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From Angiography to Angioscopy: Informal Discussion

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From Angiography to Angioscopy: Informal Discussion Informal Discussion From Angiography to Angioscopy: Informal Discussion Bruno S. Cortis, M.D., David M. Harris, Ph.D.,* and Joseph Principe, B.S. Devices for visualizing blood vessels have evolved from a rigid, illuminated tube (1913), to a tube with an added convex lens (1922), to one with a transparent inflatable balloonfor displacing bloodfrom the line ofvision (1943), to aflexible angioscope (1960s). Recentfiberoptic developments make it possible to visualize the orifices ofthe coronary arteries and simultaneous laser angioplasty. The characteristic fluorescence ofhematoporphyrin derivative under ultraviolet light has been visualized angioscopically in experimental atheroscleroticplaque, where it accumulates and acts as a marker. However, several requirements need to be met in orderfor angioscopy to fulfill its therapeutic possibilities in angioplasty, thrombolytic therapy, intraoperative inspection of vascular anastomoses, and its diagnostic potential in distinguishingplaquesfrom clots andpulmonary embolisms from other obstructions. These requirements are: (1) variously-sized angioscopes to accommodate iliac, femoral, renal, and coronary arteries; (2) percutaneous introducers in the various sizes to prevent back-bleeding; (3) a more flexible, easily manipulated fiberoptic; (4) a sufficiently inflatable balloon tip; (5) cross hairs and reference points in the optical system; and (6) optimalfocal lengthsfor the areas to be visualized. Texas HeartInstitute Journal 1986; 13.281- 289) Key words: Angiography; angioscopy; fiberoptic developments SINCE 1913, WHEN Rhea andWalker first Trimedyne Optiscope (Trimedyne, Inc., Santa inserted their rigid, illuminated tube into Ana, California), the more recent American a heart at thoracotomy,' devices for the vis- Edwards Mini-Flex Angioscope, whose inves- ualization of blood vessels have undergone tigational model was brought out by American considerable development and ingenious new Edwards Laboratories (Santa Ana, California) techniques, which have been revised and in November, 1983, and the #5 Olympus refined. In this article, we propose to review Ultrathin Fiberscope (Olympus Inc., New the history of various instruments introduced York, NewYork). In addition, we shall discuss over the years and to discuss experiences the Japanese Sumitomo Angioscope, which I during 2 years of study with currently availa- (the senior author of this article) had the ble technology in the United States: the opportunity to observe in the summer of 1984 From the Chicago MedicalSchool and the Department ofOtolaryngology-HandS, University ofIllinois and Wensky Laser Center, Chicago, Illinois. Address for reprints: Bruno S. Cortis, M.D., 7605 112 West North Avenue, River Forest, Illinois 60305. lxas HeartAHInstitutetioJoumal ypo to Angioscopy 281 while visiting the research laboratories of Dr. The next significant advance in the develop- Inoue in Tokyo, and assisting in studies using ment of angioscopic techniques was replace- this instrument. ment of the rigid instrument with a flexible one, which could be used for studying the HISTORICAL REVIEW aorta and its branches as well as the venous system.4'5 This application was useful mainly In 1913, Rhea and Walker' first introduced in cases of phlebothrombosis. the concept of an instrument to intraopera- In 1980, Moser and Shure6 used a 4 mm tively visualize the chambers of the heart. In bronchoscope to detect experimentally- 1922, Allen and Graham2 added a convex lens induced pulmonary emboli in dogs, and to the distal end of Rhea and Walker's rigid, showed the possible application of this tech- illuminated tube, which could be applied nique for diagnosis of pulmonary embolism. directly against the walls of the heart. How- In 1983, Spears et al,7 using a 1.8 mm ever, the interference of blood in the line of Olympus Ultrathin Fiberoptic Angioscope, vision remained a persistent problem for the visualized the orifices of the coronary arteries in next 20 years. dogs and in postmortem humans intraopera- Then, in 1943, Harken and Glidden3 put a tively. More recently, during cardiac catheteriza- transparent balloon at the distal end of the tion in humans, such visualization was angioscope. When the balloon was inflated, accomplished without reported complications. the blood was displaced allowing intracardiac My colleagues and I used the Trimedyne visualization. Optiscope (Fig. 1) to visualize the aortas and FIg. 1 lThmedyne Optiscope (Thmedyne, Inc., Santa Ana, California). Fig. 2 #5 Olympus Ultrathin Fiberscope (Olympus, Inc., New York, New York). 