Intravascular Imaging Research Articles

Вплив результатів внутрішньосудинного дослідження на безпосередній результат стентування основного стовбура лівої коронарної артерії

The purpose of the study is to optimize the immediate results of stenting of the main trunk of the left coronary artery (LCA) in patients with coronary heart disease (CHD) using intravascular imaging methods and modern technological approaches.Materials and methods. We present the experience of 186 consecutive patients with coronary artery disease in whom stenting of the Left Main (LM) coronary artery was performed.Results. Patients were divided into 2 groups – group I, «historical» (100 patients), where the intervention was performed without the use of intravascular imaging methods and proximal optimization methods (POT), and group II, which consisted of 86 patients in whom LM stenting was performed using intravascular imaging and modern methods of optimizing the stented segment. In general, groups I and II were comparable. About 20 % of patients had an isolated LM lesion. In other cases, according to the results of coronary angiography, multivessel lesions of the coronary vessels were recorded in the patients. The localization of the lesion was defined as ostial in 7.5 %, stem – 6.9 %, and distal with the involvement of LAD&CX in 85.6 %. Stenting with 1 stent was used in 132 patients (71 % of cases).Analyzing the final size of the stented LM segment in the groups, we noticed, that in group I, this figure was 3.41±0.41 mm, while in group II it was 3.97±0.61 mm (p<0.0001). In 3 patients of group I in 30 day period cardiac death were recorded, in the group II there were 2 (2.3 %) cases of LM dissection treated with additional stent implantation.In 3 patients (3 %) group I sudden cardiac death was registered in the 30-day period. In group II, there were 2 (2.3 %) cases of ossification, which were resolved by additional stent implantation.Conclusions. Intravascular imaging to assess the size and results of the intervention, as well as the use of the POT technique, significantly improves the positioning of the stent in the artery and provides a significantly larger diameter of the stented LM. Adequate optimization of the size of the stented LM can be obtained only with the help of intravascular imaging methods.

Intravascular Imaging and Angiography Guidance in Complex Percutaneous Coronary Intervention Among Patients With Diabetes

Data are limited regarding the effects of intravascular imaging guidance during complex percutaneous coronary intervention (PCI) in patients with diabetes. To compare the clinical outcomes of intravascular imaging-guided vs angiography-guided complex PCI in patients with or without diabetes. This prespecified secondary analysis of a subgroup of patients in RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention), an investigator-initiated, open-label multicenter trial, analyzed enrolled patients who underwent complex PCI at 20 sites in Korea from May 2018 through May 2021. Eligible patients were randomly assigned in a 2:1 ratio to undergo either the intravascular imaging-guided PCI or angiography-guided PCI. Data analyses were performed from June 2023 to April 2024. Percutaneous coronary intervention was performed either under the guidance of intravascular imaging or angiography alone. The primary end point was target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization. Among the 1639 patients included in the analysis (mean [SD] age, 65.6 [10.2] years; 1300 males [79.3%]), 617 (37.6%) had diabetes. The incidence of TVF was significantly higher in patients with diabetes than patients without diabetes (hazard ratio [HR], 1.86; 95% CI, 1.33-2.60; P < .001). Among patients without diabetes, the intravascular imaging-guided PCI group had a significantly lower incidence of TVF compared with the angiography-guided PCI group (4.7% vs 12.2%; HR, 0.41 [95% CI, 0.25-0.67]; P < .001). Conversely, in patients with diabetes, the risk of TVF was not significantly different between the 2 groups (12.9% vs 12.3%; HR, 0.97 [95% CI, 0.60-1.57]; P = .90). There was a significant interaction between the use of intravascular imaging and diabetes for the risk of TVF (P for interaction = .02). Among patients with diabetes, only those with good glycemic control (hemoglobin A1c level ≤7.5%) and who achieved stent optimization by intravascular imaging showed a lower risk of future ischemic events (HR, 0.31; 95% CI, 0.12-0.82; P = .02). In this secondary analysis of a subgroup of patients in the RENOVATE-COMPLEX-PCI trial, intravascular imaging guidance reduced the risk of TVF compared with angiography guidance in patients without diabetes (but not in patients with diabetes) during complex PCI. In patients with diabetes undergoing complex PCI, attention should be paid to stent optimization using intravascular imaging and glycemic control to improve outcomes. ClinicalTrials.gov Identifier: NCT03381872.

