BRIEF COMMUNICATIONS
Intravascular percutaneous coarctation
ultrasound-assisted angioplasty of aortic
Ashit Jain, MD,’ Stephen R. Ramee, MD,” Walter R. Culpepper, MD,b Juan E. Mesa, MD,a Joseph P. Murgo, MD,a and Christopher J. White, MD.” New Orleans, La.
Various procedures are used to define the site and severity of the stenoses in patients with coarctation of the aorta, including two-dimensional echocardiography with Doppler,l magnetic resonance imaging,2 digital subtraction angiography,3 transesophageal echocardiography, and invasive cineangiography with hemodynamic measurements. Intravascular ultrasound (IVUS) has been reported to be of value in assessing the severity of stenoses in coronary artery disease, peripheral vascular disease, aortic stenosis, and coarctation of the aorta in adults.5 We report the first use of IVUS in a child with coarctation of the aorta. MH was a 3-month-old boy who underwent surgical repair of a discrete juxtaductal coarctation of the aorta at the age of 1 month, after he presented with congestive heart failure. At the 2-month follow-up he was found to have deFrom ’ the Department of Internal Medicine, Section of Cardiology, and lJ the Department of Pediatrics, Section of Pediatric Cardiology, Ochsner Medical Institutions. Reprint requests: Chrkkopher J. White, MD, Section of Cardiology, Ochsner Medical Institutions, 1514 Jefferson Highway, New Orleans, LA 70121. 4/4f34082
creased pulses and blood pressure in his lower extremities, upper extremity hypertension, and a grade 2/6 ejection systolic murmur heard best in the left infrascapular area. Electrocardiography revealed right and left ventricular hypertrophy, and two-dimensional echocardiography confirmed the diagnosis of recurrent coarctation of the aorta. Repeat catheterization demonstrated a peak systolic gradient of 50 mm Hg across the stenosis and a mean gradient of 24 mm Hg. Angiographicaily there was a recurrent stenosis of 75% by diameter (Fig. 1). The descending aorta distal to the stenosis showed evidence of poststenotic dilatation. The region of coarctation was then assessed with a 4.9F intravascular ultrasound catheter with a 20 MHz transducer (Intertherapy, Inc., Santa Ana, Calif.) and the measurements were made (Table I). The ultrasound catheter sheath was advanced over a wire and the tip of the sheath was placed proximal to the arch of the aorta. The luminal diameter of the aorta proximal to the stenosis was 6.03 mm versus 3.08 mm (51% stenosis) at the site of the stenosis. From the cross-sectional images of IVUS the luminal area narrowing was calculated to be 58@; The coarctation was dilated with a 5.0 mm peripheral angioplasty balloon (Peripheral Systems Group, Santa Clara, Calif.). After balloon dilation both the angiographic and IVUS measurements revealed a significant residual stenoses and the lesion was redilated with a 6.0 mm balloon, with a decrease in the peak gradient to 18 mm Hg and a mean gradient of 6 mm Hg. The ultrasound images revealed a residual luminal diameter stenosis of 15 7 with no residual luminal area stenosis. In addition, intravascular ultrasound images revealed a disruption of the intima and the media after balloon inflation at the site of stenosis that was not detected with angiography. Pre- and postper-
1. Angiogram and intravascular ultrasound study (IVUS) of the descending aorta. a, Preangioplasty angiogram. b through d, Preangioplasty IVUS of the proximal, stenotic, and distal segments, respectively. e through 9, Postangioplasty IVUS of the proximal, stenotic, and distal segments, respectively. h, Postangioplasty angiogram.
Fig.
