IVUS Guidance Research Articles

Impact of intravascular ultrasound for coronary bifurcations treated with last generations stents: insights from the BIFURCAT-ULTRA registry.

Bifurcation lesions are associated with higher rates of major adverse cardiovascular events (MACE). To investigate the impact of imaging-guided PCI in a real-world population with coronary bifurcation lesions. From the ULTRA-BIFURCAT registry, we compared IVUS vs. angiographic guidance in a cohort of 3486 propensity matched patients. MACE a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization (TLR) and stent-thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease. PSM generated 1743 pairs. MACE occurred in 154 (9%) patients in the IVUS guided group and in 199 (11%) patients in the angio-guided group (p=0.09). IVUS guidance was associated with lower MACE in the ULM population [HR 0.62, 95% CI 0.46-0.83], but had no impact in the non-ULM population [HR 1.12, 95% CI 0.83-1.51], p for interaction=0.006. IVUS was associated with reduction in all-MI [HR 0.32, 95% CI 0.16-0.64] in the ULM population and with lower ST in the non-ULM population [HR 0.24, 95% CI 0.08-0.71]. Provisional stenting was associated with lower MACE in the ULM population [HR 0.67, 95% CI 0.45-0.98], whereas kissing balloon [HR 0.75, 95% CI 0.56-0.99] and ultra-thin stents [HR 0.44, 95% CI 0.29-0.67] were protective factors in the non-ULM population. In a real-world scenario, IVUS guidance during DES implantation is associated with a lower rate of MACE in patients with ULM coronary bifurcation lesions. In non-ULM bifurcations, no difference was observed on MACE, while IVUS guidance was associated with a lower rate of ST.

A retrospective study on real world, 2-stent left main bifurcation PCI using DK crush technique with IVUS guidance - a single center experience

Abstract Objectives The aim of this study is to investigate clinical outcome of the IVUS guided 2-stent bifurcation strategy using DK crush technique performed in a complex Left Main (LM) bifurcation lesions defined according to DEFINITION study in our local setting. We seek to assess the composite endpoint of target vessel failure (TVF) at 9-12 months. Methods All patients underwent IVUS guided 2-stent Bifurcation PCI with DK crush technique for complex LM bifurcation lesions defined by the DEFINITION criteria performed in a heart institute from 1.1.2019 to 31.7.2023 were included..Patient baseline characteristics, post-procedural and 12-months follow-up outcomes including cardiac death,myocardial infarction (MI),rate of target vessel failure (TVF),rate of stent thrombosis (ST) and major adverse coronary event (MACE) were analysed.Exclusion criteria are patients age <18 years and previous stenting in the target vessel Results A total of 50 patients were included in this analysis. Mean age was 64.3±9.1 years with predominant males (n= 38, 76%).Majority were hypertensive (n=37, 74%) and diabetes mellitus accounted for 32 (64%) cases.Patients with pre-existing coronary artery disease were 39 (78%) cases. 40% presented with history of recent myocardial infarction (MI), 12% had new onset angina and 6% had heart failure. Pre-existing chronic renal failure (18%) and history of CVA (2%). Among chronic renal failure cases, 50% had eGFR <50 during index procedure.Additionally, previous PCI was performed in 22 cases (44%) and 2 previous CABG cases included (4%).Majority of the cases were performed as staged elective procedure ( n=45, 90%) and others were indicated for ACS ( n=5, 10%). Radial approach was predominantly preferred with 25 cases (50%), where additional 5 cases (10%) were converted to femoral approach due to severe radial spasm. Among these 50 cases, 1 case required additional PCI to CTO LAD and mid LCX, while 7 cases (14%) had calcified lesions requiring scoring / cutting balloons and atherectomy device utilization for adequate lesion preparation prior to bifurcation stenting.All 50 patients received combination of both aspirin and a P2Y12 inhibitors for 12 months. Follow up done at at 30-day, 60-days and 1 year after the index procedure.Clinical follow-up were available in 46 (92%) patients only.4 cases were lost to follow up due to logistic reasons. At 1 year follow-up, cardiac death occurred in 5 (10.9%) patients, out of which 3 (6.5%) cases were cardiac related and 2 (4.4%) are non-cardiac. Major adverse cardiac events (MACE) and target vessel failure (TVF) occurred in total 4 (8.7%) cases, where 3 (6.5%) cases resulted in cardiac death and 1 (2.2%) case had MI and clinically driven target lesion revascularization. Conclusion Our experience demonstrates that IVUS guided, upfront 2-stent Bifurcation PCI using DK crush technique for complex bifurcation lesions is effective and safe with a low MACE and TLR rate at 1 year follow-up.

