Post on 07-May-2015
Jose Mª de la Torre HernandezUnidad de Cardiologia Intervencionista
Hospital Universitario Marques de ValdecillaSantander
IVUS/OCT como guía del intervencionismo
coronario
La importancia del diagnostico basal
Una angioplastia exitosa comienza por una adecuada indicación y un
correcto diagnostico
Lesiones Intermedias
Lesiones TRONCO
Lesiones Ostiales
Bifurcaciones
Segmentos con “flou”
Imagenes ambiguas
Re-estenosis
400 pts 400 pts
FFR IVUS
Centro-FFR vs. Centro-IVUSCentro-FFR vs. Centro-IVUS(De la Torre Hernandez, Lopez Palop, et al. )
FFR < 0.75MLA < 3,5 - 4 mm2 (based on vessel size) and PB > 50%
EuroIntervention. 2013 May 20.(Epub ahead of print)
11 estudios , incluyendo 2 en tronco (TC) (total N= 1759 pacientes, 1953 lesiones)
El corte ponderado medio fue 2.6 mm2 en estudios no-TC y de
5.5 mm2 en estudios en TC
En lesiones no-TC, el ALM mostro:Sensibilidad = 79%Especificidad = 65%
En lesiones de TC el ALM mostro: Sensibilidad = 90%Especificidad = 90%
11 estudios , incluyendo 2 en tronco (TC) (total N= 1759 pacientes, 1953 lesiones)
El corte ponderado medio fue 2.6 mm2 en estudios no-TC y de
5.5 mm2 en estudios en TC
En lesiones no-TC, el ALM mostro:Sensibilidad = 79%Especificidad = 65%
En lesiones de TC el ALM mostro: Sensibilidad = 90%Especificidad = 90%
Precision diagnostica del ALM obtenido por IVS comparado con el FFR
- Meta-analisis -
Precision diagnostica del ALM obtenido por IVS comparado con el FFR
- Meta-analisis -
FFR Significacion
IVUS Presencia de placaCantidad de placaReduccion luminalCalcioMorfologia (complicada ?)Remodelado Extension enfermedad (vaso total)
Lesiones intermediasFFR-Estenosis bien definidas 40-70%IVUS-Lesiones irregulares (ulceradas, disecadas...)-Defectos contrastacion (nodulares, lineales…)-Posibles artefactos (ostium tronco, ostium CD…)-No bien visualizables (tri-bifurcaciones, superposiciones de ramas,…)
Luz minima ?Significativo ???
ALM = 3 mm2
ALM = 3 mm2
ALM = 6 mm2
TC
Proximal DA
Proximal CxJasti et al. Circulation 2004;110:2831-6
Linear law (epicardial coronary artery)
Do = 0.678*(D1+D2)
Finet G et al. Eurointervention 2007;3:10-17
De la Torre et al. J Am Coll Cardiol 2011;58(4):351-8
Validación prospectiva de ALM = 6 mm2 como corte para revascularizacion del TC en nuestra población
354 pacientes en 22 centros
En que nos ayuda el IVUS para mejorar los resultados de la ICPEn que nos ayuda el IVUS para mejorar los resultados de la ICP
Hematoma
Hallazgos de IVUS en el stent
Enf. bordes
Rotura stentProlapso placa
Subexpansion AposicionIncompleta
Diseccionen margenes
Problemas mas comunes
Diseccion bordeSubexpansionAposicion Incompleta
IVUS en reestenosis de BMS/DES : ImplicacionesImplicaciones TerapeuticasTerapeuticas
Predomina
Subexpansion
