Intravascular Ultrasound Guidance Research Articles

TCT-555 Intravascular Ultrasound Guidance Improves the Long-term Prognosis in Patients with Unprotected Left Main Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

TCT-555 Intravascular Ultrasound Guidance Improves the Long-term Prognosis in Patients with Unprotected Left Main Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

TCT-577 Intravascular ultrasound guidance during percutaneous coronary intervention using second-generation drug-eluting stents improves clinical outcomes and reduces restenosis rates: a comparative 8,265 patient meta-analysis

TCT-577 Intravascular ultrasound guidance during percutaneous coronary intervention using second-generation drug-eluting stents improves clinical outcomes and reduces restenosis rates: a comparative 8,265 patient meta-analysis

Venous Stenting for Lower Extremity Venous Occlusive Disease: The Vancouver General Hospital Experience

Endovenous stenting of the iliocaval venous system (EndoVS) has become a viable and efficacious option for treatment of venous occlusive disease of the lower extremity. We reviewed our initial experience with this procedure to assess patient outcomes. We undertook a retrospective chart review of all EndoVS performed by vascular surgeons at the Vancouver General Hospital between February 2013 and December 2015. Patient demographics, procedure details, complications, and follow-up data were collected from the patients' charts. Data are presented descriptively. EndoVS was performed in 18 patients from February 2013 to December 2015. Fifteen of the patients (83.3%) had a prior history of deep venous thrombosis. Three of these patients (16.7%) had recent deep venous thrombosis treated with catheter-directed thrombolysis. Eight patients (44.4%) had preoperative imaging evidence of May-Thurner syndrome. Preoperative clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification was C3, C4, C5, or C6 in six, five, two, and five patients, respectively. Thirteen patients (72.2%) had symptoms of venous claudication. All patients received magnetic resonance venography before intervention. All procedures were performed percutaneously in the operating room with mobile fluoroscopy, duplex ultrasound, and intravascular ultrasound guidance. Four patients had complete occlusion of the inferior vena cava requiring recanalization and inferior vena cava stenting. Technical success was 100%. One case was complicated intraoperatively by proximal stent migration requiring piecemeal endovenous retrieval. All patients were discharged on anticoagulation. Median clinical follow-up was 5.8 months (interquartile range, 5.0-10.0). At this time, 13 patients (72.2%) had significant improvement in their symptoms of swelling or venous claudication, whereas 2 patients had minimal change. Two patients had initial improvement followed by return of their symptoms, one of whom underwent a second procedure and is doing well postoperatively. One patient stopped anticoagulation early against medical advice and presented with thrombosis of the venous stent requiring thrombolysis and venoplasty. All five patients with CEAP C6 disease demonstrated healing of their chronic venous ulcers. Median imaging follow-up was 7.4 months (5.4-10.4). Primary patency was 88.9%. Secondary patency was 94.4%. Our initial experience with EndoVS is favorable with clinical improvement in the majority of patients. Primary patency and secondary patency in this short-term follow-up were excellent. Long-term follow-up is required to properly assess the durability of these procedures.

Two-year clinical outcomes in stable angina and acute coronary syndrome after percutaneous coronary intervention of left main coronary artery disease.

Background/AimsThis study appraised the long term clinical outcomes of patients treated with percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease. There are limited data regarding long-term clinical outcomes after PCI for ULMCA disease.MethodsFrom 2001 to 2011, a total of 448 patients who underwent PCI for ULMCA disease and had 2-year clinical follow-up, were analyzed. The study patients were divided into two groups: group I (stable angina pectoris [SAP], n = 60, 48 men, 62 ± 10 years) and group II (acute coronary syndrome [ACS], n = 388, 291 men, 64 ± 10 years). We evaluated clinical and angiographic characteristics and major adverse cardiac events (MACE) during 2-year clinical follow-up.ResultsMean age of studied patients was 64 ± 10 years with 339 male patients. Average stent diameter was 3.6 ± 0.4 mm and stent length was 19.7 ± 6.3 mm. Stent implantation techniques and use of intravascular ultrasound guidance were not different between two groups. In-hospital mortality was 0% in group I and 7% in group II (p = 0.035). One-month mortality was 0% in group I and 7.7% in group II (p = 0.968). Two-year survival rate was 93% in the group I and 88.4% in the group II (p = 0.921). Predictive factors for 2-year MACE were hypertension, Killip class ≥ 3, and use of intra-aortic balloon pump by multivariate analysis.ConclusionsAlthough in-hospital mortality rate was higher in ACS than in SAP, clinical outcomes during 2-year clinical follow-up were similar between SAP and ACS after PCI of ULMCA.