C-28 | Percutaneous Coronary Intervention outcomes with IVUS guidance compared to Angiography alone: A systematic review and meta-analysis

C-28 | Percutaneous Coronary Intervention outcomes with IVUS guidance compared to Angiography alone: A systematic review and meta-analysis

Comparison of Clinical Outcomes of Calcified and Non-Calcified Coronary Artery Lesion Intervention Under IVUS Guidance

Comparison of Clinical Outcomes of Calcified and Non-Calcified Coronary Artery Lesion Intervention Under IVUS Guidance

Abstract 17708: Cardiac Nut-Cracker: Paroxysmal Left Main Coronary Compression by Inducible Pulmonary Trunk Dilatation in Pulmonary Hypertension

Case Presentation: A 56yo woman with a 12-year history of idiopathic pHTN and severe RV dysfunction presented with worsening exertional angina (CCS III). Perfusion imaging demonstrated a large apical-septal defect, corresponding to an 80% eccentric stenosis of the LMCA on angiography ( Fig 1AB ) due to compression on ostium and shaft by a severely dilated pulmonary trunk ( Fig 1C ). Right heart catheterization revealed pulmonary artery pressures (PAPs) of 90/40/68mmHg. Operative risk for CABG was deemed prohibitive, thus the patient underwent high-risk PCI of the LMCA under IV conscious sedation. Initial angiography confirmed a patent LMCA with minimal longitudinal compression. Opening PAPs (102/37/64mmHg) with supplemental oxygen (FiO 2 /PaO 2 0.76/168mmHg) were similar to preop findings ( Fig 1D ). To replicate her symptomatology, supplemental oxygen was discontinued, resulting in rapid worsening of LMCA compression with severe reduction in LMCA cross-sectional area at room air conditions (FiO 2 /PaO 2 0.21/70mmHg), with corresponding suprasystemic PAP (122/44/73mmHg) ( Fig 1E) . Under IVUS guidance, a preselected stent was deployed producing complete LMCA patency without evidence of dynamic compression; minimal stent areas were unchanged at supraphysiologic and physiologic conditions: 19 vs 20mm 2 , FiO 2 0.73 vs 0.21 ( Fig 1F ). Discussion: LMCA stenosis from extrinsic compression of the vessel by an enlarged pulmonary artery is a rare etiology of acute coronary syndromes. Treatment options include PCI, CABG, reimplantation, or PA reduction plasty. While preop imaging clearly demonstrated LMCA compression by a dilated PA, during PCI true and dynamic severity of LMCA compression was revealed only under “normoxic conditions” (FiO 2 0.21). This paroxysmal “nut-cracker” phenomenon from inadvertent reversal of dynamic LMCA compression highlights the importance of normoxia in making the diagnosis of such anomalies in susceptible individuals with pHTN.

Long-term clinical outcomes of drug-coated balloon for the management of chronic total occlusions.

This study aims to compare the clinical outcomes of patients with de novo chronic total occlusion (CTO) lesions treated by hybrid strategy and drug-coated balloons (DCB)-only strategy. DCBs have been used as an alternative to or in combination with drug-eluting stents in CTO lesions. However, the clinical impact of DCB treatment on CTO lesion remains uncertain. We retrospectively enrolled 154 patients with de novo CTO lesions treated by DCB, including 57 cases in hybrid group and 97 cases in DCB-only group. The lesions in hybrid group were more complicated than those in DCB-only group as shown by higher J-CTO score, and therefore higher percentage of retrograde approach, more IVUS guidance, more CTO guidewires, and longer procedural time were demonstrated. Although the percentage of non-flow-limiting dissection and residual stenosis of more than 30% were lower in hybrid group, TIMI flow grade, satisfactory and acceptable recanalization rate were not significantly different between two groups. During a median follow-up was 470 days, the incidence of target lesion revascularization (TLR), myocardial infarction and cardiac death was 11.0%, 1.3% and 1.9%, respectively. The long-term TLR-free survival was comparable between hybrid and DCB-only groups. By multivariate analysis, DCB length and age were predictors of TLR. DCB treatment appears effective and safe in selected de novo CTO lesions during long-term follow up. The recanalization results and long-term outcomes are comparable between hybrid and DCB-only group despite more complicated lesions in hybrid group.

