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Johnstone E, Friedl SE, Maheshwari A, Abela GS. Distinguishing characteristics of erythrocyte-rich and platelet-rich thrombus by intravascular ultrasound catheter system. J Thromb Thrombolysis 2007; 24:233-9. [PMID: 17396229 DOI: 10.1007/s11239-007-0027-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Accepted: 03/01/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute coronary syndromes are associated with platelet-rich, white thrombi (WT) and erythrocyte-rich, red thrombi (RT), but their ultrasonic characteristics are not well defined. To determine whether intravascular ultrasound (IVUS) could be used to detect specific characteristics of WT and RT, two experiments were performed. METHODS An in-vitro experiment evaluated five WT and five RT and an ex-vivo experiment evaluated thrombi from 17 atherosclerotic rabbits with disrupted plaques and overlying thrombi. Specimen were mounted flat, immersed in a saline bath and examined from the intimal surface. Thrombi were classified as WT (n = 69) or RT (n = 40) by gross inspection and histology. IVUS was performed using a 1 mm, 20 MHz transducer in a 4.8F catheter. Images were digitally converted and points integrated to account for angular and depth resolution. Sampling was performed at the water-tissue interface and four other sites at 0.3 mm radial depth increments. Signals from each depth were standardized by obtaining the ratio of each energy level to the level at the water-tissue interface. RESULTS The average energy ratio backscattered by RT was constant with increasing tissue depth while it attenuated for WT (P < 0.005; 2-way ANOVA). RT was less homogeneous and had more backscatter compared to WT. Light and electron microscopy corroborated these observations showing WT as densely homogenous and RT with loose cellular elements. CONCLUSION WT may be detected by its attenuated ultrasound pattern versus a non-attenuated pattern for RT by IVUS. This technique has potential for characterizing WT and RT.
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Affiliation(s)
- Eric Johnstone
- Cardiovascular Division, Department of Medicine, Deaconess Hospital, Harvard Medical School, Boston, MA, USA
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2
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Abstract
Angioscopy allows direct visualization of the coronary artery lumen and provides detailed information regarding the surface characteristics of the vessel wall and specific lesions causing acute coronary syndromes. Disruption of a plaque, ulceration, tears, fissures, lipid-rich or fibrous lesions, and luminal or mural thrombus can be readily detected in vivo. Characterization of culprit lesions in various coronary syndromes reveals the different mechanisms of ischemia. The predominant lesion in acute myocardial infarction is an ulcerated, yellow plaque with thrombus. In unstable angina, different substrates can be seen, from the lipid-rich lesion with thrombus to the fibrous smooth plaque, reflecting a varied physiopathology. Because of its ability to detect superficial lipid pools, angioscopy may be valuable for the detection of vulnerable plaques.
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Affiliation(s)
- Adam J Saltzman
- Cardiovascular Division, Department of Internal Medicine, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111, USA
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3
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Abela GS, Eisenberg JD, Mittleman MA, Nesto RW, Leeman D, Zarich S, Waxman S, Prieto AR, Manzo KS. Detecting and differentiating white from red coronary thrombus by angiography in angina pectoris and in acute myocardial infarction. Am J Cardiol 1999; 83:94-7, A8. [PMID: 10073790 DOI: 10.1016/s0002-9149(98)00786-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To determine the ability to detect thrombus by angiography, angioscopy was performed before angiography in patients undergoing interventional procedures and the data collected in a blinded fashion. These data demonstrated that the sensitivity of angiography to detect white thrombus was 50% and the specificity was 95%, whereas the sensitivity and specificity to detect red thrombus was 100%, respectively; the positive and negative predictive value of detecting thrombus in general was 89% and 83%, respectively.