Investigations of injection strategies to use heparinized normal saline instead of contrast media for intracoronary optical coherence tomography imaging.

The benefits of intravascular imaging-guided percutaneous coronary interventions (PCI) are well established. Intravascular imaging guidance improves short- and long-term outcomes, especially in complex PCI. Optical coherence tomography (OCT) has a higher resolution than intravascular ultrasound. However, the usage of OCT is mainly limited by the need to use contrast for flushing injections, which increases the risk of contrast-induced acute kidney injury, especially in patients with underlying chronic kidney disease. The aim of this study was to prove that flushing techniques with normal saline instead of contrast can be used in OCT imaging and can generate high-quality images. This prospective single-center observational study included patients with indications for OCT-guided PCI. For OCT pullbacks, heparinized saline was injected by an automatic pump injector at different rates, and additional extension catheters for selective coronary artery engagement were used at the operator's discretion. Recordings were made using the Ilumien Optis OCT system (Abbott) and the Dragonfly (Abbott) catheter and were analyzed at 1-mm intervals by two operators. Pullbacks were categorized as having optimal, acceptable, or unacceptable imaging quality. A clinically usable run was determined if >75% of the region of interest length was described as having optimal or acceptable imaging quality. A total of 32 patients were enrolled in the study; 47 different lesions were assessed before and after PCI. In total, 91.5% of runs were described as clinically suitable for use. Heparinized saline injections for OCT imaging are effective in generating good-quality OCT images suitable for clinical use.

Treatment of renal artery fibromuscular dysplasia with drug-eluting balloon angioplasty and intravascular imaging: a case report

Fibromuscular dysplasia (FD) is a segmental, non-inflammatory and non-atherosclerotic disease of vascular smooth muscle of unknown etiology, which leads to stenosis of smalland medium-sized arteries. The choice of surgical treatment tactics for renal artery FD depends on the severity of clinical manifestations and the response to the conservative drug treatment used. Young age, female sex, high blood pressure with failure to achieve target values with therapy, as well as the absence of atherosclerotic involvement of other arterial systems gives reason to suspect renal artery FD. According to modern guidelines, the invasive treatment of hemodynamically significant renal artery stenoses includes transluminal drug-eluting balloon angioplasty. In this disease, renal artery stenting is not recommended. However, stent implantation is required if balloon angioplasty did not give the optimal result or in case of periprocedural complications, such as arterial dissection. Open reconstructive surgery is indicated for complex anatomy of the related artery, macroaneurysms in which stent grafts are ineffective, refractory intimal fibroplastic lesions, increased risk of endovascular treatment, or after unsuccessful endovascular intervention. The article presents a case of a young patient with renal artery FD, renovascular arterial hypertension, who successfully underwent renal artery transluminal drugeluting balloon angioplasty.