Effects of Intravascular Ultrasound-GuidedVersus Angiography-Guided New-Generation Drug-Eluting Stent Implantation: Meta-Analysis With Individual Patient-Level DataFrom2,345Randomized Patients.

The aim of this study was to evaluate the clinical usefulness of intravascular ultrasound (IVUS)-guided new-generation drug-eluting stent (DES) implantation using a meta-analysis of individual patient-level data from randomized trials. Published randomized trials that compare IVUS-guided versus angiography-guided new-generation DES implantation are scarce. Searches of the MEDLINE, Embase, and Cochrane databases were performed to find randomized trials that compared IVUS-guided versus angiography-guided new-generation DES implantation. A total of 2,345 patients from 3randomized trials were identified, and all patients were treated for long lesions or chronic total occlusions. Individual patient-level data were obtained. The primary endpoint was a major adverse cardiac event, a composite of cardiac death, myocardial infarction, or stent thrombosis. An intention-to-treat analysis and per protocol analysis were performed. By 1 year post-procedure, major adverse cardiac events had occurred in 0.4% of the patients who underwent IVUS-guided DES implantation versus 1.2% of those who underwent angiography-guided DES implantation (hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.99; p= 0.040). For the IVUS-guided group, favorable clinical outcomes were observed for myocardial infarction (0% vs. 0.4%; HR: 0.09; p= 0.026). In addition, the clinical benefit of IVUS guidance was stronger in the per protocol analysis (HR: 0.32; 95% CI: 0.12 to 0.89; p= 0.021). Compared with angiographic guidance, IVUS-guided new-generation DES implantation was associated with favorable outcomes in terms of major adverse cardiac events, the composite of cardiac death, myocardial infarction, or stent thrombosis. These findings must be interpreted only for complex lesions, because all identified patients had long lesions or chronic total occlusions.

Comparison of Immediate and Intermediate - Term Outcomes of Intravascular Ultrasound - Guided versus Angiography - Guided Intervention for Type C Coronary Lesions

Background: the intravascular ultrasound (IVUS) is an invasive access technique that allows analysis of characteristics (qualitative and quantitative) of coronary atherosclerosis. Percutaneous coronary intervention (PCI) of complex lesions (i.e., American College of Cardiology/ American Heart Association class type C) remains challenging and the outcome may be compromised. The use of intravascular ultrasound (IVUS) to guide PCI was suggested to improve outcome. The Objectives: aim of this study wasto compare intravascular ultrasound-guided and angiography-guided Intervention for Type C coronary lesions regarding major adverse cardiac events (MACE). Patients and Methods: Our study was conducted on patients undergoing elective PCI for type C coronary lesions in Cardiology Department in Ain Shams University hospitals. The study included 50 patients who underwent IVUS guidance PCI for Type C lesions and 50 patients who underwent only angiographic guidance PCI for Type C lesions. We evaluated the impact of IVUS guidance on clinical outcomes of patients undergoing PCI for complex lesions defined as ACC/AHA type C. Major adverse cardiovascular events (MACE), a composite end-point of all-cause mortality, Q-wave myocardial infarction and target lesion revascularization, were compared between the 2 groups. Mean follow-up duration was 12 months. Results:baseline clinical characteristics were similar in both patient groups. Adding IVUS to the procedure lengthened the procedure time. On the other hand, lower amount of radiographic contrast was required in the IVUS guided group during the procedure. Regarding the target coronary vessel in our study was similar in both groups with no significant difference. In addition, the number of ostial, proximal, mid and distal lesions was similar between the two studied groups. Patients with IVUS-guided PCI underwent more direct stenting, more postdilatation, larger maximal stent diameter and greater number of implanted stents. Consequently, the final diameter stenosis was significantly better in IVUS guided group. A strategy of routine IVUS for drug-eluting stent implantation in complex coronary lesions did not improve the 1-year MACE rates. Conclusion: use of intravascular ultrasound (IVUS) is associated with lower amount of radiographic contrast used during the procedure, more procedural time, more post dilatation and less postintervention final diameter stenosis. In addition, use of intravascular ultrasound (IVUS) in complex lesions allows proper assessment of minimal lumen area, optimizing PCI procedures and confirming stent well apposition.

