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Performing and interpreting IVUS, VH-IVUS & OCT
Andreas SynetosFirst Department of Cardiology
University of Athens
Limitations of Angio
Plaque rupture impact
76% of sudden deaths were attributable to plaque rupture, and only 24%
of MIs were associated with severe luminal narrowing.
Falk E, …,Fuster V. Coronary plaque disruption. Circulation 1995;92:657– 671
Balance Research/Clinical
Intravascular Imaging: From sound to light
IVUS was the gold standard for
evaluation of lumen dimensions and
plaque morphology
OCT has provided us with another
useful tool with far superior
resolution (10x), but limited
penetration (<2mm)
Technical characteristics
Prati et al, EHJ 2009
Η ποιόηηηα ηηρ εικόναρ εξαπηάηαι από:
- αναλςηική ικανόηηηα ζηο σώπο (spatial resolution)(ακτινική και πλάγια αναλστική ικανότητα)
- ικανόηηηα διάκπιζηρ ιζηών (contrast resolution) (αποτρώσεις τοσ γκρι / dynamic range)
7
Απεικόνιςη Βαςικζσ αρχζσ
Αναλςηική ικανόηηηα ζηο σώπο (spatial
resolution) = η ικανόηηηα διάκπιζηρ
ανάμεζα ζε 2 διαθοπεηικά ζημεία ηηρ
εικόναρ
Δξαπηάηαι από ηη ζςσνόηηηα (MHz)
Για ησοβολέα IVUS 30-40MHz, η ακηινική
ικανόηηηα ανάλςζηρ είναι 80-100 μm,
ενώ η πλάγια είναι 200-250 μm.
- Χαμηλή ζςσνόηηηα (λίγα MHz) → βαθύηεπη
διείζδςζη ηηρ εικόναρ
- Υτηλή ζςσνόηηηα (πολλά MHz) →καλύηεπη ποιόηηηα εικόναρ (ανάλςζη)
20 MHz
40 MHz
Απεικόνιζη Βαζικέρ απσέρ
Απεικόνιςη με IVUSΒαςικζσ αρχζσ
Αξιολόγηζη ζημανηικόηηηαρ
βλάβηρ
Καθοδήγηζη ηηρ
αγγειοπλαζηικήρ
(ππιν από ηο stent)
Δκηίμηζη ηος αποηελέζμαηορ
ηηρ αγγειοπλαζηική
ρ
Αξιολόγηζη επιπλοκών μεηά από ηο
stent
Θπόμβυζη &
επαναζηένυζη ηος stent
Σύγκπιζη μεθόδυν
Δκηίμηζη ζύζηαζηρ
πλάκαρ
Ολική απηηπιακή επιθάνεια (Total arterial CSA)
Δπιθάνεια αςλού (Lumen CSA)
Μέγιζηη & ελάσιζηη διάμεηπορ αςλού
% Σηένυζη επιθάνειαρ αςλού
Μήκορ βλάβηρ
Δπιθάνεια πλάκαρ & μέζος σιηώνα
= Ολική απηηπιακή επιθάνεια - Δπιθάνεια αςλού (ζε βλάβη συπίρ stent)
= Ολική απηηπιακή επιθάνεια - Δπιθάνεια stent(ζε βλάβη με stent)
Γείκηηρ αναδιαμόπθυζηρ (remodeling index):= Δπιθάνεια αςλού (ζε βλάβη) / Δπιθάνεια αςλού (ζε ςγιέρ ημήμα)
Σε stent: επιθάνεια stent, μέγιζηη & ελάσιζηη διάμεηπορ
stent
Δπιθάνεια ςπεππλαζίαρ έζυ σιηώνα = Δπιθάνεια stent -
Δπιθάνεια αςλού
IVUS: μεηπήζειρ
Σηένωζη επιθανείαρ αςλού (%)= [(Επιθάνεια αςλού ζε
ζημείο αναθοπάρ – Ελάσιζηη επιθάνεια αςλού) /
(Επιθάνεια αςλού ζε ζημείο αναθοπάρ)] x100
% Σηένυζη επιθάνειαρ αςλού
(διαθέπει από ηην % θοπηίο πλάκαρ)
IVUS values that predict FFR<0.75
LM
IVUS: Οπιζμόρ «ζημανηικήρ»
ζηένυζηρ
% ελάττωςη διαμζτρου > 70%
% ελάττωςη επιφανείασ > 50%
MLA < 4 mm2 (εγγφσ LAD, LCX, RCA)
< 6 mm2 (ςτζλεχοσ)
Ελάχιςτη διάμετροσ < 1.8 mm (εγγφσ LAD, LCX, RCA)
< 2.9 mm (ςτζλεχοσ)
Αξιολόγηζη
ζημανηικόηηηαρ
βλάβηρΚαθοδήγηζη ηηρ αγγειοπλαζηικήρ
(ππιν από ηο stent)
Δκηίμηζη ηος αποηελέζμαηορ
ηηρ αγγειοπλαζηικήρ
Αξιολόγηζη επιπλοκών μεηά από ηο
stent
Θπόμβυζη &
επαναζηένυζη ηος stent
Σύγκπιζη μεθόδυν
Δκηίμηζη ζύζηαζηρ
πλάκαρ
Cost effectiveness
0
2
4
6
8
Minimum stent CSA (mm2)
Thrombosis
Control
p= 0,02
Fugii, K, et al, J Am Coll Cardiol. 2005 Apr 5;45(7):995-8
0
20
40
60
80
100
Stent expansion
(%)
Thrombosis
Control
p= 0,03
Stent under-expansion and residual reference segment stenosis
are associated with an increased risk of stent thrombosis after
successful drug-eluting stent implantation.
