3-D visualization of arterial structures using ultrasound and Voxel modelling

In vivo volumetric intravascular ultrasound visualization of early/inflammatory arterial atheroma using targeted echogenic immunoliposomes

OBJECTIVES

This study aimed to demonstrate three-dimensional (3D) visualization of early/inflammatory arterial atheroma using intravascular ultrasound (IVUS) and targeted echogenic immunoliposomes (ELIP). IVUS can be used as a molecular imaging modality with the use of targeted contrast agents for atheroma detection. Three-dimensional reconstruction of 2-dimensional IVUS images may provide improved atheroma visualization.

MATERIALS AND METHODS

Atheroma were induced in arteries of Yucatan miniswine (n = 5) by endothelial cell denudation followed by a 4-week high cholesterol diet. The contralateral arteries were left intact and served as controls. Anti-intercellular adhesion molecule-1 (ICAM-1) and generic gammaglobulin (IgG) conjugated ELIP were prepared. Arteries were imaged using IVUS before and after ELIP injection. Images were digitized, manually traced, segmented, and placed in tomographic sequence for 3D visualization. Atheroma brightness enhancement was compared and reported as mean gray scale values. Plaque volume was quantified both from IVUS and histologic images.

RESULTS

Anti-ICAM-1 ELIP highlighting of the atheroma in all arterial segments was different compared with baseline (P < 0.05). There was no difference in the mean gray scale values with IgG-ELIP. Arterial 3D IVUS images allowed visualization of the entire plaque distribution. The highlighted plaque/atheroma volume with anti-ICAM-1 ELIP was greater than baseline (P < 0.01).

CONCLUSION

This study demonstrates specific highlighting of early/inflammatory atheroma in vivo using anti-ICAM-1 ELIP. Three-dimensional IVUS reconstruction provides good visualization of plaque distribution in the arterial wall. This novel methodology may help to detect and diagnose pathophysiologic development of all stages of atheroma formation in vivo and quantitate plaque volume for serial and long-term atherosclerotic treatment studies.

Porcine carotid arterial material property alterations with induced atheroma: an in vivo study

OBJECTIVE

A novel methodology has been developed to evaluate regional alterations in arterial wall material properties with induced atheroma in an animal model.

METHODS

Atheromatous lesions (fatty, fibro-fatty, and fibrous) were induced in the carotid arteries of a Yucatan miniswine model by endothelial cell denudation and high cholesterol diet. The images at base line and 8 weeks after denudation were obtained using intravascular ultrasound (IVUS) imaging along with hemodynamic data. Finite element analysis (FEA) along with optimization was employed to assess regional alterations in elastic modulus in the presence of atheroma confirmed by histology.

RESULTS

In animals with 8 weeks of induced atherosclerosis, the elastic modulus increased-(elastic modulus-all values x 10(4) Pa, mean+/-S.D.) normal elements (9.34+/-0.36) compared to abnormal elements (9.52+/-0.36) (p<0.05 versus normal elements). Wall thickness increased with atheroma formation. These data demonstrate stiffening vascular wall elastic modulus with lesion progression. This is different from the behavior of femoral arteries, where the elastic modulus decreases with early stages of atheroma development followed by an increase as lesions progress.

CONCLUSIONS

This methodology permits determination of areas with early atheroma development, follow atheroma progression, and potentially evaluate interventions aimed at decreasing atheroma load and normalizing vascular material properties.

Virtual 3D IVUS vessel model for intravascular brachytherapy planning. I. 3D segmentation, reconstruction, and visualization of coronary artery architecture and orientation

Intravascular brachytherapy (IVB) can significantly reduce the risk of restenosis after interventional treatment of stenotic arteries, if planned and applied correctly. To facilitate computer-based IVB planning, a three-dimensional vessel model has been derived from information on coronary artery segments acquired by intravascular ultrasound (IVUS) and biplane angiography. Part I describes the approach of model construction and presents possibilities of visualization. The vessel model is represented by a voxel volume. Polygonal information about the vessel wall structure is derived by segmentation from a sequence of IVUS images automatically acquired ECG gated during pull back of the IVUS transducer. To detect horizontal, vertical, and radial contours, modified Canny-Edge and Shen-Castan filters are applied on Cartesian and polar coordinate representations of the IVUS tomograms as edge detectors. The spatial course of the vessel wall layers is traced in reconstructed longitudinal IVUS scans. By resampling the sequence of IVUS frames the voxel volume is obtained. For this purpose the frames are properly located in space and augmented with additional intermediate frames generated by interpolation. Their spatial location and orientation is derived from biplane X-ray angiography which is performed simultaneously. For resampling, two approaches are proposed: insertion of the vertices of the rectangular goal grid into the cells of a deformed hexahedral mesh derived from the IVUS sequence, and insertion of the vertices of the hexahedral mesh into the cells of the rectangular grid. Finally, the vessel model is visualized by methods of combined volume and polygon rendering. The segmentation process is verified as being in good agreement with results obtained by manual contour tracing with a commercial system. Our approach of construction of the vessel model has been implemented into an interactive software system, 3D IVUS-View, serving as the basis of a future system for intracoronary brachytherapy treatment planning being currently under development (Part II).