45 Intravascular ultrasound guidance of percutaneous coronary interventions in ostial chronic total occlusions

Background Inability to cross the lesion with a guidewire is the most common reason for failure in percutaneous revascularisation (PCI) of chronic total occlusions (CTOs). An ostial or stumpless CTO is an acknowledged challenge for CTO recanalisation due to difficulty in successful wiring. IVUS imaging provides the opportunity to visualise the occluded vessel and to aid guidewire advancement. We review the value of this technique in a single-centre experience of CTO PCI. Methods This series involves 22 patients who underwent CTO-PCI using IVUS guidance for stumpless CTO wiring at our institution. CTO operators with extensive IVUS experience in non-CTO cases carried out all procedures. Procedural and outcome data in this population was prospectively entered into the institutional database and a retrospective analysis of clinical, angiographic and technical data was performed. Results 17 (77%) of the 22 procedures were successful. The mean age was 59.8 ± 11.5 years, and 90.9% were male. The most commonly attempted lesions were located in the Left Anterior Descending (LAD) 36.4% (8) and Circumflex artery (LCx) 31.8% (7). Mean JCTO score was 3.09 ± 0.75 (3.06 ± 0.68, 3.17 ± 0.98 in the successful and failed groups respectively p = 0.35). The mean contrast volume was 378.7 ml ± 114.7 (389.9 ml ± 130.5, 349.2 ml ± 52.2 p = 0.3 in the successful and failed groups respectively). There was no death, coronary artery bypass grafting or myocardial infarction requiring intervention in this series. When the success rates were analysed taking into account the date of adoption of this technique, the learning curve had no significant impact on CTO-PCI success. Conclusions This series describes a good success rate in IVUS guided stumpless wiring of CTOs in consecutive patients with this complex anatomical scenario.

Optical Coherence Tomography Guidance for Percutaneous Intervention

Article, see p 906 Adoption of invasive imaging for guidance during percutaneous coronary interventions (PCI) varies largely between clinical sites and between geographies, being greatest in Japan, intermediate to low in the United States and Asia, and very low to nonexistent in Europe. Yet nearly every interventional cardiologist will agree that intracoronary images obtained by intravascular ultrasound (IVUS) and optical coherence tomography (OCT) add significant information content to what is provided by angiography alone, thereby improving the understanding of and our capacity to interpret angiographic images. Although Japanese colleagues have the opportunity to use either IVUS or OCT in the majority of cases as part of their regular procedural strategy, use of invasive imaging in the rest of the world is hampered by inadequate or restricted reimbursement. Payers and some physicians are indeed claiming that adding IVUS or OCT imaging to simple angiographic guidance has not been shown unequivocally to affect patient outcomes. Observational or retrospective data obtained with use of the more recently developed OCT are even less conclusive than those obtained over the years with IVUS guidance.1 The study reported here by Meneveau et al2 is an important milestone in the journey to accumulating sufficient global evidence to support the role of OCT-guidance eventually during complex PCI and to extend the Practice Guidelines recommendations supporting its use. As mentioned in the original article,3 the DOCTORS (Does Optical Coherence Tomography Optimize Results of Stenting?) randomized trial is an investigator-driven initiative, supported by central analyses performed at the leading participating center, and funded by the French government. DOCTORS is the first, randomized, multicenter study specifically evaluating the impact of combined angiographic and OCT imaging on PCI optimization. The study confirms prior observational or retrospective studies4–7 in identifying OCT findings that jeopardize the immediate PCI …

