When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh

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When I Use IVUS Neal Uren MD FRCPConsultant
CardiologistRoyal Infirmary Edinburgh
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• MY CONFLICTS OF INTEREST ARE
• Travel, Accomodation Registration
• PCR - May 2006 (BosSci)
• TCT - October 2006 (BosSci)
• Travel Accomodation
• Guidant Institute visit, Brussels - February
  2006 (Abbott)
• Emerging Technologies Symposium -March 2006
  (BosSci)
• Annual SpR training, Malaga June 2006 (BosSci)

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IVUS Transducers
Mechanical Transducer 40 MHz Atlantis Pro
(BosSci)
Solid-State Transducer 25 MHz EagleEye (Volcano)
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Diagnostic Applications of IVUS

• Identify specific disease
  
  - left main stem, ostial lesions
• Detect angiographically silent disease
  - transplant vasculopathy
• Identify plaque morphology
• Examine vessel when angiography is inconclusive
  - hazy lesions,
  presence or absence of thrombus or dissection
• Measure plaque load
• Measure true vessel size

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IVUS Determination of Atheroma Area
Precise Planimetry of EEM and Lumen Borderswith
Calculation of Atheroma Cross-sectional Area
Vessel Area
Lumen Diameter
LumenArea
Vessel Diameter
Atheroma Area
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Angiography versus IVUS
ANGIOGRAPHY 2 dimensional Planar Shadow of
lumen Wall structures not imaged Intermittent
snapshots or repeat contrast injections
necessary QCA measurements prone to
magnification errors
IVUS 360º view Tomographic and
sagittal Visualisation of shape and
location Visualisation of inner wall structures
and morphology Continuous image Precise
measurements
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In-Stent Restenosis
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Interventional Indications of IVUS

• PRE-INTERVENTION
• Accurate quantitation
• Assessment of reference segment disease
• Interventional strategy device selection
• In-stent restenosis
• POST-INTERVENTION
• Recognition of an ambiguous appearance
• Optimal balloon angioplasty
• IVUS-guided stenting

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IVUS Stent Expansion
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Minimum Stent Area Restenosis
40
Angio restenosis
35
TVR
30
25

20
15
10
5
0
lt6
6-7.9
8-9.9
gt10
Minimum Stent Area (mm2)
After Moussa et al, Mintz et al, CRUISE 2000
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Stent Malapposition
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The POST RegistryPredictors and Outcomes of
Stent Thrombosis
94 abnormal IVUS
60
IVUS
53 stent thromboses
50
Angio
40
33 abnormal angio
Percentage
30
20
10
0
DSgt0
Plaque protrusion
Thrombus
Edge tear/ dissection
Inflow-outflow disease
Filling defect
Malapposition
Expansion lt80
Uren et al, EHJ 2002
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The POST Registry Comparison with other trials
90
plt0.05
80
70
60
POST

50
Percentage
STRUT
CRUISE
40

AVID

30
20
10
0
Expansion Edge Tears Malapposition
In-Stent
Thrombus
Uren et al, EHJ 2002
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Wijns et al, TCT 2006
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Left Main Stenting

• PRE-INTERVENTION
• Confirm length of left main stem
• pullback time (0.5 mm/s) 2
• Confirm lesion length
• Assess for ostial disease in LAD or CFX
• Measure true vessel size
  
• maximum minimum vessel diameter 2

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IVUS Left Main Stenting

• POST-INTERVENTION
• Confirm optimal stent deployment
• Recognition of an ambiguous appearance
• Maximise stent expansion
• - clinical experience MLA 7 mm2
• - parent vessel MLA should be 1.5x daughter
  (4mm2)

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Costa et al, TCT 2006
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Cosat et al, TCT 2006
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IVUS Unprotected LMS Stenting

• 18 LMS vs. 60 non-LMS PCI
• Additional high-pressure or larger size balloon
  dilatations were more frequently performed in
  LMS stenting vs. non-LMS stenting (p lt0.05)
• After IVUS-guided stent implantation, MLA was
  9 mm2 in 88 of LMS patients vs. 19 of
  non-LMS (plt0.001)

Hong MK et al, AJC 199882670-3
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IVUS Unprotected LMS Stenting
plt0.05
25
n127 non-randomised
25.0
20
plt0.01
5
IVUS
15
4.2
Angio
4.0
Debulk/Stent
10
Stent
2.5
8.3
5
40
87
77
50
0
0
Angiographic Restenosis ()
MLD (mm)

• Reference artery size only independent
  predictor (not IVUS)
• 99.2 procedural success, 97 2 year survival

Park SJ et al, JACC 2001381054-60
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When I Use IVUS

• CLINICAL PRACTICE
• Diagnostic uncertainty
• Assessment of in-stent restenosis
• Left main stenting
• Atherosclerosis research

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Prior Coronary IVUS Progression Trials
Relationship between LDL-C and Progression Rate
1.8
CAMELOT placebo
REVERSAL pravastatin
1.2
Median Change In Percent AtheromaVolume ()
ACTIVATE placebo
0.6
REVERSAL atorvastatin
A-Plus placebo
0
-0.6
Unexplored Region
-1.2
1.25
1.5
1.75
2.0
2.25
2.5
2.75
3.0
Mean LDL-C (mmol/l)
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Atheroma Area 10.16 mm2
Baseline IVUS Exam
Lumen Area 6.16 mm2
Atheroma Area 5.81 mm2
Follow-up IVUS 24 months rosuvastatin
Lumen Area 5.96 mm2
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REVERSAL ASTEROID Trials
REVERSAL atorvastatin 80 mg vs pravastatin 40 mg
reduced LDL-C to 2.1 mmol/l ASTEROID
rosuvastatin 40 mg reduced LDL-C to 1.5 mmol/l
and raised HDL-C by 15
Median DPAV ()
Median DTAV ()
Median DTAV in most diseased subsegment ()

2.6
2
1.6
0.2
0
-0.8
-1.2
NS
-0.4


NS
-2
Percent Change
-4.2
-4

-6
-6.8
Prava40

Atorva80
-8
Rosuva40
-9.1

-10
plt0.05, p?0.001, NS non significant vs.
baseline