Predomina
Prolif. intimal
Fractura
stent
IVUS Predictores de Trombosis y Reestenosis precoz con BMS
Trombosis precoz
Reestenosis
SubexpansionSubexpansion •Cheneau et al. Circulation 2003;108:43-7
•Kasaoka et al. J Am Coll Cardiol 1998;32:1630-5•Castagna et al. AHJ 2001;142:970-4•de Feyter et al. Circulation 1999;100:1777-83•Sonoda et al. J Am Coll Cardiol 2004;43:1959-63•Morino et al. Am J Cardiol 2001;88:301-3•Ziada et al. Am Heart J 2001;141:823-31•Doi et al. JACC Cardiovasc Interv. 2009;2:1269-75
Problemas de borde Problemas de borde (“geographic miss”, carga de (“geographic miss”, carga de placa alta, disecciones,… etc)placa alta, disecciones,… etc)
•Cheneau et al. Circulation 2003;108:43-7
•Sakurai et al. Am J Cardiol 2005;96:1251-3•Liu et al. Am J Cardiol 2009;103:501-6
Longitud stentLongitud stent •Kasaoka et al. J Am Coll Cardiol 1998;32:1630-5•de Feyter et al. Circulation 1999;100:1777-83
Impacto de la longitud de lesion y area minima intrastent sobre la reestenosis
de Feyter et al. Circulation 1999;100:1777-83de Feyter et al. Circulation 1999;100:1777-83
Final Minimum Stent Area (mm2)
Stent L
ength
(mm
)Res
ten
osi
s (%
)
**
**
*
**
* **
** *
***
******
*
**
**
.1 1 10
TULIP
DIPOL
Gaster
RESIST
SIPS
AVID
OPTICUS
Favors Non-IVUSFavors IVUS Odds Ratio
Combined (RE)Combined (FE)
MACE
Meta-analisis de Trials IVUS vs Angiografia en implantacion de BMS (n=2.193 pts)
El uso de IVUS se asocio a menos:•Reestenosis Angiografica •(22.2% vs. 28.9%; p=0.02)•Revascularizacion Repetida (12.6% vs. 18.4%; p=0.004)•MACE •(19.1% vs. 23.1%; p=0.03)
Parise et al. Am J Cardiol. 2011;107:374-82
Predictores en IVUS para trombosis y reestenosis de DES
Trombosis precoz Reestenosis
SubexpansionSubexpansion •Fujii et al. J Am Coll Cardiol 2005;45:995-8)•Okabe et al., Am J Cardiol. 2007;100:615-20•Liu et al. JACC Cardiovasc Interv. 2009;2:428-34•Choi et al. Circ Cardiovasc Interv 2011;4:239-47
•Sonoda et al. J Am Coll Cardiol 2004;43:1959-63•Hong et al. Eur Heart J 2006;27:1305-10•Doi et al JACC Cardiovasc Interv. 2009;2:1269-75•Fujii et al. Circulation 2004;109:1085-1088•Kang et al. Circ Cardiovasc Interv 2011;4:9-14•Choi et al. Am J Cardiol 2012;109:455-60•Song et al. Catheter Cardiovasc Interv, in press
Problemas de borde Problemas de borde (“geographic miss”, (“geographic miss”, carga de placa alta, carga de placa alta, disecciones,… etc)disecciones,… etc)
•Fujii et al. J Am Coll Cardiol 2005;45:995-8•Okabe et al., Am J Cardiol. 2007;100:615-20•Liu et al. JACC Cardiovasc Interv. 2009;2:428-34•Choi et al. Circ Cardiovasc Interv 2011;4:239-47
•Sakurai et al. Am J Cardiol 2005;96:1251-3•Liu et al.Am J Cardiol 2009;103:501-6•Costa et al, Am J Cardiol, 2008;101:1704-11
Predictores-IVUS de reestenosis con DES
