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1、IVUS in Clinical Decision Makting,Image of IVUS and Angio,1,2,3,4,Question,Treat or No treat? Is it severe? Is there any plaque?Where and how to treat? A stent? Rotablator? Cuting Balloon? Which size?As a company guy, how can we introduce our products?,Agenda,Should I stent?Scientific evidence for I
2、VUSDetermining lesion significanceHow should I approach?Interventional device sizingImplications of vessel remodelingDid I do it right?ExpansionAppositionEdgesCoverage,How IVUS Can HelpA Practical Approach to IVUS-Guided Stenting,Imaging in Clinical Decision MakingLesion Assessment,Patient-related c
3、onsiderationsAcuitySymptomsLesion-related considerationsPlaque stability (rupture/thrombus)Ischemia,Reference Diameter 3.5mm,Reference Diameter 3.0-3.5mm,Reference Diameter 2.5-3.0mm,IVUS MLA (mm2),IVUS MLA (mm2),IVUS MLA (mm2),(%),MLA associated with ischemia is dependent on the vessel size that is
4、 being evaluated,(%),(%),Ben-Dor et al. Eurointervention. 2011 Jun;7(2): 225-33.,IVUS Determinants of LMCA FFR 0.75MLA and MLD give good estimations of significance in LM,Jasti et al. Circulation 2004;110:2831-6. The safety and efficacy of Boston Scientific stents has not been established in LM PCI.
5、,MLD,MLA,CSN,AS,%,0,20,40,60,80,100,1,2,3,4,5,2.8 mm,Sensitivity 93%,Specificity 98%,Sensitivity 90%,Specificity 88%,0,20,40,60,80,100,1,2,8,12,14,5.9 mm2,Sensitivity 93%,Specificity 94%,0,20,40,60,80,50%,Sensitivity 86%,Specificity 80%,67%,100,0,10,20,30,40,50,60,70,80,90,0,20,40,60,80,100,20,30,40
6、,50,60,70,80,90,4,6,10,%,%,%,IVUS Criteria for a Significant LMCA Stenosis,Suggested criteria for significant LMCA stenosisLumen MLA 6.0mm2 (or MLD 3.0mm) Correlates with a LMCA FFR0.75 Does not depend on finding a disease-free reference segmentLong term data (LITRO registry),De La Torre Hernandez e
7、t al. J Am Coll Cardiol 2011;58:351-8. Adapted from slide courtesy of Mintz, GS. The safety and efficacy of Boston Scientific stents has not been established in LM PCI.,Determining Lesion SignificanceLumen Area,Image courtesy Dr. Gary Mintz.Results from case studies are not predictive of results in
8、other cases. Results in other cases may vary.,Use lumen area to assess lesion significanceArea is measured in mm2,Lumen Area,Illustrations by Boston Scientific Corporation.1Abizaid A, et al. Circulation. 1999 Jul 20; 100(3):256-261.2Jasti V, et al. Circulation. 2004; 110:2831-2836.,Measure lumen are
9、a at the tightest pointGenerally, one measurement neededIn proximal epicardial vessels4.0 mm2 has been previously considered significant, but newer data suggests the vessel size matters in determining significance of lesions by IVUSIn left main vessel type6.0 mm2 is generally considered significant
10、in an average-sized patient with focal disease2,Determining Lesion SignificanceMinimum Lumen Area (MLA) IVUS,Case Example: RCA,Case Example: RCAIVUS,Case Example: RCAIVUS Measurements,Red = Proximal ReferenceYellow = LesionWhite = Distal Reference,Red = Proximal ReferenceYellow = LesionWhite = Dista
11、l Reference,Case Example: RCAIVUS Measurements,Case Example: RCAIVUS Measurements,Red = Proximal ReferenceYellow = LesionWhite = Distal Reference,Case Example: RCAPCI,Case Example: RCAPost-PCI,Lesion Significance Review,Proximal Reference,Lesion Site,Distal Reference,Lumen,% Lumen Area Stenosis,Mini
12、mum Lumen Area (MLA),Images courtesy Dr. Gary Mintz. Results from case studies are not predictive of results in other cases. Results in other cases may vary.,What information does the “proximal reference” and “lesion site” provide?,What information does the “lesion site” provide?,Lesion Significance
13、 Review,Left Main Reference Point: 14.67,Left Main MLA: 4.84,Images by Boston Scientific Corporation.Results from case studies are not predictive of results in other cases. Results in other cases may vary.,D2,MLA,Proximal reference,Lesion Length,Normal vesselInter membrance 0.5 mmDistal segment(norm
14、al-looking segment)Lesion or stent distal 5mmProximal segment(normal-looking segment)Lesion or stent proximal 5mm,Distal reference,Imaging in Clinical Decision MakingPre-intervention IVUS,Lesion size and lengthReference vessel sizeOverall plaque burdenUnusual lesion morphologyCalciumRemodelingAttenu