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Affiliation(s)
- G S Abela
- Department of Medicine, Deaconess Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Lehmann KG, Oomen JA, Slager CJ, deFeyter PJ, Serruys PW. Chromatic distortion during angioscopy: assessment and correction by quantitative colorimetric angioscopic analysis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:191-201. [PMID: 9786402 DOI: 10.1002/(sici)1097-0304(199810)45:2<191::aid-ccd19>3.0.co;2-o] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Angioscopy represents a diagnostic tool with the unique ability of assessing the true color of intravascular structures. Current angioscopic interpretation is entirely subjective, however, and the visual interpretation of color has been shown to be marginal at best. The quantitative colorimetric angioscopic analysis system permits the full characterization of angioscopic color using two parameters (C1 and C2), derived from a custom color coordinate system, that are independent of illuminating light intensity. Measurement variability was found to be low (coefficient of variation = 0.06-0.64%), and relatively stable colorimetric values were obtained even at the extremes of illumination power. Variability between different angioscopic catheters was good (maximum difference for C1, 0.022; for C2, 0.015). Catheter flexion did not significantly distort color transmission. Although the fiber optic illumination bundle was found to impart a slight yellow tint to objects in view (deltaC1 = 0.020, deltaC2 = 0.024, P < 0.0001) and the imaging bundle in isolation imparted a slight red tint (deltaC1 = 0.043, deltaC2 = -0.027, P < 0.0001), both of these artifacts could be corrected by proper white balancing. Finally, evaluation of regional chromatic characteristics revealed a radially symmetric and progressive blue shift in measured color when moving from the periphery to the center of an angioscopic image. An algorithm was developed that could automatically correct 93.0-94.3% of this error and provide accurate colorimetric measurements independent of spatial location within the angioscopic field. In summary, quantitative colorimetric angioscopic analysis provides objective and highly reproducible measurements of angioscopic color. This technique can correct for important chromatic distortions present in modern angioscopic systems. It can also help overcome current limitations in angioscopy research and clinical use imposed by the reliance on visual perception of color.
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Affiliation(s)
- K G Lehmann
- Dept. of Medicine, University of Washington School of Medicine, VA Puget Sound Health Care System, Seattle, 98108, USA
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5
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Waxman S, Mittleman MA, Zarich SW, Fitzpatrick PJ, Lewis SM, Leeman DE, Shubrooks SJ, Snyder JT, Muller JE, Nesto RW. Angioscopic assessment of coronary lesions underlying thrombus. Am J Cardiol 1997; 79:1106-9. [PMID: 9114774 DOI: 10.1016/s0002-9149(97)00056-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study examines the characteristics of coronary lesions in which thrombus is found as assessed by angioscopy before percutaneous transluminal coronary angioplasty in patients with various coronary syndromes. Our findings demonstrate that the plaque underlying intracoronary thrombus is usually yellow and/or disrupted, and support in vitro observations that lipid-rich plaques are highly thrombogenic and that disruption of these plaques is associated with in situ thrombosis.
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Affiliation(s)
- S Waxman
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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6
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Abstract
Percutaneous coronary angioscopy is an invaluable alternative imaging modality that can not be used routinely in the interventional cardiac catheterization laboratory. The major value of angioscopy lies in its ability to determine safely, quickly, and accurately intraluminal morphologies before and after coronary interventions. The results from angioscopy can then be used to target more specific treatment strategies, given the vast array of interventional treatment strategies available. Percutaneous coronary angioscopy, however, requires meticulous attention for the proper preparation and use of the angioscope to minimize the potential risks associated with the imaging procedure.
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Affiliation(s)
- B H Annex
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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7
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Mickelson JK, Lakkis NM, Villarreal-Levy G, Hughes BJ, Smith CW. Leukocyte activation with platelet adhesion after coronary angioplasty: a mechanism for recurrent disease? J Am Coll Cardiol 1996; 28:345-53. [PMID: 8800108 DOI: 10.1016/0735-1097(96)00164-7] [Citation(s) in RCA: 209] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this pilot study was to determine whether leukocyte activation occurs, whether leukocyte-platelet complexes develop and whether there is any association between these findings and clinical outcome after coronary angioplasty. BACKGROUND Increased expression of CD11b on monocytes and neutrophils promotes their adhesion to endothelial cells, extracellular matrix and smooth muscle cells. Thrombin-activated platelets adhere to monocytes and neutrophils through P-selectin. These cell complexes may affect the inflammatory process and, thus, the outcome of coronary angioplasty. METHODS During elective single-vessel coronary angioplasty in 11 men, samples were obtained for flow cytometric detection of CD11b, as well as the percent of leukocytes with adherent platelets and the intensity of bound platelet fluorescence (number of platelets/leukocyte). RESULTS After angioplasty, there was an increase in CD11b (monocytes: p = 0.001, neutrophils: p = 0.02) and leukocytes with adherent platelets (p = 0.02). During follow-up, five patients remained in stable condition and six had subsequent clinical events: restenosis and progression of disease requiring coronary artery bypass grafting (n = 3), myocardial infarction involving the dilated artery (n = 1) and unstable angina (n = 2). Values for leukocyte CD11b expression, the percent of leukocytes with adherent platelets and the intensity of bound platelet fluorescence were higher both before and after angioplasty in the six patients experiencing clinical events. CONCLUSIONS Despite standard aspirin and heparin therapy, leukocyte activation with platelet adherence occurs after coronary angioplasty. The magnitude of leukocyte activation and platelet adherence appears to be higher in patients experiencing late clinical events.