514
“olume
123
Number
2
Table
Brief Communications
I. Measurements
by intravascular
ultrasound
and angiography Angiography
Ultrasound Diameter
(mm)
Area
(mm2)
5 15
Diameter (% stenosis)
Area (% stenosis)
60%
Diameter (mm)
Diameter (X stenosis)
Pre PTCA
Proximal Lesion Distal Post PTCA After 5 mm After 6 mm
6.03
24.88
2.95 9.61
10.42 59.51
51%
3.69 5.14
13.55 25.04
40% 15%
5.8 3.5
40%
8.7
cutaneous transluminal angioplasty (PTA) morphologic assessment were done by IVUS (Fig. 1). This case is the first use of IVUS in PTA of a recurrent coarctation of the aorta in a child. Intravascular imaging quantitated the severity of stenosis before and after PTA. After using a 6.0 mm PTA balloon, the site of stenosis was dilated to the size of the proximal segment, so further balloon inflations were not performed. One should be cautious in performing the procedure and make all exchanges over a wire, as there have been incidences of catheter trauma to the site of dilation, resulting in rupture of the aorta or aneurysms at the site of dilation on long-term follow-up. Intravascular imaging reveals important details regarding the site of stenosis. We found the left subclavian artery to be widely patent both before and after PTA and confirmed that the stenosis was distal to its origin, involving the anastomosis. Another important assessment that can be made by intravascular ultrasound is the transluminal morphology of the atherosclerotic plaque and the changes in the plaque and vessel wall caused by balloon inflation. In our patient, the normal segment proximal to the site of stenosis had three distinct layers (intima, media, and adventitia) and was 1.17 mm thick with focal areas of increased ultrasound density suggesting focal areas of intimal thickening and fibrosis. After angioplasty there was no significant change in this region. At the site of stenosis the three layers could not be distinguished and the vessel wall was thickened with a decrease in lumen diameter. Also, there was a concentric increase in ultrasound density suggesting fibrosis and calcification (determined by IVUS as “dropout” of echoes). After angioplasty the lumen diameter at the site of stenosis was the same as the size of the PTA balloon, with a decrease in the concentric thickness and a localized tear, suggesting dilation of the aorta without recoil. In addition, the tear at the site of stenosis was not seen angiographically and did not extend into the left subclavian artery. Distal to the stenosis there was thinning of the layers of the aorta and there was no evidence of increased ultrasound density, suggesting minimal fibrosis. As expected, after angioplasty there was no change in the thickness or size of this segment. In summary, percutaneous intravascular ultrasound imaging is technically easy to perform in pediatric patients with coarctation of the aorta. When compared to two-
46% 0%
5.5
5%
dimensional, longitudinal images with angiography, the cross-sectional images of ultrasound provide a more accurate assessment of the arterial dimensions and morphology. The precision of the measurements with the cross-sectional ultrasound images may improve the selection of balloon size and help in assessing the angioplasty results. REFERENCES 1.
2.
3.
Shaddy RF, Snider AR, Silverman NH, et al. Pulsed Doppler findings in patients with coarctation of the aorta. Circulation 1986;73:82-8. Boxer RA, LaCorte MA, Singh S, et al. Nuclear magnetic resonance imaging in evaluation and follow-up of children treated for coarctation of aorta. J Am Co11Cardiol 1986;7:1095-8. Moodie DS, Yiannikas J, Gill CC, et al. Intravenous digital subtraction
angiography
normalities
of the aorta and aortic arch.
in the evaluation
of congenital AM
HEART
ab-
J 1982;
104628-34. 4. Stern H, Erbel
R, Schreiner G, Henkel B, Meyer J. Coarctation of aorta: quantitative analysis by transesophageal echocardiography. Echocardiography 1987;4:387-95. 5. Harrison JK, Shiekh KH, Davidosn CJ, et al. Balloon angioplasty of coarctation of the aorta evaluated with intravascular ultrasound imaging. J Am Co11 Cardiol 1990;15:906-9.
Percutaneous balloon membranotomy combined with prolonged streptokinase infusion for management of inferior vena cava obstruction Satyavan Sharma, Y. S. Loya, and B. V. Daxini. Bombay, Maharashtra, India Obstruction of the hepatic or suprahepatic portion of the inferior vena cava (IVC) producing hepatic outflow obstruction is relatively common in the Orientlm4 and, if left
From the Department ical College. Reprint Medical 4/4/34Q95
requests: College,
of Cardiology,
B. Y. L. Nair
Hospital
and T. N. Med-
Dr. Satyavan Sharma, B. Y. L. Nair Hospital Bombay 400 008, Maharashtra, India.
and
T. N.
Intravascular percutaneous coarctation
ultrasound-assisted angioplasty of aortic
Ashit Jain, MD,’ Stephen R. Ramee, MD,” Walter R. Culpepper, MD,b Juan E. Mesa, MD,a Joseph P. Murgo, MD,a and Christopher J. White, MD.” New Orleans, La.