The Usefulness of Intravascular Ultrasound and Optical Coherence Tomography in Patients Treated with Rotational Atherectomy: An Analysis Based on a Large National Registry.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve the clinical outcomes of percutaneous coronary interventions (PCIs) in selected subsets of patients. The aim was to investigate whether the use of OCT or IVUS during a PCI with rotational atherectomy (RA-PCI) will increase the odds for successful revascularization, defined as thrombolysis in myocardial infarction (TIMI) 3 flow. Data were obtained from the national registry of PCIs (ORPKI) maintained by the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The dataset includes PCIs spanning from January 2014 to December 2021. A total of 6522 RA-PCIs were analyzed, out of which 708 (10.9%) were guided by IVUS and 86 (1.3%) by OCT. The postprocedural TIMI 3 flow was achieved significantly more often in RA-PCIs guided by intravascular imaging (98.7% vs. 96.6%, p < 0.0001). Multivariable analysis revealed that using IVUS and OCT was independently associated with an increased chance of achieving postprocedural TIMI 3 flow by 67% (odds ratio (OR), 1.67; 95% confidence interval (CI): 1.40-1.99; p < 0.0001) and 66% (OR, 1.66; 95% CI: 1.09-2.54; p = 0.02), respectively. Other factors associated with successful revascularization were as follows: previous PCI (OR, 1.72; p < 0.0001) and coronary artery bypass grafting (OR, 1.09; p = 0.002), hypertension (OR, 1.14; p < 0.0001), fractional flow reserve assessment during angiogram (OR, 1.47; p < 0.0001), bifurcation PCI (OR, 3.06; p < 0.0001), and stent implantation (OR, 19.6, p < 0.0001). PCIs with rotational atherectomy guided by intravascular imaging modalities (IVUS or OCT) are associated with a higher procedural success rate compared to angio-guided procedures.

Experience with a novel high frequency optical coherence tomography device for intracoronary imaging: a case series.

Intravascular imaging, especially optical coherence tomography (OCT), has significantly improved percutaneous coronary intervention (PCI), yet its routine clinical application faces challenges. This case series introduces the Gentuity® High-Frequency Optical Coherence Tomography (HF-OCT), a novel device designed to enhance intracoronary imaging with a significantly faster pullback and smaller catheter size, potentially offering enhanced navigability in complex lesions. We aimed to assess the image quality of Gentuity® HF-OCT in complex vessel conditions, as well as presenting a case series to illustrate the application of the device in various clinical scenarios. In this case series, we included all patients who underwent intracoronary HF-OCT imaging at our center. The primary endpoint was image quality assessed by clear image length (CIL). Image quality was assessed in relation to (1) lesion severity assessed by minimum lumen area (MLA); (2) vessel size, differentiating between larger (diameter ≥ 4 mm) and smaller vessel segments; (3) pre- vs. post-PCI conditions, and (4) vessel tortuosity, categorized into none, moderate, and severe. Twenty-four HF-OCT runs from 14 patients were included. No significant differences in CIL were observed across lesion severity terciles (p = 0.449), between small and large vessel segments [mean CIL% difference 1.3%; confidence interval (CI), -9.3 to 11.8; p = 0.802], and pre- vs. post-PCI conditions (mean CIL difference -3.9 mm; CI, -14.0 to 6.1; p = 0.373). Vessel tortuosity significantly impacted image quality, with clear reductions in CIL observed in cases of moderate (74.8; CI, 73.5 to 76.0; vs. 63.9; CI, 56.2 to 71.5; p = 0.043) and severe tortuosity (74.8; CI, 73.5 to 76.0; vs. 65.0; CI, 62.1 to 67.9; p = 0.002) compared to vessels with no tortuosity. Overall, the HF-OCT demonstrated excellent catheter deliverability and crossability, with very satisfactory image quality and no significant adverse events. The Gentuity® HF-OCT is a new OCT device capable of navigating both small- and large-diameter vessels, with similar image quality, but vessel tortuosity seems to have an impact on image quality. It appears to be as usable as conventional OCT for pre-PCI diagnosis and OCT-guided PCI, potentially bringing additional benefits in terms of deliverability, lesion crossover and ease of use in routine clinical practice.

Optical coherence tomography imaging for the evaluation and treatment of calcified coronary artery disease

Coronary calcific disease represents one of the main challenges for the interventional cardiologist, for whom optimal lesion preparation and percutaneous coronary intervention optimization are paramount for correct management. In this perspective, intravascular imaging using optical coherence tomography (OCT) is becoming an increasingly indispensable tool. This work aims to provide a detailed overview of the complexity of calcified lesions, first analyzing their various morphologies and their clinical impact: spotty calcium seems to be more present in plaques at higher risk of destabilization, while diffuse calcification is typical of stable coronary stenosis; the eruptive calcific nodule is one of the three culprit lesion phenotypes responsible for acute coronary syndromes.In the second part of this review, the available technologies for the treatment of calcified lesions are described, with the aid of illustrative OCT images. Intravascular lithotripsy causes fractures at various levels of the calcified plaque, both circumferentially and longitudinally, with an improvement in vessel compliance; atherectomy acts by modifying the composition of the plaque with selective action on the hard calcific component. OCT, providing a comprehensive overview of lesion characteristics, can guide in the selection of the most appropriate therapeutic strategy, while also offering important information on the effectiveness of the chosen treatment.

