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When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh

When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh. MY CONFLICTS OF INTEREST ARE Travel, Accomodation & Registration PCR - May 2006 (BosSci) TCT - October 2006 (BosSci) Travel & Accomodation Guidant Institute visit, Brussels - February 2006 (Abbott)

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When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh

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  1. When I Use IVUSNeal Uren MD FRCPConsultant CardiologistRoyal Infirmary Edinburgh

  2. MY CONFLICTS OF INTEREST ARE • Travel, Accomodation & Registration • PCR - May 2006 (BosSci) • TCT - October 2006 (BosSci) • Travel & Accomodation • Guidant Institute visit, Brussels - February 2006 (Abbott) • Emerging Technologies Symposium -March 2006(BosSci) • Annual SpR training, Malaga – June 2006 (BosSci)

  3. IVUS Transducers Mechanical Transducer – 40 MHz Atlantis Pro (BosSci) Solid-State Transducer – 25 MHz EagleEye (Volcano)

  4. Diagnostic Applications of IVUS • Identify specific disease - left main stem, ostial lesions • Detect angiographically silent disease- transplant vasculopathy • Identify plaque morphology • Examine vessel when angiography is inconclusive - hazy lesions, presence or absence of thrombus or dissection • Measure plaque load • Measure true vessel size

  5. IVUS Determination of Atheroma Area Precise Planimetry of EEM and Lumen Borderswith Calculation of Atheroma Cross-sectional Area Vessel Area Lumen Diameter LumenArea Vessel Diameter Atheroma Area

  6. Angiography versus IVUS ANGIOGRAPHY 2 dimensional Planar Shadow of lumen Wall structures not imaged Intermittent snapshots or repeat contrast injections necessary QCA measurements prone to magnification errors IVUS 360º view Tomographic and sagittal Visualisation of shape and location Visualisation of inner wall structures and morphology Continuous image Precise measurements

  7. In-Stent Restenosis

  8. Interventional Indications of IVUS PRE-INTERVENTION • Accurate quantitation • Assessment of reference segment disease • Interventional strategy & device selection • In-stent restenosis POST-INTERVENTION • Recognition of an ambiguous appearance • Optimal balloon angioplasty • IVUS-guided stenting

  9. IVUS & Stent Expansion

  10. Minimum Stent Area & Restenosis 40 Angio restenosis 35 TVR 30 25 % 20 15 10 5 0 <6 6-7.9 8-9.9 >10 Minimum Stent Area (mm2) After Moussa et al, Mintz et al, CRUISE 2000

  11. Stent Malapposition

  12. The POST RegistryPredictors and Outcomes of Stent Thrombosis 94% abnormal IVUS 60 53 stent thromboses IVUS 50 Angio 40 33% abnormal angio Percentage 30 20 10 0 %DS>0 Plaque protrusion Edge tear/ dissection Thrombus Inflow-outflow disease Filling defect Malapposition Expansion<80% Uren et al, EHJ 2002

  13. The POST RegistryComparison with other trials 90 * p<0.05 80 70 60 POST * 50 Percentage STRUT CRUISE 40 * AVID * 30 20 10 0 Expansion Edge Tears Malapposition In-StentThrombus Uren et al, EHJ 2002

  14. Wijns et al, TCT 2006

  15. Left Main Stenting PRE-INTERVENTION • Confirm length of left main stem = pullback time (0.5 mm/s) ÷ 2 • Confirm lesion length • Assess for ostial disease in LAD or CFX • Measure true vessel size = [maximum + minimum vessel diameter] ÷ 2

  16. IVUS & Left Main Stenting POST-INTERVENTION • Confirm optimal stent deployment • Recognition of an ambiguous appearance • Maximise stent expansion - clinical experience MLA≥7 mm2 - parent vessel MLA should be 1.5x daughter (4mm2)

  17. Costa et al, TCT 2006

  18. Cosat et al, TCT 2006

  19. IVUS & Unprotected LMS Stenting • 18 LMS vs. 60 non-LMS PCI • Additional high-pressure or larger size balloon dilatations were more frequently performed in LMS stenting vs. non-LMS stenting (p <0.05) • After IVUS-guided stent implantation, MLA was ≥9 mm2 in 88% of LMS patients vs. 19% of non-LMS (p<0.001) Hong MK et al, AJC 1998;82:670-3

  20. IVUS & Unprotected LMS Stenting p<0.05 25 n=127 non-randomised 25.0 20 p<0.01 5 IVUS 15 4.2 Angio 4.0 Debulk/Stent 10 Stent 2.5 8.3 5 40 87 77 50 0 0 Angiographic Restenosis (%) MLD (mm) Reference artery size = only independent predictor (not IVUS) 99.2% procedural success, 97% 2 year survival Park SJ et al, JACC 2001;38:1054-60

  21. When I Use IVUS CLINICAL PRACTICE • Diagnostic uncertainty • Assessment of in-stent restenosis • Left main stenting • Atherosclerosis research

  22. Prior Coronary IVUS Progression Trials Relationship between LDL-C and Progression Rate 1.8 CAMELOT placebo REVERSAL pravastatin 1.2 Median Change In Percent AtheromaVolume (%) ACTIVATE placebo 0.6 REVERSAL atorvastatin A-Plus placebo 0 -0.6 Unexplored Region -1.2 1.25 1.5 1.75 2.0 2.25 2.5 2.75 3.0 Mean LDL-C (mmol/l)

  23. Atheroma Area 10.16 mm2 Baseline IVUS Exam Lumen Area 6.16 mm2 Atheroma Area 5.81 mm2 Follow-up IVUS 24 months rosuvastatin Lumen Area 5.96 mm2

  24. REVERSAL & ASTEROID Trials REVERSAL: atorvastatin 80 mg vs pravastatin 40 mg reduced LDL-C to 2.1 mmol/l ASTEROID: rosuvastatin 40 mg reduced LDL-C to 1.5 mmol/l and raised HDL-C by 15% Median DPAV (%) Median DTAV (%) Median DTAV in most diseased subsegment (%) ** 2.6 2 1.6 0.2 0 -0.8 NS -1.2 -0.4 ** NS * -2 Percent Change -4.2 -4 ** -6 -6.8 Prava40 ** Atorva80 -8 Rosuva40 -9.1 ** -10 *p<0.05, **p0.001, NS = non significant vs. baseline

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