Routine Use Of Intravascular Ultrasound Research Articles

Efficacy and utilization of intravascular ultrasound in office-based lower extremity endovascular interventions for peripheral arterial disease.

Intravascular ultrasound (IVUS) is a uniquely objective but underutilized imaging modality in the interventional treatment of peripheral arterial disease treatment. IVUS has been shown to improve device size selection and diagnose occult pathology difficult to see with routine angiography. We hypothesize that the use of IVUS in lower extremity endovascular intervention improves accuracy in stent and balloon size selection and minimizes contrast use. This is a retrospective case series performed at a single-institution outpatient center by two vascular surgeons from July 2016 through July 2017. We identified 94 total IVUS-assisted procedures. We collected data regarding demographics, balloon and stent size, IVUS-determined vessel diameter, pre-procedure and post-procedure ABI values, and contrast used during the procedure. An independent core laboratory was further utilized to characterize all IVUS and angiographic size vessel measurements. For the 94 lower extremity IVUS-assisted interventions, the average patient age was 70±9 years old, with an average contrast use of 37.1mL of Omnipaque 300. There was substantial improvement in pre- and post-procedure ABI (0.7±0.23 to 0.94±0.21). On analysis of average intraluminal IVUS vessel diameter to balloon angioplasty used, we had a correlation in size of 0.96±0.16 in our series. Additionally, in eight instances IVUS allowed for identification of a flow-limiting dissection with subsequent stenting. Routine use of IVUS offers a powerful diagnostic paradigm that has the potential to significantly decrease contrast use and to improve objectivity in choosing appropriate vascular tools to maximize intra-procedural efficacy. The discovery of adverse findings not initially noticed on angiography further reinforces the value of IVUS utilization.

P3583Optimal procedural strategy to improve clinical outcome in primary percutaneous coronary intervention

Abstract Background Current guideline recommends potent antiplatelet agents and transradial intervention. However, it is uncertain whether routine use of IVUS, thrombus aspiration and glycoprotein IIB-IIIA inhibitor is beneficial for improving clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI). Purpose The aim of this study was to investigate optimal procedural strategy to improve clinical outcome. Methods A total of 6,046 patients who underwent primary percutaneous coronary intervention (PCI) for STEMI were analyzed from the Korean Acute Myocardial Infarction Registry (KAMIR) – National Institute of Health (NIH) database. MACCEs were defined as a composition of all cause death, non-fatal MI, repeat revascularizations including repeated percutaneous coronary intervention and coronary bypass grafting, cerebrovascular accident and rehospitalizations. This research was supported by a fund by Research of Korea Centers for Disease Control and Prevention. Results During the primary PCI, potent antiplatelet agents such as prasugrel and ticagrelor were used in 2342 (38.4%). PCI was performed through transradial approach in 1490 (25.2%). Thrombus aspiration and intravascular ultrasound (IVUS) examination was done in 2204 (36.1%) and 1079 (18.1%), respectively. Glycoprotein IIB-IIIA inhibitor was administered in 1295 (21.7%). Among them, potent antiplatelet agents, transradial intervention, IVUS, and thrombus aspiration significantly reduced MACCEs at 1 year. Glycoprotein IIB-IIIA inhibitor was not effective to improved clinical outcome. In Cox-proportional hazards model, potent antiplatelet agents (hazard ratio 0.82, 95% confidence interval 0.67–0.99; p=0.045) and transradial intervention (hazard ratio 0.61, 95% confidence interval 0.47–0.78; p<0.001) was an independent predictor of MACCEs after adjusting for confounding variables. Combined use of potent antiplatelet agents and transradial intervention (hazard ratio 0.54; 95% confidence interval 0.37–0.80; p=0.002) substantially reduced MACCEs at 1 year. Conclusion Among evidence based procedures during the primary PCI, combined use of potent antiplatelet agents and transradial intervention was optimal procedural strategy to improve clinical outcome.

The role of precise imaging with intravascular ultrasound in coronary and peripheral interventions.

Angiography remains a widely utilized imaging modality during vascular procedures. Angiography, however, has its limitations by underestimating the true vessel size, plaque morphology, presence of calcium and thrombus, plaque vulnerability, true lesion length, stent expansion and apposition, residual narrowing post intervention and the presence or absence of dissections. Intravascular ultrasound (IVUS) has emerged as an important adjunctive modality to angiography. IVUS offers precise imaging of the vessel size, plaque morphology and the presence of dissections and guides interventional procedures including stent sizing, assessing residual narrowing and stent apposition and expansion. IVUS-guided treatment has shown to yield superior outcomes when compared to angiography-only guided therapy. The cost-effectiveness of the routine use of IVUS during vascular procedures needs to be further studied.

