Assessing Intermediate Lesions by IVUS_ How to and How Accurate

8/8/2019 Assessing Intermediate Lesions by IVUS_ How to and How Accurate

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Assessing Intermediate

Lesions by IVUS:How to and How Accurate

Andrea Abizaid Director, Intravascular Ultrasound

IVUS Workshop

TCT 2008 Washington, DC



Disclosure Statement of Financial InterestDisclosure Statement of Financial Interest

I, Andrea Abizaid DO NOT have a financialinterest/arrangement or affiliation with one or

more organizations that could be perceived as areal or apparent conflict of interest in thecontext of the subject of this presentation.



Definition and IncidenceDefinition and Incidence

Limitations: coronary angiographyLimitations: coronary angiography

IVUS : criteria validationIVUS : criteria validation IVUS: when to intervene?IVUS: when to intervene?

Clinical ImplicationsClinical Implications

Intermediate LesionsIntermediate Lesions



Definition and IncidenceDefinition and Incidence Limitations: coronary angiographyLimitations: coronary angiography

Best Choice? IVUS Vs. FFRBest Choice? IVUS Vs. FFR

IVUS : criteria validationIVUS : criteria validation

IVUS: when to intervene?IVUS: when to intervene?





Angiographic Significance of Coronary Lesions

1010 2020 3030 4040 5050 6060 7070 8080 9090 100100

ModerateModerate

IntermediateIntermediate

BorderlineBorderline

DiscreteDiscrete

non-ischemicnon-ischemicSevereSevere

ischemicischemic

Gould KL. Am J Cardiol, v. 33, p. 87-94, 1974

P e r c e n

t D i a m e

t e r

S t e n o s e s

Definição das Lesões Intermediárias



Correlation Among Frequency of Plaques, Percentage of Correlation Among Frequency of Plaques, Percentage of

Stenosis and Risk of ComplicationStenosis and Risk of Complication

Naghavi et al. Circulation 2003;108:1664Naghavi et al. Circulation 2003;108:1664

Intermediate Lesions: Incidence

Non-significant plaque (intermediate lesion) is 20x more frequent than severe lesionsNon-significant plaque (intermediate lesion) is 20x more frequent than severe lesions



Limitations: Coronary Angiography

“Lumenogram” Arterial Remodeling

AQAQ US

US

Diffuse Disease at the edges



7.47.4

0.60.6

00

11

22

33

44

55

66

77

88

Iskander S et al, JACC

% D

e a t h o r

M I

No ischemia Ischemia

The risk of death or MI in 5 years is 20 times higher for a ischem

lesion compared to a non-ischemic lesion !!!!!!

The Presence of Ischemia

N = 12.000 p

Same stenosis severby angiography …..



Minimal Lumen AreaMinimal Lumen Area

LesionLesion Distal ReferenceDistal ReferenceProximal ReferenceProximal Reference

Intermediate Lesions: How to Identify?Intermediate Lesions: How to Identify?

IVUS Criteria: Minimum Lumen Area (MLA)IVUS Criteria: Minimum Lumen Area (MLA)

C t Off V l V lid ti



Comparison Threshold

Abizaid, et al. (AJC 1998) CFR MLA < 4.0 mm2

Nishioka, et al. (JACC1999) SPECT MLA < 4.0 mm2

Briguori, et al. (AJC 2001) FFR MLA < 4.0 mm2

Caussin, et al. (AJC 2006) 64-CT MLA < 4.0 mm2

Cut-Off Value : Validation


http://slidepdf.com/reader/full/assessing-intermediate-lesions-by-ivus-how-to-and-how-accurate 13/40Brigouri . Am J Cardiol 2001;87:136-141

Diagnostic accuracy = 93%

120- Spect

424+ Spect

IVUS ALM

<4.0mm2

IVUS ALM

≥4.0mm2

Nishioka. JACC 1999;33:1870-8

Abizaid. Am J Cardiol 1998;82:423-428

Diagnostic accuracy = 91%

Caussin. Am J Cardiol 2006 98(7):871-87

IVUS 64-CTAngiography

4.6 ± 2.5mm2

4.5 ± 2.7mm2

5.0 ± 2.mm2

IVUS MLA

01

2

3

4

5

6

Diagnostic accuracy = 80%; sensitivity=87%

I t di t L i L ft M i



Jasti et al: Circ 110:2831, 2004

Intermediate Lesions Left Main:

Different Cut-Off Value

FFR

ALMIVUS

r = 0.74

p < 0.0001

0,5

0,6

0,7

0,8

0,9

1,0

1,1

1,2

0 2 4 6 8 10 12 14 16

6,0

0,75

Correlation: IVUS and FFR









Intermediate Lesions:



IVUS MLA (mm2

)

Death/AMI/TLR

2-32-3 3-43-4 4-54-5 ≥550

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

IVUS MLA (mm2

)

TLRDM

no-DM

2-32-3 3-43-4 4-54-5 ≥55

Abizaid et al. Circulation 1999;100:2 Abizaid et al. Circulation 1999;100:2

Intermediate Lesions:When to Intervene (or Not) ?

