Ενδοζηεθανιαία σπερητογραθία - VH

Ενδοζηεθανιαία σπερητογραθία - VH Ανδρέας Σσνεηός Α Καρδιολογική Κλινική Πανεπιζηημίοσ Αθηνών

Future IVUS utilization

Πεπιοπιζμοί αγγειογπαθίαρ

Ambiguous Lesions Angiography vs. IVUS Maehara et al. AJC 2003;91:1335-8 Hassani et al. Eur Soc Card 2005

Gonzalo et al, IJC 2008 OCT vs IVUS vs VH vs IVMRI GS IVUS IVUS RFD OCT IV MR Axial resolution (μm) 100-150 100-150 10-20 200 Probe size (mm) 1.1 1.1 0.4 1.8 Penetration depth 4-8 mm 4-8 mm 1.5-2 mm 200 μm Vessel occlusion No No No/Yes Yes Morphological information Yes Yes Yes No Lipid identification + +++ ++ +++ Thin cap detection + + +++ - Remodelling +++ +++ + - Inflammation - - + -

IVUS: μεηπήζειρ

IVUS: μεηπήζειρ Ολική απηηπιακή επιθάνεια (Total arterial CSA) Δπιθάνεια αςλού (Lumen CSA) Μέγιζηη & ελάσιζηη διάμεηπορ αςλού % Σηένωζη επιθάνειαρ αςλού Μήκορ βλάβηρ Δπιθάνεια πλάκαρ & μέζος σιηώνα = Ολική απηηπιακή επιθάνεια - Δπιθάνεια αςλού (ζε βλάβη σωπίρ stent) = Ολική απηηπιακή επιθάνεια - Δπιθάνεια stent(ζε βλάβη με stent) Γείκηηρ αναδιαμόπθωζηρ (remodeling index): = Δπιθάνεια αςλού (ζε βλάβη) / Δπιθάνεια αςλού (ζε ςγιέρ ημήμα) Σε stent: επιθάνεια stent, μέγιζηη & ελάσιζηη διάμεηπορ stent Δπιθάνεια ςπεππλαζίαρ έζω σιηώνα = Δπιθάνεια stent - Δπιθάνεια αςλού

Δνδοζηεθανιαίο Υπεπησογπάθημα (IVUS): Βαζικέρ Απσέρ, Κλινικέρ Δθαπμογέρ Eθαπμογέρ ηος IVUS Δκηίμηζη ζύζηαζηρ πλάκαρ Αξιολόγηζη ζημανηικόηηηαρ βλάβηρ Καθοδήγηζη ηηρ αγγειοπλαζηικήρ (ππιν από ηο stent) Δκηίμηζη ηος αποηελέζμαηορ ηηρ αγγειοπλαζηικήρ Αξιολόγηζη επιπλοκών μεηά από ηο stent Θπόμβωζη & επαναζηένωζη ηος stent

IVUS: εκηίμηζη ζύζηαζηρ πλάκαρ Μαλακή πλάκα: σαμηλή ησογένεια (ςτηλή πεπιεκηικόηηηα ζε λιπώδη ιζηό) Ινώδηρ πλάκα: μέηπια ησογένεια (ςτηλή πεπιεκηικόηηηα ζε ινώδη ιζηό) Μικηή πλάκα: πεπιοσέρ με διαθοπεηικέρ ησογένειερ Σκληπή πλάκα: ςτηλή ησογένεια (ςτηλή πεπιεκηικόηηηα ζε αζβέζηιο) Ινώδης πλάκα Μαλακή πλάκα

IVUS: εκηίμηζη ζύζηαζηρ πλάκαρ Αζβεζηυμένη πλάκα Φαίνεηαι ένηονα λεςκό και «λαμπεπό» Artifacts: - ακοςζηική ζκιά (shadowing) - ανηανακλάζειρ (reverberations) Ποζοηικοποίηζη αζβεζηίος με μέηπηζη ηος ηόξος ηος. Ταξινόμηζη αζβεζηίος βάζει ηηρ ενηόπιζηρ ζηην πλάκα: - Επιπολήρ αζβέζηιο (εγγύηεπα ζηον αςλό παπά ζηον έξυ σιηώνα) - Εν ηυ βάθει αζβέζηιο (εγγύηεπα ζηον έξυ σιηώνα)

Toutouzas et al,jacc Vol. 49, No. 23, 2007

IVUS: εκηίμηζη ζύζηαζηρ πλάκαρ Εςάλυηη αθηπυμαηική πλάκα Virtual Histology: amplitude and Frequency Predictive Accuracy of VH 80-93% Grey scale: amplitude only Nair et al. Circulation. 2002;106:2200

Virtual Histology

Virtual Histology Οριζμός ηοσ λεπηής κάψας ινωδοαθηρώμαηος

MACE (%) 25 20 All Culprit lesion (CL) related Non culprit lesion (NCL) related Indeterminate 20.4% 15 10 12.9% 11.6% 5 0 2.7% 0 1 2 3 Time in Years Stone GW et al., N Engl J Med 2011;364:226-35.

