calcified and complex coronary lesions: avoiding stent regret€¦ · calcified and complex...
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Calcified and Complex Coronary Lesions: Avoiding Stent Regret
Imaging to Guide PCI Decisions: Angiography, IVUS, or OCT
Arnold Seto, MD, MPAChief of Cardiology
Long Beach VA Medical CenterAssociate Clinical Professor,
University of California, Irvine
Disclosures
• Speaker’s Bureau: Terumo, Jannsen, Acist, Philips, Boston Sci
• Research funding: Acist, Philips
A brief true story:
So how do you want to fix this?
It’s a Type A lesion, focal, no Ca++, concentric. Primary stenting has been shown to save time, $, and may reduce periprocedure MI, no-reflow
I don’t know… let’s balloon it first
A brief true story:
AHA! See! I knew it!
Yessir.NC balloon high pressure -> Same resultAngiosculpt -> Same resultFlexotome -> Full dilation
What did we learn today?
When not to stent
• Unable to dilate/expand• Stent underexpansion
• Stent malapposition
• Small vessel
• Thrombus/Aneurysm
• Tortuosity
Stent underexpansion
• Failure to deploy the stent to desired/specified diameter (usually 90% of distal reference vessel)• Sometimes visible by fluoro (esp. StentBoost)• Often focal• Definitely imaged by IVUS/OCT
• Causes• Low pressure inflation• Compliant/Semicompliant balloon w/o NC postdil• High plaque burden• Eccentric lesions• Calcification• Prior stent
Basic reasons to use IVUS and OCT
Pre-PCI
• Lesion assessment
• Lesion length
• Stent sizing
• Calcification
Post-PCI
• Stent expansion
• Stent apposition
• Edge dissection
• Detect residual disease
The Korean Journal of Internal Medicine 2012;27(1):30-38.
IVUS ≠ Functional Assessment
• IVUS MLA has a modest correlation with FFR <0.80 except in the left main
• IVUS for non-LM lesion significance removed from 2018 ESC guidelines and 2017 AUC
Waksman, JACC 2013 61:917-23
FIRST study
350 patients10 sites
Best IVUS cutoff MLA <2.4mm2 <2.7 < 3.6
• Sizing Variability: – Sizing accuracy can vary by 0.3 mm depending on imaging modality used
– Recognize the risk of under/over-estimating vessel size by visual estimation
* Margin of error estimates based on resolution for each imaging modality: Resolution of OCT and IVUS: Bezerra, H.G., J Am Coll Cardiol.: Cardiovasc Interv. 2009; 2: 1035. Resolution of QCA: Dahm, J. and van Buuren, F. Int J Vasc Med. 2012. Offset and variability of visual estimate: data on file at Abbott Vascular.
Actual Size OCT IVUS QCA Visual Estimate
Over-Estimates Under-Estimates
Inter/Intra-ObserverVariabilityMost Accurate
Margin of Error*
3.0 mm 3.1 mm3.0 mm 2.8 mm 2.7 – 3.3 mm
Sizing by QCA/IVUS/OCT
IVUS vs OCT sizing European Heart Journal, May 2018 https://doi.org/10.1093/eurheartj/ehy285Most practical IVUS/OCT sizing criteria:
1) Mean distal lumen diameter with upsizing 0-0.25mm
2) Mean distal external elastic membanewith downsizing 0.25mm
Tip: Use Rotational Catheters to cross
Source: Boston Scientific
Crossing Force required
Same 3.5F crossing profile, but very different stiffness at distal end
When to use which IVUS catheter
Rotational
• Tortuosity
• Bifurcation
• Small caliber vessel
• Need for stent length
Phased-Array
• Larger straight vessel
• CTO (Short Tip)
• Short distal target
• When you are in a rush
Most common IVUS applications benefit from rotational catheter!
Phased Array vs Rotational vs HD IVUS
Phased Array 40MHz Rotational 40-45MHz HD IVUS 60 MHz
Freed, Safian Ch 12
Calcified Plaques
Calcium in OCT vs IVUS
• OCT and IVUS have similar accuracy for detecting calcium
• OCT has higher penetration of calcium, to detect thick calcium
• Degree of circumferential involvement and thickness that require atherectomy unclear
Bezerra, https://www.acc.org/latest-in-cardiology/articles/2016/06/13/10/01/intravascular-oct-in-pci
Case – LM Calcium
Case – LM Calcium
Case – LM Calcium
Case – LAD Calcium
Case – LAD Calcium
Goals of imaging post-PCI
The Korean Journal of Internal Medicine 2012;27(1):30-38.