Effect of incomplete apposition : very late thrombosis
Cook S et al, Circulation 2007;115:2426-34
Incomplete stent apposition is highly prevalent in patients with
very late stent thrombosis after DES
implantation, suggesting a role in the pathogenesis of this
adverse event.
IVUS vs Angio guided PCI
Catheterization and Cardiovascular Interventions 00:00–00 (2013)
A benefit of IVUS optimized DES implantation was observed in complex lesions in the post-procedure minimal lumen diameter. No statistically significant
difference was found in MACE up to 24 months.Chieffo et al .Am Heart J 2013;165:65-72
AVIO
Wakxman et al JACC Vol. 62, No. 17, 2013
1991 2002
Intracoronary Imaging
2004
Imaging Wire 0.019""Occlusive Method"
Regar et al. Eur Heart J 2004 (Abstract)
Regar E, van Leeuwen AMGJ, Serruys PW (Eds): Optical coherence tomography in cardiovascular research. London: Informa Healthcare. 2007.
OCT
1991 2002
Intracoronary Imaging
2004 2007 2008
2nd
Generation OCT
Fourier Domain OCT(OFDI/Frequency/Spectral Domain/Swept Source)
Monorail Imaging CatheterNon-Occlusive
OCT
Occlusive vs non-occlusive technique
Barlis et al., EuroInterv.2009Kataiwa et al., IJC.2009
OCT vs OFDI
Takarada et al, CCI 2009
Ανάλυςη εικόνων OCT
• Ενταςη ςήματοσ (intensity)
• Απόςβεςη ςήματοσ (attenuation)
• Ορια ιςτου
Intimal thickening
1st Department of Cardiology. University of Athens
Lipid Pool
Yabushita et al, Circulation. 2002;106:1640-1645
High attenuation
Lipid pool
Sensitivity: 90-95% Specifity: 90-98%Kawasaki et al., JACC 2006;48:81-88
n=357 segments
1st Department of Cardiology. University of Athens
Calcific depositions
Yabushita et al, Circulation. 2002;106:1640-1645
Low attenuation
Sensitivity: 95-100%, Specificity: 97-100%Kawasaki et al., JACC 48;2006:81-88
n=357 segments
1st Department of Cardiology. University of Athens
Rupture
1st Department of Cardiology. University of Athens
ThrombusBased on the intensity attenuation
Kume et al, Am J Cardiol 2006;97:1713–1717
Lig
ht
Inte
nsi
ty
White Thrombus
Lig
ht
Inte
nsi
ty
Red Thrombus
Sensitivity: 90%
Specifity: 92%
for identifying the
type of thrombus
(Cut-off value 250
μm)
n=108 segments
16 red thrombi
17 white thrombi
Macrophage Content
Tearney et al, Circulation. 2003;107:113-119
Sensitivity: 100% Specificity: 100% for caps >10% CD68 (raw)
Sensitivity: 70% Specificity: 75% for caps >10% CD68 (log 10)
Raw
Log 10
CD 68
OCT measurements of macrophage density were
independent of fibrous cap thicknessn=26 lipid-rich segments
R=0.84 (P<0.0001)
R=0.47 (P < 0.05)
RAW
LOG 10
Intraplaque Hemorrhage (?)
Prati et al, EHJ 2009
Neovascularization (?)