PROSPECT: Independent predictors of patient and lesion level events by logistic regression analysis Stone GW et al., N Engl J Med 2011;364:226-35.

Μελέηη PROSPECT: VH-TCFA υρ ππογνυζηικόρ δείκηηρ ζε επίπεδο βλάβηρ + μεγάλη πλάκα + μικρός σπολειπόμενος ασλός + μεγάλη πλάκα + μικρός σπολειπόμενος ασλός Stone GW et al., N Engl J Med 2011;364:226-35.

Sawada et al, EHJ (2008) 29, 1136 1146 Total 126 lesions IVUS-derived TCFA (48.4%) OCT Derived TCFA (28.6%) Non-thin-cap IVUSderived TCFA (26.2%) Definite TCFA (22.2%) Non-NCCL OCTderived TCFA 6.3%

imap (Boston Scientific Corporation, Natick, MA) has recently been introduced as an up-to-date tissue characterization method that is compatible with the latest 40-MHz mechanical IVUS imaging system (as opposed to VH- IVUS with 20-MHz solid-state IVUS system). imap discriminates tissue types based upon the degree of spectral similarity between the received signals versus the reference library data obtained from known tissue types

Ενδοζηεθανιαίο Υπεπησογπάθημα (IVUS): Βαζικέρ Απσέρ, Κλινικέρ Εθαπμογέρ Κλινικέρ εθαπμογέρ ηος IVUS Δκηίμηζη ζύζηαζηρ πλάκαρ Αξιολόγηζη ζημανηικόηηηαρ βλάβηρ Καθοδήγηζη ηηρ αγγειοπλαζηικήρ (ππιν από ηο stent) Δκηίμηζη ηος αποηελέζμαηορ ηηρ αγγειοπλαζηικήρ Αξιολόγηζη επιπλοκών μεηά από ηο stent Θπόμβωζη & επαναζηένωζη ηος stent

IVUS: Οπιζμόρ «ζημανηικήρ» ζηένωζηρ % ελάηηυζη διαμέηπος > 70% % ελάηηυζη επιθανείαρ > 50% MLA < 4 mm 2 (εγγύρ LAD, LCX, RCA) < 6 mm 2 (ζηέλεσορ) Ελάσιζηη διάμεηπορ < 1.8 mm (εγγύρ LAD, LCX, RCA) < 2.9 mm (ζηέλεσορ)

Παράμετροι IVUS ποσ προβλέποσν FFR<0.75 σε νόσο στελέτοσς

IVUS: Οπιζμόρ «ζημανηικήρ» ζηένυζηρ ζε νόζο ζηελέσοςρ 121 patients angiographically normal LMCA 214 patients with indeterminate LMCA lesions 1994-2002 at Mayo Clinic 121 Patients Normal LMCA

IVUS: Οπιζμόρ «ζημανηικήρ» ζηένυζηρ ζε νόζο ζηελέσοςρ MLA<7.5 mm 2 and Deferred Revascularization

IVUS for Indeterminate Left Main Lesions Angiographic 30-60% Diameter Stenosis MLA <6.0 mm 2 MLA 6.0-7.5 mm 2 MLA >7.5 mm 2 Revascularization FFR Medical Therapy FFR 0.76-0.80 FFR <0.75 FFR >0.80 Revascularization Cardiac PET Medical Therapy

Evaluation of Indeterminate Non-Left Main Coronary Lesions

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%

IVUS vs. FFR 53 lesions, 43 patients Area Stenosis >70% (sensitivity 100%, specificity 68% ) MLA<4.0 (sensitivity 92%, specificity 56%)

IVUS MLA< 4.0 mm 2 Associated with Adverse Outcomes 357 intermediate lesions, 300 patients, deferred intervention 1-Year Event Rates

IVUS for Indeterminate Lesions (Non-Left Main) Angiographic 50-70% Diameter Stenosis MLA <3.0 mm 2 MLA 3.1-4.0 mm 2 MLA >4 mm 2 Revascularization Area Stenosis Medical Therapy > 60% < 60% Revascularization Medical Therapy

IVUS vs. FFR 167 patients, with intermediate coronary lesions FFR-guided, 83 lesions vs. IVUS-guided, 94 lesions Chang-Wook Nam et al. JACC Interv 2010;3:812-7

US IVUS procedure penetration

IVUS utilization Balloon angioplasty Other angioplasty techniques BMS DES Cost effectiveness