A method for in-vivo analysis for regional arterial wall material property alterations with atherosclerosis: preliminary results

Atherosclerosis is a diffuse arterial disease developing over many years and resulting in a complicated three-dimensional arterial morphology. The arterial wall material properties have been demonstrated to show regional alterations with atheroma development and growth. We present a mechanical analysis of diseased arterial segments reconstructed from intravascular ultrasound images in order to quantitatively identify regional alterations in the elastic constants with atherosclerotic lesions. We employ a finite element and a displacement sensitivity analysis to divide the arterial segment into regions with different material properties and use an optimization algorithm to identify the elastic constants in these regions. The results with regional variations identified with this method correlated qualitatively with the extent and location of atherosclerotic lesions identified by visual inspection of the affected arteries. The optimized elastic modulus in regions affected by early atherosclerotic lesions ranged from 90.9 to 93.0 kPa where as the corresponding magnitudes in normal arterial segments ranged from 97.9 to 101.0 kPa. This method can be potentially employed to identify the extent and location of atherosclerotic lesions in a systematic analysis and may potentially be used for the early detection of lesion growth.

True 3-dimensional reconstruction of coronary arteries in patients by fusion of angiography and IVUS (ANGUS) and its quantitative validation

BACKGROUND

True 3D reconstruction of coronary arteries in patients based on intravascular ultrasound (IVUS) may be achieved by fusing angiographic and IVUS information (ANGUS). The clinical applicability of ANGUS was tested, and its accuracy was evaluated quantitatively. METHODS AND REUSLTS: In 16 patients who were investigated 6 months after stent implantation, a sheath-based catheter was used to acquire IVUS images during an R-wave-triggered, motorized stepped pullback. First, a single set of end-diastolic biplane angiographic images documented the 3D location of the catheter at the beginning of pullback. From this set, the 3D pullback trajectory was predicted. Second, contours of the lumen or stent obtained from IVUS were fused with the 3D trajectory. Third, the angular rotation of the reconstruction was optimized by quantitative matching of the silhouettes of the 3D reconstruction with the actual biplane images. Reconstructions were obtained in 12 patients. The number of pullback steps, which determines the pullback length, closely agreed with the reconstructed path length (r=0.99). Geometric measurements in silhouette images of the 3D reconstructions showed high correlation (0.84 to 0.97) with corresponding measurements in the actual biplane angiographic images.

CONCLUSIONS

With ANGUS, 3D reconstructions of coronary arteries can be successfully and accurately obtained in the majority of patients.

New developments in intravascular ultrasound

Intravascular ultrasound (IVUS) is a dynamic imaging modality that provides real-time in vivo visualization of atherosclerosis and other vascular pathology. The tomographic image presentation of IVUS permits detailed assessment of plaque morphology and its corresponding responses to interventional therapy. IVUS studies have confirmed vascular remodeling in vivo, have proposed a high-pressure stent implantation strategy and have shown two key mechanisms of restenosis after angioplasty: plaque proliferation and vessel shrinkage (negative remodeling). IVUS also provides accurate quantitative information regarding lumen size, vessel size and plaque burden. These observations, essential to achieving improved outcomes, have drastically changed the understanding of atherosclerotic artery disease and interventional procedures. IVUS has matured into an essential complement to daily peripheral and coronary interventional practice and is routinely incorporated as part of the interventional arsenal in the catheterization laboratory. A variety of new imaging techniques are currently being designed and tested. These include combined therapeutic devices, further miniaturization, 3-D applications and tissue characterization. These techniques may evolve to provide increased favorable clinical outcomes and more accurate information of vessel geometry and plaque composition.

Three-dimensional ultrasound imaging

The objective of this article is to provide scientists, engineers and clinicians with an up-to-date overview on the current state of development in the area of three-dimensional ultrasound (3-DUS) and to serve as a reference for individuals who wish to learn more about 3-DUS imaging. The sections will review the state of the art with respect to 3-DUS imaging, methods of data acquisition, analysis and display approaches. Clinical sections summarize patient research study results to date with discussion of applications by organ system. The basic algorithms and approaches to visualization of 3-D and 4-D ultrasound data are reviewed, including issues related to interactivity and user interfaces. The implications of recent developments for future ultrasound imaging/visualization systems are considered. Ultimately, an improved understanding of ultrasound data offered by 3-DUS may make it easier for primary care physicians to understand complex patient anatomy. Tertiary care physicians specializing in ultrasound can further enhance the quality of patient care by using high-speed networks to review volume ultrasound data at specialization centers. Access to volume data and expertise at specialization centers affords more sophisticated analysis and review, further augmenting patient diagnosis and treatment.

Ultrafast three-dimensional ultrasound: application to carotid artery imaging

BACKGROUND AND PURPOSE

Three-dimensional (3-D) vascular ultrasound can be expected to improve qualitative evaluation of vessel pathology and to provide quantitative data on vascular morphology and function. The objective of this study was to develop an ultrafast 3-D vascular system and to validate its performance for quantitation of atherosclerosis and assessment of regional arterial distensibility.

