Intravascular Ultrasound Guidance Research Articles

Intravascular Ultrasound-Guided Implantation of Drug-Eluting Stents to Improve Outcome: A Meta-Analysis

The aim of this study was to systematically review and perform a meta-analysis of randomized trials and observational studies of intravascular ultrasound (IVUS)-guided versus angiography-guided implantation of drug-eluting stents (DES). Although studies in the bare-metal stents era suggested that there were clinical benefits to IVUS guidance, it is still controversial whether percutaneous coronary intervention (PCI) with DES guided by IVUS leads to better clinical outcomes. Relevant studies published through March 31, 2013, were searched for and identified in the electronic databases. Summary estimates were obtained using a random-effects model. From 138 initial citations, 3 randomized trials and 12 observational studies with 24,849 patients (11,793 IVUS-guided and 13,056 angiography-guided) were included in this study. Comparison of IVUS- versus angiography-guided PCI disclosed odds ratios (ORs) for major adverse cardiac events of 0.79 (95% confidence interval [CI]: 0.69 to 0.91; p= 0.001). IVUS-guided PCI was also associated with significantly lower rates of all-cause mortality (OR: 0.64; 95% CI: 0.51 to 0.81; p< 0.001), myocardial infarction (OR: 0.57; 95% CI: 0.42 to 0.78; p < 0.001), target vessel revascularization (OR: 0.81; 95% CI: 0.68 to 0.95; p= 0.01), and stent thrombosis (OR: 0.59; 95% CI: 0.42 to 0.82; p= 0.002). Ameta-analysis of propensity-matched studies demonstrated similar results in terms of clinical outcomes, but not repeat revascularization. IVUS-guided DES implantation is associated with significantly lower rates of adverse clinical events compared with angiography guidance. Further study is needed to clarify which subgroups of subjects with IVUS guidance will have greater benefit.

Combination therapy of eicosapentaenoic acid and pitavastatin for coronary plaque regression evaluated by integrated backscatter intravascular ultrasonography (CHERRY study)—Rationale and design

Background and purposeMany clinical trials have shown that 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) can significantly reduce coronary artery disease in both primary and secondary prevention. A recent study showed that aggressive lipid-lowering therapy with strong statins could achieve coronary artery plaque regression, as evaluated with gray-scale intravascular ultrasound (IVUS). However, it is unknown whether coronary plaque regression and stabilization are reinforced when eicosapentaenoic acid (EPA) is used with a strong statin. Methods and subjectsWe aim to assess patients with stable angina or acute coronary syndrome who had undergone successful percutaneous coronary intervention (PCI) with integrated backscatter IVUS (IB-IVUS) guidance. They will be randomly allocated to receive pitavastatin (4mg), or pitavastatin (4mg) plus EPA (1800mg), and prospectively followed for 6–8 months. ResultsThe primary endpoint will be changes in tissue characteristics in coronary plaques, evaluated by IB-IVUS, and secondary endpoints will include absolute changes in coronary plaque volume, serum lipid levels, and inflammatory markers. The safety profile will also be evaluated. ConclusionsThe combination therapy of EPA and pitavastatin for regression of coronary plaque evaluated by IB-IVUS (CHERRY) study will be the first multicenter study using IB-IVUS to investigate the effects of combination therapy with pitavastatin and EPA on coronary plaque volume and tissue characteristics.

Relationship Between Intravascular Ultrasound Guidance and Clinical Outcomes After Drug-Eluting Stents