SIPS trial n=269 p=0,02 Although there was no significant difference in MLD at 6 months, clinical follow-up at 2 years showed a significant decrease in clinically driven TLR in the IVUS group compared with the angiography group (17% vs. 29%, p=0.02). Frey AW et al, Circulation 2000;102;2497-2502

BEST study 18 17 16 15 14 13 12 11 10 16,8 18,1 Restenosis at 6 months (%) p= NS IVUS guided PTCA Stent IVUS-guided angioplasty reduced the stent rate by half, with similar 6-month angiographic IVUS and clinical outcome compared with stent implantation Schiele F et al, Circulation 2003;107:545-51

Directional atherectomy Lesion selection for directional atherectomy: proximal or mid segments, no or only deep calcium, eccentric plaque distribution IVUS measurement of lesion arc of calcium is the most consistent predictor of effectiveness* Spatial relation between side branches and plaque orientation *Matar FA et al, J Am Coll Cardiol 1995;25:318 24

IVUS guided rotational atherectomy 15 10 5 0 12,6 6,4 7,4 1,76 Lumen CSA (mm2) P+M CSA (mm2) Preprocedure Postprocedure 200 100 0 169 Ca++ ( ) 96 Preprocedure Postprocedure IVUS showed an increase in lumen size and a decrease in plaque-plusmedia area and in arc of target lesion calcification. Mintz GS et al, Circulation 1992;86:1383-93

Cutting balloon angioplasty

IVUS effect on cutting balloon angioplasty REDUCE III trial 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 6,60% 17,90% Restenosis (p=0,016) IVUS-CBA Angio-CBA IVUS-guided CBA-BMS strategy results in low restenosis rates (6.6%) comparable to those achieved in recent DES studies. Ozaki Y et al, Circ J 2007; 71: 1 8

In BMS era, 10/12 studies supported IVUS-guided PCI Study Choi et al (AHJ 2001;142:112-8) CENIC (JACC 2002;39:54A) CRUISE (Circulation 2000;102:523-30) SIPS (Circulation 2000;102:2497-502 and AJC 2003;91:143-7) AVID (Circulation 1999;100:I-234) Gaster et al (Scan Cardiovasc J 2001;35:80-5 & Heart 2003;89:1043-9) RESIST (JACC 1998;32:320-8 & Int J Cardiovasc Intervent 2000;3:207-13) TULIP (Circulation 2003;107:62-7) BEST (Circulation2003;107:545-551) OPTICUS (Circulation. 2001;104:1343-9) PRESTO (Am Heart J. 2004;148:501-6) DIPOL (Am Heart J 2007;154:669-75) Angio Better IVUS Better IVUS Also Cheaper x x x X X X X X X X X X X x

High-pressure balloon inflation Restenosis and target vessel revascularization (TVR) rates are directly related to final minimal stent cross-sectional area (MSA) measured by IVUS Colombo A et al, Circulation 1995;91:1676-88 Görge G et al, J Am Coll Cardiol 1995;26:725-30

Criteria of a sufficient interventional result following IVUS-guided stenting (MUSIC Study) Complete stent-vessel wall apposition Stent CSA 90% of the mean reference lumen CSA (or >9mm 2 ) Symmetric stent expansion defined as minimum diameter divided by maximum diameter 0.7 J. Am. Coll. Cardiol. Intv. 2008; 1: 22-31 De Jaegere P et al, The Music study, Eur Heart J 1998;19:1214-23

CRUISE trial 7,8 7,6 7,4 7,2 7 6,8 6,6 7,8 7,1 MSA post procedure 20% 15% IVUS 10% Angiography5% 0% 8,5% 15,3% TVR at 9 months IVUS-guided group had a larger MSA post-procedure (7.8 vs. 7.1 mm2, p<0.001) No difference in MI or death IVUS-guided group required fewer TVR at 9 months (8.5 vs. 15.3%, p=0.02) IVUS Angiography Fitzerald PJ et al, Circulation 2000;102:523-30

AVID trial 14% 12% 10% 8% 6% 4% 2% 0% 8,40% 12,40% TLR at 12 months n=800 IVUS Angiography p=0,08 IVUS-guided group required fewer TLR at 12 months (most patients with vessels 3.25 mm and saphenous vein graft interventions), Russo RJ et al, Circulation 1999;100(Suppl I):I 234

TULIP study A. Cumulative combined event-free survival (p=0,026) B. Cumulative freedom from TLR (p=0,018) Angiographic and clinical outcome up to 12 months after long stent placement guided by IVUS is superior to guidance by angiography. (144 patients with long coronary lesions 20mm and a reference vessel diameter 3.0 mm) Oemrawsingh PV et al, Circulation 2003;107:545-51