Hong et al Eur Heart J 2006;27:1305-10
> 40 > 40 < 40< 40
< 5.5< 5.5
> 5.5> 5.5
Comparado con angiografia, el uso de IVUS en el implante de DES se asocio a menos:
Muerte (HR: 0.58, 95% CI: 0.47-0.71, p<0.001)
MACE(HR: 0.85, 95% CI: 0.76-0.95, p=0.005)
Trombosis de Stent(HR: 0.62, 95% CI: 0.46-0.83, p=0.002)
No efecto en IM
No efecto en TLR
Study Year Death HR (95% CI) Weight %
0.10.1
.1.1
11
1010
100100
Favors IVUS Favors Non-IVUS
P Roy SJ Park SH Kim
J Jakabcin JS Kim
BE Claessen SH Hur
K Ahmed Overall
20082009201020102011201120112011
20082009201020102011201120112011
0.81 (0.55, 1.20)0.39 (0.15, 1.02)0.21 (0.06, 0.73)
1.50 (0.15, 15.42)0.58 (0.21, 1.61)0.74 (0.37, 1.47)0.49 (0.35, 0.69)0.49 (0.28, 0.86)0.58 (0.47, 0.71)
0.81 (0.55, 1.20)0.39 (0.15, 1.02)0.21 (0.06, 0.73)
1.50 (0.15, 15.42)0.58 (0.21, 1.61)0.74 (0.37, 1.47)0.49 (0.35, 0.69)0.49 (0.28, 0.86)0.58 (0.47, 0.71)
28.004.762.800.804.219.1936.3813.86
100.00
28.004.762.800.804.219.1936.3813.86
100.00
MACE
0.10.1
.1.1
11
1010
100100
Favors IVUS Favors Non-IVUS
P Agostoni P Roy
SJ Park J Jakabcin
JS Kim BE Claessen
SH Hur K Ahmed
Overall
20052008200920102011201120112011
20052008200920102011201120112011
0.40 (0.05, 2.91)0.90 (0.71, 1.15)0.64 (0.39, 1.05)0.92 (0.37, 2.28)0.73 (0.44, 1.20)0.77 (0.56, 1.06)0.76 (0.62, 0.93)1.07 (0.86, 1.33)0.85 (0.76, 0.95)
0.40 (0.05, 2.91)0.90 (0.71, 1.15)0.64 (0.39, 1.05)0.92 (0.37, 2.28)0.73 (0.44, 1.20)0.77 (0.56, 1.06)0.76 (0.62, 0.93)1.07 (0.86, 1.33)0.85 (0.76, 0.95)
0.3120.595.091.494.9512.0329.7525.76
100.00
0.3120.595.091.494.9512.0329.7525.76
100.00
Stent Thrombosis
0.10.1
.1.1
11
1010
100100
Favors IVUS Favors Non-IVUS
P Roy SJ Park
J Jakabcin SH Kim
BE ClaessenJS Kim SH Hur
Overall
2008200920102010201120112011
2008200920102010201120112011
0.59 (0.39, 0.89) 3.00 (0.12, 76.85)0.67 (0.15, 3.00)0.28 (0.06, 1.28)0.60 (0.10, 3.51)0.33 (0.04, 2.96)0.72 (0.44, 1.17)0.62 (0.46, 0.83)
0.59 (0.39, 0.89) 3.00 (0.12, 76.85)0.67 (0.15, 3.00)0.28 (0.06, 1.28)0.60 (0.10, 3.51)0.33 (0.04, 2.96)0.72 (0.44, 1.17)0.62 (0.46, 0.83)
50.500.823.823.732.751.7936.59
100.00
50.500.823.823.732.751.7936.59
100.00
Zhang et al. Eurointervention, 2012;8:855-65
Meta-Analisis de estudios (n=19.619)
EuroIntervention 2012;8: published online ahead of print October 2012 EuroIntervention 2012;8: published online ahead of print October 2012
EstudiosconPropensityMatching
EstudiosconPropensityMatching
Estudiossin tronconi SCA
Estudiossin tronconi SCA
Eventos Clinicos a 12 meses
Constantini et al TCT 2008
IVUS mejora resultados clinicos
RESET trialEn el subgrupo de lesiones largas ( ≥28mm
longitud stent en vasos ≥2.5mm), los pacientes se randomizaron a IVUS vs solo angiografia
Kim JS, JACC Cardiovasc Interv. 2013 Apr;6(4):369-76.