Intravascular ultrasound-guided stent implantation reduces cardiovascular mortality - Updated meta-analysis of randomized controlled trials

BackgroundThe use of intravascular ultrasound (IVUS) guidance to facilitate stent implantation has been demonstrated to reduce major adverse cardiovascular events (MACE), predominantly due to a reduction in target lesion revascularization (TLR). The objectives of our meta-analysis are to assess the effect of IVUS on clinical outcomes, including cardiovascular mortality. MethodsRCTs comparing drug-eluting stent (DES) implantation using IVUS plus angiography versus angiography alone were identified from a comprehensive search in PubMed, Embase, and Cochrane library. Pooled relative risks (RR) were obtained using DerSimonian and Laird estimator for the random effects model. ResultsThe search yielded 10 RCTs (5007 participants) in which the relevant data were available. Two trials were performed in patients with chronic total occlusion (CTO), whereas other trials included patients that either had stable ischemic heart disease (22–64%) or presented as an acute coronary syndrome (ACS) (36–78%). Routine use of IVUS was effective in reducing TLR (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44, 0.80; p < 0.01), target vessel revascularization (TVR) (RR 0.59, 95% CI 0.43, 0.81; p < 0.01), and MACE (RR 0.63, 95% CI 0.51, 0.77; p < 0.01). Cardiovascular mortality was also significantly reduced (RR 0.51, 95% CI 0.27, 0.96; p = 0.04). ConclusionDuring DES implantation, the routine use of IVUS in addition to angiography improves clinical outcomes, including cardiovascular mortality. These findings reinforce the need for a broader implementation of IVUS-guidance during PCI. Since a significant proportion of patients studied presented as ACS, future trials should assess the benefit of IVUS-guidance in a more focused presentation setting.

Routine Use of Intravascular Ultrasound in Lower Extremity Peripheral Interventions Significantly Reduces Contrast Use and Maximizes Treatment Efficacy

Intravascular ultrasound (IVUS) is a uniquely objective but underutilized modality during the performance of peripheral arterial disease treatment. IVUS has been shown to improve device size selection and diagnose occult pathology that is difficult to see with routine angiography. We hypothesize that the use of IVUS in lower extremity endovascular intervention improves accuracy in stent and balloon size selection and helps to minimize contrast used.

Current Clinical Applications of Intravascular Ultrasound in Coronary Artery Disease

During the 20 years since the introduction of intravascular ultrasound (IVUS) to catheterization laboratory, there has been growing evidence supporting the role of IVUS. In this article, we review clinical application of routine use of IVUS with recent evidences, a dominant strategy even in the era of drug-eluting stents. IVUS provides pre-procedural information to evaluate stenosis severity and plaque characteristics. In addition, IVUS helps optimal stent deployment, minimizing underexpansion and geographic miss, which are major mechanisms of stent failure. Large-scale clinical trials and meta-analyses have shown that the clinical benefits of IVUS guidance are maximized in complex lesions (left main coronary artery, long lesions and chronic total occlusion). Some recent studies have also supported the cost effectiveness of IVUS-guided PCI especially when there is a high risk of stent failure. IVUS provides valuable information about lesion severity, lumen and vessel size, lesion length, and plaque characteristics. By determining appropriate stent sizes and optimizing stenting procedures, IVUS-guided PCI improves clinical outcomes especially in patients with high-risk coronary lesions.

Intravascular ultrasound as an adjunct tool for angiographically intermediate lesions and complex coronary interventions: patient selection and perspectives