Background— Prior small to modest-sized studies suggest a benefit of intravascular ultrasound (IVUS) guidance in noncomplex lesions. Whether IVUS guidance is associated with improved clinical outcomes after drug-eluting stent (DES) implantation in an unrestricted patient population is unknown. Methods and Results— Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) was a prospective, multicenter, nonrandomized “all-comers” study of 8583 consecutive patients at 11 international centers designed to determine the frequency, timing, and correlates of stent thrombosis and adverse clinical events after DES. Propensity-adjusted multivariable analysis was performed to examine the relationship between IVUS guidance and 1-year outcomes. IVUS was utilized in 3349 patients (39%), and larger-diameter devices, longer stents, and/or higher inflation pressures were used in 74% of IVUS-guided cases. IVUS guidance compared with angiography guidance was associated with reduced 1-year rates of definite/probable stent thrombosis (0.6% [18 events] versus 1.0% [53 events]; adjusted hazard radio, 0.40; 95% confidence interval, 0.21–0.73; P =0.003), myocardial infarction (2.5% versus 3.7%; adjusted hazard radio, 0.66; 95% confidence interval, 0.49–0.88; P =0.004), and composite adjudicated major adverse cardiac events (ie, cardiac death, myocardial infarction, or stent thrombosis) (3.1% versus 4.7%; adjusted hazard radio, 0.70; 95% confidence interval, 0.55–0.88; P =0.002). The benefits of IVUS were especially evident in patients with acute coronary syndromes and complex lesions, although significant reductions in major adverse cardiac events were present in all patient subgroups those with including stable angina and single-vessel disease. Conclusions— In ADAPT-DES, the largest study of IVUS use to date, IVUS guidance was associated with a reduction in stent thrombosis, myocardial infarction, and major adverse cardiac events within 1 year after DES implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00638794.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention

Background/AimsWhile drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI.MethodsIn all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated.ResultsThere was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE.ConclusionsIn patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

Correlation of intravascular ultrasound and computed tomography scan measurements for placement of intravascular ultrasound-guided inferior vena cava filters

The single puncture intravascular ultrasound (IVUS)-guided bedside placement of inferior vena cava (IVC) filters has been shown to be an effective technique. The major disadvantage of this procedure is a steep learning curve that can lead to an increased risk of filter malposition. In an effort to increase the safety and efficacy of IVUS-guided bedside IVC filter placement, we proposed that preoperative planning could reduce the incidence of IVUS-guided filter malpositions. As a first step, we examined the correlation between preoperative abdominal computed tomography (CT) scan measurements and intraprocedural IVUS derived measurements of vena cava anatomy and its surrounding structures. As a second step, we attempted to determine the safety of this protocol by assessing the incidence of malposition. A retrospective review of prospectively collected data was performed on all patients receiving bedside IVUS-guided filters from July 1, 2010 to August 31, 2011. Measurements of the IVC length from the atrial-IVC junction to the midportion of the crossing right renal artery, the lowest renal vein, and iliac vein confluence were obtained prior to IVC filter placement by both CT-based measurement, as well as intraprocedural IVUS pullback lengths. Regression analysis (significant for P < .05) was used to determine the correlation between these imaging modalities. Forty-six patients had adequate CT scans available to perform the analysis and were candidates for bedside IVUS-guided IVC filter placement. All IVUS-guided filters were placed using a single puncture technique with the Cook Celect Filter. This study found there was a close correlation between IVUS and CT derived measurements of the right atrium to right renal artery distance, lowest renal vein distance, and iliac confluence distance. In addition, we found that the IVUS distances from the atrial-IVC junction to the right renal artery and lowest renal vein were statistically similar. Nine patients had 10 vascular anatomic variations, all identified by both IVUS and CT. There were no complications or malpositions of IVC filters using this protocol. These data suggest that IVUS pullback measurements from the right atrium used in combination with preprocedure CT derived measurements of the distance from the right atrium to the lowest renal vein and iliac vein confluence provide an accurate roadmap for the placement of bedside IVC filters under IVUS guidance. We provide a method for organizing this information in a preplanning document to aid this procedure. We suggest this easily employed technique be more fully utilized to help decrease the incidence of malpositioned filters using single puncture IVUS guidance.

Two-year outcomes following unprotected left main stenting with first vs. new-generation drug-eluting stents: the FINE registry

To assess two-year outcomes following first vs. new-generation drug-eluting stent (DES) implantation in unprotected left main (ULMCA) percutaneous coronary intervention. All eligible patients from our two-centre registry treated with first and new-generation DES from October 2006 to November 2010 were analysed. The study objective was major adverse cardiac events (MACE), defined as all-cause mortality, target vessel revascularisation (TVR) and myocardial infarction (MI) at two years. In total, 186 patients were included: 93 (50.0%) treated with first vs. 93 (50.0%) with new-generation DES. No differences were observed in baseline clinical characteristics except for higher EuroSCORE with new-generation DES (3.6±2.5 vs. 4.6±2.7; p=0.007). No significant difference was observed in stenting techniques; two stents were used respectively in 53.8% vs. 44.1% (p=0.187). Notably, intravascular ultrasound guidance was more frequent with new-generation DES (46.2% vs. 61.3%; p=0.040). At 730.0 (interquartile range 365.5-1,224.5) days, there was a trend towards improved MACE with new-generation DES (31.2% vs. 19.6%; p=0.070) and a significant reduction in TVR (23.7% vs. 12.0%; p=0.038) and MI (4.3% vs. 0%; p=0.044). Notably, there were four cases of definite stent thrombosis (ST) with first vs. none with new-generation DES (p=0.044). In our study, new-generation DES had a trend for less MACE and improved results with regard to MI, TVR and definite ST at two-year follow-up.