Prati et al, EHJ 2009
Evaluation of strut coverage by OCT
Haziness…
Toutouzas, Synetos …Stefanadis Clin Cardiol 2007
…Dissection & Thrombus
Toutouzas , Synetos …Stefanadis, Clin Cardiol 2007
Recanalized Thrombus
Toutouzas , Karanasos, Synetos…Stefanadis JACC Cardiovasc Interv. 2012 Jun;5(6):688-9
Θρόμβος
Chromaflo™ Imaging
Φυσιολογικός αυλός
IVUS: απεικόνιζη θπόμβος
Stent thrombosis, restenosis or underexpansion?
Lumen area: 6.19mm2
Stent area: 6.88 mm2
Neointima thickness: 80 μm
Control
Lumen area: 7.17 mm2
Stent area: 7.45 mm2
Neointima thickness: 40 μm
OCT images28 day follow-up
Toutouzas ..Synetos..Stefanadis AHA 2009
Avastin
Αξιολόγηζη ζημανηικόηηηαρ βλάβηρ
Καθοδήγηζη ηηρ
αγγειοπλαζηικήρ
(ππιν από ηο stent)
Δκηίμηζη ηος αποηελέζμαηορ
ηηρ αγγειοπλαζηική
ρ
Αξιολόγηζη επιπλοκών μεηά από ηο
stent
Θπόμβυζη &
επαναζηένυζη ηος stent
Σύγκπιζη μεθόδυν
Δκηίμηζη ζύζηαζηρ
πλάκαρ
Area-length measurementsOCT-IVUS
IVUS measurements are greater than those of OCT. (Resolution? –
Dotter effect?)Yamaguchi et al., Am J Cardiol 2008;101:562–567
Akasaka EuroPCR 12
Akasaka EuroPCR 12
Αξιολόγηζη ζημανηικόηηηαρ βλάβηρ
Καθοδήγηζη ηηρ
αγγειοπλαζηικήρ
(ππιν από ηο stent)
Δκηίμηζη ηος αποηελέζμαηορ
ηηρ αγγειοπλαζηική
ρ
Αξιολόγηζη επιπλοκών μεηά από ηο
stent
Θπόμβυζη &
επαναζηένυζη ηος stent
Σύγκπιζη μεθόδυν
Δκηίμηζη ζύζηαζηρ
πλάκαρ
Vulnerable Plaque Components
• Fibrous Cap Thickness< 65 μm• Large Necrotic Core• Inflammation• Positive Remodelling
VP Meeting, Eur Heart J 2004.
Schaar, Stefanadis et al
VP Meeting, P. Serruys, A. Colombo,
C. Stefanadis, S. Casscells, J. Schaar, 2007
• Reduced shear stress
• Intravascular Hemorrhage
• Neovascularization
MA
CE
(%
)
Time in Years
0 1 2 3
All
Culprit lesion (CL) related
Non culprit lesion (NCL) related
Indeterminate
0
5
10
15
20
25
12.9%
20.4%
11.6%
2.7%
Stone GW et al., N Engl J Med 2011;364:226-35.
PROSPECT: Independent predictors of patient and lesion level events by logistic
regression analysis
Stone GW et al., N Engl J Med 2011;364:226-35.
Stone GW et al., N Engl J Med 2011;364:226-35.
Μελζτη PROSPECT: VH-TCFA ωσ προγνωςτικόσ δείκτησ ςε επίπεδο βλάβησ
+ μικρόσ υπολειπόμενοσ αυλόσ
+ μεγάλη πλάκα
+ μικρόσ υπολειπόμενοσ αυλόσ+ μεγάλη πλάκα
Fibrotic Pathologic intimal
thickeningFibroatheroma
Calcified FA TCFA TCFA with previous
rupturesFibrocalcific
Sangiorgi GM et al, Cath Cardiov Interv 70:203–210 (2007)
Total 126 lesions
Non-NCCL OCT-
derived TCFA
6.3%
Definite TCFA
(22.2%)
Non-thin-cap IVUS-
derived TCFA
(26.2%)
OCT Derived TCFA
(28.6%)
IVUS-derived TCFA
(48.4%)
Sawada et al, EHJ (2008) 29, 1136–1146
Vulnerable plaque characteristics are associated with thrombolysis failure
Toutouzas K, Tsiamis E, Karanasos A, Drakopoulou M, Synetos A, Tsioufis C, Tousoulis D, Davlouros
P, Alexopoulos D, Bouki K, Apostolou T, Stefanadis C. JACC Cardiovasc Interv. 2010 May;3(5):507-14
Difference in rupture between STEMI & NSTEMI
STEMI NSTEMI
Toutouzas.. Synetos…Stefanadis, Am Heart J 2011 Jun; 161:1192-9
STEMI patients have greater rupture length and greater
length of missing fibrous cap than NSTEMI patients
Rupture location in ACS
Rupture CharacteristicsRupture Length(mm) 2.27±1.70
Location of rupture
Distal to the MLS 14(36.8)
MLS 14(36.8)
Proximal to the MLS 10(26.3)
Distance from MLS(mm) 2.01±2.10
Cross Sectional Area(mm2) 4.12±2.68
Minimal Cap Thickness(μm) 59±21μm
Rupture at cap shoulder 26(68.4)
Length of missing fibrous cap(mm) 0.53±0.27
Toutouzas, Karanasos,Synetos…Stefanadis, Am Heart J 2011 Jun; 161:1192-9
OCT imaging in ACS
Toutouzas..Synetos..Stefanadis, Heart July 2010
Non-culprit lipid-
rich plaque with
thick cap
Napkin ring –
significant lesion
Plaque rupture
MLS - white
thrombus
Red thrombus
TCFA
Evaluation of culprit lesion in ACS
revealed multiple morphologies
Neoatherosclerosis
Neoatherosclerosis is frequent and more common among symptomatic patients.Importantly, neointimal rupture is associated with ACS late after stent implantation.