Intravascular Ultrasound Assessment of Arterial Dissections Following Rotarex Atherectomy: Results of the iDissection Rotarex Study

BackgroundThere are limited data on the mechanism of the Rotarex Rotational Excisional Atherectomy System in treating femoropopliteal arterial disease. The Rotarex iDissection study is a prospective, single center study evaluating the extent of excision and dissection in de novo and restenotic (not in-stent) lesions of the femoropopliteal arteries in symptomatic peripheral arterial disease patients. MethodsConsecutive patients with symptomatic peripheral arterial disease were prospectively enrolled in the Rotarex iDissection study at a single US center after obtaining informed consent. The study was approved by a central ethics committee. Quantitative vascular angiography and intravascular ultrasound images were analyzed by an independent core laboratory. The Eagle Eye Platinum ST intravascular ultrasound (Phillips) was used to identify the depth (A, B, C for intima, media, and adventitia, respectively) and arc of dissections (1 and 2 for <180° and ≥180°, respectively) using the iDissection classification. Statistical significance was determined by a P value <.05. ResultsA total of 19 patients (20 procedures) were enrolled by 1 endovascular specialist. There were 57.9% men with mean age of 71.1 ± 9.6 years. Of the patients, 31.6% had diabetes mellitus, and 84.2% were current or past smokers. Thirty percent of treated vessels were chronic total occlusions. A total of 10 patients received stents (2 covered stents due to perforation, 6 due to National Heart, Lung, and Blood Institute Type C dissections, and 2 were primary stenting). Two distal embolizations occurred; one was attributed to the Rotarex, and both were treated with no adverse consequences. Angiographic baseline stenosis was 74.7% ± 25.6%; after Rotarex, 48.7% ± 14.8%; and after percutaneous transluminal angioplasty (PTA), 16.0% ± 6.2%. Baseline minimal lumen diameter was 1.0 ± 1.0 mm; after Rotarex, 2.4 ± 1.1 mm; and after PTA, 4.4 ± 1.0 mm. Angiographically, there was 1 type A dissection at baseline; 1 A, 1 B, and 2 C after Rotarex, and 3 A and 5 C after final adjunctive PTA. Intravascular ultrasound revealed a reference diameter of 6.2 ± 1.0 mm; 70% of patients had adventitial dissections. The mean arc of calcium was 221° ± 39.4° (moderate to severe calcium). ConclusionsThe Rotarex device is an effective atherectomy device in treating complex femoropopliteal arterial disease. A high frequency of adventitial dissections is seen with the Rotarex. The long-term outcomes of this finding need to be further studied.

A Descriptive Analysis of Intravascular Imaging Practices During Coronary Angiography Procedures Amongst NSTEACS Patients in New Zealand

A Descriptive Analysis of Intravascular Imaging Practices During Coronary Angiography Procedures Amongst NSTEACS Patients in New Zealand

A Descriptive Analysis of Intravascular Imaging Practices During Percutaneous Coronary Intervention Amongst Non-ACS Patients in New Zealand

A Descriptive Analysis of Intravascular Imaging Practices During Percutaneous Coronary Intervention Amongst Non-ACS Patients in New Zealand

Intravascular imaging as the key to successful coronary interventions: a case report

Intravascular imaging as the key to successful coronary interventions: a case report

Distinct Challenges of Eruptive and Non-Eruptive Calcified Nodules in Percutaneous Coronary Intervention.

