Can IVUS Define Plaque Features
that Impact Patient Care?
A Pichard
L Satler, K Kent, R Waksman, W Suddath,
N Bernardo, N Weissman, M Angelo, D Harrington,
J Lindsay, J Panza.
Washington Hospital Center
Washington DC
Conflict of Interest
• None related to this presentation
IVUS at the WHC
Washington Hospital Center in last 12 months:
Diagnostic catheterizations: 10,000
Coronary angioplasties: 5,000
IVUS use: 70% (AP: 95%)
Organization
10 Labs: 8 Labs have IVUS integrated into the Cath
Table (Volcano and Boston).
IVUS setup is ready before physician arrives into the
room.
2 CV technicians supervise all IVUS cases. 15 CV
technicians trained in IVUS.
Core Lab analyzes of all IVUS data.
Vessel Size Remodeling.
Positive Remodeling:
large plaque mass.
plaque is soft.
more likely to have thrombus.
associated with higher CRP.
More common in young people.
Very common in acute coronary syndrome.
More common no reflow during PCI.
Negative Remodeling:
less plaque mass
plaques are fibrotic.
less likely to have thrombus.
Remodeling in Varying Coronary
Lesion Morphologies
Macrophage infiltration
Posit A.
Remodeling
NC
Medial SMC loss
4
3
SMC loss
2
1
0
-1
-2
Total occlusion
Healed rupture
Acute rupture
Plaque hemorrhage
Thin cap atheroma
Stable
-3
Erosion
IEL-Expected IEL
(/plaque area)
5
Medial SMC
apoptosis
Virmani 2009
Cardiac CT can be as good as IVUS to detect Positive Remodeling
Positive Remodeling and Plaque Composition by OCT.
Raffel et al. EHJ 2008;29:1721-8
Positive Remodeling and ISRS
Okura et al. JACC 2001, 37: 1031-35
n= 108 BMS
Positive
Remodeling
Intermed. or Negative
Remodeling
Plaque Burden and In-Stent Intimal Hyperplasia
WHC: Shiran et al, AJC 2000; 86:1318-21
Maximal IH at 6 months angio was at the zone of maximal pre
intervention plaque. Pre-intervention plaque area was an
independent predictor of IH at follow up.
Remodeling and ISRS in DES.
Mintz, Park et al. Circulation. 2003;108:1295-8
ASPECT (ASian Paclitaxel-Eluting Stent Clinical Trial)
positive
intermed
negative
Cypher RS 28.6% vs 16.7% for positive and non posit remodeling p=ns. AHA 2009
Mild LMCA Disease and Remodeling.
WHC: YJ Hong et al. JIC 2007;19:500-5
236 patients with mild (<50%) LMCA stenosis by angiography
1 year MACE
Positive Remodeling and Outcome in ACS.
Okura, Mintz et al. AJC 2009;103:791-5
Prospect. MACE in Non Culprit Lesions
Attenuated Plaque
(Black Holes, Echo Signal Attenuation)
WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72
Shadowing in spite of no visible calcium
Two attenuated plaques 6.4 mm apart were seen in this RCA.
Attenuated Plaque in ACS.
WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72
293 ACS patients: 26% with attenuated plaque ( 40% STEMI, 18% NSTEMI)
Attenuated plaque in ACS patients was associated with:
- positive remodeling and higher CRP,
- more thrombus and complex lesion morphology,
- more plaque burden and plaque rupture,
- frequent no-reflow after PCI.
Echo Signal Attenuation (EA).
Kimura et al. Circ CV Interv. 2009;2:444-54.
687 patients.
EA: 43.8% in ACS vs. 27.9% in Stable AP, p<0.001.
EA had Positive Remodeling: 55% vs 23 % for lesions
without EA.
Histology after DCA:
higher prevalence of lipid-rich plaque, macrophage
infiltration, cholesterol clefts, thrombus, and
microcalcification.
No Reflow in SVG’s with ACS.
WHC: YJ Hong et al. TCT 06
Plaque Regression by IVUS
Tardif et al. AJC 2006;98:2327
Intense Lipid Therapy x 2 years in 432 lesions <50%.
