role for evus and ivus in complex cli revascularisation...goals of presentation 1. discuss basic...
TRANSCRIPT
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Role for EVUS and IVUS in complex CLI revascularisation
Joseph Campbell, MD
Department of Cardiovascular Medicine
Cleveland Clinic
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Disclosure
Speaker name:Joseph Campbell, MD
.................................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
x I do not have any potential conflict of interest
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Goals of presentation
1. Discuss basic concepts regarding equipment selection and image interpretation
2. Review clinical utility of EVUS and IVUS in CLI revascularization
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Use of adjunctive imaging in CLI revascularization
IVUS:
➢Vessel sizing
➢Plaque morphology
➢Wire position
➢Complications
EVUS:
➢Safe access
➢Lesion crossing
➢Guide therapy
➢Complications
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EVUS
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Transducer selection
Linear array 5-9 MHz transducer
• Work horse probe for lower extremities
• Balance depth and spatial resolution
• Groin through mid tibial level
Linear array 8-15 MHz transducer
• Hockey stick probe
• Best near field spatial resolution
• Lose resolution with increasing depth
• Best for tibial vessels
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EVUS guided arterial access
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Use of EVUS for Antegrade CFA access
Added value of EVUS
➢ Precisely define femoral bifurcation
➢ Evaluate for plaque and calcium
➢ Help select access point
➢ Implication for vascular closure
➢ Single attempt anterior wall puncture
➢ Wire visualization
➢ EVUS-guided vascular closure
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EVUS-guided pedal access
Added value of EVUS➢ Diseased vessels
➢ Selection of access site➢ Calcium + plaque
➢ Hibernating lumen
➢ Optimal visualization of vessel
➢ Guide anterior wall puncture
➢ Underfilled vs. occluded vessels
➢ Often no flow with access
➢ Need to rely on US guidance
➢ May have CTO near access site
➢ US and fluoroscopy to guide wiring
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EVUS-guided intervention
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EVUS-guided puncture of CTO cap
Flush SFA occlusion Wire in SFA lumen
EVUS of femoral bifurcation
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EVUS-guided wiring
Both wires subintimal
Retrograde wire appeared to exit vessel
Retrograde
Antegrade
EVUS-guidance with 0.018 Astato
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US-guided knuckle wiring
Lesion crossing with wire loop
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Value of US guidance in Inframalleolar lesions
Concave CTO cap
US allows navigation through complex CTOs within true lumen of vessel
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US Laser Images
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IVUS
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Types of IVUS SystemsMechanical and Phased Array
Rotating Element
Drive Shaft
Phased Array
Mechanical
Multi-Element Array
❖ Single transducer rotates 1800 rotations per minute to generate image
❖ Higher resolution
❖ Multiple transducer elements combine image sectors to create one image
❖ Lower resolution
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What you see on IVUS
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Grayscale IVUS Corresponding MOVAT
Stained HistologyVH-IVUSTM
Medial Calcification
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Grayscale IVUS Corresponding MOVAT
Stained HistologyVH-IVUSTM
Calcification present within Plaque
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Grayscale IVUS Corresponding MOVAT
Stained HistologyVH-IVUSTM
Example Includes:
• Intimal thinning
• Intimal thickening
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IVUS images - Popliteal
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IVUS
True lumen
Subintimal channel
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IVUS-guided puncture of CTO cap
Diagnostic angiogram showing popliteal CTO
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Managing complications with IVUS
Poor outflow after stenting
Dissection
CFA IVUS
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Conclusions
• Both EVUS and IVUS are important tools that enhance the safety and efficacy of CLI revascularization
• Incorporating these technologies into routine practice does require some training and additional resources, but pays dividends in terms of optimizing patient outcomes in complex cases
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Role for EVUS and IVUS in complex CLI revascularisation
Joseph Campbell, MD
Department of Cardiovascular Medicine
Cleveland Clinic