The essence of IVUS session

EBC 2011 – Lisbon, Portugal

- Five presentations - A controversy: Should we use IVUS for bifurcation stenting?

Dr R. Diletti Tissue characterization of atherosclerotic plaque in coronary artery bifurcations

IVUS-VH and OCT have complementary strengths and limitations Deep penetration low penetration Validated detection of tissue composition not easy detection of tissue composition Low resolution high resolution

Optical Coherence Tomography vs Intravascular Ultrasound in Culprit Lesions 24 patients – 6 months FU

Main findings of this study :

- In a post-PCI patient population treated with standard medical therapy (aspirin,

clopidogrel and statin), most (81%) of NC rich plaques remained unchanged in

their composition as measured by IVUS-VH at six month follow-up.

- Most (83%) of the thin capped lesions remained thin-capped (< 65µm) as

measured by OCT

- The proximal rim of the side branch ostium is more likely to contain the larger

amount of NC and the thinnest fibrous cap within the bifurcation

- The plaque index defined as the ratio of necrotic-rich to non-necrotic core frames

increases, implying a progression of the disease at six months. This progression is

mostly due to an increase of NC in non NC rich plaques (development of new

necrotic core rich areas)

High risk plaques remained unchanged

Dr Diletti

Dr A. Medina Stent boost technique/IVUS correlations in bifurcation lesions

Stent boost enhances the Xray-image quality (resolution in contraste)

Stent boost and IVUS correlation in bifurcation coronary lesions (N = 52) 30 pts with one stent – 22 pts with two stents

Main findings of this study

Stent boost :

- Detects the presence and distribution of calcium before stent treatment.

- Identifies changes of the stent geometry, showing a good correlation with IVUS findings (qualitative and quantitative).

- In two stents treatment identifies struts protrusion at the carina level and the presence of gaps, similar to IVUS.

- Mild degree of stent malapposition is not detected.

StentBoost substracted technique:

Phase 1: enhanced stent

Phase 2: contrast filled image

LAD

LAD

Dg

Phase 1 Phase 2 IVUS

T and small protusion (LCx across) Dr Medina

Dr GS. Mintz Neoatherosclerosis in-stent 3 years after stenting

In-stent neoatherosclerosis after DES N=50, median FU of 32 months 52% lesions had at least one in-stent TCFA-like neointima 58% had at least one in-stent neointimal rupture. Patients presenting with unstable angina showed :

Thinner fibrous cap (55μ vs 100μ, p=0.006) Higher incidence of TCFA-like neointima (75% vs 37%, p=0.008) Higher incidence of neointimal rupture (75% vs 47%, p=0.044)

Higher incidence of thrombi (80% vs 43%, p=0.010) and red thrombi (30% vs 3%, p=0.012)

Main findings of this presentation

There is emerging evidence of the development of in-stent neoatherosclerosis

(from pathology, VH-IVUS, and especially OCT (but least with grayscale IVUS)).

While not an universal finding, in-stent neoatherosclersis is more common in DES

than in BMS and occurs earlier in DES than in BMS.

In-stent neoatherosclerosis is responsible for some cases of very late stent

thrombosis as well as late catch-up (late in-stent restenosis).

Disruption of neointima In-stent calcification Neoangiogenesis

Dr Virnami Dr Mintz – Columbia University Medical Center

Late in-stent neoatherosclerosis in DES

OFDI appearance

Late in-stent neoatherosclerosis in DES

Neointimal rupture

Microvessel TCFA-like neointima Calcium

Dr Mintz – Columbia University Medical Center

Dr J. Legutko IVUS criteria for bifurcation stenting: lessons from BLAST

Randomized study – n=220 pts (only the angiogram is used for stent placement vs angiogram, grayscale IVUS, VH used for stent placement pre and post-intervention) Assessment for MACE @ 30 days, and 1 and 2 years

Main findings from the initial results of BLAST (158 pts)

- 30 day MACE by experienced bifurcation centers is low (3.7%) and similar in the IVUS

guided and non IVUS guided groups.

- Compared to IVUS, angiogram is inaccurate to assess precisely lesion characteristics and

PCI results.

- Compared to the core laboratory, sites were less accurate in diagnosing procedural

outcome by IVUS.

- This may suggest that IVUS criteria for optimal result are probably too hard.

- Significant factors associated with 30 day MACE were: number of stents, stent length, SB

stenting, amount of Ca and necrotic core pre PCI.

- In spite of significantly higher rate of SB stenting in the IVUS guided arm, 30 day MACE was

similar in both groups.

MACE (Cardiac Death, MI, TVR)

30 Day non Q wave MI 3.7% (3) 3.9% (3) 0.999

30 Day Q wave MI 0 0 0.999

30 Day TVR 0 0 0.999

30 Day death 0 0 0.999

30 Day MACE 3.7% (3) 3.9% (3) 0.999

Blinded

(N=81)

Un Blinded

(N=77)

P value

Dr Legutko

Dr R. Costa IVUS predictor of SB stenting

Prospective randomized, single center, study – n=54 pts True bifurcation lesions with SB lesion extending from its ostium (>5mm) Comparison between single (provisional) vs. double stenting (any technique), non-LM locations - IVUS guidance procedures

Main findings from this study

- In complex coronary bifurcation lesions, double stenting was associated with larger MLA at

SB ostium compared to single stenting; given that such superiority was associated with less

restenosis at 9-month FU

- Acute SB failure was associated with %DS complex lesion morphology. At late FU, it was

associated with lumen dimensions obtained at index procedure and vessel size

Predictors of SB failure with provisional approach

- In the multivariable model, only eccentricity by IVUS was a predictor of SB failure with

provisional stenting strategy

OBJECTIVES: 1) To evaluate luminal dimensions at SB ostium in bifurcation lesions treated with 1 vs. 2

stents 2) To identify angiographic and IVUS predictors of SB failure

RESTENOSIS LOCATION

SINGLE STENT (n = 23)

VP

SB SB

PV distal

VP

PV distal

DOUBLE STENT (n = 25)

Proximal edge Proximal edge

Ostium 5 mm Ostium 5 mm

Dr R Costa

A controversy: Should we use IVUS for bifurcation stenting?

Dr HC. Gnow YES

IVUS is useful in coronary bifurcation stenting

Pre-PCI

Plaque distribution Stent strategy

Vessel size information Stent selection

SB ostium disease Stent strategy

Post-PCI

Stent expansion and apposition Reduce complications

SB ostium evaluation angiography is overestimating

Dissection

OCT is not made for the procedure guidance

IVUS guidance can improve the safety of coronary bifurcation stenting in this era of DES

(COBIS registry).

We should use IVUS for coronary bifurcation stenting in most of the cases.

Dr I. Sheiban NO

Several angiographic examples to illustrate the fact that angiography is often sufficient to

decide and plan PCI

Can pre-intervention IVUS be performed safely in all patients ?

IVUS MLA criteria alone cannot predict the result of FFR measurement and could still lead to the performance of unnecessary procedures in a considerable proportion of patients.

Questions with IVUS in bifurcations:

What is the level of evidence ?

What is the clinical use of IVUS in bifurcation?

IVUS provides nice images but the level of evidence to support a systematic IVUS guidance

in bifurcation (and non-bifurcation ) is very low

No doubt that IVUS contributes to understand the mechanism of SB ostial restenosis,

carina shifting, plaque shifting , late stent thrombosis … (Research tool)

Can IVUS improve clinical outcome? We need randomized trials