Stiffness parameter β (stiffness β) is calculated from carotid diameter, distension and local carotid pressure as an index of blood pressure-independent blood vessel elasticity suitable for measuring distensibility of the carotid artery. This value is also measured in the ascending aorta and descending thoracic aorta. Among the indices for measuring distensibility of the carotid artery, stiffness β offers good intra- and inter-observer reproducibility, showing a coefficient of variation within 10%. Measurement values differ depending on whether the vascular pulsation is measured by the ultrasonic RF-tracking method or the M-mode method, and whether vessel diameter is measured as the media-adventitia (outer vessel wall) distance or lumen-intima (inner vessel wall) distance. Also, since slight differences in pulsation width are seen depending on the apparatus used, comparison of the apparatus and measurement method in a unified manner is desirable. Outer vessel wall distance of the common carotid artery correlates more closely with age than does inner wall vessel distance, so measuring the distance to the adventitia would be more appropriate to evaluate arterial stiffness. There is a strong correlation between cardio-ankle vascular index (CAVI) and stiffness β using transesophageal echography of the descending thoracic aorta. The correlating CAVI with stiffness β of the common carotid artery is not as large as that of the aorta. Most recent studies of stiffness β have focused on indicators of early changes in arteriosclerosis, such as stiffness β in the aorta of pre-hypertensive patients decreasing with improvements in exercise and lifestyle habits. Appropriate stiffness is necessary for blood vessels to maintain good blood flow to the periphery. However, arterial stiffness increases with age. Stiffness β, as an indicator of stiffness, is used to measure early changes in local arteriosclerosis, and abnormalities in carotid arteries represent a risk factor for ischemic cerebrovascular disease.

Flow-mediated vasodilation (FMD) is an important examination for confirming progression of vascular endothelial dysfunction and arteriosclerosis-related conditions. In addition, nitroglycerin-mediated vasodilation (NMD) is recommended to determine the function of vascular smooth muscle itself. The combination of FMD and NMD can help determine whether the vascular dysfunction is caused by vascular endothelial dysfunction or vascular smooth muscle dysfunction. %FMD and %NMD were calculated as the percentage changes in peak diameter, from the resting baseline diameter, in each measurement. A previous report showed that %FMD and %NMD can be predictors of cardiovascular events. In addition, %FMD can be a predictor of cardiovascular events in coronary artery disease, myocardial infarction, chronic heart failure, hypertension, and endothelial dysfunction in carotid arteriosclerosis.

A new evaluation method of blood flow waveforms for lower limb arterial stenosis is proposed. The below-knee arteries are narrow and hard to see, making ultrasound examinations of them difficult. Transit time of vessel flow (TVF), an index for evaluating the perfusion state of the below-knee arteries, has an advantage in that it can be calculated from the blood flow waveform, which is usually measured during a standard examination. It is possible to recalculate it from past stored data. Since the calculation of TVF is affected by physiological fluctuation, it is important to acquire data in the stationary state at the time of measurement. Because it is a diagnostic method that uses precise time measurement, the ultrasound unit is set to the maximum sweep speed that can display three waveforms. The normal reference value of TVF is 30 ms or less, and it can be used to evaluate arteries that do not require treatment when it is performed as a screening test. For calculation of TVF, electrocardiogram recording is essential, and blood flow waveforms of three beats or more in the popliteal artery and the ankle artery are necessary. For follow-up study after treatment, it is used for evaluation in conjunction with image diagnosis as a method for performing hemodynamic evaluation. Various applications have also been tried with respect to the R-P time measured for the calculation of TVF. Although studies on these indices have been limited to date, further research on TVF as a method for analyzing vascular function and hemodynamics is expected.

Vascular echoes are becoming common due to the significant advances in ultrasound diagnostic equipment. However, there are cases in which they cannot be sufficiently evaluated by routine inspection methods. There are ways to use changes in blood flow dynamics using attitude transformation, compression, and exercise, etc., but it is necessary to use them properly according to the purpose. Needless to say, safety is the top priority.

