[Diagnostics and strategy of surgical treatment of multifocal atherosclerosis]

The study included 148 patients with different combinations of multifocal atherosclerosis. The inclusion criteria were clinical manifestations of chronic cerebrovascular insufficiency concomitant with diseases of other arterial basins. The treatment strategies were chosen based on the results of examination by non-invasive methods for vascular visualization. Contrast agents were used only for curative purposes. The patients were divided into 2 groups depending on surgical strategy. Patients of group 1 underwent one-step reconstruction of several affected basins, those in group 2 step-by-step revascularization of different arterial basins with the use of X-ray endovascular interventions. The former approach was applied at the initial stage of the work. It creating a high risk of complications, the latter approach was preferred in the subsequent period. The incidence of complications in group 2 was 4.05% and the lethality rate 1.49%. These values were significantly higher in patients of group 1.

Number of yellow plaques detected in a coronary artery is associated with future risk of acute coronary syndrome: detection of vulnerable patients by angioscopy

OBJECTIVES

We sought to test whether the risk of acute coronary syndrome (ACS) can be estimated by angioscopy.

BACKGROUND

Disruption of vulnerable plaque and subsequent thrombosis is regarded as a major mechanism of ACS. Although yellow plaques are supposedly vulnerable, the association between angioscopically determined extent of coronary atherosclerosis and risk of ACS events has not been reported.

METHODS

Patients (n = 552) who received catheterization and angioscopic examination for the diagnosis of coronary artery diseases were prospectively included and followed up for new onset of ACS events. Yellow color intensities of all detected yellow plaques were graded as 1, 2, or 3 according to the standard colors. Number of yellow plaques (NYP) in a coronary artery and maximum color grade of detected yellow plaques (maxYP) were determined. Association between the incidence of ACS events and angioscopic findings were analyzed.

RESULTS

Follow-up interval was 57.3 +/- 22.1 months. Acute coronary syndrome events were detected in 39 patients (7.1%). Although maxYP was not statistically different (2.0 +/- 0.7 vs. 1.8 +/- 0.9; p = 0.18), NYP was higher in the patients with an ACS event than those without the event (3.1 +/- 1.8 vs. 2.2 +/- 1.5; p = 0.008). Patients with NYP > or =2 and those with NYP > or =5 had 2.2- and 3.8-fold higher event rates, respectively, than those with NYP 0 or 1 (9.0% and 15.6%, respectively, vs. 4.1%; p = 0.02). Multivariate logistic regression analysis revealed NYP and multivessel disease as the independent risk factors of ACS events.

CONCLUSIONS

Patients with multiple yellow plaques per vessel have a higher risk of suffering ACS events than those with NYP 0 or 1. Angioscopy would be useful to detect vulnerable patients.

Detection of construction errors in ex vivo coronary artery anastomoses by 13-MHz epicardial ultrasonography

OBJECTIVE

Intraoperative detection of suboptimal coronary anastomoses allows revision before chest closure. We evaluated an epicardial 13-MHz ultrasound minitransducer as a means to detect three different coronary anastomosis construction errors.

METHODS

In total, 120 internal thoracic artery-to-coronary artery anastomoses were constructed correctly (n = 60) or incorrectly (n = 60) with one technical error: suture crossover, purse-string or deep toe stitch (n = 20 each). Anastomoses were performed on ex vivo pressure-perfused porcine (96 anastomoses) and human hearts (24 anastomoses). Two blinded observers scanned and scored the anastomoses with epicardial ultrasonography. In 24 human and 24 porcine anastomoses, angiograms were made of 24 correct and 24 incorrect anastomoses and scored by two other blinded observers. Angioscopy and cast injection served as a reference.

RESULTS

Overall, 119 of 120 anastomoses were accurately scored as correct or incorrect within a median of 67 seconds (8-381 seconds) by both observers (sensitivity 0.98, specificity 1.00, kappa 1.00 (1.00, 1.00, and 1.00 in angiography subset, respectively). One deep toe stitch that induced outflow corner stenosis was spotted by both observers but regarded as insignificant and thus inaccurately scored as correct. In 5 anastomoses, unintended irregularities were detected. By angiography, anastomoses were accurately scored with a sensitivity of 0.75 and a specificity of 0.81 ( P < .001 vs ultrasonography) and kappa of 0.54. Angioscopy and cast confirmed ultrasonographic findings and did not reveal irregularities other than detected by ultrasonography.

CONCLUSION

Ex vivo epicardial 13-MHz ultrasonography allowed rapid and accurate evaluation of coronary anastomoses and detected technical construction errors with higher sensitivity and specificity than angiography.

A method of endoscopic investigation of vascular structures directly through flowing blood

BACKGROUND

Noninvasive cardiovascular diagnosis has improved immensely due to key technological refinements such as digital subtraction angiography, ultrasonography, Doppler flow analysis, and magnetic resonance imaging. Each of these methodologies provides a unique image of the cardiovascular system but will not permit surgical maneuvers or repairs during real time imaging. Our group has developed a new method of endoscopic visualization of the luminal surface of blood vessels directly through flowing blood without interference of the blood or vessel wall. This opens new possibilities in both diagnosis and surgical interventions.