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Affiliation(s)
- J K Mickelson
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Waxman S, Sassower MA, Mittleman MA, Zarich S, Miyamoto A, Manzo KS, Muller JE, Abela GS, Nesto RW. Angioscopic predictors of early adverse outcome after coronary angioplasty in patients with unstable angina and non-Q-wave myocardial infarction. Circulation 1996; 93:2106-13. [PMID: 8925578 DOI: 10.1161/01.cir.93.12.2106] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clinical and angiographic criteria have a limited ability to predict adverse outcome in patients with unstable angina who are undergoing percutaneous transluminal coronary angioplasty (PTCA). We investigated whether the use of angioscopy can improve prediction of early adverse outcome after PTCA. METHODS AND RESULTS Angioscopic characterization of the culprit lesion was performed before PTCA in 32 patients with unstable angina and 10 with non-Q-wave infarction. Seven patients (17%) had an adverse outcome (myocardial infarction, repeat PTCA, or need for coronary artery bypass graft surgery) within 24 hours after PTCA. Six of 18 patients with a yellow culprit lesion had an adverse outcome compared with 1 of 24 in whom the culprit lesion was white (P = .03). Six of 20 patients with plaque disruption suffered an adverse outcome compared with 1 of 22 with nondisrupted plaques (P = .04). Six of 17 patients with intraluminal thrombus had an adverse outcome, whereas only 1 of 25 patients without thrombus suffered an adverse outcome (P = .01). Yellow color, disruption, and thrombus at the culprit lesion site were associated with an eightfold increase in risk of adverse outcome after PTCA. The prediction of PTCA outcome based on characteristics of the plaque that were identifiable by angioscopy was superior to that estimated by the use of angiographic variables. CONCLUSIONS In patients with unstable angina and non-Q-wave infarction, angioscopic features of disruption, yellow color, or thrombus at the culprit lesion site can identify patients at high risk of early adverse outcome after PTCA. Angioscopy was superior to angiography for prediction of PTCA outcome.
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Affiliation(s)
- S Waxman
- Institute for Prevention of Cardiovascular Disease, Boston, Mass, USA
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Ali MN, Villarreal-Levy G, Schafer AI. The role of thrombin and thrombin inhibitors in coronary angioplasty. Chest 1995; 108:1409-19. [PMID: 7587450 DOI: 10.1378/chest.108.5.1409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- M N Ali
- Department of Medicine, VA Medical Center, Houston, TX 77030, USA
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Bittl JA, Strony J, Brinker JA, Ahmed WH, Meckel CR, Chaitman BR, Maraganore J, Deutsch E, Adelman B. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Hirulog Angioplasty Study Investigators. N Engl J Med 1995; 333:764-9. [PMID: 7643883 DOI: 10.1056/nejm199509213331204] [Citation(s) in RCA: 399] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Heparin is often administered during and after coronary angioplasty to prevent closure of the dilated vessel. However, ischemic or hemorrhagic complications occur in 5 to 10 percent of treated patients. We studied whether these complications could be prevented when the direct thrombin inhibitor bivalirudin (Hirulog) was used in place of heparin. METHODS We performed a double-blind, randomized trial in 4098 patients undergoing angioplasty for unstable or postinfarction angina. Patients were assigned to receive either heparin or bivalirudin immediately before angioplasty. The primary end point were death in the hospital, myocardial infarction, abrupt vessel closure, or rapid clinical deterioration of cardiac origin. RESULTS In the total study group, bivalirudin did not significantly reduce the incidence of the primary end point (11.4 percent, vs. 12.2 percent for heparin) but did result in a lower incidence of bleeding (3.8 percent vs. 9.8 percent, P < 0.001). In the prospectively stratified subgroup of 704 patients with postinfarction angina, bivalirudin therapy resulted in a lower incidence of the primary end point (9.1 percent vs. 14.2 percent, P = 0.04) and a lower incidence of bleeding (3.0 percent vs. 11.1 percent, P < 0.001), but in a similar cumulative rate of death, myocardial infarction, and repeated revascularization in the six months after angioplasty (20.5 percent vs. 25.1 percent, P = 0.17). CONCLUSIONS Bivalirudin was at least as effective as high-dose heparin in preventing ischemic complications in patients who underwent angioplasty for unstable angina, and it carried a lower risk of bleeding. Bivalirudin, as compared with heparin, reduced the risk of immediate ischemic complications in patients with postinfarction angina, but this difference was no longer apparent after six months.