Use of IVUS guided coronary stenting with drug eluting stent: A systematic review and meta-analysis of randomized controlled clinical trials and high quality observational studies

Background/objectivesLong term safety of DES, particularly regarding thrombosis is of concern. The hypothesized underlying mechanisms (stent underexpansion, malapposition) could be prevented by IVUS guidance.Aim of this meta-analysis of randomized controlled clinical trials (RCT) and high quality observational cohort studies (HQ-OBS) is to quantify the potential clinical benefit of intravascular ultrasound (IVUS) guidance in drug-eluting stents (DES) implantation. MethodsWe performed an extensive literature search for full-text articles published in 2003–2013. The primary outcome was the rate of major adverse cardiac events (MACE) in RCT and HQ-OBS; secondary outcomes were death, myocardial infarction (MI), revascularization, thrombosis and post-procedural minimum lumen diameter (MLD). Fixed/random effect relative risks (RRs) or standardized mean difference (SMD) and 95% confidence interval (95% CI) were computed for the meta-analysis. ResultsThirty-four articles were retrieved from 268 found; of these 3 were RCT and 9 were HQ-OBS; 18,707 patients were enrolled, 1037 in RCT and 17,670 in OBS. Median follow-up was 20months. IVUS guidance was associated with a significantly lower rate of MACE (RR=0.80, 95% CI 0.71–0.89, p<0.001), death (RR=0.60, 95% CI 0.48–0.74, p<0.001), MI (RR=0.59, 95% CI 0.44–0.80, p=0.001) and thrombosis (RR=0.50, 95% CI 0.32–0.80, p=0.007) and larger MLD (SMD=0.15, 95% CI 0.03 to 0.27, p=0.014), but not of revascularization (RR=0.95, 95% CI 0.82–1.09, p=0.75). ConclusionsIn this meta-analysis, IVUS guidance in DES implantation appears to reduce MACE, mortality and MI, possibly by reducing thrombosis rather than restenosis rate. Patients at high risk for thrombosis might be identified as the best candidate for IVUS guidance.

Approach for Chronic Total Occlusion With Intravascular Ultrasound–Guided Reverse Controlled Antegrade and Retrograde Tracking Technique: Single Center Experience

Controlled antegrade and retrograde subintimal tracking (CART) or reverse CART techniques is the final step for percutaneous revascularization of coronary chronic total occlusion (CTO), but it still represents technical challenges and risk in interventional procedures. Our purpose was to utilize intravascular ultrasound (IVUS)-guided reverse CART approach for percutaneous revascularization of CTO in our heart center, focusing on its safety, efficacy, and latest technical developments. From November 2006 to November 2012, 49 patients with CTO failed to antegrade and/or retrograde percutaneous revascularization of CTO from true lumen to true lumen were enrolled in and underwent IVUS guided reverse CART approach. The mean J-CTO score of cases was 2.5. IVUS guidance was successfully implemented in 95.9%; IVUS identified that 61.7% of retrograde wires were located at intimal space, and 59.5% of antegrade wires were located at subintimal space. A Corsair channel dilator was used in 77.6% of cases. The success rates of technique and procedure were 95.9% and 93.9%, respectively; the technical minor complications were observed in 10.2% of cases, without significant clinic outcomes; 2.0% of cases occurred with a major adverse cardiac event of non-ST-elevation myocardial infarction; and no case occurred with target vessel revascularization or death. The mean length of stent implanted in a single CTO vessel was 51.3 mm. No patient appeared with radiation dermatitis and contrast-induced rise of creatinine. IVUS guided reverse CART approach is effective and safe for percutaneous revascularization of complex CTO, with a high success and a low complication rate. It is feasible to develop this approach for percutaneous revascularization of complex CTO. However, suitable case selection and lately device handling by experienced operators are the crucial points of success.