N = 300 p with intermediate lesions with 1 year FU

• MLA = only independentMLA = only independent

predictor of eventspredictor of events

• Independent predictorsIndependent predictors

of TLR: diabetes, MLAof TLR: diabetes, MLA

• When CSA > 4 mm²:When CSA > 4 mm²:

- event rate: 4%- event rate: 4%

- TLR: 2.8%- TLR: 2.8%



376 Patients with Intermediate Lesions by Angiography

MLAMLA ≥ 4,0 mm4,0 mm22

Medical TreatmentMedical TreatmentMLA < 4,0 mmMLA < 4,0 mm22

Stent ImplantationStent Implantation

Intermediate Lesions: Experience Institute Dante PazzanesIntermediate Lesions: Experience Institute Dante Pazzanese

Intravascular Ultrasound

Clinical Follow-up (death, AMI, TLR) 2 years

75 (42%)75 (42%) 98 (58%)98 (58%)

Abizaid AS Ar . Bras. Cardiol Dez

I t di t L i E i I tit t D t P



1,00 -

0,90 -

0,80 -

0,70 -

0,60 -

0,50 - - - - - - - -

0 3 6 9 12 15 18 21 24 - -

E v e n t - F r e

e S u r v i v a l

( D e a t h , A M I , T L R )

Medical Treatment

Time (months)

91%

83%

Stents

REESTENOSIS

Intermediate Lesions: Experience Institute Dante PazzanesIntermediate Lesions: Experience Institute Dante Pazzanese

Abizaid AS Ar . Bras. Cardiol Dez

Intermediate Lesions Left Main:



0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.41.8

2.22.6

3.03.4

3.84.2

4.65.0

5.45.8

DM and ≥1 untreated vessel (DS>50%)

DM and no untreated vessels

No DM and ≥1 untreated

vessel (DS>50%)

No DM and no untreated vessels

MACE

IVUS MLD (mm)

IVUS CriteriaIVUS Criteria

• MLD IVUS : 2,5 mmMLD IVUS : 2,5 mm

• MLA IVUS : 6,0 mmMLA IVUS : 6,0 mm2 2

Abizaid et al. J Am Coll Cardiol 1999;34:70 Abizaid et al. J Am Coll Cardiol 1999;34:70

N = 122 p with ambiguous lesions with 1 year FU

Independent Predictors of MACIndependent Predictors of MAC

• DiabetesDiabetes

• Untreated Vessels (DS>50%)Untreated Vessels (DS>50%)

Intermediate Lesions Left Main:When to Intervene (or Not) ?



Example 1

EEM



catheter Minimum lumen area

2.21mm2

EEM



E l 2



Example 2









Intermediate Lesions: Cost-effectiveness



Leesar et al. JACC 2003;41:111

Intermediate Lesions: Cost effectiveness

Invasive Strategy resulted in less total cumulative cos

Intermediate Lesions: DES for ALL ?Intermediate Lesions: DES for ALL ?



6.7% (167 of 2,478 pts)6.7% (167 of 2,478 pts)

93.3% (2,311 of 2,478 pts)93.3% (2,311 of 2,478 pts)

DS >50%DS >50%


SIRIUS, TAXUS IV, FUTURE I AND II (n=2.478 pts)SIRIUS, TAXUS IV, FUTURE I AND II (n=2.478 pts)

IntermediateIntermediateDS < 50%DS < 50%

Moses J. et al. J Am Coll Cardiol 47(11):21




00Stent thrombosis (%)

37.0% (20/54)1.8% (1/57)Angiographic restenosis (%)20.6*

17.0*

17.0*

3.7

0

1.6BMS (n=75)

1.8TVR (%)

2.9

0.6

1.8

0

0DES (n=92)

MACE (%)

TLR (%)

Non-Q wave MI (%)

Q wave MI (%)

Cardiac death (%)

*P value <*P value <


1-Year Clinical Follow-up1-Year Clinical Follow-up

Moses J. et al. J Am Coll Cardiol 47(11):21

PROSPECT TRIALPROSPECT TRIAL



Culprit artery, followed byCulprit artery, followed by

non-culprit arteriesnon-culprit arteries

Angiography (QCA of entire coronary tree)Angiography (QCA of entire coronary tree)

IVUSIVUS

Virtual histologyVirtual histology

PalpographyPalpography

Repeat imagingRepeat imaging

in pts with eventsin pts with events

3 – Vessel3 – Vessel

ImagingImagingpost-PCIpost-PCI

Proximal 6-8 Proximal 6-8

cm of eachcm of each

coronary coronary artery artery

MSCTMSCT

SubstudySubstudy

F/U: 1 mo, 6 mo,F/U: 1 mo, 6 mo,

1 yr, 2 yr,1 yr, 2 yr,±3-5 yrs±3-5 yrs

PROSPECT TRIALPROSPECT TRIAL

PROSPECT Imaging AnalysisPROSPECT Imaging Analysis



EEM area, mmEEM area, mm22 16.72 ± 6.36 MLD, mmMLD, mm 2.82 ± 0.64

Lumen area, mmLumen area, mm22 8.89 ± 4.12 Mean LD, mmMean LD, mm 3.26 ± 0.72

Plaque area, mmPlaque area, mm22 11.29 ± 4.1511.29 ± 4.15 MVD, mmMVD, mm 4.04 ± 0.884.04 ± 0.88