METHODS

The quantitative analysis of focal atherosclerotic lesions was validated in vitro on 27 phantoms of fibroadipous plaques of known volume (range, 100 to 600 mm3). In vivo reproducibility of plaque volume measurement was tested in 33 patients who had a total of 47 predominantly fibroadipous carotid plaques. Distensibility assessment was validated indirectly through the evaluation of age-related changes in distensibility of common carotid artery in healthy and hypertensive subjects (25 men in each group).

RESULTS

The volume of plaque phantoms measured from the 3-D data set showed a very close correlation with the true volume (r=0.99; y=0.96x+12.38; P<0.01), with the mean difference between the 2 measurements being -3.12+/-15.1 mm3. High reproducibility was found for measurement of carotid plaque volume in vivo: the mean difference between measurements from 2 observers for the same data set was 0.60+/-11.2 mm3. Indexes of arterial distensibility decreased with age in healthy population, whereas this relationship was lost in hypertensive subjects.

CONCLUSIONS

Ultrafast 3-D ultrasound imaging of carotid artery demonstrates good accuracy and reproducibility for atherosclerotic plaque volume measurements. The system also allows the study of age-related degenerative vascular changes.

Atherosclerotic coronary lesions with inadequate compensatory enlargement have smaller plaque and vessel volumes: observations with three dimensional intravascular ultrasound in vivo

OBJECTIVE

To compare vessel, lumen, and plaque volumes in atherosclerotic coronary lesions with inadequate compensatory enlargement versus lesions with adequate compensatory enlargement.

DESIGN

35 angiographically significant coronary lesions were examined by intravascular ultrasound (IVUS) during motorised transducer pullback. Segments 20 mm in length were analysed using a validated automated three dimensional analysis system. IVUS was used to classify lesions as having inadequate (group I) or adequate (group II) compensatory enlargement.

RESULTS

There was no significant difference in quantitative angiographic measurements and the IVUS minimum lumen cross sectional area between groups I (n = 15) and II (n = 20). In group I, the vessel cross sectional area was 13.3 (3.0) mm2 at the lesion site and 14.4 (3.6) mm2 at the distal reference (p < 0.01), whereas in group II it was 17.5 (5.6) mm2 at the lesion site and 14.0 (6.0) mm2 at the distal reference (p < 0.001). Vessel and plaque cross sectional areas were significantly smaller in group I than in group II (13.3 (3.0) v 17.5 (5.6) mm2, p < 0.01; and 10.9 (2.8) v 15.2 (4.9) mm2; p < 0.005). Similarly, vessel and plaque volume were smaller in group I (291.0 (61.0) v 353.7 (110.0) mm3, and 177.5 (48.4) v 228.0 (92.8) mm3, p < 0.05 for both). Lumen areas and volumes were similar.

CONCLUSIONS

In lesions with inadequate compensatory enlargement, both vessel and plaque volume appear to be smaller than in lesions with adequate compensatory enlargement.

Three-dimensional echocardiographic evaluation of aortic disorders with rotational multiplanar imaging: experimental and clinical studies

Transesophageal echocardiography has become a highly valuable method to assess aortic disorders. With this method, however, aortic disease has been visualized only in two-dimensional views. Advances in computer technology have introduced three-dimensional (3D) echocardiography as a developing modality in cardiac imaging. Previous efforts to obtain 3D reconstructions of the aorta, by various techniques, had limited clinical applicability. In this study we attempted to explore the feasibility and potential of 3D reconstructions of the aorta employing a widely used multiplane transesophageal imaging technique in an experimental setting and in patients. In the in vitro study, we created 35 lesions in 28 pig aortic trees (15 aortic dissections, five saccular aneurysms, five coarctations, five atheromas, and five clots within dissections). Suspending these specimens in a water bath, sequential two-dimensional images were acquired over a 180-degree rotation with a commercially available multiplane transesophageal probe and ultrasound system with a 3D software package. Data processing (digital reformation, interpolation, and segmentation) and 3D display were accomplished on an off-line computer system. 3D reconstructions were achieved and displayed in wire-frame, surface-rendered, and volume-rendered images. These 3D reconstructions corresponded well with the actual anatomic specimens in delineating the various pathologic findings. In patient studies, we collected a total of 36 studies in both adults and children with a mean age of 44.5 years (range 1 month to 82 years). In addition to normal aortas (n = 13), the spectrum of abnormalities studied included six atheromatous lesions, four aortic dissections, 10 coarctations, one aneurysm with a thrombus, and one dilated aortic root. We were able to accomplish volume-rendered 3D images depicting the aortic lesions in their true form that could be viewed in many different perspectives in all patients. We conclude that 3D echocardiography is able to display the aorta and aortic disease in a realistic manner. Although this modality still has limitations, further improvements in computer and ultrasound technology would strengthen 3D echocardiography as a clinically viable diagnostic tool, in the evaluation of aortic disorders.