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Affiliation(s)
- J A Bittl
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Shah D, Lal P. Acute coronary occlusion during early post-PTCA exercise testing: a rare but avoidable risk. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 33:335-9. [PMID: 7889553 DOI: 10.1002/ccd.1810330410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We describe here one instance of an acute occlusion of an angioplastied LAD coronary artery occurring during a treadmill stress test performed 2 d after the procedure. The occlusion occurred during the recovery period after a reasonably high level of stress was achieved without evidence of ischaemia. Similar instances described in the literature are summarized and discussed. In the light of these data, it might be prudent to avoid early post-PTCA exercise stress testing.
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Affiliation(s)
- D Shah
- Department of Cardiology, Apollo Hospitals, Madras, India
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den Heijer P, Foley DP, Escaned J, Hillege HL, van Dijk RB, Serruys PW, Lie KI. Angioscopic versus angiographic detection of intimal dissection and intracoronary thrombus. J Am Coll Cardiol 1994; 24:649-54. [PMID: 8077534 DOI: 10.1016/0735-1097(94)90010-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study was undertaken to compare coronary angioscopy with angiography for the detection of intimal dissection and intracoronary thrombus. BACKGROUND It has been demonstrated previously that coronary angioscopy provides more intravascular detail than cineangiography. Both imaging methods have to be compared directly to assess the additional diagnostic value of angioscopy. METHODS The angiograms and videotapes of 52 patients who had undergone angioscopy were reviewed independently by two observers unaware of other findings. Classic angiographic definitions were used for dissection and thrombus. Angioscopic dissection was defined as visible cracks or fissures on the lumen surface or mobile protruding structures that are contiguous with the vessel wall. Angioscopic thrombus was defined as a red, white or mixed red and white intraluminal mass. RESULTS Angiography and angioscopy were in agreement in 40.4% of cases in the absence of thrombus and in 11.5% in the presence of thrombus. No fewer than 25 (48.1%) angioscopically observed thrombi remained undetected at angiography. With angioscopy as the standard, although the specificity of angiography for thrombus was 100%, sensitivity was very low at 19%. Angioscopic dissection was present in 40 patients (76.9%) versus angiographic dissection in 15 patients (28.8%). With regard to dissection, there was no correlation between the two imaging methods (r phi = 0.15, p = 0.29). CONCLUSIONS Coronary angiography underestimates the presence of intracoronary thrombus. Angioscopy and angiography are complementary techniques for detecting and grading intimal dissections.
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Affiliation(s)
- P den Heijer
- Department of Cardiology, Thoraxcenter, University Hospital, Groningen, The Netherlands
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Stikovac M, Talley JD, Leesar M. Economic aspects of using alternative diagnostic techniques in addition to angiography during percutaneous coronary artery revascularization. J Interv Cardiol 1994; 7:291-6. [PMID: 10151060 DOI: 10.1111/j.1540-8183.1994.tb00459.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- M Stikovac
- Cardiovascular Division, University of Louisville School of Medicine, Kentucky
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