Appearance of aseptic vascular grafts after endovascular aortic repair on [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography.

IF 1.4 Q3 RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING World journal of radiology Pub Date : 2023-08-28 DOI:10.4329/wjr.v15.i8.241
Paige Bennett, Maria Bernadette Tomas, Christopher F Koch, Kenneth J Nichols, Christopher J Palestro
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In the case of endovascular aneurysm repair (EVAR), a minimally invasive procedure involving the transfemoral insertion of an endoprosthetic stent graft, the normal postoperative appearance of these grafts on 18F-FDG PET/CT can vary over time, potentially confounding study interpretation.</p><p><strong>Aim: </strong>To investigate the visual, semiquantitative, and temporal characteristics of aseptic vascular grafts in patients status post EVAR.</p><p><strong>Methods: </strong>In this observational retrospective cohort study, patients with history of EVAR who underwent 18F-FDG PET/CT for indications other than infection were identified retrospectively. All patients were asymptomatic for graft infection - no abdominal pain, fever of unknown origin, sepsis, or leukocytosis - at the time of imaging and for ≥ 2 mo after each PET/CT. Imaging studies such as CT for each patient were also reviewed, and any patients with suspected or confirmed vascular graft infection were excluded. One hundred two scans performed on 43 patients (34 males; 9 females; age = 77 ± 8 years at the time of the final PET/CT) were retrospectively reviewed. All 43 patients had an abdominal aortic (AA) vascular graft, 40 patients had a right iliac (RI) limb graft, and 41 patients had a left iliac (LI) limb graft. Twenty-two patients had 1 PET/CT and 21 patients had from 2 to 9 PET/CTs. Grafts were imaged between 2 mo to 168 mo (about 14 years) post placement. Eight grafts were imaged within 6 mo of placement, including three that were imaged within three months of placement. The mean interval between graft placement and PET/CT for all 102 scans was 51 ± 39 mo. PET/CT data was reconstructed with region-of-interest analysis of proximal, mid and distal portions of the grafts and background ascending aorta. Maximum standardized uptake value (SUV<sub>max</sub>) was recorded for each region. SUV<sub>max</sub>-to-background uptake ratios (URs) were calculated. Visual assessment was performed using a 2-pattern grading scale: Diffuse (homogeneous uptake less than liver uptake) and focal (one or more areas of focal uptake in any part of the graft). Statistical analysis was performed.</p><p><strong>Results: </strong>In total, there were 306 AA grafts, 285 LI grafts, 282 RI grafts, and 306 ascending aorta background SUV<sub>max</sub> measurements. For all 102 scans, mean SUV<sub>max</sub> values for AA grafts were 2.8-3.0 along proximal, mid, and distal segments. Mean SUV<sub>max</sub> values for LI grafts and RI grafts were 2.7-2.8. Mean SUV<sub>max</sub> values for background were 2.5 ± 0.5. Mean URs were 1.1-1.2. Visual analysis of the scans reflected results of quantitative analysis. On visual inspection, 98% revealed diffuse, homogeneous 18F-FDG uptake less than liver. Graft URs and visual pattern categories were significantly associated for AA graft URs (F-ratio = 21.5, <i>P <</i> 0.001), LI graft URs (F-ratio = 20.4, <i>P <</i> 0.001), and RI graft URs (F-ratio = 30.4, <i>P <</i> 0.001). Thus, visual patterns of 18F-FDG uptake corresponded statistically significantly to semiquantitative URs. The age of grafts showing focal patterns was greater than grafts showing diffuse patterns, 87 ± 89 <i>vs</i> 50 ± 37 mo, respectively (<i>P</i> = 0.02). URs were significantly associated with graft age for AA grafts (<i>r</i> = 0.19, <i>P</i> = 0.001). URs were also significantly associated with graft age for LI grafts (<i>r</i> = 0.25, <i>P</i> < 0.0001), and RI grafts (<i>r</i> = 0.31, <i>P</i> < 0.001). Quartiles of similar numbers of graft (<i>n</i> = 25-27) grouped by graft age indicated that URs were significantly higher for 4<sup>th</sup> quartile <i>vs</i> 2<sup>nd</sup> quartile URs (F-ratio = 19.5, <i>P <</i> 0.001). When evaluating URs, graft SUVmax values within 10%-20% of the ascending aorta SUV<sub>max</sub> is evident in aseptic grafts, except for grafts in the oldest quartiles. In this study, grafts in the oldest quartiles (> 7 years post EVAR) showed SUV<sub>max</sub> up to 30% higher than the ascending aorta SUV<sub>max</sub>.</p><p><strong>Conclusion: </strong>Characteristics of an aseptic vascular stent graft in the aorta and iliac vessels on 18F-FDG PET/CT include graft SUV<sub>max</sub> values within 10%-20% of the ascending aorta background SUV<sub>max</sub>. The SUV<sub>max</sub> of older aseptic grafts can be as much as 30% above background. 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Abstract