15、ated plaqueSpontaneous dissectionsPlanning adjunctive strategies,-2,-1,0,1,2,3,4,-2,-1,0,1,2,3,4,IVUS lumen-QCA (mm),IVUS midwall-QCA (mm),IVUS EEM-QCA (mm),-2,-1,0,1,2,3,4,Reference Measurements: QCA vs. IVUS,IVUS slightly larger than QCA (0-1mm),IVUS larger than QCA (0-2 mm),IVUS larger than QCA (
16、1-2mm),Mintz, G.S., 2005, Intracoronary Ultrasound, Taylor & Francis, Oxon, UK, 60-65 p.,Using IVUS diameter determination1,Measure lumen at reference point (within the image slice with the largest lumen and smallest plaque burden) Size interventional device accordingly,Interventional Device Sizing*
17、,Illustration by Boston Scientific Corporation.*IVUS measurements may be used by the treating physicians as a guide for device sizing determinations. 1Mintz G et al. American College of Cardiology Clinical Expert Consensus Document on Standards for Acquisition, measurement and Reporting of Intravasc
18、ular Ultrasound. J. Amer. College of Card. 2001:1478-1492.,B1 proximal,B2 distal,Largest reference lumen (prox or dist)MidwallMedia-to-media (typically discounted),Increasingly aggressive,Images courtesy of Gary Mintz, MD.Results from case studies are not predictive of results in other cases. Result
19、s in other cases may vary.,Using IVUS length determination,3.5 mm,3.0 mm,Interventional Device Sizing*,Illustration by Boston Scientific Corporation.*IVUS measurements may be used by the treating physicians as a guide for device sizing determinations.,Automatic pullback required to reconstruct LongV
20、iew Image InterpretationBookmark proximal reference point and distal reference pointMeasure length between two bookmarks,B1,B2,Proximal Reference,Lesion Site,Distal Reference,B1,B2,Results from case studies are not predictive of results in other cases. Results in other cases may vary. Images provide
21、d by G. Mintz.,IVUS Assessment for Intervention Sizing,IVUS Impact on Stent Length and Device Diameter,ADAPT-DES Lesion and Procedural Characteristics,Maehara, et. al. ADAPT-DES 2 year data presented at TCT 2013.,% Plaque BurdenComparison of the area of the plaque to the area of the lumen in a singl
22、e cross section of the vesselA large plaque burden can occur without flow limitations,1. Mintz G et al. J. Amer. College of Card. 2001:1478-1492,Images property of Boston Scientific, Corp.,Utilizing IVUSResearch Measurements,Normal Vessel,Minimal CAD,Moderate CAD,Severe CAD,Coronary remodeling hypot
23、hesis (Glagov),Expansion Overcome: Lumen Narrows,Compensatory ExpansionMaintains Consistent Lumen,Images property of Boston Scientific, Corp.,Image InterpretationDisease State Characteristics,Plaque Characterization and Lesion Preparation Options,CALCIFIC,FATTY,Fibro-fatty,FIBROTIC,Fibro-calcific,Ch
24、ange Lesion Compliance,Optimize Stent Placement,Avoid Slippage,Avoid Plaque Shift,POBA,Cutting Balloon Device,Rotational Atherectomy,Automatic vs. Manual Pullback,Automatic PullbackPotential AdvantagesControlled catheter withdrawal Focus on image vs. catheter manipulationLength & volume measurements
25、Uniform & reproducible image acquisitionPotential DisadvantagesEven at slow pullback speeds, skipping very focal lesionsNot enough attention may be paid to important regionsTransducer cannot “sit” in one area,Manual PullbackPotential AdvantagesConcentrate on area of interest by pausing at specific l
26、ocationPotential DisadvantagesSkipping significant pathology because catheter is moving too fastNo length or volume measurements,Case Review: LAD,Case Review: LAD,Yellow = LesionWhite = Distal ReferenceRed = Proximal Reference,Case Review: LAD,Yellow = LesionWhite = Distal ReferenceRed = Proximal Re
27、ference,Case Review: LAD,Yellow = LesionWhite = Distal ReferenceRed = Proximal Reference,Case Review: LADIVUS Measurements,Case Review: LADPCI,Postdilated with a 3.25 mm noncompliant balloon at high pressure,Case Review: LADPost-PCI,ExpansionStent expansion vs reference lumenAppositionContact betwee
28、n stent struts and vessel wallEdgesTissue integrity at stent edgeResidual plaque burdenCoverageStent coverage of entire intended lesion,Malapposition,Under-expansion,Optimal,Imaging in Clinical Decision MakingPost-intervention IVUS,ExpansionStent expansion vs reference lumen,Malapposition,Under-expa