The effect of vascular curvature on three-dimensional reconstruction of intravascular ultrasound images

OBJECTIVE

To characterize the effect of vessel curvature on the geometric accuracy of conventional three-dimensional reconstruction (3DR) algorithms for intravascular ultrasound image data.

BACKGROUND

A common method of 3DR for intravascular ultrasound image data involves geometric reassembly and volumetric interpolation of a spatially related sequence of tomographic cross sections generated by an ultrasound catheter withdrawn at a constant rate through a vascular segment of interest. The resulting 3DR is displayed as a straight segment, with inherent vascular curvature neglected. Most vascular structures, however, are not straight but curved to some degree. For this reason, vascular curvature may influence the accuracy of computer-generated 3DR.

METHODS

We collected image data using three different intravascular ultrasound catheters (2.9 Fr, 4.3 Fr, 8.0 Fr) during a constant-rate pullback of 1 mm/sec through tubing of known diameter with imposed radii of curvature ranging from 2 to 10 cm. Image data were also collected from straight tubing. Image data were digitized at 1.0-mm intervals through a length of 25 mm. Two passes through each radius of curvature were performed with each intravascular ultrasound catheter. 3DR lumen volume for each radius of curvature was compared to that theoretically expected from a straight cylindrical segment. Differences between 3DR lumen volume of theoretical versus curved (actual) tubes were quantified as absolute percentage error and categorized as a function of curvature. Tubing deformation error was quantified by quantitative coronary angiography (QCA).

RESULTS

Volumetric errors ranged from 1% to 35%, with an inverse relationship demonstrated between 3DR lumen volume and segmental radius of curvature. Higher curvatures (r < 6.0 cm) induced greater lumen volume error when compared to lower curvatures (r > 6.0 cm). This trend was exhibited for all three catheters and was shown to be independent of tubing deformation artifacts. QCA-determined percentage diameter stenosis indicated no deformation error as a function of curvature. Total volumetric error contributed by tubing deformation was estimated to be 0.05%.

CONCLUSIONS

Catheter-dependent geometrical error arises in three-dimensionally reconstructed timed linear pullbacks of intravascular ultrasound images due in part to uniplanar vascular curvature. Three-dimensional reconstruction of timed linear pullbacks is robust for vessels with low radii of curvature; however, careful interpretation of three-dimensional reconstructions from timed linear pullbacks for higher radii of curvature is warranted. These data suggest that methods of spatially correct three-dimensional reconstruction of intravascular ultrasound images should be considered when more pronounced vascular curvature is present.

Morphometric analysis in three-dimensional intracoronary ultrasound: an in vitro and in vivo study performed with a novel system for the contour detection of lumen and plaque

Currently, automated systems for quantitative analysis by intracoronary ultrasound (ICUS) are restricted to the detection of the lumen. The aim of this study was to determine the accuracy and reproducibility of a new semiautomated contour detection method, providing off-line identification of the intimal leading edge and external contour of the vessel in three-dimensional ICUS. The system allows cross-sectional and volumetric quantification of lumen and of plaque. It applies a minimum-cost algorithm and the concept that edge points derived from previously detected longitudinal contours guide and facilitate the contour detection in the cross-sectional images. A tubular phantom with segments of various luminal dimensions was examined in vitro during five catheter pull-backs (1 mm/sec), and subsequently 20 diseased human coronary arteries were studied in vivo with 2.9F 30 MHz mechanical ultrasound catheters (200 images per 20 mm segment). The ICUS measurements of phantom lumen area and volume revealed a high correlation with the true phantom areas and volumes (r = 0.99); relative mean differences were -0.65% to 3.86% for the areas and 0.25% to 1.72% for the volumes of the various segments. Intraob-server and interobserver comparisons showed high correlations (r = 0.95 to 0.98 for area and r = 0.99 for volume) and small mean relative differences (-0.87% to 1.08%), with SD of lumen, plaque, and total vessel measurements not exceeding 7.28%, 10.81%, and 4.44% (area) and 2.66%, 2.81%, and 0.67% (volume), respectively. Thus the proposed analysis system provided accurate measurements of phantom dimensions and can be used to perform highly reproducible area and volume measurements in three-dimensional ICUS in vivo.

An attempt to 3D reconstruct vessel morphology from X-ray projections and intravascular ultrasounds modeling and fusion

The emergency of interventional revascularization techniques in the treatment of atheromateous vascular diseases has resulted in the need for additional valuable diagnostic information about the 3D morphology and nature of the lesion. To overcome the limitations inherent to common vascular imaging techniques, such as Digital Angiography (DA) which only gives partial information on lumen narrowing or Intravascular Ultrasound (IVUS) which provides randomly oriented transversal images, a 3D reconstruction of the vessel by fusion of X-ray and IVUS images has been developed. For that purpose, X-ray and IVUS images are acquired according to a well-defined protocol and useful information to be fused is extracted. A geometric model then leads to the determination of the unknown parameters which allow the alignment of all data in a common reference frame. The registered data are then directly introduced into a probabilistic reconstruction process using a Markovian modeling associated with a simulated annealing-based optimization algorithm. Taking into account all the information available about the vessel, the method avoids the uncertainties and ambiguities of a reconstruction based only on one modality, and the probabilistic fusion solves the possible contradictions between both acquisitions. Results of vascular lumen 3D reconstruction are shown with data acquired on an excised dog aorta. The accuracy of reconstruction of the lumen by data fusion is significantly improved compared to results obtained with separate reconstruction from angiographic or ultrasonic data. Further work will include introduction of vessel wall texture elements into the probabilistic fusion process to increase the amount of information gained by intravascular ultrasonic tissue characterization.