IVUS-guidance
Angiography-guidance
RR p
N 297 246
MACE (cardiac death, MI, ST, TVR)
4.0% 8.1% 0.48 (0.23-0.99) 0.048
Patel Y. Am J Cardiol 2012;109:960
225 patients with 233 coronary ostial lesions underwent PCI with (n = 82) and without (n = 143) IVUS guidance.
After propensity score adjustment, IVUS use was associated with significantly lower rates of the composite of cardiovascular death, MI, or TLR, composite MI or TLR and MI compared with no IVUS.
The use of IVUS was also associated with a trend towards a lower rate of TLR.
Conclusions: PCI of coronary ostial lesions with the use of IVUS was associated with significantly lower rates of adverse cardiac events
225 patients with 233 coronary ostial lesions underwent PCI with (n = 82) and without (n = 143) IVUS guidance.
After propensity score adjustment, IVUS use was associated with significantly lower rates of the composite of cardiovascular death, MI, or TLR, composite MI or TLR and MI compared with no IVUS.
The use of IVUS was also associated with a trend towards a lower rate of TLR.
Conclusions: PCI of coronary ostial lesions with the use of IVUS was associated with significantly lower rates of adverse cardiac events
Randomized, multicentre, international, open label, investigator-driven study evaluating IVUS vs angiographically guided DES implantation in patients with
complex lesions (defined as bifurcations, long lesions, chronic total occlusions or small vessels).
The study included 284 patients.The primary study end point (MLD stent) showed a statistically significant difference in favor of the IVUS group (2.70 mm ± 0.46 mm vs. 2.51 ± 0.46 mm; P = .0002). At 24-months clinical follow-up, no differences were still observed in cumulative MACE (16.9%vs. 23.2 %)
CONCLUSIONS:A benefit of IVUS optimized DES implantation was observed in complex lesions in the post-procedure minimal lumen diameter. No statistically significant difference was found in MACE up to 24 months
Randomized, multicentre, international, open label, investigator-driven study evaluating IVUS vs angiographically guided DES implantation in patients with
complex lesions (defined as bifurcations, long lesions, chronic total occlusions or small vessels).
The study included 284 patients.The primary study end point (MLD stent) showed a statistically significant difference in favor of the IVUS group (2.70 mm ± 0.46 mm vs. 2.51 ± 0.46 mm; P = .0002). At 24-months clinical follow-up, no differences were still observed in cumulative MACE (16.9%vs. 23.2 %)
CONCLUSIONS:A benefit of IVUS optimized DES implantation was observed in complex lesions in the post-procedure minimal lumen diameter. No statistically significant difference was found in MACE up to 24 months
Outcomes in 145 propensity-matched pairs of patients receiving DES with and without IVUS guidance
Park S et al. Circ Cardiovasc Interv 2009;2:167-177
The Korean experience
IVUS guidance decreased mortality
Mortality
Death + MI TVR
Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled
analysis at patient level of 4 registries.
Jose M de la Torre Hernandez, MD, PhD, José Antonio Baz Alonso, MD, Joan Antoni Gómez Hospital, MD, PhD, Fernando Alfonso, MD, PhD, Tamara Garcia Camarero,
MD, Federico Gimeno de Carlos, MD, PhD, Gerard Roura Ferrer, MD, Angel Sanchez Recalde, MD, Íñigo Lozano Martínez-Luengas, MD, PhD, Josep Gomez Lara, MD, Felipe Hernandez, MD, María José Pérez-Vizcayno, MD, Angel Cequier Fillat, MD,
PhD, Armando Perez de Prado, MD, Agustín Albarrán, MD, Manuel Jimenez Navarro, MD, PhD, Josepa Mauri, MD, Jose A Fernandez Diaz, MD, Eduardo Pinar, MD, PhD,
Javier Zueco, MD
on behalf of the collaborative IVUS-TRONCO-ICP Spanish study
Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled
analysis at patient level of 4 registries.
