Extra & Intravascular Ultrasound (E&IVUS) Guided Intervention for Femoropopliteal Arterial Occlusive Lesions.

Background: Intravascular ultrasound (IVUS) shows vascular structures and positions of interventional devices in cross sectional-short axis to support interventions, especially for complex lesions. On the other hand, extravascular ultrasound (EVUS) visualizes the devices and vessel structures in long and short axis and reduces the radiation exposure by avoiding the use of fluoroscopy during guidewire manipulation. The images obtained from EVUS handling to guide the guidewire manipulation in both long and short axis is more difficult, time consuming, and stressful than IVUS, which is in short axis only. To solve this issue, we propose a novel guidewire crossing method in conjunctive with the use of both modalities, named “extra and intravascular ultrasound (E&IVUS)” guided intervention.Main text: This is the first report of a combined use of EVUS and IVUS for femoropopliteal occlusions. EVUS-guided intervention is mandatory to check the position of the device in long and short axis. However, the images of long axis are sometimes different from the original ones when EVUS is required to image from the short axis to the long axis. E&IVUS allows to dedicate EVUS to acquisition of the long axis and IVUS to the short axis view when confirming the device position. As a result, E&IVUS shortens the operation time and reduces the stress due to the manipulation of the probe to switch from the long to short axis image and vice versa. Moreover, we can accurately manipulate the guidewire to perform intimal tracking according to the information of EVUS long axis and the IVUS short axis images. Case involved a 76-year-old female with right superficial femoral artery occlusion was angiographically contrasted from a contralateral 6-Fr sheath. A hard wire supported with an over-the-wire typed IVUS was advanced into the CTO with EVUS and IVUS to confirm their positions until the guidewire crossing. We repeatedly performed this process, and all intimal tracking succeeded. The drug-coating balloons appropriately sized by IVUS measurement were deployed. Finally, a sufficient blood flow was achieved without complications.Conclusions: E&IVUS is a preferred strategy than using EVUS or IVUS alone. We should evaluate the clinical outcomes of this technique.

Venous Waveform Analysis Correlates With Echocardiography in Detecting Hypovolemia in a Rat Hemorrhage Model

Background Assessing intravascular hypovolemia due to hemorrhage remains a clinical challenge. Central venous pressure (CVP) remains a commonly used monitor in surgical and intensive care settings for evaluating blood loss, despite well-described pitfalls of static pressure measurements. The authors investigated an alternative to CVP, intravenous waveform analysis (IVA) as a method for detecting blood loss and examined its correlation with echocardiography. Methods Seven anesthetized, spontaneously breathing male Sprague Dawley rats with right internal jugular central venous and femoral arterial catheters underwent hemorrhage. Mean arterial pressure (MAP), heart rate, CVP, and IVA were assessed and recorded. Hemorrhage was performed until each rat had 25% estimated blood volume removed. IVA was obtained using fast Fourier transform and the amplitude of the fundamental frequency (f1) was measured. Transthoracic echocardiography was performed utilizing a parasternal short axis image of the left ventricle during hemorrhage. MAP, CVP, and IVA were compared with blood removed and correlated with left ventricular end diastolic area (LVEDA). Results All 7 rats underwent successful hemorrhage. MAP and f1 peak amplitude obtained by IVA showed significant changes with hemorrhage. MAP and f1 peak amplitude also significantly correlated with LVEDA during hemorrhage (R = 0.82 and 0.77, respectively). CVP did not significantly change with hemorrhage, and there was no significant correlation between CVP and LVEDA. Conclusions In this study, f1 peak amplitude obtained by IVA was superior to CVP for detecting acute, massive hemorrhage. In addition, f1 peak amplitude correlated well with LVEDA on echocardiography. Translated clinically, IVA might provide a viable alternative to CVP for detecting hemorrhage.

Pericardial mass in a 71-year-old man

Clinical introductionA 71-year-old man, with a history of chronic aortic regurgitation and negative follow-up after bladder cancer resection 10 months before, had an aortic valve surgery. Two months after, a mass near the right side of the heart had been detected by transthoracic echocardiography performed for dyspnoea, without a cough or fever. The quality of ultrasound images did not allow for an appropriate evaluation due to the outcomes of the sternotomy and the presence of calcified pachypleurite. In order to evaluate this finding, coronary CT (CCT) (figure 1A,B) and positron-emission tomography with 2-[18F] fluoro-2-deoxy-D-glucose (FDG-PET) (figure 1C) were performed. Finally, a cardiac magnetic resonance (CMR) was requested (figure 1D–F, see online supplementary videos).Figure 1(A) Short axis image of early contrast enhancement phase coronary CT (CCT); (B) short axis of delayed phase of the same CCT; (C) lesion on positron-emission tomography with 2-[18F] fluoro-2-deoxy-D-glucose image (white arrow); CMR short axis (D) T2-weighted image with fat saturation; (E) T1-weighted image with fat-saturation; (F) T1-weighted image without fat-saturation.QuestionWhich of the following is the most likely diagnosis of the pericardial mass?Primary pericardial tumour.Pericardial metastasis.Intrapericardial abscess.Intrapericardial haematoma.