which lasted about six months from the beginning of March to the end of August 2008, involved 60 patients suffering from symptomatic calculosis of the gall bladder.

METHODS

The patients were operated on with laparoscopy: 30 with traditional instruments, 30 using ultrasound multifunctional scissors.

RESULTS

The numerous advantages for the patient and surgeon are immediately evident; in addition, from the economic viewpoint the procedure is advantageous compared to the traditional method because single-use material is employed exclusively. We found less tissue trauma and a lower incidence of short-term complications, such as reoperation for faulty closure of the cystic duct and the cystic artery. It was never necessary to use permanent haemostatic clips. The use of a single instrument for gripping, sectioning and closing haematic and biliary vessels permitted faster, safer and more accurate surgery in the absence of any production of smoke.

CONCLUSIONS

In lithiasic pathology of the gall bladder, videolaparoscopy for cholecystectomy is presently considered the operation of first choice. The technique enables the surgeon to respect to the utmost the patient's physical and mental integrity. As the third millennium dawns, technological innovation is able to bring a significant improvement to this procedure. The ultrasound dissector Ultracision is symbolic of development and constant progress.

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children

BACKGROUND

The rationale for replacing racemic bupivacaine with the s-enantiomers levobupivacaine and ropivacaine is to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block. In a randomized, double-blind, phase III, controlled trial we compared the caudal administration of levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine 0.25% in children.

METHODS

Ninety-nine ASA I-II children less than 10 yr old scheduled for elective sub-umbilical surgery were randomized to receive caudal block with bupivacaine 0.25%, ropivacaine 0.25% or levobupivacaine 0.25%. The primary outcome of the study was the clinical efficacy of the caudal block during the operation. Secondary outcome measures were analgesic onset time, pain relief after the operation and residual motor blockade.

RESULTS

The proportion of children with effective analgesia during the operation was similar among groups. There were no significant differences in the analgesic onset time of the caudal block. Bupivacaine produced a significant incidence of residual motor block compared with levobupivacaine or ropivacaine at wake-up (P<0.01). There were no significant differences in the number of patients receiving rescue analgesia after surgery. However, analgesic block lasted significantly longer in patients receiving bupivacaine (P=0.03).

CONCLUSION

During sub-umbilical surgery, caudal levobupivacaine, ropivacaine and bupivacaine provided comparable analgesic efficacy. Bupivacaine produced a higher incidence of residual motor blockade and a longer analgesic block than ropivacaine and levobupivacaine.

Manometric study of the sphincter of Oddi in patients with and without common bile duct stones

Motor activity of the sphincter of Oddi has been evaluated in 34 patients who underwent ERCP examination. Manometric recordings from the common bile duct and the sphincter of Oddi were performed with a polyethylene triple lumen catheter. At ERCP 16 patients had undamaged biliary ducts; six had undergone cholecystectomy and six had gall bladder stones; 18 patients had common bile duct stones; nine of whom had undergone cholecystectomy, and seven had gall bladder stones. Length and amplitude of the resting sphincter pressure as well as frequency, duration, amplitude, and propagating pattern of phasic contractions did not significantly differ in patients with and without common bile duct stones. Sphincter of Oddi motor activity did not appear to be influenced by the variation in the diameter of the common bile duct or by previous cholecystectomy.