Karl Suenishi, left, and Dr. John Cogan monitor the vital signs of patient
Manabu Ida at the start of an intravascular ultrasound procedure to help
diagnose the condition of the patient's heart.
Photo by George F. Lee, Star-Bulletin

"What we're seeing on the TV screen is the actual interior of the blood vessels," Dr. John J. Cogan explained as he examined the elderly man for arterial disease.

A failed treadmill test recently drew Ida, owner and operator of a potato chip company in Kona, to The Queen's Medical Center for the procedure.

Cogan, chief of the Department of Cardiovascular Diseases, used a new technique - intravascular ultrasound, or IVUS - to get a better look at blockages in Ida's arteries.

The procedure is similar to the use of sonar in pregnancies.

Cogan was trying to determine if he could remove Ida's blockages with angioplasty or if heart surgery was needed.

Ida was awake just enough to tell the medical team if he was having any problems.

A probe mounted on a miniature ultrasound transducer - a pinging device - was slipped into the femoral artery in the top of Ida's right leg. A guide wire about .014 of an inch wide was passed to the bad blood vessels.

Sound waves pinged images of the blood vessels to the video screen.

Describing the wire as a "railroad track," Cogan said the probe can be steered anywhere. Devices such as balloons used in angioplasty, metal braces or IVUS go back and forth over the wire.

"It's your lifeline into the blood vessel," he said.

The IVUS pictures confirmed the results of an angiogram: Ida's blood vessels had deteriorated too much to be treated without bypass surgery, Cogan said.

He said intravascular ultrasound has been in general use about 18 months. The Queen's team has done more than 65 procedures since getting its equipment a few months ago.

Several St. Francis Medical Center cardiologists - primarily Dr. Danelo Canete, medical director of the heart center - also have begun using the technique.

After the procedure, Ida's family told him to stay home from the potato chip shop and work in his garden.

"But he said, 'Oh, I'm bored.' So he walks to the shop, back and forth," said his wife, Mae.

Cogan said Dr. Michael Dang had removed debris blocking blood vessels in Ida's neck after a small stroke 3-1/2 years before.

Ida had no further trouble until flunking a treadmill test during a recent visit to his Kona doctor, Stephen Denzer, Cogan said. Following up on Ida during a Kona trip, Dang referred him to Queen's for tests.

Cogan said he was investigating blockages in Ida's legs caused by lack of circulation and blockages in his heart.

"He is diabetic. That is one of the risk factors. He is getting arterial obstructions all over the body..."

This probe is about to be inserted into Manabu Ida's heart
to allow a better look at his arteries.
By George F. Lee, Star-Bulletin

"When we inject dye and record it on film, we are not looking at the artery but where the blood flow goes through the artery. Ultrasound looks at the artery itself."

In the first quarter this year, Queen's had more than 156 angioplasties, of which 62 were stent procedures. Stents are miniature metal braces - so small they can't be seen in an angiogram - used to improve the channel that blood flows through.

Lasers are another option to burn away plaque but haven't proved beneficial in treating arterial blockages, Cogan said.

He cited three key situations in which intravascular ultrasound is an advantage:

When it isn't clear from an angiogram how bad a blockage is.

To make sure when a blood vessel is opened with a balloon in angioplasty that it's sufficient to keep the artery open.

To size and deploy stents, which must be precisely implanted to prevent clots from forming on them, Cogan said.

His group had done about a dozen procedures until a second cardiac catheterization lab recently was opened, he said.

"It's really a technology that's trying to find its niche," Canete said. "Everybody now feels, since it's so expensive, deployment of stents works best."

A disposable IVUS probe costs about $800 but is a "tremendous advance" coupled with stents, Cogan said.

"By using ultrasound to assist in deployment of stents, we have impacted significantly in quality and cost of medical care," he said.

Before IVUS, a stent patient was placed on a blood thinner in the hospital for up to five days, then discharged and kept on blood thinner for 30 days, he said.

With ultrasound, he said, patients can be discharged in 24 to 48 hours, cutting the average hospital stay by two to three days and returning the patient to a normal lifestyle.

"Every day we save in the hospital," he said, "saves the health care system, the patient and insurance company - all of us - about $1,000 a day."

Angioplasty: The first nonsurgical method of treating blockages in blood vessels. A balloon is inserted and inflated in the vessels to squeeze plaque on the wall and open narrowing arteries. About 400,000 angioplasties are performed annually in the United States.

Angiography: A method of taking X-ray pictures of arteries. A plastic tube, or catheter, is inserted in the artery and dye injected in the blood stream to identify blockages. The dye test is known as an angiogram, arteriogram or cardiac catheterization.

Stent: A miniature metal brace is placed in a blockage to keep an artery open when a balloon isn't sufficient or a blockage has returned after angioplasty.

Rotablation: A diamond-tipped rotoblader is used to core a calcified blood vessel to create an adequate path for blood flow.