Intravascular ultrasound as an adjunct tool for angiographically intermediate lesions and complex coronary interventions: patient selection and perspectives Eui Im,1 Jung-Sun Kim,2,3 Myeong-Ki Hong2&ndash;4 1Division of Cardiology, Yongin Severance Hospital, Yonsei University Health System, Yongin, 2Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, 3Cardiovascular Research Institute, 4Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea Abstract: Intravascular ultrasound (IVUS) provides valuable anatomic information about the coronary arterial lumen, wall, and plaques that cannot be assessed by coronary angiography alone. For over 2 decades, IVUS has been shown to be a helpful tool for identifying significant ischemia in angiographically intermediate left main (LM) or non-LM lesions by measuring the minimum luminal area. It can also guide percutaneous coronary intervention (PCI) in complex coronary lesions such as LM, bifurcation, chronic total occlusion, in-stent restenosis, and long or calcified lesions. In these complex lesions, IVUS can reduce stent thrombosis or restenosis by accurate lesion assessment and detection of stent underexpansion, malapposition, or edge dissections. Through further intervention based on these IVUS findings, optimal stent deployment can be achieved. IVUS can also identify the culprit lesion with plaque rupture, and vulnerable lesions with a large plaque burden or thin-cap fibroatheroma. Although other new imaging modalities with improved resolution and technologies are attracting increased clinical attention, IVUS remains the most reliable intracoronary imaging modality to guide PCI until other new imaging devices are proven to be useful and improve clinical outcomes. However, current data on clinical utility are conflicting and the guidelines do not recommend routine use of IVUS when performing angiography or PCI. In this review, we focus on issues related to the selection of patients who might benefit from IVUS guidance and discuss future perspectives on intracoronary imaging. Keywords: intravascular ultrasound, angiography, coronary artery disease

Plaque characterization to identify patients at high risk of acute complications during PCI

Periprocedural myocardial infarction and angiographic no-reflow represent acute complications that may occur during percutaneous coronary intervention, and have been associated with both short- and long-term mortality. Intravascular ultrasound (IVUS), optical coherence tomography and near-infrared spectroscopy are all capable of identifying target lesions that are at heightened risk of inducing these acute percutaneous coronary intervention-related complications. The morphologic characteristics of target lesions that are most associated with these complications include attenuated plaque by IVUS, necrotic core by virtual histology-IVUS, thin-capped fibroatheroma by optical coherence tomography and lipid core plaque by near-infrared spectroscopy. Future studies are needed to determine whether routine use of IVUS, optical coherence tomography or near-infrared spectroscopy prior to percutaneous coronary intervention can improve procedural safety.

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.

Invasive intracoronary imaging in ischemic heart disease

In the last years, both the increase in percutaneous coronary revascularization and the instance of more reliable and individualized treatments have led interventional cardiologists to seek for a valuable adjunct to angiography in order to improve assessment and treatment of atherosclerotic coronary disease. Intravascular ultrasound (IVUS) allows precise tomographic measurement of lumen area, plaque size, and, to some extent, composition, with low risks and affordable costs. It is not yet clear whether routine use of IVUS provides a middle-to-long-term benefit in prevention of recurrent cardiovascular events. This review reports the main studies on IVUS imaging, underlining impact of ultrasound in the development of contemporary percutaneous revascularization techniques.

Impact of intravascular ultrasound‐guided percutaneous coronary intervention on long‐term clinical outcomes in a real world population

To compare long-term clinical outcomes between intravascular ultrasound (IVUS)-guided and angiography-guided percutaneous coronary intervention (PCI) in a large "real world" registry. The impact of IVUS-guided PCI on clinical outcomes remains unclear. Between January 1998 and February 2006, 8,371 patients who underwent IVUS- (n = 4,627) or angiography- (n = 3,744) guided PCI were consecutively enrolled. Three-year clinical outcomes were compared after adjustment for inverse-probability-of-treatment weighting (IPTW) in the overall population and in separate populations according to stent type. A crude analysis of the overall population showed that the 3-year mortality rate was significantly lower in the IVUS-guided group than in the angiography-guided group (96.4% ± 0.3% vs. 93.6% ± 0.4%, log-rank P < 0.001). When adjusted by IPTW, patients undergoing IVUS-guided PCI remained at lower risk of mortality (hazard ratio [HR] 0.627; 95% CI 0.50-0.79, P < 0.001). Similarly, in the drug-eluting stent (DES) population, the 3-year risk of mortality was significantly lower in patients undergoing IVUS-guided PCI (HR 0.46; 95% CI 0.33-0.66, P < 0.001). In contrast, IVUS-guided PCI did not reduce the risk of mortality in the bare metal stent population (HR 0.82; 95% CI 0.60-1.10, P = 0.185). However, the risks of myocardial infarction (HR 0.95; 95% CI 0.63-1.44, P = 0.810), target vessel revascularization (HR 1.00; 95% CI 0.86-1.15, P = 0.944), and stent thrombosis (HR 0.82; 95% CI 0.53-1.07, P = 0.109) were not associated with IVUS guidance. IVUS-guided PCI may reduce long-term mortality when compared with conventional angiography-guided PCI. This may encourage the routine use of IVUS for PCI in patients undergoing DES implantation. © 2012 Wiley Periodicals, Inc.

