Visipaque

All patients underwent PAE according to previously described methods (Carnevale et al, 2020a (link); Dias Jr et al, 2021 (link)). All procedures took place in a dedicated interventional radiology suite (Innova 3D CT; GE Healthcare, USA), using a nonionic contrast medium (320 mg/mL iodixanol; Visipaque; GE Healthcare, USA).
Procedures were performed under local anesthesia, through a unilateral right femoral approach. Selective 3D-angiography from the right and left internal iliac arteries was performed using a 5-F CPC catheter (Merit Medical, South Jordan, USA), to assess the blood supply to the prostate. Selective catheterization of the right and left prostatic arteries (PA) was performed using the 2.4-F SeQure® microcatheter (Guerbet, France). Anatomical findings were confirmed by Cone Beam CT (CBCT) using the EmboASSIST software (GE Healthcare, USA).
After selective injection of vasodilator in each PA, (isosorbide mononitrate 5 mg, Eurofarma, Brazil) embolization was performed with a combination of 100-300 (until near stasis) and 300-500 (until total stasis) micrometers Embosphere microspheres (Biosphere, Roissy, France), using the PErFecTED technique (Dias Jr et al, 2021 (link)). Each vial was diluted to 22 mL with equal parts of saline (10 mL) and contrast media (10 mL). All ten patients were discharged from the hospital 2-6 hours after the procedure.

Radiographic examination comprised two phases. The first phase was performed for localizing kidneys and included a native, helical scan of the abdominal cavity, starting from diaphragm domes up to aortic bifurcation. In the second phase, the length of the scan area was set to 14 cm to complete both kidneys’ coverage. Every tested individual received 25 shuttle passes, providing 375 images. The total acquisition time of the second phase was 42.6 s. During the examination, a nonionic contrast medium (320 mg/mL Visipaque, GE Healthcare) was administered to each patient at a rate of 4.0 mL/s using a power injector. The scan delay was set AT 10 s. Technical data of the protocol are shown in Table 1.

All CTA scans carried out by each center were in accordance with the guidelines recommended by the Society of Cardiovascular Computed Tomography (25 (link)). All of the scans were performed with ≥64 slice multidetector scanners (Brilliance iCT, Philips Healthcare, Cleveland, OH, USA; Somatom Definition AS, Siemens, Forchheim, Germany; Somatom Definition Flash, Siemens Healthcare, Forchheim, Germany) with retrospective or prospective ECG gating. The general scanning parameters were as follows: collimator width of (2 × 64)/128/ 320 × 0.5/0.625 mm; tube potential of 120 kV; effective tube current of 400 to 700 mA (26 (link)). Contrast media (Omnipaque, 350 mgI/ml, GE Healthcare; Visipaque 320 mg/dl, GE Healthcare; Iopromide, 370 mgI/ml, Bayer) was injected with a flow rate of 4.5 ml/s (<80 kg body weight) or 5 ml/s (≥80 kg body weight) followed by a 30 ml saline flush. The total amount of contrast media was calculated by patient weight × 0.8 ml/kg. Before the CTA scanning, patients with HR>70 bpm were administered oral ß-receptor blockers (25 mg metoprolol succinate sustained-release tablets, AstraZeneca, Sweden).

CCTA scans were performed on a 64-slice CT scanner (Discovery CT 690, GE Healthcare, Waukesha, Wisconsin, USA) in accordance with performance guidelines from the Society of Cardiovascular Computed Tomography [21 (link)]. In the absence of contraindications, patients received beta-blockade (intravenous metoprolol) and sublingual nitroglycerine prior to the scan to achieve a heart rate of <65 beats per minute and coronary dilation, respectively. A preliminary unenhanced scan was performed to assess coronary artery calcium score. During the CCTA acquisition, 80 ml of iodinated contrast (Visipaque, GE Healthcare, Princeton, New Jersey, USA) was injected followed by a 50 ml saline flush. Significant CAD was defined as >50% luminal stenosis. CCTA was carried out 1 week prior to CMR study for each participant withT2DM.

Hearts from two individuals were obtained. An approximately 20-mm-thick slice containing calcified plaque was excised from each heart and placed in 4% formalin for 1 week. During that time, a custom-3D-printed (Ultimaker 2 Extended+, Ultimaker BV) phantom holder was made to enable imaging sessions in both vertical and horizontal beam geometry. The phantom holder was cylindrical with a diameter of 14 cm, with a 0.5-cm cutout on one side. After fixation, the heart samples were removed from the formalin, the coronary arteries were sutured, and a mix of isotonic sodium chloride and Visipaque (GE Healthcare) 270 mg I/ml (1:5) was prepared. That solution was then mixed with gelatin (10 g/100 ml) and injected into the coronary arteries. This gives a concentration of approximately 5 mg I/ml which is in the clinically relevant range. The choice of gelatin is suboptimal since it is water-like and not a perfect representation of blood in terms of CT value, but was selected in order to fixate the contrast agent solution and enable imaging in both vertical and horizontal beam geometry at multiple sites.