Patient characteristics and periprocedural outcomes of percutaneous coronary intervention of the left main coronary artery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left main (LM) disease is found in 5 to 6% of all coronary angiograms. Revascularization has a class IA recommendation, but the choice of the revascularization method whether by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is currently under debate. The selection depends on patient’s characteristics (age, sex, comorbidities, frailty), as well as anatomical considerations. We aim to describe the patients with LM disease that were treated with PCI and report their short-term outcomes in a tertiary center. Methods Single-center retrospective study including all patients who underwent LM PCI from 2013 to 2019. The basal characteristics were retrieved from the electronic medical records. Acute kidney injury was defined as an absolute increase in serum creatinine of ≥ 0.3 mg/dL or ≥ 1.5-fold from baseline. Type IVa myocardial infarction was assessed by the Third Universal Definition. Results A total of 110 procedures were performed during the study period (table 1). Most of the patients were male, with a median age of 61 years. A considerable number of patients showed a reduced ejection fraction (41.2%). The left main lesions were most frequently distal and associated with left anterior descending artery disease. Radial access was used in a minority of cases (33.6%), although most were IVUS-guided (93.6%). Complete revascularization was achieved in 55.5%. The number of procedures over time is depicted in figure 1. There was only 1 death (0.9%) during index hospitalization. There was a high incidence of type IVa myocardial infarction (19.1%) and acute kidney injury (10%), and a low incidence of TIMI major bleeding (1.8%). Conclusion Current practice shows an increase of left main PCI over time, particularly from 2016, after the EXCEL trial results were published. This can be due to improved technical aspects such as IVUS guidance, which was used in most patients. Noticeable, almost half of the patients had a reduced ejection fraction. Although there was a very low short-term mortality associated with the procedure (1%), as well as a low bleeding risk (4.8%), there was a high incidence of type IVa myocardial infarction (20.2%). Only 55.5% archived a complete revascularization. Despite promising immediate results in clinical practice, long term follow up will be essential to determine the future role of left main PCI.

Ultra-low contrast PCI vs conventional PCI in patients of ACS with an increased pre-procedural risk of CI-AKI (CONSaVE-AKI study)