Comparison of Inferior Vena Cava Filters Placed at the Bedside via Intravenous Ultrasound Guidance Versus Fluoroscopic Guidance

IVCFs are usually placed under fluoroscopic guidance in dedicated angiography suites. Bedside placement of inferior vena cava filters (IVCF) is possible in patients not suitable for transportation, but data regarding their use are limited. The objective of this study is to compare utilization, procedural outcomes, complications, and long-term patient outcomes associated with bedside placement of IVCFs using intravascular ultrasound (IVUS) and fluoroscopic placement of IVCF. All patients receiving IVCF between January 2009 and December 2011 at a tertiary care institution were retrospectively identified. Data regarding patient characteristics, IVCF indications, complications, and outcomes were collected, and comparisons were made between patients receiving fluoroscopic-guided and IVUS-guided bedside IVCF. There were 117 bedside and 571 fluoroscopic-guided IVCF placed during this period. Patients receiving bedside IVCF were younger (50.8 vs. 60.7years, P<0.001), less often had malignancy (22.2% vs. 42.6%, P<0.001), and received prophylactic filters more commonly (59.9% vs. 29.9%, P<0.001). Placement-related complications occurred in 4.3% and 0.6%, respectively (bedside IVCF: 4 malpositions, 1 severe tilt; fluoroscopic-guided IVCF: 1 malposition, 1 severe tilt, P=0.01). Indwelling IVCF-related complications occurred equally during median follow-up of 463 and 488days, respectively (deep vein thrombosis: 13.7% vs. 13.3%, P=0.92; pulmonary embolism: 5.1% vs. 4.0%, P=0.61; filter thrombosis: 3.4% vs. 3.9%, P=0.82). Time to indwelling complication was similar between groups (74 vs. 127 days, P=0.29). Bedside placement of IVUS-guided IVCF is safe, but with higher procedural complications when compared with fluoroscopic placement. Long-term indwelling complications are similar between IVCF placed via bedside IVUS guidance and fluoroscopic approach.

Utility of Intravascular US–Guided Portal Vein Access during Transjugular Intrahepatic Portosystemic Shunt Creation: Retrospective Comparison with Conventional Technique in 109 Patients

PurposeTo compare safety and effectiveness of intravascular ultrasound (US)–guided portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) creation with conventional TIPS technique. Materials and MethodsIn this retrospective study, TIPS creation using intravascular US guidance in 55 patients was compared with conventional TIPS creation in 54 patients by 10 operators over a 3-year period. Operators were classified as experienced if they had performed ≥ 20 TIPS procedures at the beginning of the study period. Time to portal vein access, total radiation dose, and needle pass–related capsular perforation were recorded. ResultsBaseline demographic characteristics of patients were similar (P > .05). Mean time to portal venous access was 46 minutes ± 37 for conventional TIPS and 31 minutes ± 19 for intravascular US–guided TIPS (P = .007). Intravascular US guidance allowed significantly shorter times (48 min ± 30 vs 28 min ± 16; P = .01) to portal vein access among operators (n = 5) with limited experience but failed to achieve any significant time savings (44 min ± 43 vs 34 min ± 22; P = .89) among experienced operators (n = 5). Needle pass–related capsular perforation occurred in 17/54 (34%) patients with conventional TIPS and 5/55 (9%) patients with intravascular US–guided TIPS (P = .004). Radiation dose was 2,376 mGy ± 1,816 for conventional TIPS and 1,592 mGy ± 1,263 for intravascular US–guided TIPS (P = .004). ConclusionsIntravascular US–guided portal vein access during TIPS creation is associated with shorter portal vein access times, decreased needle pass–related capsular perforations, and reduced radiation dose.