29、nsion,Optimal,Imaging in Clinical Decision MakingPost-intervention IVUS,Illustration by Boston Scientific Corporation.1 Russo, Robert. Angiography Versus Intravascular Ultrasound-Directed Stent Placement (AVID).2 De Jaegere, P., et al. Intravascular ultrasound-guided optimized stent deployment. Euro
30、 Heart Jour (1998), 19, 1214-1223.,Stent Expansion Measurement with IVUS,%,Ensure apposition to vessel wall,Measure stentlumen at the tightest pointCompare measurement to distal reference lumen areaA stent MLD that is 90% of the distal reference lumen area is generally considered fully expanded1,2,O
31、ptimization of stent expansion,Based on stent lumen area, not plaque,From TeachIVUS.com; John Hodgson MD. Case study results not predictive of results in other cases. Results in other cases may vary.,In-stent Restenosis due to Under-expansion,Courtesy of Akiko Maehara, MD. Case study results not pre
32、dictive of results in other cases. Results in other cases may vary.,Optimal Stent Deployment,Adapted from Gary Mintz, MD. MSD = Minimum Stent Diameter RLD = Reference Lumen Diameter,N=256,Without post-dilatation, less than 30% of patients achieved optimal stent deployment,POSTIT Study,DES achieve an
33、 average of only 66% of predicted MSA (75% of MSD),Brodie B, et al. Cathet Cardiovasc Intervent 2003;59:184-192,de Ribamar Costa et al, Am Heart J 2007;153:297-303,Cypher n=133TAXUS n=67,IVUS Predictors of DES Early Thrombosis & Restenosis- Literature Base,Courtesy of Gary Mintz. Presented at TCT201
34、3.,ExpansionStent expansion vs reference lumenAppositionContact between stent struts and vessel wall,Malapposition,Under-expansion,Optimal,Imaging in Clinical Decision MakingPost-intervention IVUS,7.5mm2,Minimum Stent Area,Acute Stent Malapposition,Images courtesy of Akiko Maehara, MD.Results from c
35、ase studies are not predictive of results in other cases. Results in other cases may vary.,Clinical Impact of Early Incomplete Stent Apposition,MACE,Intimal Hyperplasia,Stent Thrombosis (def/prob),%,Steinberg et al, JACC Cardiovasc Intervent 2010;3:486-94. ISA= incomplete stent apposition,p=0.001,9-
36、month f/u of 1580 patients enrolled in IVUS substudies of TAXUS IV, V, VI, ATLAS, WH, LL, and DS trials,ExpansionStent expansion vs reference lumenAppositionContact between stent struts and vessel wallEdgesTissue integrity at stent edgeResidual plaque burden,Malapposition,Under-expansion,Optimal,Ima
37、ging in Clinical Decision MakingPost-intervention IVUS,Cheneau, Leborgne, Mintz, Kotani, et. al. Circulation 2003; 108: 43-47. Images courtesy of Gary Mintz, MD. Case study results are not predictive of results in other cases. Results in other cases may vary.,IVUS Image Interpretation Edge Dissectio
38、n,IVUS can help evaluate edge dissections, which may contribute to post-procedure complications,CASE EXAMPLE- NSTEMI,Wire in False Lumen,Side Branch,CASE EXAMPLE - NSTEMISpontaneous Dissection,CASE EXAMPLE - NSTEMIRe-Wire the RCA,CASE EXAMPLE - NSTEMIPost-PCI,ExpansionStent expansion vs reference lu
39、menAppositionContact between stent struts and vessel wallEdgesTissue integrity at stent edgeResidual plaque burdenCoverageStent coverage of entire intended lesion,Malapposition,Under-expansion,Optimal,Imaging in Clinical Decision MakingPost-intervention IVUS,S.T.L.L.R. TrialGeographic Miss During Im
40、plantation of a DES,1Costa MA, Angiolillo DJ, et al. ACC 2005.,1Costa MA, TCT 2006.,Effect of Geographic Miss on MI,1007 Angios Core Lab,All other OCT findings including the frequency of stent malapposition and the percentage of cross sections with malapposed struts were not significantly different
41、between the groups.,Habara et al. Circ Cardiovasc Interv 2012;5:193-201,Randomized comparison of IVUS vs OCT-guided stenting with blinded cross-over imaging (n=70),IVUS vs OCT-guided Stenting,CASE EXAMPLE - STEMI,Post Aspiration,CASE EXAMPLE RCA STEMI,3.0 x24mm DES,CASE EXAMPLE RCA STEMI,CASE EXAMPL
42、E RCA STEMIIVUS Post-PCI,Distal Reference,Proximal Reference,CASE EXAMPLE RCA STEMIIVUS Measurements,3.0 x24mm DES,CASE EXAMPLE RCA STEMIRCA Optimization,A,B,C,Illustration by Boston Scientific Corporation.,Review,MalappositionUnder-expansionOptimal,Match the letter with the correct description:,How IVUS Can Help,Thank you,