To provide a summary of prevalence, pathogenesis, and treatment of coronary calcified nodules (CNs). CNs are most frequently detected at the sites of hinge motion of severely calcified lesions such as in the middle segment of right coronary artery and left main coronary bifurcation. On histopathology, CNs exhibit two distinctive morphologies: eruptive and non-eruptive. Eruptive CNs, which have a disrupted fibrous cap with adherent thrombi, are biologically active. Non-eruptive CNs, which have an intact fibrous cap without thrombi, are biologically inactive, representing either healed eruptive CNs or protrusion of calcium due to plaque progression. Recent studies using optical coherence tomography (OCT) have shown a difference in the mechanism of stent failure in the two subtypes, demonstrating early reappearance of eruptive CNs in the stent (at ~ 6months) as a unique mechanism of stent failure that does not seem to be preventable by simply achieving adequate stent expansion. The cause of CN reappearance in stent is not known and could be due to acute or subacute intrusion or continued growth of the CN. Whether modification of CN is needed, the most effective calcium modification modality and effectiveness of stent implantation in eruptive CNs has not been elucidated. In this review, we discuss pathogenesis of CNs and how intravascular imaging can help diagnose and manage patients with CNs. We also discuss medical and transcatheter therapies beyond conventional stent implantation for effective treatment of eruptive CNs that warrant testing in prospective studies.

Coronary Plaque Erosion: Epidemiology, Diagnosis, and Treatment.

Plaque erosion (PE), a distinct etiology of acute coronary syndromes (ACSs), is often overshadowed by plaque ruptures (PRs). Concerning its epidemiology, PE has garnered increasing recognition, with recent studies revealing its prevalence to be approximately 40% among ACS patients, challenging earlier assumptions based on autopsy data. Notably, PE exhibits distinct epidemiological features, preferentially affecting younger demographics, particularly women, and often manifesting as a non-ST-segment elevation myocardial infarction. There are seasonal variations, with PE events being less common in winter, potentially linked to physiological changes and cholesterol solidification, while peaking in summer, warranting further investigation. Moving to molecular mechanisms, PE presents a unique profile characterized by a lesser degree of inflammation compared to PR, with endothelial shear stress emerging as a plausible molecular mechanism. Neutrophil activation, toll-like receptor-2 pathways, and hyaluronidase 2 expression are among the factors implicated in PE pathophysiology, underscoring its multifactorial nature. Advancements in intravascular imaging diagnostics, particularly optical coherence tomography and near-infrared spectroscopy coupled with intravascular ultrasound, offer unprecedented insights into plaque composition and morphology. Artificial intelligence algorithms show promise in enhancing diagnostic accuracy and streamlining image interpretation, augmenting clinician decision-making. Therapeutically, the management of PE evolves, with studies exploring less invasive approaches such as antithrombotic therapy without stenting, particularly in cases identified early through intravascular imaging. Additionally, the potential role of drug-coated balloons in reducing thrombus burden and minimizing future major adverse cardiovascular events warrants further investigation. Looking ahead, the integration of advanced imaging modalities, biomarkers, and artificial intelligence promises to revolutionize the diagnosis and treatment of coronary PE, ushering in a new era of personalized and precise cardiovascular care.

Role of Lipid-Lowering and Anti-Inflammatory Therapies on Plaque Stabilization.

Atherosclerosis is the predominant underlying etiopathology of coronary artery disease. Changes in plaque phenotype from stable to high risk may spur future major adverse cardiac events (MACE). Different pharmacological therapies have been implemented to mitigate this risk. Over the last two decades, intravascular imaging modalities have emerged in clinical studies to clarify how these therapies may affect the composition and burden of coronary plaques. Lipid-lowering agents, such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors, were shown not only to reduce low-density lipoprotein levels and MACE but also to directly affect features of coronary plaque vulnerability. Studies have demonstrated that lipid-lowering therapy reduces the percentage of atheroma volume and number of macrophages and increases fibrous cap thickness. Future studies should answer the question of whether pharmacological plaque stabilization may be sufficient to mitigate the risk of MACE for selected groups of patients with atherosclerotic coronary disease.

