Bologna 21 Aprile 2011
TAVOLA ROTONDA
Quale Ruolo Clinico e Quale Rimborso
per la Franctional Flow Reserve?
Correlazioni anatomo-funzionali
FFR vs IVUS
Luigi Vignali, Parma
IVUS guidance in PCI
Indications
When IVUS? Why IVUS?
Pre
PCI
Decide strategy
and Sizing
Vessel reference and % stenosis
Length of the lession
Plaque composition
Post
PCI
Evaluate Stent
Results
Final lumen
Expansion
Apposition
Dissection or plaque shift
IVUS in evaluation for
Post dilatation needs
Pre
Stent
Mal
apposition
Stent
Under
expansion
•Post-dilatation strategy:
•With non-compliant balloon shorter than stent in
presence of vessel remodelling or uncompletedapposition
IVUS reveals need of postdilatation
Posdil
Recommendations for specific percutaneous
coronary intervention devices
IVUS-guided stent implantation may be considered for
unprotected left main PCI
CLASS IIb
EVIDENCE C
IVUS in ISR
Beware that expected ISR might reveal under
expanded stent during previous intervention.
Because the vessel and plaque and
stents became visible, IVUS guidance
clarify substrate in failure or previous
PCI, and frequently discover under
expanded stents
IVUS reveals stent underexpansion in ISR
Performance Comparison, OCT vs
IVUS
C7XR
IVUS
Spazial Resolution
Acquisition Time
Tissue Penetration
12 - 15 mm
20 mm/s
1.0 - 2.0 mm
100 - 200 mm
0.5 - 1 mm/s
10 mm
Contrast enjection
during acquisition
Every images
No contrast
Image Comparison
• Edge dissection
???
???
10
during stent
implantation
 Neointimal growth on
previously implanted
stent at follow-up
Validation of IVUS Assessment of
Ischemia-producing Stenoses (Doppler
FloWire, SPECT, and Pressure Wire)
IVUS MLA
4.0mm2
IVUS MLA
<4.0mm2
CFR < 2.0
2
27
CFR  2.0
39
4
Diagnostic accuracy = 92%.
Abizaid et al. Am J Cardiol 1998;82:42-8
+ Spect
- Spect
IVUS MLA
4.0mm2
IVUS MLA
<4.0mm2
4
42
20
1
Diagnostic accuracy = 93%.
Nishioka et al. J Am Coll Cardiol 1999;33:1870-8
Takagi, et al. Circulation
1999;100:250-5
IVUS in intermediate assessment
Proximal LAD, CX, RCA
Intermediate stenosis
assessment:
Takagi, et al. Circulation 1999;100:250-5
If in Proximal LAD, CC
or RCA, the stenosis
MLA ≤ 4 mm2
then is cause isquemia;
and must be treated
IVUS reveals significance of intermediate lesions,
with morphological assessment
Clinical follow-up in 357 Intermediate Lesions in 300
Pts with Deferred Intervention after IVUS Imaging
IVUS MLD (mm)
Death/MI/TLR
DM
4
3
2
35
35
30
30
25
25
20
20
15
15
10
10
5
5
2-3
3-4 4-5 5
0
IVUS MLA (mm2)
2-3
3-4 4-5 5
0
IVUS MLA (mm2)
1
r=0.339
0
0
•
•
•
•
TLR
1
2
3
QCA MLD (mm)
4
no-DM
Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR)
Death/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mm2
Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041)
Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042)
Abizaid et al. Circulation 1999;100:256-61
In Intermediate stenosis assessment:
Event Free Survival is better for the IVUS Criteria
vs. the FFR >0.75 Criteria.
Confidential information of Boston Scientific Corporation. Do not copy or distribute.
Follow-up of 122 patients with moderate LEFT MAIN disease
Indipendent predictors of MACE @11.7
Months:DM (p=0.004) and IVUS MLD
(p=0.005)- but NOT the palque burden
Abizaid, et al. J Am Coll Cardiol 1999;34:707-715
IVUS in intermediate assessment
in Left Main
Intermediate Main Left
stenosis assessment:
If Main Left MLA ≤ 6 mm2
cause isquemia and
must be treated
Abizaid, et al. J Am Coll Cardiol
1999;34:707-715
IVUS assess significance of Main Left lesions, where angio fails
IVUS determinants of LMCA FFR<0.75
Jasti et al Circulation 2004; 110;2831-6
MULTICENTERDED LITRO STUDY
INTERMEDIATE LEFT MAIN CORONARY ARTERY LESION
Kaplan-Meier survival free from mortality and infarction
Cumulative proportion surviving
100
DEF 98.1%
75
REV 93.4%
Logrank test: p = 0.04
50
179 pt MLA>6 mm2 (DEF group)
25
331 Patients
152 pt MLA<6 mm2 (REV group)
0
0
Jose’ M de la torre Hernandez et al.JACC 2010;vol55
12
Months
PCI 44%
CABG 55%
24
IVUS Criteria for a “significant” LMCA stenosis
Absolute lumen CSA <5.9 mm2 (or MLD < 2.8 mm) is the
suggested criterion for significant LMCA stenosis
LA= 5,5
LA= 4,5
LA= 8,0
FFR= 0,70
FFR vs IVUS in Intermediate Coronary Lesions
167 consecutive patients
(FFR-guided,83 lesion vs IVUS-guided,94 lesion)
75
91.5%
50
25
33,7%
100
Event Free Survaival (%)
100
90
80
P>0.05
70
60
0
FFR guided
IVUS guided
The rate of performing PCI according to guiding device
Cutoff value FFR 0.80
100
200
Time to event (days)
Cutoff value IVUS MLA >4mm2
Chang-Wook Nam et al 2010;JACC interventions vol 3 :812-7
300
400
CORRELATION BETWEEN FFR AND IVUS LUMEN
AREA IN 150 INTERMEDIATE CORONARY STENOSIS
For lesion with vessel reference diameters of 2.5-3 mm, 3-3.5
mm and >3.5 mm, the MLA threshold for FFR <0.8 were 2.5,2.8
and 3.7 mm2 respectively
Itsik Ben-Dior, Ron Waksman et al 2011.JACC
FFR= 0,74
COMPLEMENTARY ROLE IVUS FFR OCT
PRE INTERVENTION
IVUS
vessel size
FFR
Severity lesion
POST INTERVENTION
IVUS
lesion lenght
Expansion
Apposition
Coverage
Complication
Underexpansion
Edge problems
OCT INDICATION
Immediatelly after stent
implantation
1 Year after DES
Implantation
1 Year after BMS
Implantation
Delayed healing; new intimal growth
Thank you for your attention
For any correspondence:
gbiondizoccai@gmail.com
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