METHODS

Transluminal imaging through flowing blood was performed in normal animals using laser frequency light delivered and retrieved via conventional fiberoptic angioscopic instruments. The reflected light energy was reconstructed into a viewable image using a specialized method of optical data processing and filtering systems. Unlike conventional angioscopy, displacement of flowing blood was not needed as the images were obtained with higher frequency laser light.

RESULTS

A total of 20 canine experiments were performed between 1996 and 1997 using our endoluminal imaging system. The images obtained revealed details of luminal surfaces, although primitive and low resolution with this first generation of technology. Images of the topography of the femoral, axillary, and subclavian arteries and veins, as well as several intracardiac structures (aorta and aortic valve) were successfully obtained without trauma or physiologic consequence to the animal.

CONCLUSIONS

Using conventional fiberoptic angioscopes coupled with laser light of differing wavelengths, it was possible to image the interior of vascular structures through flowing blood. This method visualizes the intraluminal surface in real time and is dependent only on the delivery and capacity of the endoscope. The implications for future cardiovascular diagnosis and corrective surgical procedures are widespread.

Usefulness of intracoronary angioscopy for elucidating the cause of subacute thrombosis after stenting

Stent thrombosis is rare with anti-platelet therapy, which consists of aspirin and ticlopidine as a post-stenting administration. A 77-year-old man had repeated stent thrombosis, which was not predicted by coronary angiography, despite using contemporary periprocedural anti-platelet therapy. Only intravascular fiberscopy was able to detect the cause of the stent thrombosis.

[Arteriography, endoscopy and periscopy: simultaneous digital imaging]

The author reports his personal, limited experience as well as a literature review concerning first results of a simultaneous study of the blood vessels obtained in a similar approach to conventional angiography, but using a digital approach of the vascular lumen, the normal or pathological endothelium, the adventice and/or the perivascular environment. A static and morphologic iconography aims to demonstrate the potential of this imaging approach in the future, especially knowing that those images may be combined to kinetic and/or functional images of the blood circulation.

Angioscopic evaluation of rotational atherectomy followed by additional balloon angioplasty versus balloon angioplasty alone in coronary artery disease: a prospective, randomized study

OBJECTIVES

This study sought to compare, by angioscopy, the morphologic changes induced by rotational atherectomy, followed by additional angioplasty, with those observed after balloon angioplasty alone.

BACKGROUND

Rotational atherectomy and balloon angioplasty act by different mechanisms, which could explain the difference in morphologic changes induced by these two techniques.

METHODS

The study group included 50 patients with 50 lesions who were randomly assigned to undergo rotational atherectomy (n = 24) or balloon angioplasty (n = 26). Rotational atherectomy with a single burr (approximately equal to 70% of coronary diameter) was systematically followed by additional balloon angioplasty. Angioscopy was performed immediately after the procedure. Abnormal angioscopic findings were 1) flaps, graded from 1 to 3 (1 = intimal flap; 2 = flap protruding into < 50% of the lumen; 3 = flap protruding into > or = 50% of the lumen); 2) thrombi, graded from 1 to 3 (1 = flat deposits; 2 = protruding but nonocclusive thrombus; 3 = occlusive thrombus); 3) subintimal hemorrhage; 4) longitudinal dissection. The two groups were comparable for clinical and angiographic baseline data.

RESULTS

On angioscopy, flaps were observed less frequently after rotational atherectomy followed by additional balloon angioplasty (8 [33%] of 24 lesions) than after balloon angioplasty alone (14 [54%] of 26 lesions, p = 0.08) and were also less severe (grade 1 in 6 lesions, grade 2 in 2 and grade 3 in none vs. grade 1 in 4 lesions, grade 2 in 5 and grade 3 in 5). Longitudinal dissections were also significantly less frequent: one versus six (p = 0.05). There was no difference in the incidence of angioscopic thrombi (p = 0.16) or subintimal hemorrhage (p = 0.15), but the power to detect a significant difference was low for these variables (37% and 26%, respectively).

CONCLUSIONS

Rotational atherectomy followed by additional balloon angioplasty leads to fewer angioscopic dissections and a trend toward fewer intimal flaps than balloon angioplasty alone. However, our angioscopic differences did not lead to an outcome difference between the two groups.

False aneurysms after aortic operations

Between 1980 and August 1991, we encountered 11 non-infected aortic pseudoaneurysms after aortic surgery. The interval between the initial operation and revision varied from 1.8 to 26.8 years (mean 15.2 years). Three were found more than 20 years after operation. Pulling off of and degrading of the silk sutures were considered to be the causes. All patients underwent operative correction without mortality. In thoracic aortic pseudoaneurysm repair, a temporary bypass between the right axillary artery and left external iliac artery was generally adopted. There was no need for heparinization with this technique.