Multivessel disease in patient with acute myocardial infarction: current treatment strategies and future perspectives

Patients who present with acute myocardial infarction (AMI) often suffer from coronary multivessel disease (MVD). This condition is associated with an increased mortality rate; it is, therefore, important to improve clinical outcomes through appropriate treatment strategies. Over the past decades, extensive research in AMI and MVD patients has consistently shown that complete revascularization is superior to treatment of the only culprit lesion. Another controversial issue concerns the most appropriate timing for percutaneous coronary intervention in non-culprit lesions. Fractional flow reserve (FFR) is considered the best method for identifying ischemic coronary lesions in the context of acute coronary syndromes, but the detection of vulnerable plaques in non-culprit vessels could further improve clinical outcomes. Intravascular imaging goes beyond physiology and it is potentially useful to recognize patients who are vulnerable, despite negative FFR. Therefore, we analyzed the most relevant studies that have investigated the relationship between physiological indexes and plaque vulnerability. However, ongoing trials aim to clarify how coronary physiology can be combined with the benefits of intracoronary imaging.

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The two identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The artificial intelligence model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to one of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our artificial intelligence model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the artificial intelligence-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

Late coronary artery injury following chemoradiotherapy for thymic carcinoma: a case report

IntroductionSurgery remains the primary treatment modality for thymic carcinoma, with adjuvant radiotherapy being recommended to effectively mitigate local recurrence and metastasis rates subsequent to incomplete or complete resection. Chemoradiotherapy has the potential to induce coronary artery occlusion, thereby potentially impacting patients’ long-term survival rates. The existing literature currently lacks comprehensive research on the lesion characteristics of coronary artery injury resulting from chemoradiotherapy.Case presentationThe male patient, aged 55, was admitted to the hospital due to recurrent chest tightness and pain persisting for one week. Notably, the patient had previously undergone curative resection surgery for thymic carcinoma seven years ago. After the surgical procedure, the patient underwent a course of adjuvant chemotherapy comprising docetaxel and platinum. 11 months later, imaging examination diagnosed tumor recurrence, and concurrent chemoradiotherapy was administered at a total dose of 62 Gy/31F for planning gross target volume (PGTV) and 54 Gy/31F for planning target volume (PTV) with 2 cycles of paclitaxel and cisplatin. Re-admission of the patient occurred after a 7-year interval subsequent to the completion of concurrent chemoradiotherapy, leading to a subsequent diagnosis of acute non-ST segment elevation myocardial infarction. Following administration of antiplatelet, anticoagulant, and anti-myocardial ischemia therapy, coronary angiography revealed the presence of a bifurcation lesion at the distal end of the left main trunk. Intravascular ultrasound (IVUS) examination demonstrated significant negative remodeling of both the main trunk and its branches at the bifurcation site, characterized by minimal atherosclerotic plaque components.ConclusionsChemoradiotherapy may induce damage to endothelial cells, resulting in an inflammatory response. Negative remodeling of blood vessels is likely to occur, primarily characterized by vasoconstriction but with less atherosclerotic plaque burden. Routine stent implantation in negatively remodeled areas may lead to vascular rupture, necessitating intravascular imaging examination.

Assessment of Coronary Stenoses for Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis of Randomized Trials

Evidence regarding the comparative efficacy of the different modalities to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available modalities guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses undergoing potential PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the GRADE approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (IQR 32.6%, 100%) acute coronary syndrome (ACS) participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared to coronary angiography (CA) (Risk ratio (RR) 0.68, 95% Confidence Interval (CI) 0.56, 0.82; high certainty), fractional flow reserve (FFR) (RR 0.73, 95%CI 0.58, 0.92; moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95%CI 0.49, 0.82; moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93; 95%CI 0.82, 1.06; moderate certainty) and iFR (RR 1.07, 95%CI 0.90, 1.28; moderate certainty) likely did not decrease the risk of MACE compared to CA. Intravascular imaging (IVI) may not be associated with a significant decrease in MACE compared to CA (RR 0.85; 95%CI 0.62, 1.17; low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared to CA, FFR and iFR in a mixed stable coronary disease and ACS population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.