Baseline IVUS
IVUS at 24 months
IVUS images of the same cross section of coronary artery at baseline (left) and
follow-up (right). The presence of a large branch at 10 o’clock and a smaller
branch at 7 o’clock confirms that the same matched cross section has been
studied at the 2 time points.
Progression of Disease in SVG
Change in area (mm2)
Change
(mm2)
area (mm2)
in area
Change in
WHC: YJ Hong JACC 2009;53:1257-64
Statin Therapy and Fibrous Cap Thickness
Takarada et al. Atherosclerosis 2009;202:491-7
Statin Group
Statin Group
Control Group
Statin Therapy and Plaque Rupture
Chia et al. Cor Art Dis 2008;19:237-42
OCT study in 48 patients.
Statin therapy patients had:
- less plaque rupture (8 vs 36%)
- increased fibrous cap thickness (78 vs
49 microns)
Summary
Positive remodeling with large plaque
burden is an important observation that
determines clinical and PCI outcomes.
CALCIFIED LESIONS
Patient with Angina and LAD Perfusion Defect
Simple PCI ?
IVUS of LAD
In view of IVUS findings Roto-DES or LIMA need to be chosen
Different Strategies based on IVUS findings
Direct Stenting
A
5
m
m
Roto-Stent
B
Concealed Vessel Perforation
Most Perforations are Not Seen by Angio.
Maehara et al. WHC 2001
15,000 IVUS reviewed
76 perforations found on IVUS.
Angio:
21% totally normal
33% dissections
22% mild stenosis
24% perforation suspected
12 months Follow up
30% MACE
Virtual Histology
(A) Pathological intimal thickening.
(B) Thin-capped fibroatheroma.
(C) Thick-capped fibroatheroma.
(D) Fibrotic plaque.
(E) Fibrocalcific plaque.
The PROSPECT Trial
IVUS of culprit lesion + 2 non culprit vessels
700 pts with ACS
QCA of entire coronary tree
IVUS with Virtual histology
Palpography (n=~350)
Meds rec
Aspirin
Plavix 1yr
F/U: 1 mo, 6 mo,
Statin
1 yr, 2 yr,
Repeat biomarkers
±3-5 yrs
@ 30 days, 6 months
MSCT
Substudy
N=50-100
Repeat imaging
in pts with events
PROSPECT: MACE
25
20.4%
MACE (%)
20
All
15
Culprit Lesion
10
Non Culprit Les.
5
Indeterminate
12.9%
11.6%
2.7%
0
0
1
2
3
Time in Years
Number at risk
ALL
697
557
506
480
CL related
697
590
543
518
NCL related
697
595
553
521
Indetermina
Plaque Burden, VH and Outcomes
MACE
in non
Culprit
lesions
•
A ≥ 70% plaque burden lesion
by gray scale IVUS has a risk of
9.2% at three years
•
A ≥ 70% plaque burden
lesion defined as VH TCFA has
an elevated risk of 15.3%
at three years
•
A ≥ 70% plaque burden lesion
defined as PIT has a reduced
risk of only 2.6% at three years
•
VH Definitions in PROSPECT can
swing the risk profile
The same lesions by grayscale IVUS (Plaque Burden ≥ 70%)
have dramatically different risk profiles when looking at VH
Dynamic Nature of Plaque by VH.
Kubo, Maehara et al. JACC 2010;55:1590-7
Stable
Progressive
ACTIVE
Stenting and Plaque by VH.
Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4
Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4
Stent in AMI
Darius Dudek. TCT 2009
40%
NC covered
50%
NC uncovered
10%
Distal segment
Proximal segment
Plaque Healing after Stenting
Kubo et al. Am Heart J. 2010;159:271-7.
Necrotic Core in contact with stent before and after Stenting
DES
BMS
Conclusions
Plaque characterization by IVUS allows for:
Better PCI planning and execution.
Better PCI outcome.
Better prediction of near and long term
outcome.
Better delineation of need for optimal medical
therapy for that lesion.
Better understanding of Coronary
Atherosclerosis.
The end