Goal: 90% of distal reference lumen area or 80% of average reference lumen area
Pascal Motreff, and Geraud Souteyrand JIMG 2009;2:245-246
American College of Cardiology Foundation
56 yo man, 6 months after successful DES with angiographically good result.
Underexpansion “y” found at OCT associated with restenosis
Author Name (Year)
MACE
IVUS guidance (n=12,499 pts) was associated with:
▪ Larger stents ▪ Larger post-procedural MLD▪ More stents ▪ Longer stents
▪ Significant lower rates of:▪ MACE (OR 0.74, p<0.001) ▪ Death (OR 0.61, p<0.001)▪ MI (OR 0.57, p<0.001)▪ ST (OR 0.59, p<0.001)▪ TLR (OR 0.81, p=0.046)
Ahn JM, et al. Am J Cardiol. 2014;113:1338-47
Meta-analysis of outcomes after IVUS vs angiographic-guided DES implantation (n=26,503 pts from 3 RCT and 14 observational studies)
0.01 100
Favors CAGFavors IVUS
0.1 1 10
Odd Ratio and 95% CI
Ahn JM et al. (2013)
Ahn SG et al. (2013)
Chen SL et al. (2012)
Chieffo A et al. (2013)
Claessen BE et al. (2011)
Hur SH et al. (2012)
Jakabcin J et al. (2010)
Kim JS et al. (2011)
Kim JS et al. (2013)
Kim SH et al. (2010)
Park KW et al. (2012)
Park SJ et al. (2009)
Roy P et al. (2008)
Witzenbichler B et al. (2013)
Yoon YW et al. (2013)
Youn YJ et al. (2011)
Random Effect Model
0.000
0.006
0.190
0.186
0.057
0.091
0.820
0.577
0.171
0.015
0.155
0.006
0.322
0.000
0.789
0.202
<0.001
p-Value
Secondary Outcomes
Even
ts (
%)
Hong SJ, et al. JAMA. 2015;314(20):. doi:10.1001/jama.2015.15454700 673 660 643 624
700 671 665 654 641
Number at risk:
Angiographyarm
IVUS arm
Pati
ents
Wit
h P
rim
ary
End
po
int
Even
t (M
AC
E, %
)
0
5
10
Time Since Randomization (Months)
0 3 6 9 12
2.9%
5.8%
IVUS-guided PCI
Angiography-guided PCI
IVUS-XPL: Clinical Outcomes at 1 YearIVUS-guidance Led to 50% Reduction in MACE,Driven by Reduction in TLR
Primary Outcome: MACE(Cardiac Death, Target-lesion MI,
Ischemia-driven TLR)
HR 0.48 (95% CI, 0.28-0.83)P=0.007
0.40.0
2.5
0.30.7
0.1
5.0
0.3
0
2
4
6
8
10
CardiacDeath
MI TLR ST
P=0.48 P=0.32 P=0.02 P=1.00
All P-values calculated by log-rank
Angiography-guided PCIIVUS-guided PCI
Ultimate Trial
• 1448 patients• IVUS vs angio-guided PCI• 12 month f/u• Composite of
Death/MI/TVR• 2.9% IVUS vs 5.4% Angio
Target vessel failure
Zhang JACC 2018
Stent Malapposition
• Stent expanded adequately, but not well apposed to wall
• Causes• Late thrombus resolution
• Positive remodeling
• Inadequate post-dilatation
• Undersized stent
• Large vessel/aneurysm
Circulation 2007;115:2426-2434
Stent Malappositionwell-tolerated?
Prati JACC Cardiovasc Imaging. 2015 Nov;8(11):1297
Illumien III
Results
Ali Z, Lancet 2016; 388:2618-28
Illumien III
OCT-guided PCI:
Conclusions from Ilumien III
• Superior to angio-guided but noninferior to IVUS-guided PCI for achieving stent expansion.
• Resulted in:
Fewest untreated major dissections and areas of major stent malapposition
More contrast use than IVUS (220 vs 190ml)
• Only use OCT when cine would be necessary anyway
Clinical outcomes pending Ilumien IV (3,650 pts)
IVUS vs OCTEuropean Heart Journal, May 2018 https://doi.org/10.1093/eurheartj/ehy285
Summary
• Angiography is inadequate to diagnose calcium and detect stent underexpansion/malapposition/dissection
• IVUS and OCT both provide imaging to guide your interventions and avoid stent regret