Towards in vivo photoacoustic imaging of vulnerable plaques in the carotid artery.

The main indicator for endarterectomy is the grade of stenosis, which results in severe overtreatment. Photoacoustic imaging (PAI) can provide patient-specific assessment of plaque morphology, and thereby vulnerability. A pilot study of PAI on carotid plaques in patients (n=16) was performed intraoperatively with a hand-held PAI system. By compensating for motion, the photoacoustic (PA) signal-to-noise ratio (SNR) could be increased by 5 dB in vivo. PA signals from hemorrhagic plaques had different characteristics compared to the signals from the carotid blood pool. This study is a key step towards a non-invasive application of PAI to detect vulnerable plaques.

Feasibility of wall stress analysis of abdominal aortic aneurysms using three-dimensional ultrasound.

OBJECTIVE: Abdominal aortic aneurysms (AAAs) are local dilations that can lead to a fatal hemorrhage when ruptured. Wall stress analysis of AAAs is a novel tool that has proven high potential to improve risk stratification. Currently, wall stress analysis of AAAs is based on computed tomography (CT) and magnetic resonance imaging; however, three-dimensional (3D) ultrasound (US) has great advantages over CT and magnetic resonance imaging in terms of costs, speed, and lack of radiation. In this study, the feasibility of 3D US as input for wall stress analysis is investigated. Second, 3D US-based wall stress analysis was compared with CT-based results. METHODS: The 3D US and CT data were acquired in 12 patients (diameter, 35-90 mm). US data were segmented manually and compared with automatically acquired CT geometries by calculating the similarity index and Hausdorff distance. Wall stresses were simulated at P = 140 mm Hg and compared between both modalities. RESULTS: The similarity index of US vs CT was 0.75 to 0.91 (n = 12), with a median Hausdorff distance ranging from 4.8 to 13.9 mm, with the higher values found at the proximal and distal sides of the AAA. Wall stresses were in accordance with literature, and a good agreement was found between US- and CT-based median stresses and interquartile stresses, which was confirmed by Bland-Altman and regression analysis (n = 8). Wall stresses based on US were typically higher (+23%), caused by geometric irregularities due to the registration of several 3D volumes and manual segmentation. In future work, an automated US registration and segmentation approach is the essential point of improvement before pursuing large-scale patient studies. CONCLUSIONS: This study is a first step toward US-based wall stress analysis, which would be the modality of choice to monitor wall stress development over time because no ionizing radiation and contrast material are involved.

New image processing and noise reduction technology allows reduction of radiation exposure in complex electrophysiologic interventions while maintaining optimal image quality: a randomized clinical trial.

BACKGROUND: Despite their carcinogenic potential, X-rays remain indispensable for electrophysiologic (EP) procedures. OBJECTIVE: The purpose of this study was to evaluate the dose reduction and image quality of a novel X-ray technology using advanced image processing and dose reduction technology in an EP laboratory. METHODS: In this single-center, randomized, unblinded, parallel controlled trial, consecutive patients undergoing catheter ablation for complex arrhythmias were eligible. The Philips Allura FD20 system allows switching between the reference (Allura Xper) and the novel X-ray imaging technology (Allura Clarity). Primary end-point was overall procedural patient dose, expressed in dose area product (DAP) and air kerma (AK). Operator dose, procedural success, and necessity to switch to higher dose settings were secondary end-points. RESULTS: A total of 136 patients were randomly assigned to the novel imaging group (n = 68) or the reference group (n = 68). Baseline characteristics were similar, except patients in the novel imaging group were younger (58 vs 65 years, P < .01). Median DAP and AK were 43% and 40% lower in the novel imaging group, respectively (P < .0001). A 50% operator dose reduction was achieved in the novel imaging group (P < .001). Fluoroscopy time, number of exposure frames, and procedure duration were equivalent between the two groups, indicating that the image quality was similarly adequate in both groups. Procedural success was achieved in 91% of patients in both groups; one pericardial tamponade occurred in the novel imaging group. CONCLUSION: The novel imaging technology, Allura Clarity, significantly reduces patient and operator dose in complex EP procedures while maintaining image quality.

Determination of brachial artery stiffness prior to vascular access creation: reproducibility of pulse wave velocity assessment.