Factors influencing coronary artery target lesion revascularization after drug-coated balloon angioplasty.

Concerns regarding restenosis after treatment with drug-coated balloons (DCB) remain. We aimed to identify the incidence of target lesion revascularization (TLR) and explore clinical, procedural, and other factors influencing it. Single-center retrospective analysis of a prospective cohort PCI registry study included 80 patients (100 lesions) who underwent successful DCB angioplasty between January 2020 and October 2023 and follow-up angiography within 2 years of either planned or unplanned reason. Incidence and factors associated with TLR were analyzed. Angiographic evaluation was conducted within a median of 151 days (interquartile range: 109 days). During index procedure, 54% were complex lesions. Intravascular imaging (IVI) was performed in 80% of lesions. TLR occurred in 11% of the lesions and was less frequent in the IVI group compared to the angiography-alone group [6.3 vs. 54.5%; odds ratio: 0.156, 95% confidence interval (CI): 0.042-0.580; p = 0.002]. No association was found between baseline and lesion characteristics, lesion complexity, plaque morphology, pre-dilatation procedure balloon type, maximal inflation pressure, or length of DCB between the groups (p > 0.05). Multivariate analysis revealed that IVI utilization was independently associated with a lower TLR rate (adjusted odds ratio: 0.116, 95% CI: 0.020-0.669; p = 0.016). In DCB angioplasty, only IVI use exhibited a significant difference in the TLR rate among baseline lesion characteristics and lesion preparation and was independently associated with a lower TLR rate.

PATIENT WITH CHRONIC CORONARY SYNDROME: USE OF MULTIMODAL IMAGING FOR CORRECT DIAGNOSIS AND TREATMENT

Abstract In the context of CCS, CCTA allows us to discriminate with almost certainty between patients with the absence of disease. In case of a positive test, the characteristics of the plaque allow to stratified risk of developing future events. In doubtful cases it is necessary to resort to a multimodal imaging strategy for the correct diagnosis. We present the case of a 63-year-old hypertensive and dyslipidemic man who started presenting two months ago episodes of asthenia associated with tachycardia and jugular constriction after taking the usual CCB therapy. With a pre-test probability of 26%, a CCTA scan was requested which highlighted a non-calcific fibrous plaque (Image 1) at the level of the middle circumflex inducing a moderate stenosis (Cad-Rads 3). The patient underwent coronary angiography which confirmed this lesion and also highlighted a similar one downstream of the first. (Image 2) The OCT evaluation showed: 7 mm eccentric fibrous proximal plaque with evidence of multiple intimal layers (Healed plaque) in its distal third and with evidence of a medial-intimal flap involving three quadrants in the proximal two thirds (270°), with current intact endothelium and presence of neo-angiogenesis; MLA 2.33 mm² and AS 70%. Picture compatible with healed spontaneous dissection of the vessel. (Image 3) The subsequent 12 mm concentric plaque (360° involvement of the vessel) had a predominantly lipid component with macrophages and fibrous cap of 60 µm, MLA of 2.3mm² and AS 72%. Panel compatible with high risk plaque. (Image 4) It was decided to implant a 3.5x26mm drug-eluting stent through OCT-guided PCI with final MSA of 7.62 mm², stent expansion of 81%, absence of dissections at the edges and residual distal edge plaque with MLA of 7.6 mm². (Image 5). Conclusions Healed plaques are more frequent in patients with CCS and represent a plaque complicated by medial-intimal ulceration subsequently healed by neo-endothelialization. On CCTA they appear as non-calcific fibrous plaques with an intermediate density expressed in Hounsfield Units but the definitive diagnosis can only be obtained using an Intravascular Imaging method (OCT in the case presented). The patient appears asymptomatic after resuming his usual antihypertensive therapy at 30-day FU.