Long term clinical effects in IVUS guided PCI Number of MACE is significantly lower in the IVUS guided group than in the angiography (CAG) group, mainly because there were fewer repeat percutaneous coronary interventions in this group. The difference increases during the first two years, after which it appears to stabilize. Gaster AL et al, Heart 2003;89:1043-9

9 studies on IVUS guided stenting 20% 15% 10% 15,00% 18,70% 10,00% 15,00% IVUS-guided Angio-guided 5% 0% MACE (p=0,03) TVR (p=0,00003) IVUS-guided stenting has a favorable effect on MACE and significantly lowers 6-month angiographic restenosis and target vessel revascularizations compared to an angiographic optimization. Casella G et al, Cathet Cardiovasc Intervent 2003;59:314 321

OPTICUS study n=550 p=0,87 Kaplan-Meier estimate of the probability of event-free survival. At 12 months, repeat angiography revealed no significant differences between the groups with IVUS or angio-guided stent implantation with respect to dichotomous restenosis rate, minimal lumen diameter, percent diameter stenosis and MACE. Mudra H et al, Circulation 2001;104:1343-9

Role of IVUS in DES development Late lumen loss within stents correlated strongly with tissue growth (neointimal tissue accumulation), but only weakly with stent recoil. These in vivo IVUS observations were instrumental in the development of strategies to treat in-stent restenosis, and consequently led to the evolution of DES. Hoffmann R et al, Circulation 1996;94(6):1247-54

Effect of incomplete apposition : thrombosis 3,5 3 2,5 2 1,5 1 0,5 0 3,4 TLR at 6 months 0 0 0 Stent thrombosis No ISA ISA Incomplete stent apposition after DES does not increase stent thrombosis or restenosis, but Tanabe K et al, Circulation. 2005 Feb 22; 111:900-905 (TAXUS II Trial)

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;115:2426-34

Effect of underexpansion (inadequate stent dimensions) 100 80 60 40 20 0 p= 0,03 Thrombosis Control 8 6 4 2 0 Minimum stent CSA (mm2) p= 0,02 Thrombosis Control Stent expansion (%) 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. 2005 Apr 5;45(7):995-8

IVUS Guided DES Deployment Associated with Lower MACE 1296 IVUS-guided vs. 884 propensity-match angiographically guided PCI Roy. Eur Heart J 2008; 29: 1851-7

Roy P et al, J Interven Cardiol 2007;20:307 313 IVUS and DES thrombosis 80% 73,00% 70% 60% 50% 40% 30% 20% 54,60% IVUS guidance (p=0,019) Subacute stent thrombosis No stent thrombosis Lack of IVUS guidance was the only modifiable predictor identified for subacute and late ST after DES implantation.

Left Main Disease Impact of IVUS Guidance on Left Main Stenting: Main Compare Study IVUS guidance was used in 756/975 pts undergoing unprotected LM stenting. Propensity matching was used to create 201 matched pairs (145 pairs). Park S-J, et al. Circ Cardiovasc Intervent. 2009;2:167-177

IVUS Predictors of Stent Thrombosis and Outcome Stent underexpansion Edge dissection Significant plaque (>57%) at edge of stent Major malapposition

IVUS: απεικόνιζη θπόμβος

IVUS: απεικόνιζη θπόμβος Chromaflo Imaging Φυσιολογικός αυλός Θρόμβος

IVUS image: measurements Artery with a stent Stent CSA Intimal hyperplasia CSA = Stent CSA - Lumen CSA Intimal hyperplasia P + M

IVUS image: in-stent restenosis In-stent restenosis (intimal hyperplasia) (IH) often appears with a very low echogenicity Could be less echogenic than the blood speckle Appropriate system settings are critical to visualize IH (do not black out center)

ACC/AHA PCI Guidelines for IVUS Class IIa Class IIb Class III Circulation. 2006 Jan; 67(1):87-112

3D IVUS SHEAR STRESS J.V. Soulis et al. / Medical Engineering & Physics 30 (2008) 9 19

3D OCT Shear Stress Development of an algorithm that can provide us with automated measurements and provide us with the 3d structure of the vessel allowing the measurement of ESS First Dept. of Cardiology, Athens Medical School

3D OCT Fusion of Angiography and OCT 3D Reconstructed RCA Toutouzas K, Synetos A, Chatzizisis Y,, Stefanadis C First Department of Cardiology, University of Athens First Cardiology Department, University of Thessaloniki University of Chicago, Medical School

Shear Stress Map of the Reconstructed RCA Toutouzas K, Synetos A, Chatzizisis Y, Stefanadis C First Department of Cardiology, University of Athens First Cardiology Department, University of Thessaloniki University of Chicago, Medical School

MUSIC Criteria for Optimal Stent Deployment J. Am. Coll. Cardiol. Intv. 2008; 1: 22-31