BACKGROUND: Despite routine ultrasound mapping of upper extremity arteries and veins, early thrombosis and nonmaturation remain frequent complications following vascular access (VA) surgery. Besides vascular diameters, brachial artery stiffness is assumed to play an important role; however, reproducibility of measurements has never been established. The purpose of this study was to determine within-session and between-session variabilities of pulse wave velocity (PWV) assessment by using ultrasonography and blood pressure registration. METHODS: Beat-to-beat changes in brachial artery diameter and pressure were obtained in 21 subjects in measurement sessions on Day 1 and Day 3. Each session consisted of three acquisitions. For each acquisition, systolic and diastolic diameter and pressure were determined and used for calculation of brachial artery PWV. Within-session variability of diameter and pressure, as well as the estimated PWV, was expressed using the intraclass correlation coefficient with corresponding coefficient of variation (CoV). Between-session variability was reported using Bland-Altman analysis in combination with CoV analysis. RESULTS: Significant agreement (P < 0.001) was obtained for all diameter and pressure measurements obtained on Day 1 and Day 3. Within-session CoV of pulse pressure, diastolic diameter and distension were 7.0, 1.6 and 18.3%, respectively. Subsequent estimation of local PWV resulted in a CoV of 10.6%. Between-session CoV was 15.1, 3.8 and 18.9% for pulse pressure, diastolic diameter and distension, respectively. For PWV estimation, this resulted in a CoV of 13.5%. CONCLUSIONS: Diameter and pressure can be recorded accurately over the cardiac cycle, and calculations of distensibility, pulse pressure and PWV show a slight to moderate degree of variation. Larger studies elaborating on interindividual differences need to determine the clinical efficacy of PWV measurements prior to VA creation.

Toward noninvasive blood pressure assessment in arteries by using ultrasound.

A new method has been developed to measure local pressure waveforms in large arteries by using ultrasound. The method is based on a simultaneous estimation of distension waveforms and velocity profiles from a single noninvasive perpendicular ultrasound B-mode measurement. Velocity vectors were measured by applying a cross-correlation based technique to ultrasound radio-frequency (RF) data. From the ratio between changes in flow and changes in cross-sectional area of the vessel, the local pulse wave velocity (PWV) was estimated. This PWV value was used to convert the distension waveforms into pressure waveforms. The method was validated in a phantom set-up. Physiologically relevant pulsating flows were considered, employing a fluid which mimics both the acoustic and rheologic properties of blood. A linear array probe attached to a commercially available ultrasound scanner was positioned parallel to the vessel wall. Since no steering was used, the beam was perpendicular to the flow. The noninvasively estimated pressure waveforms showed a good agreement with the reference pressure waveforms. Pressure values were predicted with a precision of 0.2 kPa (1.5 mm Hg). An accurate beat to beat pressure estimation could be obtained, indicating that a noninvasive pressure assessment in large arteries by means of ultrasound is feasible.

Automatic localization of intimal and adventitial carotid artery layers with noninvasive ultrasound: a novel algorithm providing scan quality control.

Transcutaneous ultrasound measurements of common carotid artery (CCA) diameter and intima-media thickness (IMT) give insight on arterial dynamics and anatomy, both correlating well with atherosclerosis and risk of cardiovascular disease. We propose a novel automatic algorithm to estimate CCA diameter and IMT in ultrasound (US) images, based on separate analysis of anterior and posterior CCA walls and able to distinguish internal (intima-intima) and external (adventitia-adventitia) diameter. The method combines off-line signal- and image-processing techniques to accommodate echo images acquired at a frame rate of 30 Hz and composed directly from RF data, circumventing digital video-grabbing. Segmentation consists of automatic CCA recognition, followed by adventitial delineation performed with a sustain-attack filter with exponentially decaying reference functions. Intimal delineation is then based on the multiscale anisotropic barycenter (MAB), which is an extension of a known delineation method involving the "first order absolute central moment" of the echo amplitude. An automatic measure of the quality of the US beam incidence for each wall is superimosed on the CCA contour overlays for visual feedback. Validation is carried out on 36 US CCA acquisitions from 12 healthy volunteers, as well as on synthetic US images. Results indicate good accuracy on synthetic US images (within 1.3% for diameter and 3% for IMT). The in vivo intra-recording beat-to-beat variations are on average lower than 50 microm for external diameter and IMT, and lower than 100 microm for internal diameter. A comparison with a commercial device (ART.LAB system) shows that the proposed algorithm performs better in terms of inter-recording precision. The beam incidence control significantly improves the repeatability of IMT estimates, and motivates sonographers actively to maintain a proper scan plane throughout the acquisition to minimize the incidence of confounding factors. The method is clinically viable, providing robust estimates of CCA internal and external diameter and IMT waveforms for both CCA walls, even at a low B-mode update rate of 30 Hz.

Improving the thermal dimensional stability of flexible polymer composite backing materials for ultrasound transducers.

