IVUSGuidedCaseReviewCasePerformedbyFrankR.Arko III,MD

Charlotte,NC

Theopinionsandclinicalexperiencespresentedhereinareforinformationalpurposesonly.Dr.Arko isapaidconsultantforPhilipsVolcano.Theresultsfromthesecasestudymaynotbepredictiveforallpatients. Individualresultsmayvarydependingonavarietyof

patient-specificattributesandrelatedfactors.TrademarksarethepropertyofPhilipsVolcanoortheirrespectiveowners.

PatientPresentation

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51year-oldAfricanAmericanmalepresentedwithrestpaininleftlegwithahistoryofpriorself-expandingstentinleftSFA.

Presentedwithrestpaininleftleg

Underwentnon-invasiveperipheralarterialstudiespriortoourassessmentwhichconfirmedin-stentrestenosis,and

indicatedfreshthrombusin-stent.

HistoryofstentinginleftSFA

Imageisamodel,notanactualpatient

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InitialAngiogram

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LeftProximalSFA LeftSFAMid-DistalOcclusion

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InitialIVUSPullback

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IVUSassistedindeterminingthe:

• Diameteroftreatmentarea

• Plaquemorphology

• Lengthofstenosis

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TherapyUsed

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Basedoffthepatientpresentation,angiogramandIVUSthephysiciandecidedtotreatthepatientwith:

• Catheter-infused10mgoftPA toassistinresolvingthethrombusinsidethepreviouslystentedportionoftheSFA.

• A5x150mmViabahnstenttotreatthein-stentrestenosisinthemidtodistalSFA.

• A5x120mm(2each)and5x40mmMedtronicIN.Pact Admiraldrug-coatedballoontotreatthediseasedareaintheproximalSFA.

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IVUSGuidanceConclusions

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IVUSconfirmedin-stentrestenosisinthedistallesion.Also,IVUSimagedfreshthrombuswithinthein-stentrestenosis.

IVUSidentifiedthevesseldiameterthusassistingthephysiciantoappropriatelypre-dilatethedistallesionanddeterminepropersizedViabahnstenttotreatthein-stentrestenosissegment.

IVUSidentifiedtheproximalvesseldiameterandwherethenormalproximalsegmentofthevesseloccurred.Thisassistedthephysicianindeterminingtheappropriatesizeandlengthofdrugcoatedballoonneededtotreattheproximaldiseasedsegment.

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VIPERTrial-Results

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Theoverall1-yearprimarypatencyrateforcomplexlesionswithameanlengthof19cmwas73%.

The1-yearprimarypatencyratefordevicesthatwerenotoversized(≤20%)relativetotheproximallandingzonewas88%,significantlybetterthanthe70% 1-yearprimarypatencyratefordevicesthatwereoversized>20%(P=.047).

SaxonR.,MDet.al.Heparin-bonded,ExpandedPolytetrafluoroethylene- linedStentGraftintheTreatmentofFemoropopliteal ArteryDisease:1-YearResultsoftheVIPER(Viabahn Endoprosthesis withHeparinBioactiveSurfaceintheTreatmentofSuperficialFemoralArteryObstructiveDisease)Trial.JVasc Interv Radiol 2013;24:165–173.

VIPERTrial- SizeMatters

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Primarypatencyratewas88%intheVIPERtrialifthestentwassized≤20%relativetotheproximallandingzonetothevessel.

IntheVIPERTrialifthestentwasoversizedbymorethan20%thentheprimarypatencyratedroppedto70%(P<0.05)

Pertheinvestigators,“Mostoftheexcessiveoversizinginthistrialresultedfromoperators’overestimationofthediameterofthearteriallumen.Toavoidthis,cliniciansmayemployquantitativetechniquestooptimizestentgrafttreatment.”

SaxonR.,MDet.al.Heparin-bonded,ExpandedPolytetrafluoroethylene- linedStentGraftintheTreatmentofFemoropopliteal ArteryDisease:1-YearResultsoftheVIPER(Viabahn Endoprosthesis withHeparinBioactiveSurfaceintheTreatmentofSuperficialFemoralArteryObstructiveDisease)Trial.JVasc Interv Radiol2013;24:165–173.

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PostIVUSAfterTreatment

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PosttherapyIVUSpullbackperformedtoassessadequacyoftherapy.

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FinalAngiogram

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Finalangiogramperformedposttreatment.

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Conclusion

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IVUSSolution:

• IVUSconfirmedin-stentrestenosis,aswellasdemonstratingfreshthrombusinthein-stentrestenosissegment.

• IVUSidentifiedthevesseldiameterthusassistingthephysiciantoappropriatelypre-dilatethedistallesionanddeterminepropersizedViabahnstenttotreatthein-stentrestenosissegment.

• IVUSidentifiedtheproximalvesseldiameterandwherethenormalproximalsegmentofthevesseloccurred.Thisassistedthephysicianindeterminingtheappropriatesizeandlengthofdrugcoatedballoonneededtotreattheproximaldiseasedsegment.

• Followingtherapy,IVUSwasusedtovisualizetheminimumluminalareaandlookforanyflowlimitingdissectionsthattheangiogrammayhavemissed.Thisassistedthephysicianindeterminingthatanadequateresultwasachievedforthepatient.

IVUSSolution:

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