MRI-Induced Stent Dislodgment Soon After Left Main Coronary Artery Stenting

Several studies have shown the safety of MRI after coronary stenting; however, few of them included patients soon after stenting. In this report, we describe a case of MRI-induced stent dislodgment from left main coronary artery (LMCA) 2 weeks after stenting. A 56-year-old woman underwent coronary angiography for recurrence of angina 12 months after coronary artery bypass graft surgery. Coronary artery bypass graft surgery had been performed with left internal mammary artery grafted to left anterior descending artery and a saphenous vein graft to obtuse marginal branch for LMCA stenosis (Figure 1). The comorbidities of patient included hypertension, dyslipidemia, diabetes mellitus, and prior neurosurgery for a pituitary adenoma. The repeat angiogram showed known stenosis in LMCA, nonobstructive disease of left anterior descending artery and right coronary artery, patent saphenous vein graft to obtuse marginal branch, and an occluded left internal mammary artery (Figure 2). After discussion, stenting of the LMCA with a 3.5×8 mm drug-eluting stent (Cypher; Cordis Corp, Markham, Ontario) was deployed after predilatation under intravascular ultrasound guidance (Figure 3). Figure 1. Baseline coronary angiography. Baseline coronary angiography showing a significant and eccentric left main coronary artery (LMCA) stenosis ( A ) that …

TCT-23 Clinical Impact of Intravascular Ultrasound Guidance in Drug-eluting Stent Implantation for the Left Main: Patient Level Pooled Analysis of 4 Registries.

TCT-23 Clinical Impact of Intravascular Ultrasound Guidance in Drug-eluting Stent Implantation for the Left Main: Patient Level Pooled Analysis of 4 Registries.

Two-year outcome of the self-expandable stent for chronic total occlusion of the iliac artery

To evaluate the 2-year results obtained with self-expandable stent for chronic total occlusion (CTO) of the iliac artery, a retrospective study was performed of patients who underwent endovascular therapy (EVT) for chronic iliac artery CTO who presented from April 2007 to September 2012. 82 patients with 86 occluded iliac arteries underwent successful recanalization and stenting with a self-expandable stent. The primary equivalence end point was a composite of restenosis, mortality, target vessel revascularization, and limb salvage rates. Patients were followed up with the presence of a palpable femoral artery pulse, resolution of symptoms, and noninvasive vascular laboratory testing reviewed at 1, 3, and 6months after EVT and then were evaluated at 6-month intervals. In patients who gave consent, repeat angiography was done in sixty-one of 86 lesions (70.1%) for follow-up. The mean follow-up was at 27.6±17.8months (range 3-60months). All stents were placed in the true lumen under intravascular ultrasound (IVUS) guidance. There were no cases of peripheral embolization or iliac artery rupture after the procedure. The ankle-brachial index increased significantly from 0.55±0.19 to 0.88±0.17 (P<0.001). The primary patency rate was 96.5% at 2years. The MLD immediately after the procedure was 5.10±0.26mm and increased significantly to 5.40±0.28mm at the period of follow-up angiography. The 2-year outcome of endovascular therapy with self-expandable stents for CTO of the iliac artery had an acceptable result.

Usefulness of Intravascular Ultrasound to Predict Outcomes in Short-Length Lesions Treated With Drug-Eluting Stents

Intravascular ultrasound (IVUS) offers tomographic images of the coronary artery, helping physicians to refine drug-eluting stent (DES) implantation in angiographically complex lesions. However, controversy exists regarding whether the routine use of IVUS in short-length lesions leads to improved clinical outcomes after DES implantation. Therefore, we evaluated the usefulness of IVUS in predicting major adverse cardiac events (MACE), including cardiovascular death, myocardial infarction, or target vessel revascularization, at 1 year after DES implantation in short-length lesions. The present study was a subanalysis of the REal Safety and Efficacy of a 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation (RESET) study with different clinical outcome parameters. The study population consisted of 662 patients with IVUS guidance and 912 patients with angiography guidance who underwent DES implantation (stent length ≤24 mm). In the IVUS-guided group, adjuvant postdilation was more frequently performed (43.0% vs 34.6%, p <0.001), and the postintervention minimal lumen diameters were greater (2.88 ± 0.44 mm vs 2.72 ± 0.43 mm, p <0.001). MACE occurred in 15 IVUS-guided (2.3%) and 19 angiographically guided (2.1%) patients (p = 0.872). In a subset of patients with diabetes mellitus (n = 292), the MACE rate was 3.4% (n = 4) and 1.7% (n = 3) in the IVUS- and angiographically guided patients, respectively (p = 0.384). The MACE rate in the IVUS- and angiographically guided patients with acute coronary syndrome (n = 601) was 1.1% (n = 3) and 2.7% (n = 9), respectively (p = 0.194). The clinical benefits of IVUS-guided DES implantation compared with angiographically guided DES implantation in short-length lesions could not be confirmed even in patients with clinically high-risk presentations (acute coronary syndrome and diabetes mellitus). In conclusion, routine IVUS guidance does not provide clinical benefits when performing short-length DES implantation.

