Quantitative Techniques of Ultrasonography in the Assessment of Femoropopliteal Atherosclerotic Lesions Using Peak Systolic Velocity Ratio: Results From the TURN-UP Study.

PURPOSE: Duplex ultrasound (DUS)-measured peak systolic velocity ratios (PSVRs) are commonly used to evaluate arterial stenosis in lower extremity artery disease (LEAD). However, these measurement methods have not yet been standardized. This study aimed to reveal the influence of measuring methods on PSVR values. METHODS: A 132 femoropopliteal lesions with PSVR ranging from 1.5 to 3.5 evaluated using method A (angle correction 60°, the direction of blood flow, the no or few atherosclerotic changes closest to the lesion proximal side was defined as the nonstenotic area) were included. The following 4 different methods were then compared with method A: method B, angle correction 45°; method C, angle correction 60° measured along the vessel wall; D, angle correction 60°, with the nonstenotic area the lowest peak systolic velocity area; and E, angle correction 60°, with the reference point fixed at 2 cm proximal to the target lesion area. The difference in PSVR values was analyzed using the Bland-Altman method. RESULTS: The mean PSVR value measured by method A was 2.27±0.51, those measured by methods B, C, D, and E were 2.21±0.55, 2.31±0.66, 2.34±0.63, and 2.11±0.63, respectively. The 95% prediction intervals of the differences in PSVR measurements versus A were -0.64 to +0.53 for method B, -0.59 to +0.68 for method C, -0.77 to +0.91 for method D, and -1.12 to +0.79 for method E. CONCLUSION: PSVR values considerably differed between measuring methods. PSVR values by DUS are largely dependent on the measurement methods, which could considerably affect the judgment of LEAD. CLINICAL IMPACT: Due to differences in several DUS measurement methods, the PSVR results could be changed. Therefore, to need further investigations and unification of measurement method.

Changes in cardiac sympathetic nerve activity on 123 I-metaiodobenzylguanidine scintigraphy after MitraClip therapy.

AIMS: In patients with heart failure, over-activation of the cardiac sympathetic nerve (CSN) function is associated with severity of heart failure and worse outcome. The effects of MitraClip therapy on the CSN activity in patients with mitral regurgitation (MR) remained unknown. In this study, we evaluated the impact of the MitraClip therapy on CSN activity assessed by 123 I-metaiodobezylguanidine (MIBG) scintigraphy. METHODS AND RESULTS: We enrolled consecutive patients with moderate-to-severe (3+) or severe (4+) MR who were scheduled to undergo MitraClip procedure in this prospective observational study. MIBG scintigraphy was performed at baseline and 6 months after the MitraClip procedure to evaluate the heart-mediastinum ratio and washout rate (WR). Changes in these MIBG parameters were analysed. Of the 13 consecutive patients, 10 were successfully treated with MitraClip procedure and completed follow-up assessment. With regard to the MIBG parameters, changes in the early and delayed heart-mediastinum ratio from baseline to 6 months were not significant (2.16 ± 0.42 to 2.06 ± 0.34, P = 0.38 and 1.87 ± 0.39 to 1.83 ± 0.39, P = 0.43, respectively), whereas WR was significantly decreased (38.6 ± 3.9% to 32.6 ± 3.94%, P = 0.002). CONCLUSIONS: The CSN activity of the WR on MIBG imaging was improved 6 months after MitraClip therapy in patients with 3+ or 4+ MR.

Duplex criteria for in-stent restenosis in the superficial femoral artery.

OBJECTIVES: To elucidate the optimal cutoff and accuracy of duplex ultrasonography (DUS) parameters for in-stent restenosis (ISR) after nitinol stenting in the superficial femoral artery (SFA). BACKGROUND: Few data are available regarding the performance of DUS for binary ISR based on quantitative vessel analysis (QVA) in the era of SFA nitinol stenting. METHODS: This retrospective study included 74 in-stent stenoses of SFA who underwent DUS before follow-up angiography. DUS parameters, such as peak systolic velocity (PSV) and the peak systolic velocity ratio (PSVR), were compared with percent diameter stenosis (%DS) from a QVA basis. RESULTS: There was a statistically significant correlation (P < 0.001) between "%DS and PSV" and "%DS and PSVR," and the correlation with %DS proved to be stronger in PSVR (R = 0.720) than in PSV (R = 0.672). The best performing parameter for ISR (50% or greater stenosis) was revealed PSVR, as the areas under the receiver operator characteristics curves using PSVR and PSV were 0.908 and 0.832, respectively. A PSVR cut off value of 2.85 yielded the best predictive value with sensitivity of 88%, specificity of 84%, and accuracy of 86%. The positive predictive value was 85% and the negative predictive value was 88%. CONCLUSIONS: A PSVR of 2.85 is the optimal threshold for ISR after nitinol stenting in the SFA. Further large prospective studies are required for the validation and establishment of uniform criteria for DUS parameters.

