Percutaneous coronary angioscopy in patients with ischemic heart disease

PROGRESS IN CARDIOLOGY

Percutaneous with ischemic

coronary angioscopy heart disease

Yasumi Uchida,* Takanobu Tomaru,* Yoshiharu Fujimori,*** and Kichinori

Fumitaka Nakamura,* Akira Furuse,** Hasegawa. *** Tokyo and Chiba, Japan

Morphologic changes in the coronary arteries in patients with ischemic heart disease were evaluated by angiography. Although a powerful diagnostic tool, angiography can show only the shadow of the luminal changes and therefore is an insufficient tool for diagnosis of disease. Recent advances in fiberoptic endoscopy enabled observation of the luminal changes even in small-diameter vessels. The fiberscope is now used for observation of experimental thrombosis and thrombolysis,l laser irradiationinduced changes in cadaveric heart and vessels,2*3 luminal changes in the carotid or femoral arteries in From the *Second Department of Internal Medicine, Faculty of Medicine, University of Tokyo, the **Department of Thoracic Surgery, University of Tokyo, and the ***Department of Internal Medicine, Kensei Hospital, Chiba. Received for publication Feb. 4, 1987; accepted May 26, 1987. Reprint requests: Yasumi Uchida, M.D., Second Department of Internal Medicine, Faculty of Medicine, University of Tokyo, Hongo, Bunkyo-Ku, Tokyo, Japan.

Fig. 1216

in patients

patients,4*5 laser-induced changes in femoral arteries in patients with obstructive atherosclerosis,6 and thromboemboli in patients with pulmonary embolism.7 The angioscope is also used for observation of the coronary arteries during coronary artery bypass surgery.s Recently, Spears et aLs observed the coronary artery during cardiac catheterization. However, their observation was limited to the ostium of the coronary arteries, probably because they used a stiff and relatively large-diameter angioscope. Thin (1.4 mm in external diameter) and flexible angioscopes are now available in Japan. Therefore we examined the applicability of this angioscope to percutaneous transluminal coronary angioscopy in patients with ischemic heart disease. METHODOLOGY

The Angioscope and accompanying equipment. angioscope used in this study was manufactured by Olympus Company, Tokyo, Japan. The scope was

1. Angioecope, catheter systems,and cinecameraused in this study.

Volume Number

114 5

Percutaneous

cinecamera

coronary

angioscopy

12 17

angioscope guiding

catheter

4’ \

pressure transducer power injector (saline 37°C. heparin 3OlJM) Fig. 2. Schematic representation of the angioscope,catheter systems,and cinecamera.

Fig. 3. Patient was a 68-year-old man. Left, Cineangiogram of LCA (posteroanterior projection). Segmentobservedby angioscopyindicated by arrow. Angiography by 7F Judkins catheter. Right, Position of the tip of the angioscope.

flexible, 1.4 mm in external diameter and 120 cm in length. For coronary angioscopy, the scope was connected to a light source @LX-F, Olympus Co.) and a cinecamera. The tip of the scope was introduced through a Y connector with a sealing device into the guiding catheter (No. 8 or No. 9 French), which was used for percutaneous transluminal coronary angioplasty (PTCA). The Y connector was connected to stopcocks generally used for coronary angiography. The stopcocks were then connected to a syringe used for injections of the contrast material (76% Urografln), a bottle containing the contrast

material, pressure transducer to monitor the pressure at the catheter tip, and to a power injector that contained warmed saline solution (37’ C) (Figs. 1 and 2). During angioscopy, 15 to 20 ml saline solution was injected at a rate of 7 to 10 mI/sec and the lumen was photographed on 16 mm color cinefilms at 18 frames/set. Patients. Eight patients underwent coronary angiography and angioscopy (two women and six men; 52 to 74 years old; three had previous myocardial infarction and five had stable angina pectoris). Informed consent for angiography and angioscopy