Cyclosporine impairs release of endothelium-derived relaxing factors in epicardial and resistance coronary arteries

BACKGROUND

Cyclosporin A is reported to impair endothelium-mediated vasorelaxation and induce endothelin release in some noncoronary vascular beds. We wished to determine whether acute cyclosporine administration induces endothelial dysfunction in coronary conductance or resistance arteries.

METHODS AND RESULTS

We examined the effect of intracoronary acetylcholine, N omega-nitro-L-arginine methyl ester (L-NAME), L-arginine, nitroglycerin, and adenosine before and after acute cyclosporine administration (3 mg/kg IV over 30 minutes) in anesthetized dogs. Flow velocity was measured with a 0.014-in Doppler wire to assess resistance vessel responses, and epicardial coronary lumen area was simultaneously measured with a 4.3F, 30-MHz imaging catheter inserted over the Doppler wire. In 6 dogs, acetylcholine-induced increase in flow velocity was attenuated by cyclosporine in vehicle (137% to 55% at 10(-5) mol/L, P < .001), as was acetylcholine-induced epicardial vasodilation (14.1% to 6.7% at 10(-5) mol/L, P < .001). Vasodilation in response to intracoronary nitroglycerin (200 micrograms) and adenosine (6 mg) were unchanged by cyclosporine. Epicardial vasoconstriction with L-NAME (10(-4) mol/L) was reduced by cyclosporine (Pre, 7.4 +/- 0.9%; Post, 2.6 +/- 1.2%; P = .04), but L-arginine (10(-4) mol/L) had no effect after cyclosporine. In another 5 dogs, pure cyclosporine impaired acetylcholine-induced vasodilatation to the same degree as cyclosporine in vehicle (Cremophor); vehicle infusion did not impair endothelial function. In 5 more dogs, cyclosporine did not increase either arterial or coronary sinus concentrations of endothelin-1.

CONCLUSIONS

The present study shows that cyclosporine acutely impairs release of endothelium-derived relaxing factor in canine conductance and resistance coronary arteries and provides evidence for decreased epicardial nitric oxide release after cyclosporine. The potential contribution of acute cyclosporine-induced coronary endothelial dysfunction to posttransplant vasculopathy needs further study.

Three-dimensional imaging of cardiac mass lesions by transesophageal echocardiographic computed tomography

Three-dimensional echocardiography is a new imaging technique that allows more realistic visualization of cardiac morphology. This study presents data about the diagnostic potentials of this technique concerning cardiac mass lesions, as well as its feasibility in clinical application. After the conventional investigation, multiple cross-sectional images were obtained during automatic forward advancement of a monoplane transducer mounted on a transesophageal probe. Three-dimensional reconstruction and volume determination were performed off line. Twenty-four patients were studied. In 14 cases results of echocardiographic computed tomography (echo-CT) were compared with those of monoplane/biplane transesophageal echocardiography. In 23 patients a conventional transesophageal investigation with the echo-CT probe and in 20 patients tomographic scanning were possible. Data acquisition required 12 +/- 4 minutes and three-dimensional reconstruction required 35 +/- 14 minutes. In 13 patients mass lesions were found; in 11 of 13 patients echo-CT provided diagnostic information about the precise spatial orientation and morphology of cardiac structures that could not be obtained by monoplane/biplane transesophageal echocardiography. The technique revealed accurate distance measurements and volume determination of mass lesions. Echo-CT is a further step toward the application of clinically useful three-dimensional echocardiography.

Three-dimensional reconstruction of intracoronary ultrasound images. Rationale, approaches, problems, and directions

Although intracoronary ultrasonography allows detailed tomographic imaging of the arterial wall, it fails to provide data on the structural architecture and longitudinal extent of arterial disease. This information is essential for decision making during therapeutic interventions. Three-dimensional reconstruction techniques offer visualization of the complex longitudinal architecture of atherosclerotic plaques in composite display. Progress in computer hardware and software technology have shortened the reconstruction process and reduced operator interaction considerably, generating three-dimensional images with delineation of mural anatomy and pathology. The indications for intravascular ultrasonography will grow as the technique offers the unique capability of providing ultrasonic histology of the arterial wall, and the need for a three-dimensional display format for comprehensive analysis is increasingly recognized. Consequently, three-dimensional imaging is being rapidly implemented in the catheterization laboratories for guidance of intracoronary interventions and detailed assessment of their results. However exciting the prospects may be, three-dimensional reconstructions at present remain partially artificial because the true spatial position of the imaging catheter tip is not recorded, and shifts in its location and curves of the arterial lumen result in pseudoreconstructions rather than true reconstructions. In this report, we address the principles of three-dimensional reconstruction with a critical review of its limitations. Potential solutions for refinement of this exciting imaging modality are presented.

