A technique for type 4a coronary bifurcation lesions: initial results and 6-month clinical evaluation

In routine practice, lesions in coronary bifurcations are frequent. This relatively high frequency may be underestimated due to the presence of false bifurcation lesions (lesions of the main branch without significant lesion of the sidebranch), which may become true bifurcation lesions after stenting due to axial plaque redistribution. In this report, we describe our initial experience with a new technique for the treatment of type 4a bifurcation lesions (main branch ostial lesion stenosis of the main vessel immediately after the bifurcation, not involving the sidebranch) using a new technique for primary stenting of the main vessel with simultaneous kissing balloon of the sidebranch in an effort to avoid the snowplough effect.     

Ultrasound-guided percutaneous biopsy for diagnosis of gastrointestinal lesions

Background and aims

Endoscopical examination is not always sufficient for the diagnosis of gastrointestinal masses. This study assessed the diagnostic accuracy and safety of ultrasound-guided percutaneous biopsy of gastrointestinal lesions.

Methods

This retrospective study evaluated 114 patients who underwent ultrasound-guided biopsy of gastrointestinal masses with a 18G needle. Thirty-two of these patients underwent a 22G fine-needle biopsy for cytology. Histology was compared with a composite standard of reference for diagnosis (i.e. post-surgery histological evaluation in 73 cases and computed tomography or magnetic resonance scan findings, together with a compatible clinical follow-up for at least 24 months, in the remaining 41 cases). Safety was assessed by recording side effects for up to 4 h after the procedure.

Results

Of the 114 lesions evaluated, 112 were malignant (98.2%) and 2 benign (1.8%). Specimens were adequate for histology in all but one case. Specimens were obtained from the stomach (n = 38; 33.3%), small bowel (n = 36; 31.6%) and colon (n = 40; 35.1%). Diagnosis was correct in 113/114 cases (99.1%). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 99.1%, 100%, 100%, 66%, and 99%, respectively. One of the 114 patients (0.9%) bled from a gastric GIST.

Conclusions

Ultrasound-guided percutaneous biopsy of gastrointestinal lesions is a valid alternative when diagnosis of a gastrointestinal mass cannot be obtained with an endoscopical procedure.     

"Side balloon stenting": a novel technique for bifurcation lesions

We describe a new technique to treat stenoses of coronary bifurcations. The aim of this technique, called "side balloon stenting," is to treat the bifurcation lesions with the kissing balloon technique, implanting one or more stents without removing the guidewires which remain in place during the whole procedure, avoiding potential problems of access to the vessels jailed by stent struts. In addition, implanting the stent using the kissing balloon technique would prevent the "snow-plow" phenomenon (plaque shifting) in the side branch. The "side balloon stenting" technique was applied in 29 cases at various levels of coronary artery segments involving bifurcations (Table 1). The technical success rate of the side balloon stenting was 90% (25 procedures). The elective placement of one stent in the main vessel was done in 20/25 procedures (80%), and in only 5/25 (20%), it was also necessary to insert a second one in the side branch (due to suboptimal results), using the "culotte" technique in two and the T-technique in the other three. We were unable to advance the system to the right position in 4 patients (13%): in 2 due to twisting of the guidewires and in the other due to vessel tortuosity and insufficient backup of the system (guiding catheter and guidewires). In these four last cases, the delivery system was retrieved and a stent was successfully implanted in the right position in the main branch. Angiographic success (residual stenoses < 30% and TIMI 3 flow in both branches) was obtained in 100% of the cases. The post-intervention period was uneventful. These preliminary results show that the side balloon stenting technique is both feasible and safe in th treatment of coronary bifurcations with a satisfactory rate of procedural success and often (82%) positioning only one stent in the parent vessel, thus avoiding stenting the side branch. It will be necessary, however, to assess, based mainly on restenosis rate, whether these promising immediate results will persist in the long run.     

