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Intravascular Ultrasound Imaging: Tips and tricks on lesion assessment.. Benefits of IVUS Mortality Stent Thrombosis TLR...  No good clinical data  “My patients do fine”  IVUS use

Intravascular Ultrasound Imaging:

Tips and tricks on lesion

assessment

Ramesh Daggubati, MD FACC FSCAI

Associate Chief of Cardiology Director of Interventional Cardiology Fellowship

Program Winthrop University Hospital

Mineola NY USA

Do all patients require IVUS?

2014 ESC Guidelines on myocardial revascularization

Post

Benefits of IVUS

Mortality

Stent Thrombosis

TLR

 No good clinical data

 “My patients do fine”

 IVUS use is associated with a high rate of

 Image interpretation – not understanding the image

and how to use the information

 Too much information – don’t know what is/is not

important

 Lack of consensus among experts

 Guidelines do not give Class I indication

 Inertia – especially among senior interventionalists

 Lack of education – especially for junior

interventionalists

• Poor image quality or inconsistency – often requires

expert interpretation and inhibits confidence in new

users

• Intimidation by experts

• OCT is better

Reasons for lack of IVUS use/adoption

• Ambivalence among stent companies

• Rapidly changing PCI landscape

• Procedural inefficiency

• Resistance from staff

• Past history and experience

• Poor catheter performance and recalls

• Chronic, nagging hardware problems

• Poor marketing strategies both domestically and internationally – no “magic bullet”; and every country is different

• No open interface

• Mature technology

• No new advances in IVUS despite major investments

ADAPT-DES - Current Cohort -

A ssessment of D ual A nti P latelet T herapy with D rug- E luting S tents

8582 pts prospectively enrolled

No clinical or anatomic exclusion criteria

11 sites in US and Germany

Clinical FU at 30 days, 1 year, 2 years

PCI with ≥1 non-investigational DES

Successful and uncomplicated

clinicaltrials.gov NCT00638794

Stone et al Lancet 2013; 382: 614–23

Relationship Between IVUS Use and MACE (Definite/Probable ST, Cardiac Death, MI) Within 2Yrs

4.9% 7.4%

IVUS Used

No IVUS Used

Witzenbichler et al Circulation 2014;129:463-470

Association of IVUS Use with MACE (Definite/Probable ST,

Favors IVUS Use Favors Angio Use

*Non-Left Main, Non-Bifurcation

Witzenbichler et al Circulation 2014;129:463-470

Mechanical vs Electronic Array

Step 1: Setting up the

console

Moment the case is decided for IVUS

imaging the console is switched on and the IVUS catheter will be prepped and connected to the PIM of the console and instantly image will start appearing

Tips & Tricks of IVUS?

Step 2: IVUS Run in coronary

Pre dilate if

necessary IC

NTG

Saline flush to avoid the artifacts

once we are comfortable with the image we can

do the pull back from distal to proximal either manually or auto matic pull back with the recording of the image

in the console

ivus and angio co registration also can be

done

Step 3: Basic Measurements & Artifacts

Step 4: Image interpretation pre PCI

 What should you expect, when you see

“haziness” after stenting?

 What kind of dissection do we need

another stent?

 How big is enough for final stent Area?

Take home Message 1

{

IVUS Assessment for Angiographic “Haziness”

Angiographical Haziness : 31/201 segments (15%)

Ziada et al Am J Cardiol 1997

48%

45%

7%

 What kind of malapposition do we need to dilate more?

 If you would fix malapposition, how?

 What do you expect, if you leave the

malapposition?

Take home Message 2

{

Wire

At follow-up, your wire may be outside of stent…

Intramural Hematoma

Cross sectional image

Hematoma

 If you see “new stenosis” in the reference site, consider

“intramural hematoma”

Take home Message 3

{

Angiographical Finding of Hematoma

Dissection Type C,D

No Abnormality

New Stenosis

Step 4: PCI Optimization Post PCI : Criteria for optimal

stent deployment

Complete stent apposition to the vessel wall

Adequate stent expansion (ie - > MSA of 6.0 mm2)

Full lesion coverage with minimal residual plaque burden

No stent related complications ( such as edge

dissection, stent fracture, thrombus, or others)

Guidelines for use of IVUS

No Class I Recommendation

Class II A : Mechanism of ISR, ST,

Assessment of indeterminate LMCA

PCI of Unprotected LMCA

Post stent Optimization

Post transplant allograft vasculopathy

Class III : Routine lesion assessment without PCI

Summary

Before reviewing IVUS images,

please imagine what you should

expect in relation to angiography and procedure

Expect and Learn!

 "Any intelligent fool can make things bigger, more complex, and more violent It takes a touch of genius and a lot of courage

to move in the opposite

direction."

Albert Einstein