Thread by @billgogas

IVUS-guided vs. Angio-guided PCI

A state-of-the-art talk for the
17th GICS 2019 gics.org,
the major Interventional Cardiology meeting in Gwangju, South Korea directed by Prof. Myung Ho Jeong.

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@NanjingFirst

#SBKCathLab #precisionPCI

Gray scale IVUS, is a sound-based imaging modality that enables accurate assessment of vessel geometry / plaque phenotype and a major adjunctive imaging tool during coronary stenting

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The IVUS principle is based on the degree of reflectivity of the emitted  ultrasound which is highly dependent on tissue composition

IVUS spatial resolution is in the range of 150-200 μm which is ~ 10 times lower than OCT’s spatial resolution (~ 10 μm)

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“Soft plaques” which have lipid rich content attenuate the reflected sound and are hypoechogenic when imaged with IVUS (dark-gray); while calcified plaques, are highly reflective presenting as hyperechogenic areas (bright-white)

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IVUS-based imaging modalities have been also developed delivering more specific phenotypic characterization.
VH-IVUS, is such a modality which classifies atheromas w/ a color coding as: 1) red: NC, 2) light green: FF tissue, 3) dark green: F tissue and 4) white: DC

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IVUS delivers suitable information for the operator before stenting to assess:

1) vessel geometry
2) stent size
3) plaque phenotype
4) lesion length

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As well as after stenting for optimization of the end result by:

1) maximizing the mean stent area
2) treat any remaining complications

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IVUS-guidance vs. Angio-guidance
& Stent Thrombosis

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Early observations leveraging IVUS imaging in the era of 1st gen DES eluted on the:

1) importance of stent underexpansion:
MSA < 5 mm2 &

2) residual reference segment stenosis

which predicted stent thrombosis (ST) after successful DES implantation

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Mean stent area (MSA) < 5 mm2
predicts ST

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Residual Plaque Burden > 50% within the stented segment predicts ST

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The AVIO trial, a prospective RCT of IVUS-guided vs. angio-guided DES implantation showed that pts who underwent DES deployment w/
IVUS-guidance had significantly higher MLDs compared to the angio-guided group: 2.70 mm vs. 2.51  mm, respectively.

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AVIO showed no difference in MACE

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AVIO conclusion:
IVUS-guided PCI significantly increases post-steering MLD

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Another study focusing in CBLs by @NanjingFirst treated with 2-stent strategy indicated that IVUS-guidance has definite benefits by significantly reducing late ST

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IVUS- and Angio-guided groups were both treated w/ #DKCrush technique

@NanjingFirst @jameszll1

#SBKCathLab

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IVUS-guided 2 stent technique is associated w/ significantly reduced
late ST

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In a larger all-comers trial, the ADAPT-DES which enrolled over 8.000 pts, IVUS-guidance vs. Angio-guidance was associated with reduced 1-year rates of definite/probable ST (0.6% vs. 1.0%; adjusted HR, 0.40; 95% confidence interval, 0.21–0.73; p=0.003), respectively.

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Similarly, MI rates with IVUS-guidance outperformed angio-guidance: 2.5% vs. 3.7%; [adjusted hazard radio, 0.66; 95% confidence interval, 0.49–0.88], p=0.004 respectively

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ADAPT-DES, suggested that IVUS-guidance leads to significantly lower MACE rates compared to Angio-guidance.

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ADAPT-DES Overview

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These observations were enriched with larger trials investigating whether IVUS-guidance has benefits in reducing MACE rates aiming in hard clinical endpoints such as cardiac death and revascularization.

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@NanjingFirst randomized in a 2:1 fashion 1,465 patients w/ CBLs treated with DES w/ either adjunctive imaging guidance or not.

IVUS-guided group showed significantly lower 1-year MACE rates and all individual components of cardiac death, MI and any Revasc.

#SBKCathLab

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The MAIN-COMPARE registry involved patients with UPLM followed-up to 3-years.

Mortality rates in the IVUS-guided group were significantly lower compared to the angio-guided group: 4.7% (1.0-8.3%) vs. 16% (7.5%-24.6), p=0.048

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MAIN-COMPARE Overview

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Recently, two RCTs eluted on the definite benefits of IVUS-guided PCI

The XPL randomized 1,400 patients assigned to receive in a 1:1 fashion EES implantation. The primary outcome measure was the composite of MACE: cardiac death, MI, or ischemia-driven TLR

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IVUS-guided DES implantation was associated with a significant 48% relative reduction in the risk of MACE at 1Y compared with angio-guided DES implantation. These differences were mainly driven by the reduction of TLR in the IVUS-guided group.

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#ULTIMATE presented @TCTConference @TCTMD by @jameszll1 randomized 1,448 patients 1:1 to either IVUS-guidance or angio-guidance.

The primary endpoint was target vessel failure at 1-year a composite of:
cardiac death, MI, & clinically driven target revascularization

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IVUS-guided DES implantation significantly improved outcomes particularly in patients with IVUS-defined optimal procedure:

1) MLA > 5.0 mm2
2) PB < 50% at the 5-mm prox. or distal to the stent edge
2) No edge dissection involving media with length > 3mm

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Optimal vs Suboptimal IVUS-guidance

Suboptimal result despite IVUS-guidance similar to Angio-guided clinical outcomes

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#ULTIMATE overview

#SBKCathLab

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In aggregate, IVUS-guided PCI leads to lower MACE rates by decreased ST and TLR

IVUS-guidance mandatory for complex coronary interventions

Achieving optimal IVUS-defined anatomy critical as suboptimal results lead to similar to angio-guidance outcomes

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