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Table

Uchida et al. I. Angioscopy

November 1987 HearI Journal

Amdcan

of the left coronary

artery Guiding

catheter Amplatz

Judkins Patient (disease)

Age (sex)

Y. I. (OMI) T. M. (AP) N. Y. (OMI)

74 (F)

A. I. (OMI) K. M. (AP)

68 @I) 60 04

K. H. (AP) S. H. (AP;PTCA)

52 (M) 68 (M)

67 (M) 64 0’)

I

II

8F

9F

8F

9F

w(G)

-

nw (0) nw (0) w(G)

-

nw -

nw -

-

-

-

Injected solution

w (0) nw (0) w(G) -

w (0) w (0)

saline (ml)

Stenosis in LCA f%)

20 15-20 20

LAhdW;D,(50) LAD,,(95);OM(75);LAD,js(75) LAD,r.x(75)

20 15-20

LCX,,,,(lOO) None

20

LAD,,(lOO)

20

LAD,mm

Abbreviations: OMI = old myocardial infarction; AP = angina pectoris; 0 = original curve; G = curved for LAD; w = wedged; nw = not wedged; s = successful in angioscopy; f = failed to visualize; fp = failed to pass the fiberscope; ne = not examined; LMT = left main trunk, LAD = left anterior descending artery; LCX = left circumflex artery; prox = proximal; mid = middle; dis = distal; D, = the first diagonal branch; OM = obtuse marginal branch.

Table

II. Angioscopy

of the right coronary

artery Guiding

Judkins Patient (disease)

N. Y. (OMI) A. I. (OMI) K. M. (AP) K. H. (AP) S. R. (AP) Abbreuiations:

Age (sex)

8F

74 (F)

W

68 CM) 60 52

(M) (M)

60 (Ml

PD = posterior

descending

catheter

Amplatz

I Amplatz 8F

9F

8F

9F

-

-

-

nw

-

-

-

nw

nw -

nw -

W

-

-

-

artery;

W

h = horizontal;

u = upward;

was obtained from all patients. Informed consent for PTCA was also obtained from one patient. All patients were pretreated with oral diazepam (10 mg) before being transferred to the catheterization laboratory. No. 8 or No. 9 French sheaths were introduced into the right femoral artery and vein by the Seldinger technique. An 8F Swan-Ganz catheter was introduced into the pulmonary artery for measurement of cardiac output by the thermodilution method and for pressure monitoring. After left ventriculography and coronary angiography with Judkins catheters, a No. 8 or No. 9 French guiding catheter was introduced into the coronary artery. When the catheter tip pressure pulses showed ventricularization, the catheter was judged to have wedged into the coronary artery. The fiberscope was introduced through the guiding catheter into the coronary artery and the tip of the scope was identified by repeated injections of the contrast material through the guiding catheter. After the safety of saline injection by hand was tested, the blood was replaced

W

II

Direction

of RCA,,,

-

d = downward;

h ; d d

Injected solution

saline (ml)

15 15-20 15 15 15

for others see Table I.

by saline solution, which was injected by a power injector, to photograph the lumen. When necessary, the angioscope was advanced during saline injection since this method facilitated blood replacement. Usually a Judkins guiding catheter was first used. When the catheter tip did not wedge, the catheter was changed to an Amplatz catheter. In one patient, PTCA was performed with Simpson-Robert balloon catheters. OBSERVATIONS

Fig. 3 shows the cineangiograms of the left coronary artery and the position of the tip of the angioscope. Angiography showed that the middle segment of the left anterior descending artery (LAD,,& was irregular and the proximal segment of the left circumflex artery (LCX,,) was obstructed. In this patient, an 8F Judkins guiding catheter was wedged in the left main trunk (LMT). Angioscopy showed that the luminal surface of the LAD,M had shallow and spiral folds with yellowish coloration,