Ultrasonic three-dimensional reconstruction: in vitro and in vivo volume and area measurement

This study validates the use of an ultrasound three-dimensional reconstruction system to measure phantom and blood conduit geometry. Independently determined uniform and stenotic phantom dimensions are compared with reconstruction-based measurements. Lower extremity saphenous vein bypass graft reconstructions were performed to demonstrate clinical application. Uniform phantom independent and reconstructed volume correlation was high (r = 0.989), the average volume difference was 4.68 mm3 and the average area difference was 0.4 mm2. An in vitro 28% diameter reduction was detected. Stenotic bypass graft segment volume was 795 mm3; following successful angioplasty the volume increased to 1419 mm3. Advantages of this technique are its accuracy, the luminal information it provides and the absence of mechanical arm or acoustic transmitter limitations. We are exploring the possibility that measurement of luminal change over time may allow stenosis detection prior to hemodynamic disturbance, in an ongoing clinical saphenous vein bypass graft surveillance study.

Three-dimensional intravascular ultrasonography: reconstruction of endovascular stents in vitro and in vivo

BACKGROUND

Intravascular ultrasonography displays an artery in loosely related cross-sectional images with limited axial information. However, intravascular ultrasound images are suited to three-dimensional reconstruction.

METHODS

A comprehensive intravascular ultrasound imaging system was used to reconstruct planar images in three-dimensions. This system consisted of a 25MHz transducer-tipped rigid probe (for in vitro studies) or a 25MHz transducer-tipped catheter within a 3.9F monorail imaging sheath (for in vivo studies), a motorized catheter pullback device that withdraws the transducer at 0.5mm/s, and an image processing computer that stacks 15 cross-sectional images/mm of stent axial length and then performs thresholding-based three-dimensional image rendering. We imaged 10 stents (4 Palmaz-Schatz, 3 Wiktor, 2 Strecker, and 1 Medinvent) in vitro after implantation in freshly harvested saphenous veins and 37 Palmaz-Schatz stents in vivo, 10 in native coronary arteries and 27 in vein grafts, 21 acutely and 18 on follow-up.

RESULTS

Three-dimensional reconstruction of images obtained with this system reproduced the geometry of each stent design. In vitro, images of the Palmaz-Schatz stents showed the expanded diamonds, the central articulation, and flaring of both ends of both halves of the stents. Images of the Wiktor stents showed the sinusoidal wave-shaped coils in their helical configuration. Images of the Strecker stents showed the interlocking-loop design with gaps between the terminal loops at either end of the stent. Images of the Medivent stent reproduced the woven texture formed by braiding the stent wires. Three-dimensional reconstruction of images obtained in vivo also reproduced the spatial geometry of the Palmaz-Schatz stent. However, reconstruction of in vivo images was limited by cardiac-cycle-linked vessel motion and torsion and the presence of echo-dense tissue that could not be separated completely from the stent itself.

CONCLUSIONS

Properly acquired intravascular ultrasound images can be used to reconstruct the spatial geometry of endovascular stents. Because stent spatial geometry is known and unambiguous, reconstruction of endovascular stents should be one of the tests of imaging systems designed to perform three-dimensional reconstruction of ultrasound images.

3D display: a survey from theory to applications

We survey some of the literature on three-dimensional medical imaging. We report both on technical developments and on medical applications, with a concentration on material that has been published within the years 1990-1992.

Three- and four-dimensional cardiovascular ultrasound imaging: a new era for echocardiography

Three-dimensional and four-dimensional ultrasonography were pioneered in the 1960s yet have been used little clinically. Only recently have advances in cardiovascular ultrasound equipment and in digital image storage, manipulation, and display techniques made three- and four-dimensional imaging clinically feasible. In this report, we review the historical development of these technologies during 3 decades to their culmination in current state-of-the-art technology. Examples of such multidimensional images are presented, with special emphasis on clinical applications. Although several limitations persist, three-dimensional cardiovascular ultrasonography seems likely to enhance imaging of the heart and vessels in a manner similar to the advent of two-dimensional echocardiography in the M-mode era. Clinician-scientists will soon be able to extract an object, such as the heart, from the body electronically for the purpose of anatomic, functional, and histologic analysis without adverse effect on the patient.

Cardiovascular flow velocity measurements by 2D Doppler imaging for assessment of vascular function

Clinical two-dimensional (2D) Doppler ultrasound flow velocity measurement is important for determination of arterial wall shear stress, blood-tissue exchange, myocardial and valvular function. Such 2D Doppler flow velocity images are usually displayed in color, superimposed on the gray-scale, cross-section structural images of the tissue. There are several limitations to this technique of flow measurement, some due to the instrumentation and some to the way the measurement is made. In this report we concentrate on the latter, identifying the main causes of errors and distortion, and outlining the methodology for minimizing them. The suggested method takes into account the spatial location and orientation of both the ultrasound transducer and the blood vessel. It allows quantification of vascular flow patterns, thus enhancing the usefulness of this important non-invasive diagnostic tool.