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with acute coronary syndrome (ACS) and at an increased risk of developing CI-AKI can be identified prior to percutaneous coronary intervention (PCI) based on their pre-procedural risk scores. Ultra-low contrast PCI (ULC-PCI) is a novel contrast conservation strategy in such high risk patients for prevention of CI-AKI, however evidence of its feasibility and clinical utility is limited with no prospective randomized control trial available. Purpose This single center, prospective, randomized study assessed short-term outcomes and safety of ULC-PCI vs conventional PCI. It tested the hypothesis that in ACS patients undergoing PCI who are at an increased pre-procedural risk of developing CI-AKI, use of ULC-PCI strategy will cause less incidence of CI-AKI than in conventional PCI. Methods 82 patients [age 60.12 (±8.98) years] undergoing PCI for ACS were enrolled between December 2019 and August 2021 in a tertiary care center in India having creatinine clearance <60 ml/min/1.73 m2 by the MDRD equation and having a moderate to very high pre-procedural risk of developing CI-AKI as calculated by Maioli et al risk score(1). They were randomized into two groups of 41 patients each. In the ULC-PCI group, the total volume of contrast used was ≤ 1 x patient’s GFR and in the conventional PCI group, contrast volume was kept ≤ 3 x patient’s GFR. ULC-PCI protocol used aggressive intra-procedural contrast sparing strategies along with the use of IVUS guidance or staging of the multi-vessel PCI whenever feasible. Patients were followed up for primary end point of development of CI-AKI and secondary end point of any need for dialysis, re-hospitalization, death, repeat myocardial infarction or unplanned coronary re-interventions in a follow-up of 30 days. Primary PCI, chronic total occlusions and patients on maintenance hemodialysis were excluded from the study. Results Baseline clinical and angiographic characteristics were similar between groups. The primary outcome of CI-AKI occurred more in patients of the conventional PCI group [7 (17.1%)] than in the ULC PCI group [(0 patients), p = 0.012]. Contrast volume (41.02 (±9.8) mL vs 112.54 (±25.18) mL; P<.0001) was markedly lower in the ULC-PCI group. 6 patients had stage 1 AKI with recovery and 1 patient had stage 3 AKI requiring dialysis. ULC PCI was reasonably safe and effective with no significant difference in secondary safety outcomes between the two study arms. It was also applicable without lesion restriction. IVUS was used in 17% patients in the ULC PCI group. Conclusion An ULC-PCI in patients with increased risk of developing CI-AKI is feasible, appears to be safe, and has the potential to decrease the incidence of CI-AKI, compared with conventional PCI specially in resource limited setting such as ours where coronary imaging by IVUS is not possible in every patient. Also, in ACS patients with baseline renal dysfunction, revascularization is associated with improved GFR post PCI.

TCTAP C-063 Salvage for Long-tract False Lumen via IVUS Guidance in CTO Lesion

TCTAP C-063 Salvage for Long-tract False Lumen via IVUS Guidance in CTO Lesion

363 Old but fashioned: IVUS and chromaflo guidance for definition of thrombosis mechanism

Abstract Aims Plaque rupture and plaque erosion are the main causes of coronary thrombosis. While the first one involves fibrous cap disruption, the second one is caused by loss of endothelial continuity. In selected cases with evidence of plaque erosion, antithrombotic therapy without stenting has been suggested as a possible option. OCT is considered the gold standard for definition of thrombosis mechanism and has recently been included in algorithms for evaluation and management of patients with ACS. Also, high definition IVUS was compared with OCT in defining plaque erosion showing promising results. However, the cost and the large amount of contrast medium needed for OCT performance make these diagnostic tools of scarce applicability in daily practice. Methods and results We herein describe the case of a young man acceding to the Cath Lab with the diagnosis of NSTEMI. After baseline angiography and IVUS confirmed presence of Thrombus (Figure 1A and B), thromboaspiration was successfully performed (Figure 1D). The definition of thrombosis mechanism, revealing plaque rupture, was then performed with IVUS and ChromaFlo devices (Figure 1C and E). Also, IVUS was used to optimize stent implantation. Conclusions Although requiring further confirmations, we believe that in selected cases IVUS and ChromaFlo could provide a more applicable first-line diagnostic tool to define thrombosis mechanism. 363 Figure 1Baseline angiographic and IVUS evaluation confirming presence of coronary thrombus (A, B). After successful performance of thromboaspiration (D), plaque rupture was revealed by IVUS and ChromaFlo (C).

Real-time intravascular ultrasound guidance: A novel technique for accurate placement of ostial stents.

To describe a novel technique for ostial stent placement using real-time IVUS guidance. Accurate placement of coronary stents at ostial locations is challenging with the true ostium frequently being missed increasing the risk of adverse events. We have developed a novel technique for ostial stent placement and report our benchtop testing and initial clinical experience. Benchtop testing was performed to validate the appearance of the stent and delivery system on IVUS. Benchtop testing of real-time IVUS guided ostial stent positioning was carried out in a left main bifurcation phantom. Real-time IVUS guidance of stent placement in aorto-ostial, ostial left anterior descending (LAD), or ostial circumflex lesions was assessed in a prospective registry. Bench model IVUS demonstrated clear differences between the appearances of the stent and other components of the delivery system. Positioning of 10 consecutive stents into the ostial LAD using real-time IVUS guidance was assessed in a left main bifurcation model. Median distance from proximal stent edge to LAD ostium was 0.39 mm (interquartile range 0.31 to 0.73). Real-time IVUS guidance of ostial stent placement was performed in 50 patients (51 lesions). Angiographic success was 100%. IVUS post-stenting demonstrated median distance from the proximal stent edge to the ostium was 0.2 mm (interquartile range 0.1 to 0.5 mm). There was one periprocedural myocardial infarction but no other major adverse cardiac events at 30-days. We have developed a novel technique using real-time IVUS guidance allowing accurate ostial stent placement.

