IVUS Image Interpretation and Analysis

Dr Arindam PandeConsultant Cardiologist,

Academic Coordinator: DNB Cardiology and PGDCC Training

Apollo Gleneagles Hospital, Kolkata

“IVUS ImageInterpretation and Analysis”

© 2006 Boston Scientific Corporation or its affiliates. All rights reserved. 2

Introduction to Intravascular Ultrasound – IVUS

Image by Boston Scientific Corporation

© 2006 Boston Scientific Corporation or its affiliates. All rights reserved.


Comparing Angiography and IVUS

In angiography, angle of view determines what we see.


Clinical Utility for IVUS

• Stenting of smaller vessels– Vessels ≤ 3mm

• Intra-stent restenosis– Visualize the stent

• Difficult to assess lesions– More sensitive plaque detection

1. Moussa C, et al J Am Coll Cardiol 1997; 29 (Suppl A) 60A


Image Interpretation


Lower Density Plaques

Eccentric fibrous plaque Concentric fibro-fatty plaque


Lower Density Plaques

Eccentric fibrous plaque Concentric fibro-fatty plaque

IVUScatheter

Eccentricfibrousplaque

Lumen

IVUScatheter

Concentricfibro-fattyplaque

LumenMedia

Guidewireartifact


Mixed Plaque

Mixed eccentric plaque(fibrous, fibro-fatty, and calcified)

Thin concentric fibrous plaquemixed with calcium


Mixed Plaque

Mixed eccentric plaque(fibrous, fibro-fatty, and calcified)

Thin concentric fibrous plaquemixed with calcium

IVUScatheter

IVUScatheter

Fibro-fattyplaque Media

Guidewireartifact

Calcified plaqueCalcifiedplaque

Fibrousplaque

Fibrousplaque

Guidewireartifact

Fibrousplaque


Calcified Plaque

90° arc (one quadrant)of deep calcium

Mixed deep and superficialcalcified plaque


Calcified Plaque

90° arc (one quadrant)of deep calcium

Mixed deep and superficialcalcified plaque

IVUScatheter

Calcifiedplaque

Fibrousplaque

Fibrousplaque

Guidewire artifact

Fibrousplaque

Shadowing (IVUS signaldoes not pass throughcalcified plaque)

Fibrousplaque

Superficialcalcium

IVUScatheter

Superficialcalcium

Reverberations Deep calcium

Shadowing


Calcified Plaque (continued)

180° arc of eccentric superficialcalcified plaque

270° arc of superficialcalcified plaque


Calcified Plaque (continued)

180° arc of eccentric superficialcalcified plaque

270° arc of superficialcalcified plaque

IVUS catheter

Calcified plaqueReverberations

IVUS catheter

Lumen

Calcified plaque


Stents

Fully apposed stent Incompletely apposed stent


Stents

Fully apposedstent

Incompletely apposedstent

IVUScatheter

IVUScatheter

Apposed

Concentric mixed fibrousand fibro-fatty plaque

Stentstruts

Stentstruts

Vessel wall

UnopposedUnopposed

Apposed


Stents (continued)

Stent deployment in a heavily calcified vessel


Stents (continued)

Stent deployment in a heavily calcified vessel

IVUS catheter

Stent struts

Stent struts

Calcified plaque

Guidewire artifactStent struts


Dissections

Fibrous plaque dissectionextending into the intima

Deep fibro-fatty plaque dissectionextending into the media


Dissections

Fibrous plaque dissectionextending into the intima

Deep fibro-fatty plaque dissectionextending into the media

Fibrousplaque Fibro-fatty

plaque

Lumen

IVUScatheter

IVUScatheter

Fibro-fattyplaque

Fibro-fattyplaque

Dissection arm Dissectionarm

Fibrousplaque

Media


Dissections (continued)

Horseshoe dissection of fibrousplaque extending into the media

Horseshoe dissection ofcalcified plaque


Dissections (continued)

Horseshoe dissection of fibrousplaque extending into the media

Horseshoe dissection ofcalcified plaque

IVUScatheter

Dissectionarm

IVUScatheter

Calcifiedplaque Superficial

calcium

Bloodspeckle

Dissectionarm: calcifiedplaque


Measurement and Analysis

Maximum plaquethickness

Lumen borderMaximum lumendiameter

Minimum lumendiameter

Minimum plaquethickness

Media-adventitia(MA) border

Measurementsrequiredfor analysisof IVUSimages

Lumen CSA

Plaque CSA

Maximum plaque thicknessMinimum plaque thicknessEccentricity =

Plaque CSA* = MA CSA – Lumen CSA

Plaque CSAMA CSA% Plaque area =

Reference lumen CSA –Lesion lumen CSAReference lumen CSA

% Area stenosis =

* Plaque CSA includes variable amounts of smooth muscle from media


Measurement and Analysis


Calculating – Area

D(mm) = 0.0A1 = 5.9mm2


Lumen Diameter Measurements

2.5

3.0


IVUS-Guided Stenting• Measurement and Analysis

Lumen Diameters vs. Cross Sectional Areas (CSA)Lumen Diameter

(mm)Lumen CSA

(mm2)90% of Lumen

CSA (mm2)Lumen Diameter at 90% of CSA (mm)

2.5 4.9 4.4 2.43.0 7.0 6.4 2.83.2 8.0 7.2 3.03.4 9.0 8.2 3.2

Minimum Lumen Cross Sectional Area Potential Restenosis Rate

The incidence of restenosis has an inverse relationship to post-procedure absolute IVUS lumen CSA.

<5mm2 46%5.0-5.9mm2 33%6.0-7.9mm2 27%8.0-8.9mm2 21%

≥9mm2 8%

“The Predictive Value of Different Intravascular Ultrasound Criteria for Restenosis After Coronary Stenting”1

1 Moussa et al., ACC 97: 707-6. Data did not include DES.

IVUS: Dissection

FL

TL◄


Take Home Messages

• How to determine lesion length morphology• How to identify dissections• Determining appropriate stent placement• Determining lesion size• Understanding the shortfalls of angiography

Thank You

IVUS Image Interpretation and Analysis

Health & Medicine

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