Endoscopic ultrasound-guided biopsy for the diagnosis of focal lesions of the spleen

OBJECTIVES: Needle biopsy of splenic lesions using computed tomography (CT) or ultrasound (US) is difficult if the size of the lesion is small. It may be dangerous if the lesion is adjacent to the splenic hilum or located peripherally. We used endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to elucidate the tissue diagnosis of splenic abnormalities. METHODS: EUS-FNA was performed in 12 patients when US- or CT-guided biopsy was inconclusive (n = 5), was not attempted because of small tumor size (0.9-1.4 cm; N = 4), or was considered dangerous (n = 3). A linear echo-endoscope and 22-gauge needles were used for cytology and bacteriology. RESULTS: The age of the patients was 19-68 yr (median 32 yr). Seven patients were male and five female. The size of the lesions was 0.8-4.2 cm (median 1.4 cm). Cytology was inadequate in one patient. Bacteriology was positive for Staphylococcus aureus and Serratia in one patient each, and cultures were positive for Mycobacterium tuberculosis in two patients. A positive diagnosis was made in 10 of 12 patients (83%). Final diagnoses were tuberculosis in two patients, Hodgkin's disease in two, sarcoidosis in two, abscesses in two, metastatic colon cancer in one, and infarction in one. Suspected recurrence of non-Hodgkin's lymphoma was not confirmed in one case. One patient experienced pain after puncture, but no hematoma was demonstrated on subsequent US examination. CONCLUSIONS: EUS-FNA cytodiagnosis in patients with unknown splenic lesions seems feasible, even in very small foci, when CT- or US-guided biopsy fails. Additional material for bacteriology may show benign treatable diseases such as abscesses or tuberculosis.     

Jumbo biopsy is useful for the diagnosis of colonic prolapsing mucosal polyps with diverticulosis

We report here a case of multiple prolapsing mucosal polyps with diverticulosis in the sigmoid colon. A 52-yearold man was admitted to our hospital because of bloody diarrhea. Colonoscopy and barium enema showed multiple diverticula, markedly thickened mucosal folds and polypoid lesions with mucus on the top of them in the sigmoid colon. Endoscopic ultrasonography showed thickening of the mucosal and submucosal layers. Several endoscopic biopsy specimens were taken from the polypoid lesions. Histological examination revealed only chronic inflammatory cell infiltration. In order to obtain a definite diagnosis, we performed endoscopic jumbo biopsy for the polypoid lesions after obtaining informed consent. Histological examination revealed marked lymphocyte infiltration, hemosiderin deposits and fibromuscular obliteration in the lamina propria, features similar to those of mucosal prolapsing syndrome. After anti-diarrhetic treatment, clinical findings were improved. Thus, jumbo biopsy is useful for diagnosis and treatment of prolapsing mucosal polyps.     

Echo guided percutaneous needle biopsy for diagnosis of thoracic lesions

Echo guided percutaneous needle biopsy was performed in 32 cases with thoracic lesions. A definitive diagnosis was made histopathologically in 11 (100%) of 11 malignancies, 4 (67%) of 6 benign tumors and 7 (47%) of 15 inflammatory lesions. Furthermore, using cytological specimens, definitive diagnosis was successfully made in 10 (91%) of 11 malignancies and 1 (17%) of 6 benign tumors. Such highly accurate diagnostic rates were due to 1) the accurate puncture of the lesions under real time sonographic guidance, 2) repeated biopsy in case in which sample was inadequate for cytological diagnosis, and 3) aggressive application of needle biopsy for histopathological diagnosis. Following this procedure, three patients suffered from a minor pneumothorax. To prevent pneumothorax, great care is necessary, especially in high risk cases, such as with a pneumatic pattern and thin lesion. One patient suffered from minor hemoptysis but recovered without any medication. No complications were noticed in cases of extrapulmonary lesions. We conclude that echo guided percutaneous needle biopsy is not only a complementary method for biopsy of mediastinal, peripheral pulmonary and chest wall lesions, but due to its simplicity and convenience, it should be a routine method for biopsy of thoracic lesions.     

Light-induced autofluorescence spectroscopy for tissue diagnosis of GI lesions

BACKGROUND: The present article describes light-induced autofluorescence spectroscopy using violet-blue excitation light for endoscopic in vivo measurements in the upper GI tract. The spectra of normal mucosa, cancer, and dysplastic lesions of the esophagus and stomach are presented and compared. METHODS: Over 120 spectra were obtained in 11 patients of normal mucosa and malignant lesions in the esophagus and stomach during routine endoscopy. A special light source capable of delivering either white or violet-blue light was used for the excitation of tissue auto-fluorescence via the endoscope. Endogenous fluorescence spectra emitted by the tissue were collected with a fiberoptic probe and analyzed with a spectrograph. After spectrographic measurements biopsies were taken for definitive classification of histopathologic status. RESULTS: As compared with normal mucosa, (pre) cancerous lesions were associated with special changes in the emitted fluorescence spectra.The spectrographic records were influenced by the intensity of the illumination and on the position of the probe (distance and angle). CONCLUSION: Fluorescence spectroscopy with a slightly modified conventional light source might be useful for the endoscopic detection of dysplasia and early-stage carcinoma in the upper GI tract. Prospective trials need to determine the sensitivity and specificity of this new method.     