Percutaneous retrograde revascularization of the occluded celiac artery for chronic mesenteric ischemia using intravascular ultrasound guidance

A 47-year-old male presented with a triad of postprandial abdominal pain, food fear and significant weight loss since 1year suggestive of chronic mesenteric ischemia. CT angiogram revealed chronic total occlusion of the celiac artery (CA), inferior mesenteric artery and 80-90% stenosis of the proximal superior mesenteric artery (SMA). After SMA stenting, successful retrograde recanalisation of chronically occluded CA through pancreatico-duodenal arcade using intravascular ultrasound (IVUS) guidance was done when standard tools failed. The role of IVUS in such challenging lesions is described in the following case report.

Randomized Comparison of Clinical Outcomes Between Intravascular Ultrasound and Angiography-Guided Drug-Eluting Stent Implantation for Long Coronary Artery Stenoses

This study sought to assess the impact of intravascular ultrasound (IVUS) guidance on clinical outcomes following drug-eluting stent implantation when treating long lesions. The role of IVUS guidance when treating long lesions has been tested during bare-metal stent, but not during drug-eluting stent, implantation. A total of 543 patients treated with stents ≥ 28 mm in length were randomly assigned to IVUS guidance (n = 269) versus angiography guidance (n = 274). The primary endpoint was a composite of major adverse cardiac events (MACE), including cardiovascular death, myocardial infarction, target vessel revascularization, or stent thrombosis at 1 year following intervention. In the intention-to-treat analysis, total stent length was 32.4 mm in the IVUS-guided arm versus 32.3 mm in angiography-guided arm (p = 0.84). Adjunct post-dilation was more frequently performed in the IVUS-guided arm (54.6% vs. 44.5%, p = 0.03); post-intervention minimal lumen diameters were similar (2.55 vs. 2.55 mm, respectively, p = 0.50); and MACE occurred in 12 (4.5%) patients in IVUS-guided arm and in 20 (7.3%) patients in the angiography-guided arm (p = 0.16). However, among the 269 patients assigned to IVUS guidance, IVUS was not used in 13 patients (4.8%); conversely, in 274 patients assigned to angiography alone, 41 patients (15.0%) were treated with IVUS guidance. Therefore, in a per-protocol analysis according to actual IVUS usage, minimum lumen diameter was larger (2.58 vs. 2.51 mm, p = 0.04), and MACE rates were lower: 4.0% in the IVUS-guided arm versus 8.1% in the angiography-guided arm (p = 0.048). A strategy of routine IVUS for drug-eluting stent implantation in long lesions did not improve the 1-year MACE rates. The IVUS use per operator decision was associated with improved results. (A New Strategy Regarding Discontinuation of Dual Antiplatelet; NCT01145079).

Safety in a Very Long Term Follow-up (> 5 Years) of a Cut-off Value of 6 mm2 for the Minimal Lumen Area of Intermediate Left Main Coronary Artery Lesions

