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Patients At Increased Risk Of Endovascular Procedural Difficulty And Immediate Technical Failure Are Accurately Defined With UTE MRI
Alexander B. Crichton, MBChB, MS, Eniko Pomozi, MD, Judit Csore, MD, PhD, Janak Lamichhane, MD, Christof Karmonik, PhD, Alan B. Lumsden, MD, Trisha Roy, MD, PhD.
Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA.
Introduction There are critical gaps in our understanding of why endovascular treatments fail. It is clear that patient selection for treatment has not been optimized. Ultrashort Echo Time (UTE) MRI is a non-contrast technique that has been validated in ex vivo samples to evaluate plaque characteristics. The aim of this study was to evaluate the effect of MRI-defined plaque characteristics on procedural difficulty and immediate technical failure (ITF) in peripheral vascular interventions (PVI). Methods Patients attending an academic vascular center with CLTI undergoing PVI were included and underwent a 3T non-contrast MRI UTE sequence. The key MRI feature was to identify was whether the lesions were predominantly >50% soft (thrombus, cholesterol/lipid plaque) or predominantly hard (calcific/collagenous plaque). Surgeons were blinded to the MRI images analysis and proceeded with the procedure based on clinical pre-operative imaging. The primary and secondary outcomes measured were ITF and crossing time. Results 43 patients with 86 arterial lesions were included (mean age 67.5 years old, 40.0% female, 60.0% male). 14 lesions were excluded (7 diagnostic DSA only, 7 non-diagnostic MRI). 66.7% of lesions were defined as soft and 33.3% were predominantly made up of hard components (figures 1 and 2). ITF occurred in 15.3% of lesions, for which 72.7% was due to crossing failure, which is in keeping with the literature. ITF was significantly more likely in hard lesions when compared to soft lesions (41.7% vs 2.1% p<0.001 Chi 19.3). In a subgroup analysis of those with >75% stenosis/total occlusion, this difference was even greater (58.8% hard ITF vs 4.3% soft ITF, p<0.001, Chi 14.5). Crossing time was also significantly higher in hard lesions compared to soft lesions (535 seconds vs 38 seconds, p=0.024). Conclusions UTE MRI analysis of plaque characteristics acts as a key predictor procedural difficulty and ITF. Yet the ability to evaluate the diseased vessel wall characteristics prior to peripheral vascular intervention remains heavily underutilized. This imaging technique can clearly delineate differences in vessel wall morphology. Integrating this imaging into clinical CLTI practice could revolutionize patient selection, approaches to treatment and ultimately, patient outcomes.
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