PS137 Effectiveness and Safety of Intravascular Ultrasound Guidance on Clinical Outcomes Following Drug-Eluting Stent Implantation in Unprotected Left Main Coronary Artery

PS137 Effectiveness and Safety of Intravascular Ultrasound Guidance on Clinical Outcomes Following Drug-Eluting Stent Implantation in Unprotected Left Main Coronary Artery

Clinical impact of undersized- versus oversized-stenting approaches in ST-elevation myocardial infarction.

Primary percutaneous coronary intervention (PCI) is the standard treatment in patients with ST-elevation myocardial infarction (STEMI). However, some patients still develop ST re-elevation during PCI, resulting in further myocardial damage and a poor outcome. An undersized-stenting approach may prevent ST re-elevation. We aimed to determine the association between final stent area and ST re-elevation during primary PCI for STEMI. Overall, 102 consecutive STEMI patients who underwent primary PCI under integrated backscatter intravascular ultrasound guidance were enrolled. The stent-reference (SR) ratio was defined as the stent cross-sectional area (CSA) divided by the average CSA of the 5-mm proximal and distal reference lumens. The patients were divided into two groups according to the SR ratio: undersize group (SR<1.0, n=62) and oversize group (SR≥1.0, n=40). The incidences of ST re-elevation and total ST resolution (STR) were compared. The oversize group showed a higher incidence of ST re-elevation (32.5 vs. 9.7%, p=0.004) and a lower total STR (22.4±62.7 vs. 43.4±38.6%, p=0.04). After adjustment, the oversized-stenting approach was independently associated with ST re-elevation [odds ratio: 3.74, 95% confidence interval (CI) 1.27-12.1, p=0.02]. The peak creatine kinase-MB level was higher in the oversize group (341±259 vs. 242±208IU/l, p=0.04). The incidences of stent thrombosis and restenosis were similar between the two groups. An oversized-stenting approach in patients with STEMI was associated with a higher incidence of ST re-elevation and a lower total STR, resulting in increased myocardial damage.

TCTAP A-025 Efficacy of Long 2nd Generation Drug-Eluting Stent Implantation from Healthy to Healthy Segment Under Intravascular Ultrasound Guidance in Acute Myocardial Infarction

TCTAP A-025 Efficacy of Long 2nd Generation Drug-Eluting Stent Implantation from Healthy to Healthy Segment Under Intravascular Ultrasound Guidance in Acute Myocardial Infarction

Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience

PurposeTo assess whether intravascular ultrasound (US) guidance impacts number of needle passes, contrast usage, radiation dose, and procedure time during creation of transjugular intrahepatic portosystemic shunts (TIPS). Materials and MethodsIntravascular US–guided creation of TIPS in 40 patients was retrospectively compared with conventional TIPS in 49 patients between February 2010 and November 2015 at a single tertiary care institution. Patient sex and age, etiology of liver disease (hepatitis C virus, alcohol abuse, nonalcoholic steatohepatitis), severity of liver disease (mean Model for End-Stage Liver Disease score), and indications for TIPS (variceal bleeding, refractory ascites, refractory hydrothorax) in conventional and intravascular US–guided cases were recorded. ResultsThe two groups were well matched by sex, age, etiology of liver disease, Child-Pugh class, Model for End-Stage Liver Disease scores, and indication for TIPS (P range = .19–.94). Fewer intrahepatic needle passes were required in intravascular US–guided TIPS creation compared with conventional TIPS (2 passes vs 6 passes, P < .01). Less iodinated contrast material was used in intravascular US cases (57 mL vs 140 mL, P < .01). Radiation exposure, as measured by cumulative dose, dose area product, and fluoroscopy time, was reduced with intravascular US (174 mGy vs 981 mGy, P < .01; 3,793 μGy * m2 vs 21,414 μGy * m2, P < .01; 19 min vs 34 min, P < .01). Procedure time was shortened with intravascular US (86 min vs 125 min, P < .01). ConclusionsIntravascular US guidance resulted in fewer intrahepatic needle passes, decreased contrast medium usage, decreased radiation dosage, and shortened procedure time in TIPS creation.

