Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, how to use and how to...
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Transcript of Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, how to use and how to...
Intracoronary imaging in CTOs
When to use, how to use and
how to interpret the images
Philip Dingli MD
Javier Escaned MD PhD
Hospital Clinico San Carlos
Madrid
Spain
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use
Balloon sizing with
IVUS to maximise
subintimal space
and to facilitate
entry of retrograde
wire
Ensuring with IVUS
that retrograde wire
guidewire is within
antegrade lumen
IVUS imaging in reverse CART
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use
• Limited room for guidewire maneuvering.
• Lack of spatial orientation.
• Target is a compressed / collapsed part of the vessel
Challenges for IVUS-guided re-entry
Work in the angiographic angulation
showing the largest distance between
IVUS probe and working wire.
Apply the same principle to
contralateral distal vessel
opacification
Use a wire with high steerability and
tip control to re-enter
Correlate your IVUS and angiographic
images as much as possible
Tips for IVUS-guided re-entry
Correlating IVUS and Angio Images
Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books
Tips for IVUS-guided re-entry
Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use
• Small distal vessel size with
negative remodelling
predicted by MSCT.
• Identification of CTO ostium
with MSCT.
• Guidance with IVUS.
• Favorable CTO
characteristics(absence of
calcium, no tortuosity).
Learning messages from this case
How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management and prevention of complications
• Reduction in contrast use
Learning messages from this case
• Understanding ambiguous angiographic result of CTO PCI
• Optimization of stenting in complex PCI
• Superb visualisation of endoluminal surface and implanted
stents
• Providing valuable clues on long-term results of CTO PCI.
• Limited by the need of contrast administration (avoidance
of CIN in CTO patients is a major issue).
• Cannot be used by guidance without injections (a problem
in CART)
A word on OCT in chronic total occlusions
Use of Intravascular Imaging During Chronic Total O
• 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers
• Intravascular imaging in 38%
• IVUS was used in 67% of retrograde vs 31% of antegrade-only cases (P<0.0001).
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
• Stent sizing : 26.3%
• Stent optimization : 38.0%
• CTO crossing : 35.7%
– Antegrade : 27.9%
– Retrograde : 7.8%
• Imaging for crossing was used more commonly with:
– proximal cap ambiguity (49% versus 26%, p<0.0001)
– side branch at the proximal cap (61% versus 47%, p=0.035),
– blunt/no stump (68% versus 55%, P=0.009)
– longer occlusion length (30 mm [IQR: 22, 50] versus 28 mm [15, 44], p=0.009)
– Higher JCTO (2.8 vs 2.4, p=0.001) and Progress CTO( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
• Similar success
• Similar MACE (2.7% versus 3.2%, p=0.772)
• Longer procedure
– 192 min [IQR 130, 255] vs 131 min [90, 192], p<0.0001
• Longer fluoroscopy
– 71 min [44, 93] vs 39 min [25, 69], P<0.0001
• Higher mean air kerma radiation dose
– 4.98 Gray [3.11, 6.04] versus 3.42 Gray [2.09, 5.09], P<0.0001
• More median contrast volume
– 310 mL [240, 400] versus 270 mL [200, 360], p=0.004
• Trend toward larger number of stents
– (2.71.3 versus 2.51.2, P=0.07)
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
Kang J et al PLoS One. 2015 Oct 14;10(10):e0140421
126 patients who underwent DES stenting, and post-PCI IVUS of CTO lesions
IVUS-based post-PCI MLD (<2.4 mm) and stent expansion ratio (≤70%)
values seem to be predictors of ISR in CTO stenting
Does IVUS influence outcomes in CTO PCI?
402 patients with CTOs randomized to IVUS-guided and angiography-guided
groups. Secondarily randomized to ZES or BES.
Kim BK et al Circ Cardiovasc Interv. 2015;8:e002592.
Does IVUS influence outcomes in CTO PCI?
Tian et al. EuroIntervention 2015;10:1409-1417
• 230 patients• Recanalised CTO lesion• Randomised to IVUS-guided or
the angiography-guided• The use of IVUS for penetration
of the true lumen andoptimisation of stent expansionwas only done in the IVUS-guided group.
• Followed with office visits ortelephone contact up to 24months.
Saito S et al Am J Cardiol 2016;117:727e734)
In 8 vessels in whom the stent was implanted into a subintimal space
maximum percent neointimal hyperplasia and minimum lumen area was
similar in the subintimal segment compared with the adjacent intraplaque
segment.
Does stenting the subintimal space influence outcomes in CTO PCI?
Available at the PCR Bookshop at prconline.com
Coronary Stenosis: Imaging, Structure and Physiology
Additional information on topics
covered in this presentation