Diagnosis and treatment of venous lymphedema

Chronic venous disease (CVD) is a common cause of secondary lymphedema. Venous lymphedema is sometimes misdiagnosed as primary lymphedema and does not receive optimal treatment. We have routinely used intravascular ultrasound (IVUS) imaging in all cases of limb swelling. The aim of this study is to show that (1) routine use of IVUS can detect venous obstruction missed by traditional venous testing, and (2) iliac-caval venous stenting can yield satisfactory clinical relief and can sometimes reverse abnormal lymphangiographic findings. The study comprised CVD patients who underwent iliac vein stenting. Lymphangiography was abnormal in 72 of 443 CEAP C(3) limbs, with leg swelling as the primary complaint (abnormal lymphangiography group). Clinical features and stent outcome were compared with a control group of 205 of 443 with normal lymphangiography (normal lymphangiographic group). Clinical features were a poor guide to the diagnosis of lymphedema. Isotope lymphangiography was not helpful in differentiating primary from secondary lymphedema. Venography had 61% sensitivity to the diagnosis of venous obstruction. IVUS had a sensitivity of 88% for significant (≥50% area stenosis) venous obstruction. At 40 months, cumulative secondary stent patency was similar for the abnormal (100%) and normal lymphangiographic (95%) groups. Swelling improved significantly after stent placement in the abnormal lymphangiographic group (mean [standard deviation] swelling grade improvement 0.8 ± 1.1) but was less (P < .004) than in the control group (1.4 ± 1.3). Complete swelling relief was 16% and 44% (P < .001) and partial improvement (≥1 grade of swelling) was 45% and 66% (P < .01) in the abnormal and normal lymphangiographic groups, respectively. Associated pain was present in 50% and 36% of the swollen limbs in the abnormal and normal lymphangiographic groups. Pain relief (≥3 visual analog scale) at 40 months was 87% and 83%, respectively (P = .3), with 65% and 71%, experiencing complete pain relief. Quality of life criteria improved after stent placement in both groups but to a better extent in the normal lymphangiographic group. Abnormal lymphangiography improved or normalized in 9 of 36 (25%) of those tested after stent correction. Prevailing practice patterns and diagnostic deficiencies probably result in the misdiagnosis of many cases of venous lymphedema as "primary" lymphedema. IVUS is recommended to rule out venous obstruction as the associated or initiating cause of lymphedema. Iliac venous stenting to correct the obstruction has excellent long-term patency and good clinical outcome, although results are not as good as in those with normal lymphatic function.

A Retrospective Study of Intravascular Ultrasound use in Patients Undergoing Endovascular Aneurysm Repair: Its Usefulness and a Description of the Procedure

Objectives To verify the usefulness and limitation of intravascular ultrasound (IVUS) in endovascular aneurysm repair (EVAR). Methods A total of 112 consecutive patients, who underwent EVAR to treat abdominal aortic aneurysms, were examined retrospectively. Of these, 33 patients were assigned to the IVUS group because of renal failure, a suspected allergy to contrast agents or anatomical difficulties; the remaining 79 patients were assigned to the non-IVUS group. Results Patients in the IVUS group required fewer intra-arterial contrast agents (IACAs) than those in the non-IVUS group (67 ± 34 ml vs. 123 ± 50 ml; p < 0.01). Blood loss and operation time were comparable between the two groups. No patients died within 30 days of the operation. Three major renal complications occurred in the non-IVUS group. Renal deterioration evaluated by chronic kidney disease (CKD) stage was found to a greater extent in the non-IVUS group. Conclusions IVUS is a powerful auxiliary method in EVAR for reducing the required volume of contrast agents. The combination of IVUS and IACA usage showed good overall performance; thus, we propose the routine use of IVUS in EVAR procedures.

Routine Use of Intravascular Ultrasound for Endovascular Aneurysm Repair: Angiography is not Necessary

Introduction: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography.Materials/methods: eighty consecutive patients (median age 69 years (range 25–90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference.Results: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190ml (range: 20–350) for angiography versus 0ml for IVUS (p<0.01). Median X-ray exposure time 24min (range 9–65min) versus 8min (range 0–60min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures.Conclusions: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.