Clinical Impact of IVUS-guided Left Main PCI: Insights from the Multicenter Study ESTROFA-LM. Fernando Alfonso, Jose Maria De La Torre Hernandez, Angel Sanchez Recalde, Manuel F. Jimenez Navarro, Armando Perez De Prado, Felipe Hernandez, Omar Abdul-Jawad Altisent, Gerard Roura, Tamara Garcia Camarero, Jaime Elizaga, Fernando Rivero, Federico Gimeno, Ramon Calvio, Jose Moreu, Francisco Bosa, Jose Ramon Rumoroso, Juan A. Bullones, Arsenio Gallardo, Jose A. Fernandez Diaz, Jose R. Ruiz Arroyo, Victor Aragon, Monica Masotti. Hospital Universitario Marques de Valdecilla, Santander, Spain; Hospital Clinico San Carlos, Madrid, Spain; Hospital La Paz, Madrid, Spain; Hospital Virgen de la Victoria, Malaga, Spain; Hospital de Leon, Leon, Spain; Hospital 12 de Octubre, Madrid, Spain; Hospital Vall d’Hebron, Barcelona, Spain; Hospital Bellvitge, Barcelona, Spain; Hospital Gregorio Maranon, Madrid, Spain; Hospital La Princesa, Madrid, Spain; Hospital de Valladolid, Valladolid, Spain; Hospital de la Corua. CHUAC, La Corua, Spain; Hospital Virgen de la Salud, Toledo, Spain; Hospital Clinico de Tenerife, Santa Cruz de Tenerife, Spain; Hospital de Galdakano, Bilbao, Spain; Hospital Carlos Haya, Malaga, Spain; Hospital de Albacete, Albacete, Spain; Hospital Puerta de Hierro, Madrid, Spain; Hospital Clinico Lozano Blesa, Zaragoza, Spain; Hospital de Jaen, Jaen, Spain; Hospital Clinic, Barcelona, Spain. Background: Percutaneous revascularization of left main coronary artery (LMCA) lesions with drug eluting stent (DES) is an alternative to surgery in high risk patients and in those cases with non severe coronary disease. Whether the use of intravascular ultrasound (IVUS) during the procedure adds a clinical benefit remains unclear. There is only one single study (MAIN COMPARE) that supports this statement. Therefore we sought to investigate the clinical impact of the use of IVUS in this setting. Methods: From a retrospective multicenter study that compared different DES in the setting of left main we have analyzed the clinical impact of the use of IVUS. Consecutive patients from 21 different hospitals with leftmain lesions treatedwithDESwere included. A systematic follow upwas performed. A propensity scorematchingmethodwas used to obtain matched pairs of patients with and without IVUS guidance during DES implantation in LMCA. Results: A total of 770 pts were included in the registry. IVUS was used in 233 cases (30.2%) and not used in 537 pts. After a three years follow up period the use of two stents, age, diabetes and acute coronary syndrome were found independent predictors of events in the global group after a Cox analysis. In the subgroup of 409 (53.1%) patients with distal left main lesions the independent predictors were the use of two stents, age, diabetes and the use of IVUS, being the latest a protective predictor (HR 0.5, IC 95% 0.23-0.99; p1⁄40.04). After propensity score matching 200 matched pairs of patients treated with DES in LMCA with and without IVUS were included in the analysis. Among these, 80 and 85 pts in each group respectively were treated in distal LM lesions. The data for survival free of events at 3 years are shown in table: No IVUS N1⁄4200 IVUS N1⁄4200 p Cardiac death, MI and TLR 86.7% 90.2% 0.9 Cardiac death and MI 89.2% 94.7% 0.6 TLR 97.3% 94% 0.4 Distal lesions No IVUS n[85 IVUS n[80 Cardiac death, MI and TLR 82% 94.4% 0.08 Cardiac death and MI 84% 95.7% 0.09 TLR 97.5% 95.7% 0.9 The American Journal of Cardiology APRIL 23e26, 2013 AN Conclusion: The results of this multicenter registry suggest a potential clinical benefit derived from IVUS-guided PCI with DES in distal left main lesions.

Intravascular Ultrasound-Guided Inferior Vena Cava Filter Placement Using a Single-Puncture Technique in 99 Patients

To assess the feasibility and safety of intravascular ultrasound (IVUS) to guide inferior vena cava (IVC) filter placement using a single venous puncture technique. Medical records of all patients who had IVC filters placed under IVUS guidance between January 1, 2005 and December 31, 2011 were retrospectively reviewed for pertinent history, results, and complications. All filters were placed using a single venous puncture technique. Filters were successfully placed within the IVC in 94% of the patients with 6 malpositioned filters (4 in the iliac veins and 2 in the suprarenal IVC). Complications included groin hematoma (4%), deep venous thrombosis at the site of vascular access (2%), and filter tilt >15° along the long axis of the IVC (2%). The IVUS-guided IVC filter placement using a single venous puncture technique is technically feasible and safe when compared to case series using a double venous puncture technique.