Jose M de la Torre Hernandez, MD, PhD, José Antonio Baz Alonso, MD, Joan Antoni Gómez Hospital, MD, PhD, Fernando Alfonso, MD, PhD, Tamara Garcia Camarero,
MD, Federico Gimeno de Carlos, MD, PhD, Gerard Roura Ferrer, MD, Angel Sanchez Recalde, MD, Íñigo Lozano Martínez-Luengas, MD, PhD, Josep Gomez Lara, MD, Felipe Hernandez, MD, María José Pérez-Vizcayno, MD, Angel Cequier Fillat, MD,
PhD, Armando Perez de Prado, MD, Agustín Albarrán, MD, Manuel Jimenez Navarro, MD, PhD, Josepa Mauri, MD, Jose A Fernandez Diaz, MD, Eduardo Pinar, MD, PhD,
Javier Zueco, MD
on behalf of the collaborative IVUS-TRONCO-ICP Spanish study
De la Torre et al. JACC Intv. 2013 (Accepted, in press)De la Torre et al. JACC Intv. 2013 (Accepted, in press)
Registries pooled: Pts with DES in LM: F up:ESTROFA-LM (770 pts in 21 centers) 3 yrs
RENACIMIENTO (596 pts in 30 centers) 1 yr
Bellvitge (189 pts in 1 center) 3 yrs
Valdecilla (200 pts in 1 center) 3 yrs
1.670 patients with PCI with DES in LM
505 patients under IVUS guidance (IVUS group)
Propensity score matched to:
505 patients without the use of IVUS (no-IVUS group)
Registries pooled: Pts with DES in LM: F up:ESTROFA-LM (770 pts in 21 centers) 3 yrs
RENACIMIENTO (596 pts in 30 centers) 1 yr
Bellvitge (189 pts in 1 center) 3 yrs
Valdecilla (200 pts in 1 center) 3 yrs
1.670 patients with PCI with DES in LM
505 patients under IVUS guidance (IVUS group)
Propensity score matched to:
505 patients without the use of IVUS (no-IVUS group)
LM distal subgroupLM distal subgroup
LM distal-2 stents subgroupLM distal-2 stents subgroup
Meta-analysis
0,1 1 10
Odds ratio
RENACIMIENTO (1yr)
ESTROFA-LM (3 yrs)
Valdecilla (3 yrs)
Bellvitge (3 yrs)
Total (fixed effects)
Total (random effects)
IVUS better Angio betterIVUS better Angio better
Overall population
HR 95% CI pIVUS 0.70 0.52 – 0.99 0.04Age 1.03 1.01 – 1.05 0.0001LVEF 0.98 0.97 – 0.99 0.01Diabetes 1.81 1.32 – 2.47 0.0002Distal LM with 2 stents 2.23 1.44 – 3.48 0.0004ACS 1.84 1.30 – 2.60 0.0006
Subgroup with distal LM disease
HR 95% CI pIVUS 0.54 0.34 – 0.90 0.02Age 1.02 1.004 – 1.05 0.02Diabetes 1.62 1.02 – 2.59 0.04Distal LM with 2 stents 2.86 1.71 – 4.77 0.0001ACS 1.95 1.14 – 3.31 0.01
Predictors of adverse outcome(Cardiac death, MI, TLR)
BifurcacionesOstialesLargas TroncoOTC
Fallo RenalDiabetes FE deprimidaLimitaciones a terapia antiagregante
Cuando hacer IVUS trae cuenta
Angiografia confusa, no clara, flou,.... “La angio no resulta del todo correcta ....”
