The fluoro-less and contrast-less peripheral endovascular intervention: Halfway there.

INTRODUCTION: Percutaneous endovascular revascularization requires the use of fluoroscopic guidance and radiopaque contrast. We present a successful intervention without the use of iodinated contrast. CASE: A 92-year-old man with dry gangrene involving the second and fourth left toes had acute on chronic kidney injury. Arterial duplex showed severe stenosis in bilateral superficial femoral arteries (SFAs). Fluoroscopic and ultrasound guidance and intravascular imaging were used to avoid iodinated contrast. After right to left femoral crossover, the entire left SFA was imaged with ultrasound. The lesion was delineated with radiopaque measuring tapes then wired. Near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) imaging were performed. Points of interest were correlated with corresponding radiopaque markings on the ruler. Stenting and post-dilation resulted in complete stent expansion and no evidence of dissection by IVUS. The total procedure time was 113min and the total radiation dose 813mGy. The day after the procedure, there was a palpable dorsalis pedis pulse. He was discharged to inpatient rehabilitation on dual antiplatelet therapy. DISCUSSION: Contrast and radiation continue to limit the feasibility of endovascular angiography and intervention. Carbon dioxide (CO2) digital subtraction angiography is an alternative for these patients but has several disadvantages. Previously proposed projects demonstrated the real potential of performing endovascular peripheral intervention without fluoroscopy or contrast. CONCLUSION: This case is a clear demonstration of a successful use of a combination of fluoroscopy, ultrasonography and intravascular imaging to achieve a successful endovascular intervention to treat critical limb ischemia, without the use of iodinated contrast.

Increased right-to-left ventricle diameter ratio is a strong predictor of right ventricular failure after left ventricular assist device.

BACKGROUND: Predictors of right ventricular failure (RVF) in patients with left ventricular assist devices (LVADs) have not been fully elucidated and are comprised mostly of clinical variables. We evaluated echocardiographic parameters associated with adverse outcomes in this population. METHODS: Transthoracic echocardiograms (TTEs) before continuous-flow LVAD implantation were analyzed in 109 patients. Twenty-six 2-dimensional and Doppler parameters were assessed for their association with the primary outcome of 30-day RVF, defined as a requirement of an RV assist device or ≥ 14 consecutive days of inotropic support, and the secondary composite outcome of 30-day death or RVF. Multivariate analysis adjusted for known clinical risk prediction models was performed. RESULTS: Overall, 25 (22.9%) and 27 (24.8%) patients reached the primary and secondary end-points, respectively. An increased RV/LV diameter ratio was the only TTE variable independently associated with both the primary (odds ratio [OR] = 5.40; 95% confidence interval [CI] 2.40 to 12.40; p = 0.012) and secondary (OR = 2.70; 95% CI 1.06 to 6.22; p = 0.03) outcomes after multivariate analysis. Scatterplot analysis with regression determined the optimal cut-off value for RV/LV diameter to be 0.75. Based on receiver operating characteristic curves, an increased RV/LV diameter ratio provided an additional predictive value to clinical risk scores. CONCLUSIONS: A TTE-measured RV/LV diameter ratio of ≥0.75 is independently associated with a higher risk for RVF in patients with continuous-flow LVAD. When used alone, this simple, easily derived, practical echocardiographic measurement has a predictive value equivalent to known clinical risk scores, whereas their combination provides stronger risk prediction for adverse outcomes.