282 Angiography to Angioscopy ibl. 13, Dio. 3, September, 1986 Fig. 3 Orifice of a canine left coronary artery viewed Flg. 4 Bifurcation of a canine coronary artery viewed through the #5 Olympus Ultrathin Fiberscope. through the #5 Olympus Ultrathin Fiberscope. coronary arteries in vivo in dogs and rabbits, Inoue's group used a catheter with a trans- and in postmortem humans.8 For the past several parent balloon at the distal end and photo- months, we also have used the newly developed graphed the chamber wall with a high-speed #5 Olympus Ultrathin Fiberscope (Fig. 2) in camera at the moment of balloon inflation. dogs, both postmortem and in vivo. Figure 3 As early as 1982, Lee et al'3 (the Trimedyne shows the inner structure of a canine left coro- Company) described a laserscope as a flexible nary artery orifice viewed through the Ultrathin fiberoptic scope for directing a beam of laser Fiberscope. Figure 4 shows the inner structure energy under direct vision. A channel in the of a canine coronary artery bifurcation also Trimedyne instrument accommodates an viewed through the Ultrathin Fiberscope. Argon laser fiber that can be used for illumina- The Cedars-Sinai Medical Center, Los tion and for laser beam simultaneously. The Angeles, headed by Forrester,9 monitored the company now plans clinical trials under their circulation of the coronary and peripheral Laserscope Certification Program, dependent vessels by intraoperative vascular endoscopy upon FDA approval. They use the Trimedyne with both American Edwards and Trimedyne Laserscope system to study laser angioplasty instruments (outside diameter: 1.5, 2.5, and techniques. The FDA has approved the use of 3.7 mm). Myler, Stertzer et all' inspected the laser by certain institutions in connection patients undergoing iliac angioplasty by using with peripheral bypass surgery. During angio- a Trimedyne Optiscope with a 3 mm outside scopy, an angiograph also can be made, and in diameter fiberoptic. Where conventional some cases, having both endoscopic and angiography showed a smooth lumina after the radiographic images may be advantageous. angioplasty, detailed angioscopic visualiza- tion revealed fibrin strands, atheromatous RECENT DEVELOPMENTS material, and shagginess of the vessel wall at the operative site, in contrast to smoothness of Although angioscopy is still experimental, a the vessel wall at adjacent sites. wide range of clinical applications have been Inoue et al,""2 using a Sumitomo Angio- envisioned for this technique. Among those scope (Fig. 5), visualized experimental arte- deserving the most immediate study may be rial endothelial lesions and vascular thrombi in the inspection of vascular anastomoses at the vivo in dogs. The cardioscope was French #5, time of the procedure to discover the existence and they used 160-cm-long catheters in French of any intimal flap for correction. This could sizes 7, 8, 9, and 14. For intracardiac study, possibly eliminate the need for angiography. In Texas Heart Institute Journal Angiography to Angioscopy 283 , ;._.. Fig. 5 Sumitomo Angioscope (Japan). Left: (1) Catheter, irrigation channel; (2) Connection to light source; (3) Eyepiece-camera connection; and (4) TV camera connection. Right: (1) Close-up of catheter tip (distal end). (By courtesy of Drs. Inoue and Kuwaki). Fig. 6 American Edwards Mini-Flex Angioscope (American Edwards Laboratories, Santa Ana, CA). peripheral angioplasty, angioscopy can be vessels. They reported seeing the following used before and after the procedure to reduce fine details not previously seen: (1) fatty occlusive phenomena. Thrombolytic therapy streaks, ulcerations and atheroma; (2) occlu- can be tailored to the individual patient by sive and nonocclusive thrombi; (3) damaged angioscopically visualizing the vessel's inti- saphenous vein valves; (4) lesions proximal mal layer before and after the treatment. and distal to anastomosis; and (5) suture lines In the forseeable future, angioscopic inspec- on the luminal surface.9 tion may provide a definitive diagnosis of Spears, Serur et al'4 have shown in studies certain conditions: the direct vision of a with experimental animals that hemato- problem area may enable plaques to be distin- porphyrin derivative is a useful marker for guished from clots. Forrester, Grundfest et a19 neoplasms because it accumulates and glows have studied intravascular images of the under ultraviolet light. The hematoporphyrin coronaries, bypass grafts, dialysis access derivative also accumulates in atheroma- fistulas, iliofemoral systems, and native tous plaques in experimental animals. This 284 Angiography to Angioscopy Vol. 13, No. 3, September1986 Flg. 7 Magnified view of rabbit abdominal aorta with whitish areas of atherosclerotic plaque. .. 'a. -.* . V.. 'I'm.- . 'I b.S .1' Flg. 8 Same as Figure 7 under ultraviolet light. Red areas are porphyrin-produced fluorescence. Fig. 9 Same aorta as in Figure 7 viewed through the Fig. 10 Same as Figure 9 under ultraviolet
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