Κλινική Χρήση IVUS και OCT. Άγγελος Παπανικολάου MD, MEAPCI Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών Ιπποκράτειο ΓΝΑ

Transcript

1 Κλινική Χρήση IVUS και OCT Άγγελος Παπανικολάου MD, MEAPCI Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών Ιπποκράτειο ΓΝΑ

2 I do not have any potential conflict of interest

3 Need for Intravascular Imaging Falk E,,Fuster V. Coronary plaque disruption. Circulation 1995;92:

4 DEVELOPMENT OF INTRACORONARY IMAGING the characterisation of atherosclerotic plaque morphology optimising stent sizing minimising the complications associated with percutaneous coronary intervention (PCI)

5

6 IVUS Μετρήσεις Ολική αρτηριακή επιφάνεια (Total arterial CSA) Επιφάνεια αυλού (Lumen CSA) Μέγιστη & ελάχιστη διάμετρος αυλού % Στένωση επιφάνειας αυλού Μήκος βλάβης Επιφάνεια πλάκας & μέσου χιτώνα = Ολική αρτηριακή επιφάνεια - Επιφάνεια αυλού (σε βλάβη χωρίς stent) = Ολική αρτηριακή επιφάνεια - Επιφάνεια stent(σε βλάβη με stent) Δείκτης αναδιαμόρφωσης (remodeling index): = Επιφάνεια αυλού (σε βλάβη) / Επιφάνεια αυλού (σε υγιές τμήμα) Σε stent: επιφάνεια stent, μέγιστη & ελάχιστη διάμετρος stent Επιφάνεια υπερπλασίας έσω χιτώνα = Επιφάνεια stent - Επιφάνεια αυλού

7 IVUS values that predict FFR<0.75 LM

8 Non LM- Minimum Lumen Area (MLA) and Area Stenosis (AS) vs. FFR (83% sensitivity, 92.3 % specificity) (92% sensitivity, 88.5 % specificity) MLA <3.0 mm 2 AS > 60%

9 IVUS: Ορισμός «σημαντικής» στένωσης % ελάττωση διαμέτρου > 70% % ελάττωση επιφανείας > 50% MLA < 4 mm 2 (εγγύς LAD, LCX, RCA) < 6 mm 2 (στέλεχος) Ελάχιστη διάμετρος < 1.8 mm (εγγύς LAD, LCX, RCA) < 2.9 mm (στέλεχος)

10 IVUS Showing a Circumferential Calcified Lesion and Eccentric Mixed Plaque

11 OCT and IVUS Showing a Well-opposed Stent and Malapposed Stent

12 Effect of underexpansion (inadequate stent dimensions) 100 p= 0,03 8 p= 0, Stent expansion (%) Thrombosis Control Minimum stent CSA (mm2) Thrombosi s Control Stent under-expansion and residual reference segment stenosis are associated with an increased risk of stent thrombosis after successful drug-eluting stent implantation. Fugii, K, et al, J Am Coll Cardiol Apr 5;45(7):995-8

13 Effect of incomplete apposition : very late thrombosis Incomplete stent apposition is highly prevalent in patients with very late stent thrombosis after DES implantation, suggesting a role in the pathogenesis of this adverse event. Cook S et al, Circulation 2007;115:

14 OCT optical analogue of IVUS Imaging Wire 0.019" Non-Occlusive Method Selective Guide Catheter Engagement Prati et al. Circ J 2008 Χρήση ηλεκτρομαγνητικών κυμάτων αντί ηχητικών. Μια φωτεινή πηγή εκπέμπεται προς το υπό εξέταση αγγείο και οι πληροφορίες που λαμβάνονται από την αντανάκλαση (εξαρτώμενες από τη καθυστέρηση και τις σκεδαστικές ιδιότητες του υπό εξέταση αγγείου) χρησιμοποιούνται για τη δημιουργία της εικόνας

15 OCT superior resolution (10x), but limited penetration (<2mm) compared to IVUS

16 Clinical Application of OCT Intracoronary Imaging nd Generation OCT Fourier Domain OCT (OFDI/Frequency/Spectral Domain/Swept Source) Monorail Imaging Catheter Non-Occlusive

17

18 Vulnerable Plaque Components Rupture Increased Plaque size Positive remodeling Increased Necrotic core ~34% of plaque area ~3.8 mm 2 & ~9 mm long Fibrous cap Reduced Thickness, ~23 μm (95% <65 μm) Increased Macrophage Density, ~26% of cap Reduced Smooth Muscle Cells Increased Angiogenesis Intraplaque hemorrhage Perivascular inflammation Reduced Calcification & Spotty Detected by OCT Thrombosis Virmani R, et al., JACC 2006;47:C13 8