Outcomes With Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis of Randomized Trials in the Era of Drug-Eluting Stents.

In the era of drug-eluting stents, it is unknown if intravascular ultrasound (IVUS) guidance for percutaneous coronary intervention should be routinely endorsed. This study aimed to determine if IVUS-guided stent implantation is associated with improved outcomes. Randomized trials that reported clinical outcomes and compared routine IVUS-guided stent implantation with an angiography-guided approach in the era of drug-eluting stents were included. Summary estimates were constructed primarily using the Peto model. Seven trials with 3192 patients were analyzed. The mean length of the coronary lesions was 32 mm. At a mean of 15 months, routine IVUS-guided percutaneous coronary intervention was associated with a reduction in the risk of major adverse cardiac events (6.5% versus 10.3%; odds ratio, 0.60; 95% confidence interval, 0.46-0.77; P<0.0001), mainly because of reduction in the risk of ischemia-driven target lesion revascularization (4.1% versus 6.6%; odds ratio, 0.60; 95% confidence interval, 0.43-0.84; P=0.003). The risk of cardiovascular mortality (0.5% versus 1.2%; odds ratio, 0.46; 95% confidence interval, 0.21-1.00; P=0.05), and stent thrombosis (0.6% versus 1.3%; odds ratio, 0.49; 95% confidence interval, 0.24-0.99; P=0.04) also appeared to be lower in the IVUS-guided group. In the era of drug-eluting stents for diffuse coronary lesions, IVUS-guided percutaneous coronary intervention is superior to angiography-guided percutaneous coronary intervention in reducing the risk of major adverse cardiac events. This is primarily because of reduction in the risk of ischemia-driven target lesion revascularization. This analysis also suggests that risk of cardiovascular mortality and stent thrombosis might be lower with an IVUS-guided approach.

Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study

The feasibility, safety, and clinical utility of percutaneous coronary intervention (PCI) without radio-contrast medium in patients with advanced chronic kidney disease (CKD) are unknown. In this series, we investigated a specific strategy for 'zero contrast' PCI with the aims of preserving renal function and preventing the need for renal replacement therapy (RRT) in patients with advanced CKD. A total of 31 patients with advanced CKD [creatinine = 4.2 mg/dL, inter-quartile range (IQR) 3.1-4.8, estimated glomerular filtration rate = 16 ± 8 mL/min/1.73 m2] who had clinical indication for PCI based on a prior minimal contrast coronary angiogram were included. Zero contrast PCI was performed at least 1 week after diagnostic angiography using real-time intravascular ultrasound (IVUS) guidance, with pre- and post-PCI measurements of fractional flow reserve and coronary flow reserve to confirm physiological improvement. This approach resulted in successful PCI, no major adverse cardiovascular events and preservation of renal function without the need for RRT within a follow-up time of 79 days (IQR 33-207) in all patients. In patients with advanced CKD who require revascularization, PCI may safely be performed without contrast using IVUS and physiological guidance with high procedural success and without complications.

Intravascular US–Guided Portal Vein Access: Improved Procedural Metrics during TIPS Creation