Percutaneous

coronary

angioscopy

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Observed segments LAD Prox

Mid

Dis

D, 5

I

ne

ne

ne

s

f fP f

f

f

ne

ne

LMT

ne

ne

s

s

s

ne

s

s

9

S

f

ne ne

S

f

ne

s

S

ne

ne ne

4. Same patient as in Fig. 3. Yellowish luminal surface with shallow spiral folds of LAD,,,. Fig.

Observed segments RCA Stenosis of RCA (%J RCA,,d

(75); RCA,,, (100) RCL (50) RCA,, (75) RCAmu (75)

RCA,,

(75);

Prox PD (75)

Mid

Dis

I

ne f ne

ne S

5

ne

S

8

S

5

ne

indicating atherosclerosis (Fig. 4). Fig. 5 shows an angiogram of the right coronary artery in a patient with a previous myocardial infarction. In this patient, the middle segment of the right coronary artery (RCAtid) showed 75% narrowing. Angioscopy showed spiral narrowing in the same segment (Fig. 6). In one patient in whom no changes were angiographically observed in the LAD, the luminal surface of the LAD,, and the ostium of a septal artery were clearly observed with angioscopy after the guiding catheter for LAD use (FLIG, USCI) wedged in the LAD,,, (Figs. 7 and 8). In one patient who underwent PTCA of the LAD,,,, changes in the stenosed segment induced by PTCA were clearly shown by angioscopy. After PTCA, multiple circular folds and scattered thin thrombi were observed in the dilated segment (Figs. 9 and 10). However, since the tip ,of the angioscope was not positioned at the same portion, it was difficult to assess the magnitude of dilatation induced by PTCA. Thus angioscopy of the LAD was successful in six of seven patients

(Table I). In three of these patients in whom the original Judkins guiding catheters did not wedge, Judkins catheters curved for LAD wedged in the LAD and facilitated replacement of the blood with saline solution. In one patient in whom the guiding catheters did not wedge in the artery, angioscopy was unsuccessful despite the injection of up to 20 ml saline solution. Angioscopy of the LCX was not tested in any of the patients. Five patients underwent angioscopy of the RCA and it was successful in four patients (Table II). In one patient in whom angioscopy failed, the RCA,,, was directed upwards and prevented the guiding catheter from wedging into the ostium whereas in those in whom the or downwards, RCA,,, was directed horizontally Judkins or Amplatz guiding catheters wedged in the ostium. Injection of 10 to 20 ml saline solution was enough to visualize the luminal changes (Table II), In a patient with stenosis in the RCA,, (SR in Table II), complete atrioventricular block occurred during angioscopy, but it was of short duration. In four patients the contrast material that remained in the guiding catheter was injected with saline solution. In these patients, sinus bradycardia, ECG changes in the ST-T segment, and a decrease in systemic blood pressure occurred. However, these changes were smaller than those usually observed during coronary angiography. COMMENTS

In this study, angioscopy was used successfully in 21 of 31 coronary segments in eight patients with no serious complication. Spears et al9 observed the luminal changes of the coronary arteries by percutaneous transluminal coronary angioscopy but their

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Nowmbar $887 Heart Journal

Fig. 5. Patient was a 75year-old woman. Cineangiogram of the RCA with 75 % narrowings in the RC&d and posterior descendingartery (PD, right anterior oblique projection). Segment observedby angioscopy indicated by arrow. ,

Fig. 6. Same patient as in Fig. 5. Note narrowing of

RCA,id with spiral folds.

observation was limited to the ostium. We were able to examine not only the proximal but also the distal segments of the LAD and RCA. This was possible by the use of a thin flexible fiberscope and wedging of the guiding catheters into the coronary artery. Previously we examined the luminal changes of isolated perfused atherosclerotic human coronary arteries and reported that the lumen of the atherosclerotic segments has narrowings with smooth surface or spiral folds with yellow coloration, indicating atheroma.‘s5 In this in vivo study, the changes