Specific morphological characteristics, such as cap thickness and macrophage infiltrationare associated with rupture of neoatherosclerotic plaques
Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands1st Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece
OCT - Thermography
37,16
37,18
37,2
37,22
37,24
37,26
ΔΤ=0.03°C
Cap thickness 100 μm
Toutouzas , Synetos , … Stefanadis ACC 2009
,03
,04
,05
,06
,07
,08
,09
,1
,11
,12
Min
Cap T
hic
kness
No Yes
Box Plot
Grouping Variable(s): HOT
Low ΔΤ Ηigh ΔΤ
37.1
37.15
37.2
37.25
37.3
Cap thickness 20 μm
Toutouzas, Synetos…Stefanadis., ESC 2010
ΔΤ= 0.8oC
Experimental study
DT M
R(°
C)
DTIVT(°C)
R=0.61, p<0.001
Measurements with MR are corellated with
measurements with IVT
Toutouzas…Synetos..Stefanadis ,Atherosclerosis 2010
3D OCT – Shear Stress
Development of an algorithm that can provide us with automated measurements and provide
us with the 3d structure of the vessel allowing the measurement of ESS
First Dept. of Cardiology, Athens Medical School
Shear Stress Map of the Reconstructed RCA
First Department of Cardiology, University of AthensAristotle University of ThessalonikiHarvard Medical School
Μελζτη PREDICTION:Συςχζτιςη shear stress με μελλοντικά ςυμβάματα
Stone P, Circulation. 2012 Jul 10;126(2):172-8
Το χαμηλό shear stress ήταν
ανεξάπτητορ ππογνωστικόρ
παπάγονταρ για εξέλιξη βλάβηρ
Volumetric assessment of TCFA
3D reconstruction for measurement of the area of the thin fibrous cap
Chamie D et al, Curr Cardiovasc Imaging Rep (2011) 4:276–283
Hybrid IVUS-OCT catheters
Li et al, Catheter CardiovascInterv 2012Li et al
Micro OCT
Liu et al, Nat Med 2011 17(8)
Prati et al.EuroIntervention 2012;8:823-829
PCI 2011 GUIDELINES
Recommendations for Use of FFR, IVUS, and OCT
Lofti et al . Catheterization and Cardiovascular Interventions 00:00–00 (2013)
• FFR reproducibility data from the landmark DeferralVersus Performance of PTCA in Patients WithoutDocumented Ischemia (DEFER) trial was analyzed
• Two repeated FFR measurements in the samelesion, 10 min apart
• Outside the [0.75 to 0.85] FFR range, measurementcertainty of a single FFR result is >95%
• However, closer to its cut-off, certainty falls to lessthan 80% within 0.77 to 0.83, reaching a nadir of 50%around 0.8
Pedraco et al , JACC Cardiovasc Interv. 2013 Mar;6(3):222-5.
CONCLUSIONS
• OCT and IVUS are nowadays considered as important modalities for the evaluation of the morphological characteristics of a coronary plaque, for the guidance of the PCI, and for the assessment of its result
• Both OCT and IVUS are important tools for the understanding of the natural history of coronary artery disease and the evaluation of the VP
Conclusions
• Cost effectiveness of IVUS has been proved byrandomised prospective studies, however the costeffectiveness of OCT still needs to be established
• Technologies that increase the overall cost of medicalcare may still be acceptable in the future, but only ifwe can demonstrate improved clinical outcomes thatare meaningful to our patients (i.e., increased lifeexpectancy, reduced symptoms, or improved QOL)