PurposeTo evaluate transjugular intrahepatic portosystemic shunt (TIPS) outcomes and procedure metrics with the use of three different image guidance techniques for portal vein (PV) access during TIPS creation. Materials and MethodsA retrospective review of consecutive patients who underwent TIPS procedures for a range of indications during a 28-month study period identified a population of 68 patients. This was stratified by PV access techniques: fluoroscopic guidance with or without portography (n = 26), PV marker wire guidance (n = 18), or intravascular ultrasound (US) guidance (n = 24). Procedural outcomes and procedural metrics, including radiation exposure, contrast agent volume used, procedure duration, and PV access time, were analyzed. ResultsNo differences in demographic or procedural characteristics were found among the three groups. Technical success, technical success of the primary planned approach, hemodynamic success, portosystemic gradient, and procedure-related complications were not significantly different among groups. Fluoroscopy time (P = .003), air kerma (P = .01), contrast agent volume (P = .003), and total procedural time (P = .02) were reduced with intravascular US guidance compared with fluoroscopic guidance. Fluoroscopy time (P = .01) and contrast agent volume (P = .02) were reduced with intravascular US guidance compared with marker wire guidance. ConclusionsIntravascular US guidance of PV access during TIPS creation not only facilitates successful TIPS creation in patients with challenging anatomy, as suggested by previous investigations, but also reduces important procedure metrics including radiation exposure, contrast agent volume, and overall procedure duration compared with fluoroscopically guided TIPS creation.

Novel Image Guidance Techniques for Portal Vein Targeting During Transjugular Intrahepatic Portosystemic Shunt Creation

The most challenging part of transjugular intrahepatic portosystemic shunt creation is arguably the transvenous access from the hepatic vein to the portal vein. As experience and technology have evolved, the image guidance aspect of this critical step in the procedure has become more robust. Improved means to target the portal vein include both direct and indirect methods of portal vein opacification, cross-sectional imaging for both targeting and access, and novel use of transabdominal and intravascular ultrasound guidance. These techniques are described herein.

Local anesthetic systemic toxicity: Continuing Professional Development.

Regional anesthesia is enjoying a renaissance due in part to the advent of ultrasound guidance and the development of new techniques such as tissue plane blocks and local infiltration analgesia. The purpose of this Continuing Professional Development module is to provide practitioners with an understanding of the current state of knowledge surrounding local anesthetic systemic toxicity (LAST) in order to help them prevent and manage this complication more effectively. The causes of LAST are multifactorial, but recognized risks include patient factors, drug doses, pharmacokinetics, and choice of regional anesthetic technique. Local anesthetic systemic toxicity produces a biphasic course of clinical events that generally begin with central nervous system excitation followed by inhibition. At the same time, it causes cardiovascular compromise due to dysrhythmias, myocardial depression, and reduced systemic vascular resistance. Clinical presentation can be highly variable, however, and atypical presentations are not uncommon. Local anesthetic systemic toxicity is prevented by careful choice and dosing of drugs, aspiration before injection, dose fractionation, use of intravascular markers and ultrasound guidance. The management of LAST includes adequate oxygenation and ventilation, seizure termination, maintenance of circulation, and intravenous lipid emulsion therapy. Local anesthetic systemic toxicity is a potentially lethal condition with protean manifestations, and anesthesiologists must understand its risks, prevention, and safe management.

Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): Study protocol for a randomized controlled trial

BackgroundOptical coherence tomography is becoming increasingly widespread as an adjunctive intravascular diagnostic technique in percutaneous coronary intervention (PCI), because of its ability to visualize coronary structures at high resolution. Several studies have reported that intravascular ultrasound (IVUS) guidance in PCI might be helpful to reduce subsequent stent thrombosis, restenosis, repeat revascularization, myocardial infarction, and cardiac death. The OPtical frequency domain imaging vs. INtravascular ultrasound in percutaneous coronary InterventiON (OPINION) trial is aimed at evaluating the impact of optical frequency domain imaging (OFDI) guidance in PCI on clinical outcomes compared with IVUS guidance. Methods and designThe OPINION trial is a multicenter, prospective, randomized, controlled, open-label, parallel group, non-inferiority trial in Japan. The eligible patients are randomly assigned to receive either OFDI-guided PCI or IVUS-guided PCI. PCI is performed using the biolimus-eluting stent in accordance with a certain criteria of OFDI and IVUS for optimal stent deployment. All patients will undergo a follow-up angiography at 8 months. The primary endpoint is target vessel failure composed of cardiac death, myocardial infarction attributed to the target vessel, and clinically-driven target vessel revascularization at 12 months. ConclusionWhen completed, the OPINION trial will contribute to define the clinical value of the OFDI guidance in PCI.