Plaque burden %Plaque burden % 47 ± 1147 ± 11 Mean VD, mmMean VD, mm 4.45 ± 0.874.45 ± 0.87

MLA, mmMLA, mm22 6.36 ± 3.75 Max VD, mmMax VD, mm 4.90 ± 1.024.90 ± 1.02

Remodeling indexRemodeling index 0.94 ± 0.160.94 ± 0.16 Lumen ecc.Lumen ecc. 0.93 ± 0.700.93 ± 0.70

IVUS of angiographic non-culprit lesionsIVUS of angiographic non-culprit lesions

PROSPECT Imaging AnalysisPROSPECT Imaging Analysis

PROSPECT Análise ImagensPROSPECT Análise Imagens



EEM area, mmEEM area, mm22 16.72 ± 6.36 MLD, mmMLD, mm 2.82 ± 0.64

Lumen area, mmLumen area, mm22 8.89 ± 4.12 Mean LD, mmMean LD, mm 3.26 ± 0.72

Plaque area, mmPlaque area, mm22 11.29 ± 4.1511.29 ± 4.15 MVD, mmMVD, mm 4.04 ± 0.884.04 ± 0.88

Plaque burden %Plaque burden % 47 ± 1147 ± 11 Mean VD, mmMean VD, mm 4.45 ± 0.874.45 ± 0.87

MLA, mmMLA, mm22 6.36 ± 3.75 Max VD, mmMax VD, mm 4.90 ± 1.024.90 ± 1.02

Remodeling indexRemodeling index 0.94 ± 0.160.94 ± 0.16 Lumen ecc.Lumen ecc. 0.93 ± 0.700.93 ± 0.70

IVUS of angiographic non-culprit lesionsIVUS of angiographic non-culprit lesions

210 (26.7%) angiographically210 (26.7%) angiographically

mild lesions had an MLA <4.0 mmmild lesions had an MLA <4.0 mm22

PROSPECT Análise ImagensPROSPECT Análise Imagens

The Mythe of The “Dangerous” Plaque



2.0 - 2.92.0 - 2.9(n=17)(n=17)

3.0 - 3.93.0 - 3.9(n=36)(n=36)

4.0 - 4.94.0 - 4.9(n =55)(n =55)

>> 55(n=193)(n=193)

Minimum Luminal CSA (mm²)Minimum Luminal CSA (mm²)

0

5

10

15

20

25

30

35

Any Cardiac Event at 13 months(%)Any Cardiac Event at 13 months(%)

Abizaid et al. Circulation, 1999 Abizaid et al. Circulation, 1999

IVUSIVUSN=300N=300

Alderman et al. J Am Coll Cardiol 1993 Alderman et al. J Am Coll Cardiol 1993

Coronary AngiographyCoronary Angiography2161 patients2161 patients

None 5-49% 50-80% 81-95%

% Occlusion at 5 Years

StenosisStenosis Severity at Baseline

0

5

10

15

20

25

Qiao J-H et al. JACC 1991Qiao J-H et al. JACC 1991

0

10

20

30

40

50

60

70

67-75% 76-80% 81-90% >90

Area Stenosis (%)Area Stenosis (%)

% of Total Number of Stenoses% of Total Number of Stenoses

PathologyPathologyN=82N=82

The Risk of Coronary Events Increases with the Severity of The Risk of Coronary Events Increases with the Severity of

Luminal Narrowing:Luminal Narrowing: prospective studies prospective studies

y g q

Intermediate Lesions: Conclusions



We recomend the use of IVUS criteria with a MLA coff of 4.0 mm2, that has been show a favorable prognos

in a long-term follow-up (4.0%).

At 1-year follow-up, the rates of MACE for the treatme

of intermediate lesions with DES are very low (2.9%).

te ed ate es o s Co c us o s

Intermediate Lesions: Conclusions



Stenting an intermediate lesion (non-ischemic, MLA

4.0 mm2) stenosis does not benefit patients with sta

chest pain, neither in prognostic nor symptoma

respect.

Stenting with DES an intermediate lesion should

reversed for high-risk lesions (vulnerable plaques) wh

we know that these lesion are potential candidates

instabilize and cause AMI or a fatal event.

Intermediate Lesion: IVUS Decision Maker



Intermediate Lesion: IVUS



Virtual Histology: Morphological Aspect of the Plaque



Thanks for

your Attention

Assessing Intermediate Lesions by IVUS_ How to and How Accurate

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