Provisional Stenting for Left Main Bifurcation Disease under IVUS guidance: A Case Series

Around 15-20% of coronary lesions include bifurcation, and among which left main (LM) bifurcation lesions are critical and complex to manage. Though the two-stent strategy is the preferred option for complex LM bifurcation lesions, the provisional strategy should be considered if the side branch is disease-free to avoid peri- and post-procedural complications. Thus, precise anatomical and physiological assessment of LM lesion should be made using intravascular imaging techniques for appropriate decision making. Here, we report three cases of successfully managed LM bifurcation lesions using the provisional stenting technique with the guidance of intravascular ultrasound, fractional flow reserve, and heart team. All three patients were doing well and were ischemia-free on stress echocardiography at three months follow-up.

Successful re-entry using the outback\xae elite catheter via retrograde popliteal access with IVUS guidance for femoropopliteal occlusion: a case report

BackgroundThere are still cases that are difficult to treat for femoropopliteal chronic total occlusion (CTO). The Outback® Elite catheter is effective re-entry device to treat such kind of difficult cases, however, it might be difficult to use the Outback® Elite catheter antegradely in cases with severely calcified lesions. In this case, we performed EVT using the Outback Elite® catheter via the retrograde popliteal approach.Case presentationWe report a case of a 77-year-old male with end-stage renal disease who presented with pain and cyanosis of his left foot. Control angiography showed total occlusion from the middle of the left superficial femoral artery to the proximal portion of the popliteal artery. The CTO lesion was severely calcified, which prevented the antegrade advancement of any guidewire. Retrograde popliteal puncture was performed with the patient in the supine position. After intentional retrograde subintimal wiring, the Outback® Elite catheter was advanced via the retrograde approach after the identification of a suitable re-entry site using intravascular ultrasound. After wire crossing, one nitinol stent was deployed and sufficient antegrade flow was achieved without any complications.ConclusionsUsing Outback® Elite from retrograde should be considered in cases where antegrade advancement fails and bidirectional wiring cannot pass through the CTO lesion.

IVUS guidance during left main PCI: not if, but when and how.

IVUS guidance during left main PCI: not if, but when and how.

Game changers in vascular and endovascular surgery

Game changers in vascular and endovascular surgery

3285Impact of intravascular ultrasound-guided percutaneous coronary intervention in patients with diabetes mellitus and chronic kidney disease