Percutaneous Treatment of an Injured Coronary Stent Using the Looping Wire Technique

Drug-eluting stent implantation is an effective treatment for coronary artery disease, yet unexpected serious complications during stent implantation are possible. A 70-year-old man with unstable angina presented with a left main bifurcation lesion. Two drug-eluting stents were successfully deployed at the left main bifurcation lesion by the mini-crush technique under intravascular ultrasound guidance. However, after removal of the wire and intravascular ultrasound catheter, the stent of the proximal left circumflex artery was damaged and shortened at the distal edge. We used a looping wire technique to cross the injured stent and we successfully re-dilated the damaged portion of the stent. Finally, we deployed an additional drug-eluting stent at the left circumflex artery over the damaged stent. Our case illustrates the importance of gentle handling of devices during coronary intervention. Furthermore, interventionists should keep in mind the role of intravascular ultrasound when treating this kind of serious complication.

Comparison of pre-dilation with a non-compliant balloon versus a dual wire scoring balloon for coronary stenting

Purpose: The aim of this study was to determine the influence of lesion preparation using the dual wire scoring balloon on stent expansion and long-term outcomes. Methods: Forty-six consecutive de novo lesions treated with a single >2.5 mm drug-eluting stent under intravascular ultrasound guidance, using two implantation strategies, were randomly assigned to: 1) pre-dilation with a non-compliant balloon (NC group; n = 23) or 2) pre-dilation with a dual wire scoring balloon (DS group; n = 23). Results: Although the balloon size and the maximal dilation pressure for pre-dilatation was larger (3.33 ± 0.28 vs 3.09 ± 0.33 mm, p = 0.01) and higher (11.6 ± 3.2 vs 8.6 ± 2.7 atm, p < 0.01) in the NC group than the DS group, there were no significant differences in the stent expansion. Quantitative coronary angiography at the follow-up demonstrated a smaller in-stent late loss (0.71 ± 0.63 mm vs 0.23 ± 0.52 mm, p = 0.03) in the DS group. During the long-term follow-up, there were no significant differences in the major adverse cardiac event rates. Conclusions: Lesion preparation with a dual wire scoring balloon prior to drug-eluting stent implantation might therefore be a more feasible strategy than that using a non-compliant balloon.

Comparison of Two Different Strategies of Intravascular Ultrasound Guidance during Percutaneous Coronary Intervention; Routine versus Selective

Background and ObjectivesIntravascular ultrasound (IVUS) is helpful during percutaneous coronary intervention (PCI), because it can be used to confirm good apposition or optimal expansion of stents. In this study, we compared angiographic result as well as clinical outcomes between two different strategies of IVUS-guidance, the selective vs. the routine.Subjects and MethodsThe study population consisted of 279 patients undergoing electric and emergency intracoronary implatation of TAXUS stent from August 2003 through September 2006. For this study, we divided physicians into two groups; doctors to perform PCI under 'routine' IVUS-guidance vs. PCI under 'selective' IVUS-guidance. Among a total of 279 patients (384 lesions) who underwent PCI with TAXUS stent, 87 patients underwent the procedure under the strategy of 'routine' IVUS-guidance, whereas 192 patients under 'selective' IVUS-guidance.ResultsThe baseline clinical features of the patients are similar between the two groups. The actual rate of IVUS usage was 89.2% in the routine group and 68.2% in the selective group (p<0.01). A high rate of adjunctive ballooning was determined as a remarkable procedure-related parameter which was comparable between the two groups (72.5% vs. 76.1% in routine vs. selective, p=0.57). The minimal lumen diameter at immediate post-PCI was significantly larger in the routine IVUS group than that in the selective group (2.58 mm vs. 2.48 mm, p=0.03). However, the difference disappeared during the follow-up period (1.98 mm vs. 1.98 mm, p=0.94). Clinical outcomes at 1 year were not different between the two groups.ConclusionPCI under the strategy of 'selective' IVUS-guidance was comparable to PCI under 'routine' IVUS-guidance in terms of angiographic and clinical outcomes in circumstances with frequent use of adjunctive ballooning after stenting.

Comparison of Two Different Strategies of Intravascular Ultrasound Guidance during Percutaneous Coronary Intervention; Routine versus Selective

Comparison of Two Different Strategies of Intravascular Ultrasound Guidance during Percutaneous Coronary Intervention; Routine versus Selective