Suresh P. Jain

Influence of various instrument settings on the flow information derived from the power mode

To evaluate the factors influencing flow information displayed by the power operating mode, color Doppler flow mapping was used to image the flow in an in vitro left heart pulse duplicator system. The effect of changing one instrument setting, such as pulse repetition frequency, color filter and frame rate while keeping all other instrumental settings constant, was noted on the displayed flow areas. The flow areas derived using power and velocity modes were also compared. An increase in pulse repetition frequency and color filter decreased the flow areas significantly, and a flow area increase occurred with a decrease in frame rate. No significant difference was observed between the flow areas derived using the two operating modes. Like the velocity mode, the power mode display is also influenced by instrument settings. Although low velocity flows are better delineated using this mode, however, no significant difference occurred in the flow areas measured by this mode and velocity mode. Further studies need to be conducted to address its potential applications in the clinical setting and in quantitation.

Utilization of the Coronary Balloon-Expandable Coil Stent Without Anticoagulation or Intravascular Ultrasound

BACKGROUNDnThe balloon-expandable coil stent has been proved effective in the management of acute and threatened closure after coronary balloon angioplasty and has been shown to reduce restenosis in patients with suboptimal results after coronary balloon angioplasty. Coronary artery stenting has been limited by the occurrence of stent thrombosis and comorbidity related to anticoagulation. This study was undertaken to determine whether anticoagulation may be removed from poststenting protocols, thus reducing comorbidity without increasing stent thrombosis.nnnMETHODS AND RESULTSnBetween September 1994 and May 1995, 369 patients received balloon-expandable coil stents in native coronary arteries at our institution. Of these patients, 216 were selected for a protocol of aspirin and ticlopidine (for 1 month) without anticoagulation. Eligibility for this protocol followed satisfaction of certain procedural and angiographic criteria. These criteria included adequate coverage of intimal dissections, absence of residual filling defects, and normal (TIMI grade 3) flow in the stented vessel after high-pressure balloon inflations. Intravascular ultrasound was not used to guide stent deployment. The stenting procedure was planned in 37% of patients and unplanned in 63% of patients, including 25 (12%) for acute or threatened closure. During the 30-day follow-up period, stent thrombosis occurred in 2 patients (0.9%), there was 1 death (0.5%), and 2 patients (0.9%) underwent coronary bypass surgery. Vascular access-site complications occurred in 4 patients (1.9%), and bleeding that required blood transfusion occurred in 4 patients (1.9%).nnnCONCLUSIONSnPatients who receive the coronary balloon-expandable coil stent with optimal angiographic results without intravascular ultrasound guidance can be managed safely with a combination of aspirin and ticlopidine without anticoagulation.

Comparison of aspirin alone versus aspirin plus ticlopidine after coronary artery stenting

This prospective nonrandomized study was performed comparing aspirin alone (n = 46) versus aspirin and ticlopidine (p = 338) following native coronary artery stenting. There were significantly more stent thrombosis events in the aspirin-only group than in the aspirin and ticlopidine group (6.5% vs 0.9%, p = 0.02) and significantly more Q-wave myocardial infarctions and cardiac-related deaths in the aspirin-only group than in the aspirin and ticlopidine group (6.5% vs 0%, p = 0.002 and 4.4% vs 0.3% p = 0.02, respectively).

Comparison of Balloon Angioplasty Versus Debulking Devices Versus Stenting in Right Coronary Ostial Lesions

Angioplasty of aorto-ostial stenosis is associated with lower procedural success and a higher complication rate. The aim of the present study was to compare the acute and long-term results of balloon and new device angioplasty in 110 consecutive patients with right coronary ostial lesions. Patients were divided into 3 groups according to the angioplasty device used: group I (balloon only, n = 26), group II (debulking devices including excimer laser, directional and rotational atherectomy, n = 26), group III (stent, n = 58). Procedural success was highest in group III (96%) followed by group I (88%), and group II (77%). In-hospital complications were similar among the groups (p = NS). Patients in group III achieved the highest acute gain (2.61 mm) followed by groups II (1.92 mm), and I (1.39 mm, p <0.05). During follow up, target lesion revascularization and/or bypass surgery was required in 24% of patients in group III compared with 47% and 40% in groups I and II, respectively (p <0.05). Cardiac-event free survival was highest in the stent group (74%, p <0.005) and was similar between the balloon (39%) and debulking device groups (45%). Thus, among the currently available technologies, stenting of right coronary ostial lesions appears to provide excellent angiographic and long-term results.