Various procedures are used to define the site and severity of the stenoses in patients with coarctation of the aorta, including two-dimensional echocardiography with Doppler,l magnetic resonance imaging,2 digital subtraction angiography,3 transesophageal echocardiography, and invasive cineangiography with hemodynamic measurements. Intravascular ultrasound (IVUS) has been reported to be of value in assessing the severity of stenoses in coronary artery disease, peripheral vascular disease, aortic stenosis, and coarctation of the aorta in adults.5 We report the first use of IVUS in a child with coarctation of the aorta. MH was a 3-month-old boy who underwent surgical repair of a discrete juxtaductal coarctation of the aorta at the age of 1 month, after he presented with congestive heart failure. At the 2-month follow-up he was found to have deFrom ’ the Department of Internal Medicine, Section of Cardiology, and lJ the Department of Pediatrics, Section of Pediatric Cardiology, Ochsner Medical Institutions. Reprint requests: Chrkkopher J. White, MD, Section of Cardiology, Ochsner Medical Institutions, 1514 Jefferson Highway, New Orleans, LA 70121. 4/4f34082
creased pulses and blood pressure in his lower extremities, upper extremity hypertension, and a grade 2/6 ejection systolic murmur heard best in the left infrascapular area. Electrocardiography revealed right and left ventricular hypertrophy, and two-dimensional echocardiography confirmed the diagnosis of recurrent coarctation of the aorta. Repeat catheterization demonstrated a peak systolic gradient of 50 mm Hg across the stenosis and a mean gradient of 24 mm Hg. Angiographicaily there was a recurrent stenosis of 75% by diameter (Fig. 1). The descending aorta distal to the stenosis showed evidence of poststenotic dilatation. The region of coarctation was then assessed with a 4.9F intravascular ultrasound catheter with a 20 MHz transducer (Intertherapy, Inc., Santa Ana, Calif.) and the measurements were made (Table I). The ultrasound catheter sheath was advanced over a wire and the tip of the sheath was placed proximal to the arch of the aorta. The luminal diameter of the aorta proximal to the stenosis was 6.03 mm versus 3.08 mm (51% stenosis) at the site of the stenosis. From the cross-sectional images of IVUS the luminal area narrowing was calculated to be 58@; The coarctation was dilated with a 5.0 mm peripheral angioplasty balloon (Peripheral Systems Group, Santa Clara, Calif.). After balloon dilation both the angiographic and IVUS measurements revealed a significant residual stenoses and the lesion was redilated with a 6.0 mm balloon, with a decrease in the peak gradient to 18 mm Hg and a mean gradient of 6 mm Hg. The ultrasound images revealed a residual luminal diameter stenosis of 15 7 with no residual luminal area stenosis. In addition, intravascular ultrasound images revealed a disruption of the intima and the media after balloon inflation at the site of stenosis that was not detected with angiography. Pre- and postper-
1. Angiogram and intravascular ultrasound study (IVUS) of the descending aorta. a, Preangioplasty angiogram. b through d, Preangioplasty IVUS of the proximal, stenotic, and distal segments, respectively. e through 9, Postangioplasty IVUS of the proximal, stenotic, and distal segments, respectively. h, Postangioplasty angiogram.
Fig.