observed ex vivo were clearly observed and photographed. We also examined the luminal changes in the isolated perfused human coronary arteries after balloon angioplasty and found that the luminal surface exhibited multiple circular folds with frequent exfoliation of the endothelium.1° In this study, the luminal changes induced by PTCA were observed in one patient. The dilated segment showed similar changes. During balloon dilatation, the balloon expands toward shorter axis and also longitudinally. The multiple circular folds observed in the patient were probably due to longitudinal expansion of the balloon. Although the patient was pretreated with aspirin (250 mg/day) and intravenous heparin (7000 units), thin thrombi were formed in the dilated segment, probably from endothelial damage. Although the angioscope used in this study was sufficient to observe the coronary luminal changes, wedging the guiding catheter was necessary for replacement of blood with saline solution and manipulation of the catheters to wedge was not easy. A more reliable and safe apparatus for replacement of the blood with saline solution is required to avoid the failure of angioscopy and to minimize the volume of injected saline solution. Angioscopy is a suitable method for diagnosis of pathologic changes in the coronary arteries and therefore can be used to differentiate thrombi from atheroma, to identify intimal dissection induced by PTCA, or to observe the effects of thrombolytic agents on coronary thrombi.

Volume Number

114 5

Percutaneous

coronary

angioscopy

122 1

Fig. 7. Patient wasa 60-year-old man. Cineangiogramshowsthe LCA (right anterior oblique projection). Arrow indicates the segmentobserved angioscopically.

Fig. 8. Same patient as in Fig. ‘7.Left, LADmidand the ostium of a septal artery. Right, Backflow of the

blood.

SUMMARY

Percutaneous transluminal coronary angioscopy was performed during routine coronary angiography in seven patients and during PTCA in one patient with ischemic heart disease. A flexible fiberscope with an external diameter of 1.4 mm was introduced through an 8F or 9F guiding catheter used for PTCA into the coronary arteries. Warmed saline solution (15 to 20 ml) was injected through the guiding catheter into the coronary arteries for replacement of blood. Twenty-one of the 31 coronary segments were visualized and photographed on color cine-

films. The lumen of the atherosclerotic segment showed narrowing with smooth surface or with spiral folds. PTCA caused dilatation of the &nosed segment with scattered thin thrombi. These findings indicate the usefulness of angioscopy to observe luminal changes in the coronary arteries of patients with ischemic heart disease.

REFERENCES

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Kato A, Sugimoto and thrombolysis

T. in

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Fig. 9. Patient was a 6%year-old man. Cineangiograms showed the LCA (right anterior oblique projection). Left, LAD,,, before PTCA. Middle, During inflation of a Simpson-Robert catheter (balloon diameter 3 mm). Right, after PTCA of the LAD,,,.

10. Same patient as in Fig. 9. Left, Before PTCA. Right, After PTCA. Tip of the angioscopewas positioned in the dilated segment. Multiple circular folds seen on luminal surface with thin thrombi Fig.

(arrow).

2.

3.

4.

5.

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6. Abela GS, Seeger JM, Barberi E, Franzini D, Fench A, Pepine CJ, Conti CR. Laser angioplasty with angioscopic guidance in humans. J Am Co11 Cardiol 1986;8:184. 7. Shure D, Gregoratos G, Moser KM. Angioscopy is useful in the evaluation of chronic pulmonary arterial obstruction. Circulation 1984;7O(Suppl 2):182. 8. Sherman CT, Litvack F, Grundfest W, Lee M, Hickey A, Chaux A, Kass R, Blanche C, Matroff J, Morgenstern L, Ganz W, Swan HJC, Forrester J. Coronary angioscopy in patients with unstable angina pectoris. N Engl J Med 1986;315:913. 9. Spears JR, Sponkojny AM, Marias HJ. Coronary angioscopy during cardiac catheterization. J Am Co11 Cardiol 1985;6:93. 10. Uchida Y, Masuo M, Tomaru T, Kate A. Fiberoptic observation of coronary luminal changes caused by coronary angioplasty. Circulation 1985;72(Suppl 3):218.