Novel ultrasound backing materials based on polymer composites with improved dimensional stability and low coefficient of thermal expansion are being developed and analyzed. For this purpose a filled epoxy resin (Stycast(1265)), a commonly used backing material, was considered reference material and polyurethane composites (PU(2305), PU(2350)) were proposed as better alternatives. When compared to the reference, the PU(2350) filled with a mixture of Al(2)O(3) and tungsten exhibited an approximately 15 times lower glassy transition temperature and a 2.5 time lower longitudinal thermal expansion at 20 degrees C. This ensures that within the entire operational temperature range the backing material is flexible, minimizing the thermal stresses induced onto transducer elements soldered joints and piezoceramic core. For the same material, the attenuation at 5MHz was similar to the reference material while at 7 and 8.5MHz it was 33% and 54% higher respectively. From these analyses it is concluded that the newly developed polyurethane composites outperform the reference backing with respect to the thermal dimensional stability as well as to the damping properties. An integrated rigorous mechano-acoustical approach is being proposed as an appropriate passive material design path. It can be easily extended to any other passive materials used for ultrasound transducer conception.

Nonlinear processing in B-mode ultrasound affects carotid diameter assessment.

Noninvasive diameter assessment in the common carotid artery (CCA) by means of ultrasound is a useful technique for estimation of arterial mechanical and dynamic properties, clinical screening and treatment monitoring. Before presentation on screen, ultrasound images are subjected to nonlinear processing, e.g., logarithmic compression and noise-level thresholding, to improve visualization. In addition, signal saturation may occur, either in the received radiofrequency (RF) signals or in their envelopes. The objective of this study is to evaluate the effect of signal nonlinearities on CCA diameter measurements by means of noninvasive B-mode ultrasound, comparing the performance of two different edge detectors. In 14 healthy subjects, three repeated ultrasonic acquisitions (6 s) without saturation were performed. The acquired RF signals were subjected off-line to envelope detection, logarithmic compression and various degrees of saturation applied to the signals before or after envelope detection. For the purpose of CCA diameter estimation, artery walls were automatically outlined frame by frame. As automatic edge detectors, we considered the sustain attack filter (SAF), based on exponentially decaying reference functions, and a derivative approach (DER), relying on the positions of first derivative maxima. Both methods are applied within a region-of-interest located on the CCA. No regularization of the detected wall positions by means of pre- or postprocessing is presently applied to directly relate the outcome of the edge detectors to the applied nonlinear processing. Diameter values assessed with SAF are unaffected by logarithmic compression because of the possibility to integrate the compression characteristic of the ultrasound system into the method. The estimated diameters values obtained with DER instead show differences in the order of 10% because of compression. Saturation affects DER more than SAF; DER exhibits larger intrarecording and intrasubject variations in the estimated diameter values. Therefore, SAF gives more precise and robust CCA diameter estimates than DER, and is more suited for integration in algorithms meant for vascular ultrasound image segmentation. This study demonstrates the relevant effects of nonlinearities such as saturation and logarithmic compression on the quality of noninvasive US CCA diameter measurements.

Real-time in vivo photoacoustic and ultrasound imaging.

A real-time photoacoustic imaging system is designed and built. This system is based on a commercially available ultrasound imaging system. It can achieve a frame rate of 8 frames/sec. Vasculature in the hand of a human volunteer is imaged, and the resulting photoacoustic image is combined with the ultrasound image. The real-time photo acoustic imaging system with a hybrid ultrasound probe is demonstrated by imaging the branching of subcutaneous blood vessels in the hand.

Automatic recognition of the common carotid artery in longitudinal ultrasound B-mode scans.

Many morphological and dynamic properties of the common carotid artery (CCA), e.g. lumen diameter, distension and wall thickness, can be measured non-invasively with ultrasound (US) techniques. As common to other medical image segmentation processes, this requires as a preliminary step the manual recognition of the artery of interest within the ultrasound image. In real-time US imaging, such manual initialization procedure interferes with the difficult task of the sonographer to select and maintain a proper image scan plane. Even for off-line US segmentation the requirement for human supervision and interaction precludes full automation. To eliminate user interference and to speed up processing for both real-time and off-line applications, we developed an algorithm for the automatic artery recognition in longitudinal US scans of the CCA. It acts directly on the envelopes of received radio frequency echo signals, eventually composing the ultrasound image. In order to properly exploit the information content of the arterial structure the envelopes are decimated, according to the two-dimensional resolution characteristics of the echo system, thereby substantially decreasing computational load. Subsequently, based upon the expected diameter range and a priori knowledge of the typical pattern in the echo envelope of the arterial wall-lumen complex, parametrical template matching is performed, resulting in the location of the lumen position along each echo line considered. Finally, in order to reject incorrect estimates, a spatial and temporal clustering method is applied. Adequate values for the parameters involved in the processing are obtained via off-line testing of the proposed algorithm on 128 echo data recordings from 45 subjects. Using those robust parameter values, correct and fast recognition of the artery is achieved in more than 98% of the 6185 processed frames. Since these results are obtained via rigorous data decimation and using a cascade of rather simple steps, the proposed automatic algorithm is suitable for real-time recognition of the CCA.