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IVUS Guidance Improves Outcomes in Unprotected Left Main PCI
1. Jose Mª de la Torre Hernandez
Unidad de Cardiologia Intervencionista
Hospital Universitario Marques de Valdecilla
Santander
IVUS/OCT como guía del
intervencionismo
coronario
2.
3.
4. La importancia del
diagnostico basal
Una angioplastia exitosa comienza por
una adecuada indicación y un
correcto diagnostico
6. 400 pts 400 pts
FFR IVUS
Centro-FFR vs. Centro-IVUSCentro-FFR vs. Centro-IVUS
(De la Torre Hernandez, Lopez Palop, et al. )
FFR < 0.75
MLA < 3,5 - 4 mm2
(based on vessel size) and PB > 50%
EuroIntervention. 2013 May 20.
(Epub ahead of print)
7. 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 -
8. FFR Significacion
IVUS Presencia de placa
Cantidad de placa
Reduccion luminal
Calcio
Morfologia (complicada ?)
Remodelado
Extension enfermedad (vaso total)
9.
10.
11. Lesiones intermedias
FFR
-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,…)
13. ALM = 3 mm2
ALM = 3 mm2
ALM = 6 mm2
TC
Proximal DA
Proximal Cx
Jasti 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
14. 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
15. En que nos ayuda el IVUS para
mejorar los resultados de la ICP
16. Hematoma
Hallazgos de IVUS en el stent
Enf.
bordes
Rotura stent
Prolapso placa
Subexpansion Aposicion
Incompleta
Diseccion
en margenes
18. IVUS en reestenosis de BMS/DES :
ImplicacionesImplicaciones TerapeuticasTerapeuticas
Predomina
Subexpansion
Predomina
Prolif. intimal
Fractura
stent
19. 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 bordeProblemas 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
20. 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 Length
(m
m
)
Restenosis(%)
*
*
*
*
*
*
*
* *
*
*
* *
*
*
*
*
*
**
*
*
*
*
*
*
*
21. .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
22. 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 bordeProblemas 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
35. RESET trial
En 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
37. 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
38. 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
39.
40. 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
41. 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)
42. 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)
55. Trombo RojoTrombo Rojo
Masa que protruyeMasa que protruye
con sombracon sombra
Trombo BlancoTrombo Blanco
Masa que protruyeMasa que protruye
sin sombrasin sombra
Sensibilidad: 95%
Especificidad: 88%
68. 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).
70. 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
77. Aleatorizados a:
IVUS = 35 pac
OCT = 35 pac
Aleatorizados a:
IVUS = 35 pac
OCT = 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
78. 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