Angiographic classification of coronary dissections after plain old balloon angioplasty for prediction of regression at follow-up.

Coronary dissection after plain old balloon angioplasty often shows regression during follow-up. This study sought to determine whether we can predict such phenomenon angiographically. We analyzed 64 patients with 71 type B-D coronary dissections determined by the National, Heart, Lung, and Blood Institute (NHLBI) criteria. Regression was considered present when minimal lumen diameter increased by more than 0.3 mm during follow-up. Dissections were divided into subgroups using the NHLBI criteria and our classification in which type a and b dissections were characterized by the width of a dissection lumen exceeding one quarter of the reference diameter with the outer edge of the dissection lumen within the boundary of reference in type a and beyond it in type b. In type c and type d dissections, the width of the dissection lumen was within one quarter of the reference with its outer edge within the boundary of reference in type c and beyond it in type d. Type e dissection had a protruding flap or spiral appearance. Regression was recognized in 23.9%. The distribution of dissection types was similar in the groups with and without regression by the NHLBI criteria, but type c dissection had regression more frequently than the other types of coronary dissections (p<0.001) using our classification.

Beneficial application of quantitative coronary angiography (edge detection algorithm) in analysis of dissected coronary arteries to predict long-term patency.

The present study evaluated the application of quantitative coronary angiography (edge detection algorithm) for the analysis of coronary dissection lesions after balloon angioplasty. Acute and late results were obtained by the edge detection algorithm in 60 patients with 66 dissected lesions (NHLBI types B-C). The edge detection algorithm delineated the border of the true lumen in 32 lesions (group with automated analysis alone, 48.5%) and included the dissection cap in the analysis in 34 lesions in which manual editing was adjuncted (group with manual editing, 51.5%). In both groups, the minimal lumen diameter after balloon angioplasty obtained by initial automated analysis was correlated to that obtained at the 5.3-month follow-up similarly (r=0.554, p=0.0010 for the group with automated analysis alone and r=0.613, p=0.0001 after automated analysis for the group with manual editing). However, additional manual editing reduced the correlation coefficient (r=0.240, p=0.1707) in the latter group. Thus, in terms of predicting long-term patency, it is reasonable to let the edge detection algorithm decide the measurements in types B and C dissected lesions.

[Assessing the physiologic significance of intermediate coronary lesions: comparison of coronary flow measurements with exercise electrocardiography].

Angiography may provide limited assessment of intermediate coronary stenoses. Doppler coronary flow reserve has been applied to determine the physiologic significance of such lesions. This study compared coronary flow reserve derived from intracoronary Doppler flow wire with the results of the exercise tolerance test to evaluate the validity of intracoronary flow measurements in the assessment of intermediate stenoses. Sixty eight patients with 91 vessels harboring angiographically mild-to-severe coronary stenoses in the left anterior descending or right coronary artery were studied. All patients had single-vessel disease, and angiography showed the target vessel. Distal coronary flow reserve was measured with the Doppler guide wire during cardiac catheterization. Exercise tolerance tests by bicycle ergometer were performed the day before catheterization. Quantitative coronary angiography showed a mean percentage diameter stenosis of 44 +/- 21%(range 0-90%). Forty seven of 91 vessels combined intermediate lesions(40% to 70%). Percentage diameter stenosis and coronary flow reserve were linearly correlated in both overall and intermediate lesions(r = -0.52 vs -0.42; both p < 0.0001). Percentage diameter stenosis of overall lesions was significantly higher in the positive exercise test group than the negative group(59.8 +/- 17.2% vs 37.7 +/- 18.1%, p < 0.0001), but not significantly different in intermediate lesions(49.1 +/- 7.8% vs 54.7 +/- 6.6%, p = 0.03). The positive exercise test group showed significantly lower coronary flow reserve compared to the negative group in both overall and intermediate lesions(overall: 1.6 +/- 0.5 vs 2.6 +/- 0.9, p < 0.0001; intermediate: 1.6 +/- 0.5 vs 2.5 +/- 0.7, p < 0.0001). Coronary flow reserve < 2.0 and positive exercise test agreed in 38 of 46 intermediate lesions(83%), and percentage diameter stenosis > or = 50% and positive exercise test agreed in 34 of these 46 lesions(74%). Coronary flow reserve, more than percentage diameter stenosis, correlated with the results of the exercise tolerance test, and is considered to be useful to evaluate the functional severity of intermediate stenosis.

Vascular intimal carcinomatosis: an autopsy case of unusual form of pulmonary metastasis of transitional cell carcinoma.

A 44-year-old woman with an unusual form of pulmonary metastasis is described. She presented with pulmonary thrombosis and clinical signs of disseminated intravascular coagulation (DIC) and died of cerebral hemorrhage. The autopsy study revealed transitional cell carcinoma of the left renal pelvis with pulmonary thrombosis in the large arteries. The intima of the vessels were intact on gross inspection except where the thrombi adhered to. The thrombi contained no tumor cells. However, microscopic examination identified that the metastatic carcinoma diffusely replaced the endothelium and proliferated on to the intimal surface without invasion of the wall and metastatic nodules in the parenchyma. Other examined organs had neither primary nor metastatic tumors, except for microscopic metastasis to the inferior vena cava. To date, this pattern of metastasis has not been noted in previous literature. This condition was designated as being vascular intimal carcinomatosis because of its characteristic manner of tumor proliferation on vascular intima.