Abstract Background Several studies have shown favorable results using IVUS-guided PCI. Nevertheless, patient background in which use of IVUS is effective is not well elucidated. Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) tend to have complex coronary artery lesions. We sought to assess the impact of IVUS guidance on clinical outcomes in these patients. Methods Kumamoto Intervention Conference Study is a multicenter registry which has enrolled consecutive patients who underwent PCI in 16 centers in Japan. Between August 2008 and March 2014, 11,195 consecutive patients were enrolled in this registry. To elucidate the efficacy of IVUS usage in DM and CKD patients, 10,822 consecutive subjects with 1-year follow-up data were analyzed. In this patient population, 69.2% (n=7,493) of patients were treated with IVUS-guided PCI. Patients were divided into 4 groups: the No Risk Group, the DM only Group, the CKD only Group, and the DM+CKD Group. Results Maximum stent diameter, post dilatation rate, usage of distal protection device, and rotational atherectomy rate were significantly higher in the IVUS-guided PCI patients in all 4 groups. 1-year MACE (cardiovascular death, non-fatal myocardial infarction, and MI with stent thrombosis) was significantly lower in the IVUS-guided PCI patients than angiography-guided PCI patients in each subset, except for the No Risk Group. In contrast to angiography-guided PCI patients, there were no significant differences among the 4 groups as regards 1-year MACE in the IVUS-guided PCI patients except for the DM+CKD Group. In multiple regression analysis, IVUS usage was an independent negative predictor for 1-year MACE in the DM only Group (HR=0.374, 95% CI 0.194–0.719, p=0.003) and in the CKD only Group (HR=0.604, 95% CI 0.379–0.962, p=0.010). When the No Risk Group was used as a reference, the HR has increased according to increased risk factors in the angiography-guided PCI patients, but such tendency was not necessarily observed in the IVUS-guided PCI patients (Table). Risk Stratification of DM and CKD Variable IVUS-Guided PCI Angiography-Guided PCI HR 95% CI P HR 95% CI P The No Risk Group Reference – – Reference – – vs. the DM only Group 0.627 0.321–1.227 0.173 2.036 1.090–3.804 0.026 vs. the CKD only Group 1.334 0.795–2.237 0.275 2.730 1.541–4.836 0.001 vs. the DM+CKD Group 2.114 1.287–3.474 0.014 2.225 1.160–4.266 0.016 Conclusion The efficacy of IVUS usage as regards 1-year MACE was confirmed in DM and CKD patients, but not observed in patients without them or in the combination of DM and CKD patients. Acknowledgement/Funding None

Intravascular ultrasound guidance improves patient survival (mortality) after drug-eluting stent implantation: review and updated bibliography.

Individual studies IVUS vs angiography-guided DES implantation studies, whether randomized clinical trials or registries are underpowered, to show a reduction in mortality, especially at 1year of follow-up. However, either meta-analyses or the few studies with long-term (> 5year) follow-up showed that IVUS guidance reduced mortality and improved patient survival, even with second-generation DES.

TCTAP C-059 A Case That No Stent Strategy Was Achieved by DCA+DCB with IVUS Guidance in the LMT True Bifurcation Lesion

### Patient Initials or Identifier Number I.O ### Relevant Clinical History and Physical Exam A 70’s-year-old man was admitted with exertional chest pain for 1 month. His coronary risk factors were hypertension and smoking. His past history was IgA nephropathy and prostatic hypertrophy. ###

TCTAP C-094 Primary Revascularization of Occluded Saphenous Vein Graft to Detect Anastomosis with IVUS Guidance for Treatment of Long RCA CTO Lesion

### Patient Initials or Identifier Number E.I ### Relevant Clinical History and Physical Exam A 70’s old man that had undergone previous coronary artery bypass surgery was admitted for angina of effort. Coronary angiography showed proximal RCA was occluded, proximal LAD and distal LCX was

IVUS guidance can optimise DCB treatment in the SFA

Aim Drug-coated balloon (DCB) angioplasty is a common endovascular treatment that has lower rates of restenosis compared to plain angioplasty. Restenosis rates remain higher than is desirable even with the use of DCB technology. This study was undertaken to investigate whether guidance using IVUS resulted in lower rates of restenosis. Methods A subgroup of patients who undergone primary treatment with DCB and had one year follow-up available was extracted from cases enrolled in an on-going RCT investigating the use of IVUS guidance in femoropopliteal endovascular interventions. Patient, lesion and procedural parameters were compared between the treatment group (who had IVUS and angiographic guidance) and the control group (only angiography guidance). The rate of binary restenosis was compared between the two groups. Results A total of 76 patients had treatment by DCB (36 in control group and 40 in treatment group). There was no difference in parameters between the two groups. There was a significantly higher rate of binary restenosis at one year in the control group compared to the treatment group (47% v 15%, p=0.003). Median balloon size was significantly larger in the treatment group than the control group (6 mm v 5 mm, p=0.019). The median difference between the angiographic measurement and the actual treated length was significantly greater in the treatment group compared to the control group (40 v. 0 mm), p=0.010. Conclusion These findings suggest that the reduced rate of restenosis rates found when IVUS guidance was used may be due to optimised drug delivery during DCB treatment by improved matching of the DCB to the vessel lumen dimensions and better coverage of the true lesion length.