Endobronchial ultrasound-driven biopsy in the diagnosis of peripheral lung lesions

STUDY OBJECTIVES: The aim of our study was to compare the diagnostic yield of two bronchoscopic procedures: endobronchial ultrasound-driven transbronchial biopsy (EBUS-TBB) and transbronchial biopsy (TBB) in peripheral pulmonary lesions. DESIGN: Prospective, randomized, blinded study. SETTING: University Hospital of Rome, Italy. PATIENTS AND METHODS: We examined 799 patients with peripheral lung lesions using bronchoscopy. Patients who could undergo a complete clinical diagnostic follow-up (n = 293) were enrolled in the study and randomly assigned to EBUS-TBB or TBB. We performed these two procedures on 221 patients (97 EBUS-TBB and 124 TBB). Patients in whom biopsies were not diagnostic underwent more invasive procedures to obtain a final diagnosis, and a complete follow-up was possible in 206 patients (87 EBUS-TBB and 119 TBB). RESULTS: Lung cancer was diagnosed in 61 patients in the EBUS-TBB group and in 83 patients in the TBB group. Pulmonary diseases other than cancer were diagnosed in 26 patients and 36 patients, respectively. For patients with lung cancer, sensitivity was 0.79 in the EBUS group and 0.55 in the TBB group (p = 0.004), and accuracy was 0.85 and 0.69, respectively (p = 0.007). The analysis of a subset of patients with lesions > 3 cm showed no significant difference in diagnostic ability between the two procedures. In lesions < 3 cm, we found a considerable decline in TBB sensitivity and accuracy (0.31 and 0.50) while EBUS-TBB maintained their diagnostic yield (0.75 and 0.83) [p = 0.0002 and p = 0.001, respectively]. A similar difference was observed when we compared the sensitivity of the two procedures in lesions < 2 cm (0.23 vs 0.71, p < 0.001). CONCLUSIONS: EBUS-TBB can be an important option in the early diagnosis of peripheral lung cancer, especially in small-sized lesions and in patients who are not eligible for surgery.     

Hot biopsy forceps in the diagnosis of endobronchial lesions.

Electrocoagulation bronchoscopy biopsy forceps may prevent bleeding, but could also impair the quality of the specimens obtained. Patients with endobronchial lesions during bronchoscopy underwent six endobronchial biopsies each with a hot biopsy forceps, alternating between with electrocoagulation ("hot") and without ("cold"). Bleeding was quantified on a scale of 1-4, with 1 being no bleeding. The generator was set on "soft coagulation" mode, with power settings of 40, 60, 80 and 100 W for each group of 10 patients in a sequential fashion. Clinical pathology results were recorded before samples were reviewed by a second, blinded, pulmonary pathologist. A total of 39 patients with 40 endobronchial lesions had six biopsies performed (one patient had only four samples taken), giving a total of 238 biopsy samples. Concordance between hot and cold samples was 92.5% for the clinical pathologist and 87% for the blinded pathologist. Paired analysis suggested lower average bleeding score with the use of hot forceps. Overall bleeding rates for cold and hot biopsies, respectively, were as follows: grade 1: 30.3 and 41.2%; grade 2: 62.2 and 49.6%; grade 3: 7.6 and 9.2%; and grade 4: 0 and 0%. In conclusion, the use of hot biopsy forceps for endobronchial biopsy does not appear to have a negative impact on the pathological samples. Hot biopsy forceps showed a statistically significant reduction in bleeding score, which is unlikely to be of clinical significance.     

Modified crush technique with double kissing balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.     

Fine-needle aspiration biopsy of bowel lesions under ultrasound guidance: indications and results

Twenty-four patients with bowel lesions that could be imaged on a sonogram underwent ultrasound-guided fine-needle aspiration biopsy. Indications for biopsy included: poor condition of the patient precluding the use of barium studies and/or endoscopy (9 cases) or hindering technically adequate examinations (3); nonspecific radiographic images (6); inability to obtain an adequate biopsy sample during endoscopy (6). The results of biopsy were correct in the 18 cases proven by surgery or autopsy; in the remaining 6 patients, histologic results were considered conclusive, and were later confirmed by clinical, radiographic, and ultrasound follow-up. Fine-needle aspiration biopsy may be considered a simple, rapid, and accurate diagnostic procedure when an alternative approach to the study of gastrointestinal tract lesions is needed.