Assessment of macro- and microcirculation in contemporary critical limb ischemia.

OBJECTIVES: A paucity of data exists regarding manifestations of macro- and microcirculation in contemporary critical limb ischemia (CLI). The aim of this study was (1) to evaluate the differences in foot circulation based on angiographic findings, (2) to clarify the relationship between macro- and microcirculation, and (3) to investigate the effects of postural changes on micro as well as macrocirculation between the supine position to the dependent position. METHODS: A total of 40 critically ischemic limbs in 29 patients were included in this study. Noninvasive evaluation of macrocirculation, based on the ankle brachial index (ABI) and ankle pressure, and microcirculation, using skin perfusion pressure (SPP), was performed in both the supine and dependent positions. RESULTS: There was no significant difference in macro- and microcirculations between any angiographical involvements. In the supine position, dorsal SPP correlated significantly with ABI (P = 0.021, r = 0.363) and ankle-pressure (P = 0.001, r = 0.495), whereas plantar SPP failed to correlate with ABI (P = 0.198, r = 0.208) or ankle-pressure (P = 0.185, r = 0.214). In the dependent position, however, SPP showed no significant correlation with ABI and ankle pressure. Postural change from the supine to dependent position yielded a significant increase in SPP (dorsal: 37.2 ± 16.2 to 77.9 ± 17.7 mm Hg, P < 0.001; plantar: 33.6 ± 17.3 to 75.7 ± 18.3 mm Hg, P < 0.001) as well as ABI and ankle-pressure (ABI: 0.70 ± 0.35 to 0.78 ± 0.42, P = 0.003; ankle-pressure; 108 ± 61 to 111 ± 60 mm Hg, P = 0.038). The effect of postural change on SPP showed no difference between patients with and without any clinical and angiographical complications. CONCLUSIONS: Of microcirculation assessed, only dorsal SPP correlated significantly with macrocirculation in the supine position. Furthermore, postural change from the supine to dependent position produced a dramatic improvement in microcirculation due to the effects of gravity.

Stent-assisted below-the-ankle angioplasty for limb salvage.

PURPOSE: To report the clinical outcome of stent-assisted below-the-ankle angioplasty for limb salvage in the setting of critical limb ischemia (CLI). METHODS: A retrospective single-center study was conducted of 40 critical ischemic limbs in 31 patients (mean age 67 ± 8 years, range 46-94) undergoing below-the-ankle stent-assisted angioplasty between April 2006 and April 2009. Coronary bare metal stents were implanted in cases of failed balloon angioplasty due to significant recoil, flow-limiting dissection, abrupt closure, or repeat early reocclusion. RESULTS: Technical success was 93% (37 limbs), with 3 failures to cross the occlusive lesions. Acute or subacute occlusion was evident in 9 (23%) limbs. The number of runoff vessels increased significantly (p < 0.001) from 0.6 ± 0.8 to 1.8 ± 0.8. During a clinical follow-up of 19.3 ± 11.4 months (range 1-48), the number of repeat interventions for limb salvage was 2.2 ± 1.6 (range 1-9), and a total of 1.6 ± 0.9 stents (range 1-3) were implanted in 8 dorsalis pedis arteries. Acute or subacute stent thrombosis after stenting was observed in 2 of these, and symptomatic in-stent restenosis was detected in 4, which were all treated by repeat intervention. At 6, 12, and 24 months, the freedom from repeat intervention was 39.6%, 39.6%, and 35.2%, respectively. Amputation-free survival was 80.0%, 69.7%, and 62.7%, and limb salvage was 94.7%, 91.4%, and 82.1% at the same time points. Patient survival rates were 77.4%, 71.0%, and 71.0%, respectively. During a mean follow-up of 13.4 ± 12.7 months (range 1-31 months) in 7 of the 8 stented arteries, all examined stents were deformed: stent compression was evident in 5 and stent fracture in 5. However, 7 limbs undergoing dorsalis pedis artery stenting showed complete wound healing; 1 limb had a resistant wound in the heel. CONCLUSION: Stent-assisted below-the-ankle angioplasty produced a satisfactory clinical outcome but with the need for repeat intervention. Thus, further refinement in endovascular technology is mandatory to reduce the need for repeat interventions and to resolve stent deformity issues.