Lesiones Intermedias
Tronco
Ostiales
Bifurcaciones
“Flou”
Ambiguas
Reestenosis
ICP
Basal Optimizacion ICP
Tomografia de coherencia optica
Placa fibrosa TCFA Placa calcificadaPlaca fibrosa TCFA Placa calcificada
Gonzalo N, J Am Coll Cardiol. 2012 Mar 20;59(12):1080-9Gonzalo N, J Am Coll Cardiol. 2012 Mar 20;59(12):1080-9
Erosión / Disección endotelioDisecciones
Gran diseccion(hematoma)
Trombo RojoTrombo Rojo
Masa que protruye Masa que protruye con sombracon sombra
Trombo BlancoTrombo Blanco
Masa que protruye Masa que protruye sin sombrasin sombra
Sensibilidad: 95%Especificidad: 88%
Diseccionesborde
Diseccionesintrastent
Prolapsotisular
Aposicionincompleta
Mas sensibilidad para hallazgos
STENTS: implante
Gonzalo N, Heart. 2009;95:1913-9Gonzalo N, Heart. 2009;95:1913-9
Kato K et al. ACC 2013Kato K et al. ACC 2013
BIFURCACIONESBIFURCACIONES
Reestenosis de DESMecanismos y opciones de Tx
Reestenosis de DESMecanismos y opciones de Tx
SubexpansionProliferacion intimalFractura stent
SubexpansionProliferacion intimalFractura stent
11
2233
11
22
33
Trombosis a los 7 añosde un DES
Trombosis a los 7 añosde un DES
Neo-aterosclerosisNeo-aterosclerosis
Trombosis de DESMecanismosOpciones de Tx
Trombosis de DESMecanismosOpciones de Tx
Falta de cobertura initmalFalta de cobertura initmal
Trombosis a los 3 mesesde un DES
Trombosis a los 3 mesesde un DES
Estudio DES en el seguimiento
DES: cobertura intimal y aposicion
Tamaño real de la placa o del vaso ?
Carga de placa ? Distribucion de la placa ?Remodelado del vaso ?
?
?
EuroIntervention 2012;8: published online ahead of print October 2012 EuroIntervention 2012;8: published online ahead of print October 2012
Methods
• Consecutive patients undergoing PCI with angiographic plus OCT guidance (OCT group) at three high OCT-volume Italian centers between 2009 and 2011 were included.
• Patients in the OCT group (335 pts) were matched 1:1 with randomly-selected patients undergoing during the same month PCI with angiographic only guidance Angio group (335 pts).
Stent malapposition • > 200 µ• lenght > 600 µ
Edge dissection• > 200 µ• lenght > 600 µ
Under-expansion
In-stent MLA ≥90% of the average reference lumen area or ≥100% of lumen area of the reference segment with the lowest lumen area
Thrombus• > 200 µ• lenght > 600 µ
Absence of residual stenosisadjacent to stent endings (MLA <4.0 mm2)
Distal ProxMSA
MLA <4.0 mm2 MLA <4.0 mm2
Aleatorizados a:IVUS = 35 pacOCT = 35 pac
Aleatorizados a:IVUS = 35 pacOCT = 35 pac
Conclusions: FD-OCT guidance for stent implantation was associated with smaller stent expansion and more frequent significant residual
reference segment stenosis compared with conventional IVUS guidance
Conclusions: FD-OCT guidance for stent implantation was associated with smaller stent expansion and more frequent significant residual
reference segment stenosis compared with conventional IVUS guidance
Aun reconociendo la limitada evidencia con IVUS, aun mas limitada con OCT, ambas mejoran:
- La indicación de la ICP
- Los resultados “mecánicos” inmediatos y muy probablemente los clínicos, especialmente en lesiones de riesgo(Tronco, Bifurcaciones, Reestenosis,...)
Aun reconociendo la limitada evidencia con IVUS, aun mas limitada con OCT, ambas mejoran:
- La indicación de la ICP
- Los resultados “mecánicos” inmediatos y muy probablemente los clínicos, especialmente en lesiones de riesgo(Tronco, Bifurcaciones, Reestenosis,...)
EN CONCLUSIÓN