Author + information
- Received September 10, 2015
- Accepted September 24, 2015
- Published online January 11, 2016.
- ∗Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina
- †Division of Interventional Radiology, University of North Carolina, Chapel Hill, North Carolina
- ↵∗Reprint requests and correspondence:
Dr. George A. Stouffer, Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina 27599-7075.
A 59-year-old man with hypertension and hyperlipidemia presented with symptoms of chest pain, claudication, and erectile dysfunction. He reported exertional chest discomfort occurring with less than a flight of stairs and bilateral lower extremity pain after walking 40 feet. Claudication persisted despite treatment with cilostazol. Ankle-brachial indices and distal pulses were reduced in both legs (right and left ankle-brachial indices = 0.7 and 0.8, respectively).
Coronary angiography with fractionated flow reserve evaluation showed hemodynamically significant lesions in the mid-right coronary artery and mid-left anterior descending coronary artery. These lesions were treated with percutaneous coronary intervention.
There was severe atherosclerotic disease of the distal aorta with a significant infrarenal stenosis (Figures 1A and 1B) with eccentric plaque apparent on intravascular ultrasound (IVUS) (Figure 1C). The infrarenal stenosis was treated with balloon angioplasty and a 14 mm × 40 mm endovascular self-expanding Zilver stent (COOK, Bloomington, Indiana) (Figure 1D). There was a 10 to 20 mm Hg pressure drop across the stenosis at rest that increased to 50 to 60 mm Hg following the administration of 400 μg of nitroglycerin into the distal aorta (Figure 1E). Following stent placement, there was a minimal pressure gradient at rest or with administration of nitroglycerin (Figure 1E).
Provocative intra-arterial nitroglycerin was used to increase flow in the distal aorta and simulate the hemodynamic changes that occur during exercise. The pressure drop across the lesion increased significantly under conditions of increased flow, which explains his symptoms of claudication and erectile dysfunction. IVUS allowed accurate assessment of the length and cross-section diameter of the stenosis and helped optimize stent sizing. In addition, it excluded an underlying aneurysm.
Vasodilation challenge with hemodynamic monitoring and IVUS are useful measures to validate clinical symptomatology in atherosclerotic disease conditions and allow optimum endovascular management.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 10, 2015.
- Accepted September 24, 2015.
- American College of Cardiology Foundation