Intracoronary Imaging For Complex PCI A Pichard, L Satler, Ron Waksman, I Ben-Dor, W Suddath, N Bernardo, D Harrington.
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1 Intracoronary Imaging For Complex PCI A Pichard, L Satler, Ron Waksman, I Ben-Dor, W Suddath, N Bernardo, D Harrington. Medstar Washington Hospital Center Washington, DC
2 Conflict of Interest None for this presentation
3 Accepted Basic principles Angiography (QCA) is no longer the Gold Standard for lesion assessment. Complex lesions often inadequately defined by Angio. IC Imaging (IVUS/OCT) leads to optimal PCI less complications, less stent thrombosis and improved outcomes. IVUS, OCT, NIRS, HD IVUS, CT all useful.
4 Angiography is no Longer the Gold Standard to Indicate Revascularization in Coronary Lesions. 1. Angiography is adequate for: a. mild lesions (20-40%). b. severe lesions (>80-90%). 2. Angiography is not adequate for intermediate lesions: 50-80%.
5 881 Lesions with IVUS/FFR. Han et al. EuroIntervention. 2012;8:N74.
6 Angio is Most Inaccurate in LM. Olivier Muller. ESC 2011 FFR 0.89 FFR 0.68
7 ADAPT-DES: IVUS Changed the Procedure 74% of the Time Witzenbichler et al. Circ 2014;129:463-70
8 OCT Impacts Decision Making in PCI W Wijns et al. EHJ 2015;36: patients with stable/unstable AP Pre PCI OCT changed PCI strategy in 55% of patients. Post PCI OCT led to further optimization in 25% of patients. Less periprocedural MI in OCT patients
![8% (184) 0.68 [0.52, 0.88] 0.](/docs-images/89/100155576/images/9-6.jpg "003 Stable CAD 4.2% (61) vs 6.")
![5% (165) 0.63 [0.47, 0.85] 0.002 0.](/docs-images/89/100155576/images/9-7.jpg "1 1 Favors IVUS Use Favors Angio")
9 IVUS Use and MACE (Definite/Probable ST, Cardiac Death, MI) Event Rate (n) IVUS vs Angio HR [95%CI] P-Value All 4.9% (158) vs 7.5% (373) 0.65 [0.54, 0.78] < STEMI 3.7% (15) vs 6.4% (24) 0.56 [0.29, 1.07] 0.07 NSTEMI/UA 6.1% (82) vs 8.8% (184) 0.68 [0.52, 0.88] Stable CAD 4.2% (61) vs 6.5% (165) 0.63 [0.47, 0.85] Favors IVUS Use Favors Angio Use ADAPT-DES Clinicaltrials.gov NCT
10 IVUS is most Effective in Complex Lesions. Witzenbickler et al. ADAPT-DES. Circ 2014;129:463-70
11 Intracoronary Imaging Koskinas et al. European Heart Journal (2016) 37,
12 LMCA PCI: Is the CX Ostium Involved? LCX-pullback A Two-stent Crush LCX-pullback B SJ Park et al. Single-stent
13 PCI Strategy for Ostial Disease Direct Stenting A 5 m m Roto-Stent B
14 Pre Case done without IC Imaging Post Stent
15 2 hours later Intramural Hematoma
16 Systematic IVUS Search for IMH after PCI. WHC: Maehara et al. Circulation 2002;105: IVUS identified intramural hematoma in 6.7% of 1025 PCIs. 1/3 of IMH not seen on angiography
17 Cutting/Scoring Balloon for IH/Dissection MWHC: Negui, Pichard et al. In Press
18 OCT Guided PCI. CLI-OPCI II Trial. Prati et al. JACC 2015;8: lesions. 56% acute coronary syndrome. 75% B2/C lesions.
19 IVUS Guidance Decreases Stent Thrombosis. WHC: Roy et al. EHJ 2008;29: IVUS P=0.013 No IVUS n=1768 patients (2608 lesions) propensity matched. No IVUS was a significant predictor of cumulative ST at 12 months: HR 3.3, CI , p=0.01
20 IVUS and Definite/Probable Stent Thrombosis ADAPT-DES. Witzenbichler et al. Circ 2014;129: Definite/Probable ST (%) 2 1 HR: 0.47 [95% CI: 0.28, 0.80] P = No IVUS Used 1.16% IVUS Used 0.55% Number at risk: IVUS Used IVUS Not Used Time in Months
21 Very Late StentThrombosis of Bifurcations and IVUS Use. Kim, SJ Park et al. AJC 2010;106:612-8 DES no IVUS BMS no IVUS DES IVUS BMS IVUS
22 IVUS in Long Stents (>28mm) Hong SJ et al. JAMA. 2015;314: patients in 20 Centers in Korea. EES Randomized to IVUS: Yes or No.
23 IVUS in Long Stents (>28mm) IVUS-XPL Trial. Hong SJ et al. JAMA. 2015;314: patients in 20 Centers in Korea. EES Randomized to IVUS: Yes or No optimal Non-optimal
24 Outcome of Bifurcations with IVUS Kim, SJ Park et al. AJC 2010;106:612-8 n=758 pts DES BMS
25 IVUS for non LM Bifurcations Kim et al. Korean Registry. AHJ 2011;161: patients. Propensity matched Death or MI Stent Thrombosis
26 IVUS-guided PCI for Bifurcation treated with 2-Stent Technique; n= months IVUS N=324 No IVUS N=304 P-Value Stent thrombosis 1.2% 6.9% <0.001 Definite 0.6% 5.3% <0.001 Probable 0% 1.6% Possible 0.6% 0% 0.50 Death 2.2% 3.9% 0.54 Cardiac death 0.9% 3.3% MI 4.6% 8.9% TLR 8.6% 13.5% TVR 10.2% 15.5% MACE 15.7% 19.7% 0.21 Chen et al CCI. 2013;81(3):456-63
27 IVUS Guided CTO Yangsoo Jang et al. Yonsei University, S Korea. TCT 2014
28 Restenosis and Under Expansion ISR % Overall lesions Two-stent 46% % Underexpansion 5% Complete Expansion Underexpansion Underexpansion of at least 1 segment Adequate expansion at all sites Kang et al. Circ Cardiovasc Interv ;4: % Complete Expansion
29 IVUS-guided Implantation of DES to Improve Outcome: A Meta-analysis 24,849 patients from 3 randomized trials and 12 observational studies, IVUS- vs Angiographyguided PCI OR (95% CI) P Value MACE 0.79 ( ) All-cause Mortality 0.64 ( ) < MI 0.57 ( ) < Stent Thrombosis 0.59 ( ) Conclusion: IVUS guidance is associated with significant reductions in PCI outcomes compared with angiography alone. Jang J-S, et al. J Am Coll Cardiol Intv. 2014;Epub ahead of print.
30 Randomized Trials of PCI with/without IVUS. Metanalysis Elgendy et al. Circ Cardiovasc Interv. 2016;9:e patients MACE
31 Conclusion Routine use of Intra Coronary Imaging results in: Safer, faster, optimal procedure. Prevents complications. Improves outcomes: less ST, less restenosis, less MACE. No stress for the operator: no unknowns to deal with!
32 Reimbursement Dilemma FFR and IVUS usually not reimbursed. If PCI deferred: benefit for the patient, but the cost may not be reimbursed to the Hospital.
33 The end
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