Background: Diagnosis of prosthetic vascular graft infection with [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) allows for early detection of functional changes associated with infection, based on increased glucose utilization by activated macrophages and granulocytes. Aseptic vascular grafts, like all foreign bodies, can stimulate an inflammatory response, which can present as increased activity on 18F-FDG PET/CT. Consequently, distinguishing aseptic inflammation from graft infection, though important, can be difficult. In the case of endovascular aneurysm repair (EVAR), a minimally invasive procedure involving the transfemoral insertion of an endoprosthetic stent graft, the normal postoperative appearance of these grafts on 18F-FDG PET/CT can vary over time, potentially confounding study interpretation.

Aim: To investigate the visual, semiquantitative, and temporal characteristics of aseptic vascular grafts in patients status post EVAR.

Methods: In this observational retrospective cohort study, patients with history of EVAR who underwent 18F-FDG PET/CT for indications other than infection were identified retrospectively. All patients were asymptomatic for graft infection - no abdominal pain, fever of unknown origin, sepsis, or leukocytosis - at the time of imaging and for ≥ 2 mo after each PET/CT. Imaging studies such as CT for each patient were also reviewed, and any patients with suspected or confirmed vascular graft infection were excluded. One hundred two scans performed on 43 patients (34 males; 9 females; age = 77 ± 8 years at the time of the final PET/CT) were retrospectively reviewed. All 43 patients had an abdominal aortic (AA) vascular graft, 40 patients had a right iliac (RI) limb graft, and 41 patients had a left iliac (LI) limb graft. Twenty-two patients had 1 PET/CT and 21 patients had from 2 to 9 PET/CTs. Grafts were imaged between 2 mo to 168 mo (about 14 years) post placement. Eight grafts were imaged within 6 mo of placement, including three that were imaged within three months of placement. The mean interval between graft placement and PET/CT for all 102 scans was 51 ± 39 mo. PET/CT data was reconstructed with region-of-interest analysis of proximal, mid and distal portions of the grafts and background ascending aorta. Maximum standardized uptake value (SUVmax) was recorded for each region. SUVmax-to-background uptake ratios (URs) were calculated. Visual assessment was performed using a 2-pattern grading scale: Diffuse (homogeneous uptake less than liver uptake) and focal (one or more areas of focal uptake in any part of the graft). Statistical analysis was performed.

Results: In total, there were 306 AA grafts, 285 LI grafts, 282 RI grafts, and 306 ascending aorta background SUVmax measurements. For all 102 scans, mean SUVmax values for AA grafts were 2.8-3.0 along proximal, mid, and distal segments. Mean SUVmax values for LI grafts and RI grafts were 2.7-2.8. Mean SUVmax values for background were 2.5 ± 0.5. Mean URs were 1.1-1.2. Visual analysis of the scans reflected results of quantitative analysis. On visual inspection, 98% revealed diffuse, homogeneous 18F-FDG uptake less than liver. Graft URs and visual pattern categories were significantly associated for AA graft URs (F-ratio = 21.5, P < 0.001), LI graft URs (F-ratio = 20.4, P < 0.001), and RI graft URs (F-ratio = 30.4, P < 0.001). Thus, visual patterns of 18F-FDG uptake corresponded statistically significantly to semiquantitative URs. The age of grafts showing focal patterns was greater than grafts showing diffuse patterns, 87 ± 89 vs 50 ± 37 mo, respectively (P = 0.02). URs were significantly associated with graft age for AA grafts (r = 0.19, P = 0.001). URs were also significantly associated with graft age for LI grafts (r = 0.25, P < 0.0001), and RI grafts (r = 0.31, P < 0.001). Quartiles of similar numbers of graft (n = 25-27) grouped by graft age indicated that URs were significantly higher for 4th quartile vs 2nd quartile URs (F-ratio = 19.5, P < 0.001). When evaluating URs, graft SUVmax values within 10%-20% of the ascending aorta SUVmax is evident in aseptic grafts, except for grafts in the oldest quartiles. In this study, grafts in the oldest quartiles (> 7 years post EVAR) showed SUVmax up to 30% higher than the ascending aorta SUVmax.