Artifacts in intravascular ultrasound imaging: analyses and implications

The ability of an intravascular ultrasound catheter to give cross-sectional images of vessel walls and surrounding tissues, and the behavior of ultrasound in heterogeneous media, are at the origin of degradation of image quality. Qualitative and quantitative analyses of in vivo studies are then operator-dependent and are limited by artifacts. We investigated these limitations by an in vitro study on plexiglass phantoms and segments of fresh arteries. We used a 20 MHz transducer mounted on the tip of a 4.8 F catheter and an interventional ultrasound system. The ultrasound beam is reflected onto the rotating transducer at 600 rotations per minute (RPM), creating 360 degrees real-time images (10 images/second). We then observed, analyzed and interpreted the most specific reasons for image artifacts: geometric distortions, multiple echoes, the point spread function (PSF) of the imaging system, near-field effects, "petal-shaped" effect, and ultrasound speckle. Various practical implications have resulted from this study. Only a thorough knowledge of how to avoid some of the most obvious pitfalls will enable the user to obtain maximum benefits from intravascular ultrasound imaging, and to appreciate its limitations.

In vitro validation of three-dimensional intravascular ultrasound for the evaluation of arterial injury after balloon angioplasty

OBJECTIVES

The hypothesis of this study was that three-dimensional ultrasound imaging would facilitate the evaluation of arterial dissection after balloon angioplasty.

BACKGROUND

The presence and extent of arterial dissection occurring at the time of balloon angioplasty may be important predictors of abrupt vessel closure or late restenosis.

METHODS

Forty-one human arterial segments obtained after death were imaged in an in vitro system at physiologic pressure (80 to 100 mm Hg) before and after balloon angioplasty. Images were acquired with a 20- to 30-MHz mechanical intravascular ultrasound imaging system (Cardiovascular Imaging Systems) with a constant pullback technique (1 mm/s). Standard 0.5-in. (1.27-cm) video tapes were used for data storage and later playback for analog to digital conversion. Digitized data were reconstructed to three-dimensional images with use of voxel space modeling. The vessels were opened longitudinally and subjected to pathologic examination, photographed and classified histologically as normal, fibrous or calcified. Dissection was defined as a disruption and separation of components of the arterial wall. The length and depth of arterial dissection were evaluated grossly and microscopically.

RESULTS

Of the 41 arteries studied, 36 (88%) exhibited dissection on pathologic examination after balloon angioplasty. Three-dimensional reconstruction of intravascular ultrasound images identified dissection in 11 (92%) of 12 normal, 8 (100%) of 8 fibrous and 11 (69%) of 16 calcified arteries. Excellent agreement between ultrasound and pathologic findings was achieved in the evaluation of length and depth of dissection for histologically normal and fibrous arteries (kappa = 0.72 to 1.0). When the vessels were severely calcified, the agreement was not as good (kappa = 0.27 to 0.56), particularly in detection of small, non-raised intimal flaps.

CONCLUSIONS

This histopathologic validation study suggests that three-dimensional intravascular ultrasound imaging facilitates the evaluation of both quantitative and morphologic features of arterial dissection induced by balloon angioplasty. The advantage of three-dimensional intravascular ultrasound is its ability to assess the length and morphology of arterial injury over an entire vessel segment.

Intravascular ultrasound in coronary atherosclerosis: a new approach to clinical assessment

Intravascular ultrasound evaluation of the coronary arteries by means of a selective coronary catheter attached to an ultrasound unit has afforded precise depiction of coronary lumen diameter and area at the level of the catheter tip. The arterial wall at this level can be evaluated for lipid, fibrous tissue, calcification, wall dissections, and intraluminal thrombi. The technique has the advantage over coronary angioscopy and angiography in that it does not require infusions or injections to allow visualization, and it has the ability to depict the inside of the arterial wall. The current disadvantages include the inability to visualize the vessel segments distal to the catheter tip. Three-dimensional reconstruction techniques allow depiction of the segment of the artery traversed by the catheter tip. The use of Doppler ultrasound imaging provides information on coronary flow velocities through coronary obstructions. Intravascular ultrasound images may provide information that complements the coronary arteriogram and may have an impact on patient care and clinical investigation strategies.

3D-surface reconstruction of intravascular ultrasound images using personal computer hardware and a motorized catheter control

A system for three-dimensional (3D) presentation of intravascular ultrasound (US) images was designed. A standard hardware configuration based on personal computer equipment was used for acquisition and processing of image data. Pullback imaging with the US catheter was controlled by a specially designed motor assembly and performed either in equidistant 1-10 mm steps or at a constant retraction speed. Curvature of the vessel was documented on biplane digital subtraction angiograms and the US images were arranged according to the vessel shape in the angiograms. 3D reconstruction appears essential for spatial orientation of intravascular US and may be helpful in the planning of vascular interventions for a better appreciation of the extent and morphology of vascular lesions.