A man in his 60s complained of lower leg edema and exertional dyspnea on Y-8 months, 20XX. He visited a former doctor on Y-4 months, 20XX because of worsening symptoms. He was diagnosed with heart failure and treated with medications. He was referred to our Department of Cardiology on Y month, 20XX because his symptoms persisted. He was scheduled to undergo examinations on an outpatient basis, but he complained of dyspnea, abdominal pain, and diarrhea and underwent emergency hospitalization. Although it was difficult to determine the cause of gastrointestinal symptoms in the emergency department, bradycardia and hypotension persisted. He was admitted and underwent temporary pacemaker implantation. A permanent pacemaker was implanted for sick sinus syndrome on the 4th hospital day. On the 6th hospital day, echocardiography showed a left ventricular ejection fraction of 47%, diastolic dysfunction, bi-ventricular hypertrophy, epicardial brightness and thickening, as well as apical sparing on longitudinal strain. Cardiac amyloidosis was suspected based on these findings. Upper and lower gastrointestinal endoscopy revealed erosion in the stomach and large intestine. Biopsy showed amyloid deposits, and immunostaining revealed the ALκ type. Based on these findings, systemic AL amyloidosis was diagnosed. Although medications were started, the symptoms of heart failure persisted, and cardiac arrest and death occurred on the 48th hospital day. An autopsy was performed to evaluate the pathology of the underlying diseases, and amyloid was found to be deposited in multiple organs including the heart, gastrointestinal tract, lungs, and kidneys. It was diffusely deposited in myocardial tissue and unevenly deposited in the epicardium in a way that penetrated adipose tissue. Amyloid deposits in myocardial tissue are common, but cases with amyloid deposits found in the epicardium are rare, and given that the possibility of this was suggested by echocardiography before death, we report this case with a review of the literature.

A man in his 40s was admitted to our hospital for exertional dyspnea. Echocardiography revealed left ventricular dilatation and hypertrophy with reduced left ventricular systolic and diastolic functions indicating heart failure. He had abused anabolic androgenic steroids for 6 years for muscle training. Blood examination showed increased serum concentration of testosterone. Therefore, he was diagnosed with anabolic androgenic steroid-induced heart failure. Two months after discontinuation of anabolic androgenic steroids, left ventricular systolic and diastolic functions improved and his symptoms diminished. Here we report a case of anabolic androgenic steroid-induced cardiomyopathy precisely assessed using echocardiography.

Hepatic intracystic hemorrhage is a rare complication of congenital cysts. The imaging findings are often nonspecific and complicated, so it is difficult to differentiate from hepatic cystic tumors. Hemorrhagic hepatic cysts show an internal heterogeneous echo level, intracystic mass-like structure, and septum-like structure on ultrasonography (US), but they are difficult to detect on computed tomography (CT) because the clot has a CT value equivalent to that of the fluid in the cyst, so it is characterized by a discrepancy between the US and CT findings. On the other hand, hepatic cystic tumors have mural nodules that can also be recognized on CT, and various contrast studies show contrast enhancement of mural nodules and septa. We herein report a case with a hemorrhagic hepatic cyst that was suspected at first glance to be a hepatic cystic tumor because CT showed an enhanced mural nodule. A comprehensive evaluation with various modalities is necessary to differentiate cystic lesions of the liver, and contrast-enhanced US (CEUS) in particular may be effective. In the post-vascular phase of CEUS, hepatic cystic tumors were reported to have a contrast effect, which hepatic hematomas due to intracystic hemorrhage were reported not to have, suggesting that this may be a key finding for differentiation. Furthermore, we were able to retrospectively examine the process from a simple cyst by investigating the past imaging studies. It was an interesting change in imaging findings as it showed the natural history from a simple cyst to a hemorrhagic cyst.