Conclusion: Characteristics of an aseptic vascular stent graft in the aorta and iliac vessels on 18F-FDG PET/CT include graft SUVmax values within 10%-20% of the ascending aorta background SUVmax. The SUVmax of older aseptic grafts can be as much as 30% above background. The visual uptake pattern of diffuse, homogeneous uptake less than liver was seen in 98% of aseptic vascular grafts, making this pattern particularly reassuring for clinicians.

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血管内主动脉修复后无菌血管移植物在[(18)F]氟脱氧葡萄糖正电子发射断层扫描/计算机断层扫描上的表现
背景:使用[(18)F]氟脱氧葡萄糖正电子发射断层扫描/计算机断层扫描(18F-FDG PET/CT)诊断假体血管移植感染可以早期发现与感染相关的功能变化,这是基于活化的巨噬细胞和粒细胞对葡萄糖的利用增加。无菌血管移植物,像所有异物一样,可以刺激炎症反应,在18F-FDG PET/CT上表现为活性增加。因此,区分无菌性炎症和移植物感染,虽然重要,但可能是困难的。在血管内动脉瘤修复(EVAR)的情况下,一种微创手术涉及经股插入内假支架,这些移植物在18F-FDG PET/CT上的正常术后外观可能会随着时间的推移而变化,这可能会混淆研究的解释。目的:探讨EVAR后无菌血管移植的视觉、半定量和时间特征。方法:在这项观察性回顾性队列研究中,回顾性识别有EVAR病史的患者,这些患者因感染以外的适应症接受了18F-FDG PET/CT检查。所有患者在成像时和每次PET/CT后≥2个月均无移植物感染症状,无腹痛、不明原因发热、败血症或白细胞增多。我们还回顾了每位患者的CT等影像学检查,排除了任何怀疑或证实血管移植感染的患者。对43例患者进行了102次扫描(男性34例;9雌性;年龄= 77±8岁(PET/CT终末扫描时)。43例患者均行腹主动脉(AA)血管移植,40例患者行右髂(RI)肢体移植,41例患者行左髂(LI)肢体移植。1次PET/CT 22例,2 ~ 9次PET/CT 21例。移植物放置后2个月至168个月(约14年)成像。8个移植物在植入后6个月内成像,其中3个在植入后3个月内成像。所有102次扫描中,移植物放置和PET/CT之间的平均间隔为51±39个月。PET/CT数据通过移植物近端、中端和远端以及背景升主动脉的兴趣区分析进行重建。记录每个区域的最大标准化吸收值(SUVmax)。计算suvmax -background摄取比(URs)。视觉评估采用两种模式分级量表:弥漫性(均匀摄取小于肝脏摄取)和局灶性(移植物任何部位的一个或多个局灶性摄取区域)。进行统计学分析。结果:共有306例AA片,285例LI片,282例RI片,306例升主动脉背景SUVmax测量。在所有102次扫描中,AA移植物近端、中端和远端段的平均SUVmax值为2.8-3.0。LI接枝和RI接枝的平均SUVmax值为2.7 ~ 2.8。背景平均SUVmax值为2.5±0.5。平均URs为1.1 ~ 1.2。扫描的视觉分析反映了定量分析的结果。在目视检查中,98%显示弥漫性,均匀的18F-FDG摄取少于肝脏。AA型、LI型和RI型分别与移植URs (f比= 21.5,P 0.001)、LI型(f比= 20.4,P 0.001)和RI型(f比= 30.4,P 0.001)有显著相关性。因此,18F-FDG摄取的视觉模式与半定量URs在统计学上显著对应。病灶型移植物的年龄大于弥漫性移植物,分别为87±89和50±37个月(P = 0.02)。AA移植的URs与移植年龄显著相关(r = 0.19, P = 0.001)。URs也与LI移植的移植年龄(r = 0.25, P < 0.0001)和RI移植的移植年龄(r = 0.31, P < 0.001)显著相关。按移植年龄分组的相似数量的四分位数(n = 25-27)表明,第4四分位数的URs明显高于第2四分位数(f比= 19.5,P < 0.001)。在评估URs时,在升主动脉10%-20%范围内的移植物SUVmax值在无菌移植物中是明显的,除了最老四分位数的移植物。在这项研究中,最老四分之一(EVAR后> 7年)的移植物SUVmax比升主动脉SUVmax高出30%。结论:在18F-FDG PET/CT上,主动脉和髂血管内无菌血管支架的SUVmax值在升主动脉背景SUVmax值的10%-20%之间。年龄较大的无菌移植物的SUVmax可高达背景以上的30%。在98%的无菌血管移植物中可见弥漫性、均匀性摄取少于肝脏的视觉摄取模式,这使临床医生特别放心。
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来源期刊
World journal of radiology
World journal of radiology RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING-
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