Intravascular ultrasound imaging: a current perspective

Catheter-based intravascular ultrasound imaging has evolved from a research tool to a device that has received Food and Drug Administration approval. Although it is currently employed as an adjunct to contrast angiography in both the peripheral and the coronary circulation, the indications for its use and its clinical utility have yet to be defined. Much of the research on the technique has explored its qualitative and quantitative capabilities to improve the assessment of atherosclerotic vascular disease. There is the hope that this imaging technique may ultimately improve the performance of endovascular interventions. This review describes the development of the technology from early in vitro validation studies to its present use in human subjects. Wherever possible, studies that validate the findings (that is, by comparison with histopathology results) of intravascular ultrasound are emphasized. Although there is great promise for this technology, limitations such as loss of image quality in severely diseased or heavily calcified vessels hinder its use. The application of imaging with endovascular intervention, imaging of intracardiac structures and the pulmonary circulation and new techniques such as computer image analysis are discussed.

Three-dimensional reconstruction of human coronary and peripheral arteries from images recorded during two-dimensional intravascular ultrasound examination

BACKGROUND

Intravascular ultrasound provides high-resolution images of vascular lumen, plaque, and subjacent structures in the vessel wall; current instrumentation, however, limits the operator to viewing a single, tomographic, two-dimensional image at any one time. Comparative analysis of serial two-dimensional images requires repeated review of the video playback recorded during the two-dimensional examination, followed by a "mind's eye" type of imagined reconstruction.

METHODS AND RESULTS

Computer-based, automated three-dimensional reconstruction was used to generate a tangible format with which to assess and compare a "stacked" series of two-dimensional images. Three-dimensional representations were prepared from sequential images obtained during intravascular ultrasound examination in 52 patients, 50 of whom were studied before and/or after percutaneous revascularization. Conventional two-dimensional ultrasound images were acquired by means of a systematic, timed pullback of the ultrasound catheter through the respective vascular segments. Images were then assembled in automated fashion to create a three-dimensional depiction of the vessel lumen and wall. Computer-enhanced three-dimensional reconstructions were generated in both sagittal and cylindrical formats. The sagittal format resulted in a longitudinal profile similar to that obtained during angiographic examination; in contrast to angiography, however, the sagittal reconstruction offered 360 degrees of limitless orthogonal views of the plaque and arterial wall as well as the vascular lumen. The cylindrical format yielded a composite view of a given vascular segment, and a hemisected version of the cylindrical reconstruction enabled en face inspection of the reconstructed luminal surface. Sagittal reconstructions facilitated analysis of dissections and plaque fractures resulting from percutaneous revascularization, and the hemisected cylindrical reconstructions enhanced analysis of endovascular prostheses.

CONCLUSIONS

This preliminary experience demonstrates that computer-based three-dimensional reconstruction may further augment the use of intravascular ultrasound in assessing vascular pathology and guiding interventional therapy.

Intravascular ultrasound imaging for guidance of atherectomy and other plaque removal techniques

Intravascular ultrasound imaging provides a direct view of atherosclerotic disease, generating in vivo information about the depth and mechanical characteristics of plaque at any point in the vessel wall. For this reason, ultrasound has significant potential to serve as a guidance modality for catheter-based techniques designed to remove or ablate plaque. Although the current generation mechanical atherectomy, laser ablation and ultrasound pulverization techniques all have some specificity for attacking plaque as opposed to normal vessel wall, it appears that in practice all of these devices will continue to carry a risk of traumatizing or even perforating arteries. In addition, it seems highly likely that aggressive 'debulking' of plaque will require some type of guidance beyond angiography - a role which ultrasound is theoretically well suited to play. The purpose of this review is to consider the theoretical and practical applications of ultrasound imaging as a guide to catheter-based plaque removal and ablation techniques. Specific uses will be discussed with respect to both directional and coaxial therapeutic devices.

Intravascular ultrasound imaging and three-dimensional modeling of arteries

In this article, we describe the reconstruction of arterial structures using solid modeling. The alternative approaches to three-dimensional modeling are discussed and the voxel space system we use for intra-arterial imaging, based on ultrasonic data, is described. The complete three-dimensional ultrasonic imaging system comprising a purpose-built, catheter-mounted ultrasound probe, ultrasonic transceiver, and computer system is presented. This system has been used to recreate three-dimensional computer models of arterial sections in vitro and in vivo. Examples to illustrate the power and flexibility of voxel space modeling in terms of postprocessing and software manipulation are given. Preliminary work on tissue differentiation, using arterial models and color coding of the image, and three-dimensional presentation of flow data is included.

Intravascular and intracardiac ultrasound imaging: current research and future directions

Intravascular and intracardiac ultrasound imaging is a newly emerging catheter-based imaging modality with considerable promise. This review article presents the rationale behind attempts at developing intravascular imaging methods, the design features of intravascular instrumentation, the knowledge obtained with in vitro studies, the in vivo experience in humans, and the potential applications of intravascular imaging in arterial atherosclerosis. The feasibility of pulmonary artery imaging and the potential applications of intracardiac echocardiography are discussed. Finally, future directions in intravascular imaging are outlined.