514
“olume
123
Number
2
Table
Brief Communications
I. Measurements
by intravascular
ultrasound
and angiography Angiography
Ultrasound Diameter
(mm)
Area
(mm2)
5 15
Diameter (% stenosis)
Area (% stenosis)
60%
Diameter (mm)
Diameter (X stenosis)
Pre PTCA
Proximal Lesion Distal Post PTCA After 5 mm After 6 mm
6.03
24.88
2.95 9.61
10.42 59.51
51%
3.69 5.14
13.55 25.04
40% 15%
5.8 3.5
40%
8.7
cutaneous transluminal angioplasty (PTA) morphologic assessment were done by IVUS (Fig. 1). This case is the first use of IVUS in PTA of a recurrent coarctation of the aorta in a child. Intravascular imaging quantitated the severity of stenosis before and after PTA. After using a 6.0 mm PTA balloon, the site of stenosis was dilated to the size of the proximal segment, so further balloon inflations were not performed. One should be cautious in performing the procedure and make all exchanges over a wire, as there have been incidences of catheter trauma to the site of dilation, resulting in rupture of the aorta or aneurysms at the site of dilation on long-term follow-up. Intravascular imaging reveals important details regarding the site of stenosis. We found the left subclavian artery to be widely patent both before and after PTA and confirmed that the stenosis was distal to its origin, involving the anastomosis. Another important assessment that can be made by intravascular ultrasound is the transluminal morphology of the atherosclerotic plaque and the changes in the plaque and vessel wall caused by balloon inflation. In our patient, the normal segment proximal to the site of stenosis had three distinct layers (intima, media, and adventitia) and was 1.17 mm thick with focal areas of increased ultrasound density suggesting focal areas of intimal thickening and fibrosis. After angioplasty there was no significant change in this region. At the site of stenosis the three layers could not be distinguished and the vessel wall was thickened with a decrease in lumen diameter. Also, there was a concentric increase in ultrasound density suggesting fibrosis and calcification (determined by IVUS as “dropout” of echoes). After angioplasty the lumen diameter at the site of stenosis was the same as the size of the PTA balloon, with a decrease in the concentric thickness and a localized tear, suggesting dilation of the aorta without recoil. In addition, the tear at the site of stenosis was not seen angiographically and did not extend into the left subclavian artery. Distal to the stenosis there was thinning of the layers of the aorta and there was no evidence of increased ultrasound density, suggesting minimal fibrosis. As expected, after angioplasty there was no change in the thickness or size of this segment. In summary, percutaneous intravascular ultrasound imaging is technically easy to perform in pediatric patients with coarctation of the aorta. When compared to two-
46% 0%
5.5
5%
dimensional, longitudinal images with angiography, the cross-sectional images of ultrasound provide a more accurate assessment of the arterial dimensions and morphology. The precision of the measurements with the cross-sectional ultrasound images may improve the selection of balloon size and help in assessing the angioplasty results. REFERENCES 1.
2.
3.
Shaddy RF, Snider AR, Silverman NH, et al. Pulsed Doppler findings in patients with coarctation of the aorta. Circulation 1986;73:82-8. Boxer RA, LaCorte MA, Singh S, et al. Nuclear magnetic resonance imaging in evaluation and follow-up of children treated for coarctation of aorta. J Am Co11Cardiol 1986;7:1095-8. Moodie DS, Yiannikas J, Gill CC, et al. Intravenous digital subtraction
angiography
normalities
of the aorta and aortic arch.
in the evaluation
of congenital AM
HEART
ab-
J 1982;
104628-34. 4. Stern H, Erbel
R, Schreiner G, Henkel B, Meyer J. Coarctation of aorta: quantitative analysis by transesophageal echocardiography. Echocardiography 1987;4:387-95. 5. Harrison JK, Shiekh KH, Davidosn CJ, et al. Balloon angioplasty of coarctation of the aorta evaluated with intravascular ultrasound imaging. J Am Co11 Cardiol 1990;15:906-9.
Percutaneous balloon membranotomy combined with prolonged streptokinase infusion for management of inferior vena cava obstruction Satyavan Sharma, Y. S. Loya, and B. V. Daxini. Bombay, Maharashtra, India Obstruction of the hepatic or suprahepatic portion of the inferior vena cava (IVC) producing hepatic outflow obstruction is relatively common in the Orientlm4 and, if left
From the Department ical College. Reprint Medical 4/4/34Q95
requests: College,
of Cardiology,
B. Y. L. Nair
Hospital
and T. N. Med-
Dr. Satyavan Sharma, B. Y. L. Nair Hospital Bombay 400 008, Maharashtra, India.
and
T. N.