19 PROSPECT: Independent predictors of patient and lesion level events by logistic regression analysis Stone GW et al., N Engl J Med 2011;364:

20 Can addition of VH increase the diagnostic accuracy of OCT? Addition of VH to OCT imaging helped to properly classify an extra 8% of plaques Goderie et al, Int J Cardiovasc Imaging April 2010

21 Vulnerable plaque characteristics are associated with thrombolysis failure Toutouzas K, Tsiamis E, Karanasos A, Drakopoulou M, Synetos A, Tsioufis C, Tousoulis D, Davlouros P, Alexopoulos D, Bouki K, Apostolou T, Stefanadis C. JACC Cardiovasc Interv May;3(5):507-14

22 Intimal thickening 1 st Department of Cardiology. University of Athens

23 Lipid Pool Sensitivity: 90-95% Specifity: 90-98% Kawasaki et al., JACC 2006;48:81-88 n=357 segments Yabushita et al, Circulation. 2002;106: High attenuation Lipid pool 1 st Department of Cardiology. University of Athens

24 Calcific depositions Sensitivity: %, Specificity: % Kawasaki et al., JACC 48;2006:81-88 n=357 segments Yabushita et al, Circulation. 2002;106: Low attenuation 1 st Department of Cardiology. University of Athens

25 Rupture 1 st Department of Cardiology. University of Athens

26 Light Intensity Light Intensity Thrombus Based on the intensity attenuation White Thrombus n=108 segments 16 red thrombi 17 white thrombi Red Thrombus Sensitivity: 90% Specifity: 92% for identifying the type of thrombus (Cut-off value 250 μm) Kume et al, Am J Cardiol 2006;97:

27 Macrophage Content Sensitivity: 100% Specificity: 100% for caps >10% CD68 (raw) Sensitivity: 70% Specificity: 75% for caps >10% CD68 (log 10) R=0.84 (P<0.0001) Raw RAW Log 10 R=0.47 (P < 0.05) CD 68 LOG 10 OCT measurements of macrophage density were independent of fibrous cap thickness Tearney et al, Circulation. 2003;107: n=26 lipid-rich segments

28 Intraplaque Hemorrhage (?) Prati et al, EHJ 2009

29 Neovascularization (?) Prati et al, EHJ 2009

30 Dissection Edge dissection Intra-stent dissection IVUS-detected edge dissection has been associated with restenosis and must be treated, however there are no data about OCT-detected dissections Gonzalo N et al, Heart Dec 2009

31 Clinical impact of edge dissections in ACS Deep vessel wall injury at stent edges with a dissection flap thickness more than 0.31mm carries an adverse clinical impact on long-term clinical outcome Bouki..Toutouzas.. Catheter Cardiovasc Interv Jan 23

32 Haziness Toutouzas, Synetos Stefanadis Clin Cardiol 2007

33 Dissection & Thrombus Toutouzas, Synetos Stefanadis, Clin Cardiol 2007

34 Recanalized Thrombus Toutouzas, Karanasos, Synetos Stefanadis JACC Cardiovasc Interv Jun;5(6):688-9

35 IVUS: απεικόνιση θρόμβου Chromaflo Imaging Φυσιολογικός αυλός Θρόμβος

36 Stent thrombosis Heart 2012;98:1213e1220. doi: /heartjnl

37 Stent thrombosis, restenosis or underexpansion?

38 Inferior STEMI Toutouzas, Synetos,..Stefanadis Int J Cardiol Oct 20;152(2)

39 OCT evaluation of the LCx Toutouzas, Synetos,,Stefanadis Int J Cardiol Oct 20;152(2)

40 JACC Cardiovasc Imaging Mar;6(3):283-7.

41 JACC Cardiovasc Imaging Mar;6(3):283-7.

42 EROSION Study Haibo Jia et al, Eur Heart Journal 2016

43 BVS 5years FU Karanasos at al, J Am Coll Cardiol Dec 9;64

44 5 years FU BVS Karanasos et al, Circulation. 2012;126:e89-e91

45 BVS STEMI Diletti R, Karanasos A, Muramatsu T et al, Eur Heart J 2014 Mar;35(12):

46 VLST IN BVS Karanasos et al,ijc 167 (2013) e17 e19

47 3D OCT for bifurcation guidance Okamura et al, Eurointervention 13 Oct 2011

48 Area-length measurements OCT-IVUS IVUS measurements are greater than those of OCT. (Resolution? Dotter effect?) Yamaguchi et al., Am J Cardiol 2008;101:

49 Kubo et al,jacc Cardiovasc Imaging Oct;6(10)

50 Kubo et al,jacc Cardiovasc Imaging Oct;6(10)

51 IVUS vs Angio guided PCI Catheterization and Cardiovascular Interventions 00:00 00 (2013)

52 AVIO A benefit of IVUS optimized DES implantation was observed in complex lesions in the post-procedure minimal lumen diameter. No statistically significant difference was found in MACE up to 24 months. Chieffo et al.am Heart J 2013;165:65-72

53 IVUS Guided META (26,503 Patients in 3 Randomized Trials and 14 Observational Studies) IVUS-guided PCI was associated with lower risk of death, MI, TLR, and stent thrombosis after drug-eluting stent implantation Am J Cardiol 2014;113:1338e1347

54 ADAPT-DES Study IVUS guidance was strongly associated with lower 1-year rates of definite/probable DES thrombosis, MI, and MACE, as well as ischemic TLR and TVR; The greatest absolute benefits of IVUS guidance were present in patients with acute coronary syndromes and complex coronary anatomy Bernhard Witzenbichler, MD et al, Circulation 2014;129:463 70

55 The MOZART (Minimizing contrast utilization With IVUS Guidance in coronary angioplasty) Randomized Controlled Trial Mariani et al JACC Cardiovasc Interv Nov;7(11):

56 The MOZART (Minimizing contrast utilization With IVUS Guidance in coronary angioplasty) Randomized Controlled Trial Mariani et al JACC Cardiovasc Interv Nov;7(11):

57 Prati et al.eurointervention 2012;8:

58 Difference in rupture between STEMI & NSTEMI STEMI NSTEMI STEMI patients have greater rupture length and greater length of missing fibrous cap than NSTEMI patients Toutouzas.. Synetos Stefanadis, Am Heart J 2011 Jun; 161:1192-9

59 Rupture location in ACS Rupture Characteristics Rupture Length(mm) 2.27±1.70 Location of rupture Distal to the MLS 14(36.8) MLS 14(36.8) Proximal to the MLS 10(26.3) Distance from MLS(mm) 2.01±2.10 Cross Sectional Area(mm2) 4.12±2.68 Minimal Cap Thickness(μm) 59±21μm Rupture at cap shoulder 26(68.4) Length of missing fibrous cap(mm) 0.53±0.27 Toutouzas, Karanasos,Synetos Stefanadis, Am Heart J 2011 Jun; 161:1192-9

60 OCT imaging in ACS Non-culprit lipidrich plaque with thick cap Napkin ring significant lesion Red thrombus MLS - white thrombus Evaluation of culprit lesion in ACS revealed multiple morphologies Toutouzas..Synetos..Stefanadis, Heart July 2010 Plaque rupture TCFA

61 Neoatherosclerosis Neoatherosclerosis is frequent and more common among symptomatic patients. Importantly, neointimal rupture is associated with ACS late after stent implantation. Specific morphological characteristics, such as cap thickness and macrophage infiltration are associated with rupture of neoatherosclerotic plaques Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands 1st Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece

62 OCT/FFR Cutt of points

63 OPINION trial low rate of target vessel revascularization, a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization at 12 months in patients undergoing OFDI-guided PCI (5.2%) versus patients randomized to IVUS-guided PCI (4.9%). Dr Takashi Kubo et al, EuroPCR 2016

64 Αξιολόγηση σημαντικότητας βλάβης Cost effectiveness Καθοδήγηση της αγγειοπλαστικής (πριν από το stent) Εκτίμηση σύστασης πλάκας Εκτίμηση του αποτελέσματος της αγγειοπλαστικής Σύγκριση μεθόδων Θρόμβωση & επαναστένωσ η του stent Αξιολόγηση επιπλοκών μετά από το stent

65

66

67 IVUS has better data when it comes to LMS-related Lesions OCT seems to be superior in arteries with an MLA of <3 mm2. Establishing diagnosis and optimising stent deployment, OCT has the advantage of better resolution. Assessing the significance of intermediate coronary stenosis, physiological assessment with FFR should remain the first choice as IVUS- and OCT-derived MLA cut-off values have at best moderate correlation and accuracy.

68