Two-dimensional echocardiography and Doppler color flow mapping in the diagnosis and prognosis of ventricular septal rupture.

Doppler color flow mapping in conjunction with two-dimensional echocardiography was used to evaluate ventricular septal rupture after myocardial infarction (seven anterior and eight inferior) in 15 patients and to correlate these findings with cardiac catheterization and surgical or autopsy data. Ventricular septal rupture was diagnosed by turbulent flow traversing the ventricular septum. The direction and velocity of shunt flow was determined by color M-mode and conventional Doppler methods. In all patients, Doppler color flow mapping correctly defined the site of septal rupture, which occurred at areas of discordant septal wall motion or hinge points (six posterior inlet, three anterior inlet, and six apical trabecular septum). Each of three patients with moderate tricuspid regurgitation and three of four patients with right-to-left shunting during diastole died, and all had an elevated right ventricular end-diastolic pressure. Right ventricular wall motion index was significantly higher in the patients who died compared with those who survived (mean +/- SEM; 2.8 +/- 0.2 vs. 2.0 +/- 0.2, p = 0.012), but there was no difference in left ventricular wall motion index. The rupture size measured by Doppler color flow imaging (1.7 +/- 0.1 cm) correlated with the size determined during surgery or autopsy (1.8 +/- 0.2 cm, r = 0.68, p = 0.022) and the pulmonic-to-systemic shunt flow ratio by cardiac catheterization (2.4:1 +/- 0.3, r = 0.74, p = 0.004). Color-guided continuous-wave Doppler estimates of right ventricular systolic pressure (47 +/- 2 mm Hg) correlated with cardiac catheterization measurements (48 +/- 3 mm Hg, r = 0.90, p = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Closure of an iatrogenic femoral artery pseudoaneurysm by transcutaneous coil embolization

Pseudo-aneurysm following diagnostic or interventional procedures is a well-recognized complication. Ultrasound guided compression repair is routinely used to close an uncomplicated pseudo-aneurysm. We describe a patient with a femoral artery pseudo-aneurysm following iliac angioplasty and stenting in which ultrasound guided compression repair failed. Pseudoaneurysm was successfully closed by transcutaneous coil embolization technique.

Intravascular ultrasound‐guided transluminal extraction atherectomy for restenosis after Gianturco‐Roubin coronary stent implantation

Two patients with restenosis following implantation of the Gianturco-Roubin stent were successfully treated with the transluminal extraction atherectomy device, with the assistance of intravascular ultrasound guidance and adjunctive balloon angioplasty. The optimal management strategy of in-stent restenosis remains unclear, but the transluminal extraction atherectomy device may be an option for the management of restenosis within the Gianturco-Roubin stent.

Intravascular ultrasound imaging of saphenous vein graft stenosis.

Abstract Coronary angiography has been used as a gold standard for assessing the results of such interventional procedures as balloon angioplasty, atherectomy and laser angioplasty. However, it is still imprecise in defining the extent and composition of atheromatous plaques, and can underestimate the severity of disease process in an eccentric lesion. 1,2 The introduction of intravascular ultrasound as an imaging modality for atherosclerotic coronary artery disease has opened a new field for studying the morphologic changes before and after interventional procedures. Because of the incorporation of high-frequency transducers, it is possible to obtain images of the coronary arterial wall and assess the structural composition of the diseased segments. 3–5 With the increasing number of procedures and devices being developed currently to deal with atherosclerotic obstruction, there is a need for a technique that will permit accurate assessment of alterations in the luminal area, integrity of the intimal surface, and the presence or absence of ulcerated plaques and thrombi. The present study describes our initial experience in using intravascular ultrasound to evaluate stenosed saphenous vein grafts undergoing angioplasty.

Results of Elective Stenting of Branch-Ostial Lesions

Coronary stenting using both Palmaz-Schatz and Gianturco-Roubin stents for branch ostial lesions was performed in 48 patients with high success and low complication rates. The 6-month event-free survival rates were high in these patients.

Diagnosis of arteriovenous fistula between common iliac artery and vein by color Doppler flow imaging

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