performing and interpreting ivus, vh-ivus & oct · monorail imaging catheter non-occlusive oct....

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



ηηρ αγγειοπλαζηικήρ


stent

Θπόμβυζη &




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


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


Rupture


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 (?)


Neovascularization (?)


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






ρ


stent

Θπόμβυζη &




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

Αξιολόγηζη ζημανηικόηηηαρ βλάβηρ






ρ


stent

Θπόμβυζη &




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



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)

performing and interpreting ivus, vh-ivus & oct · monorail imaging catheter non-occlusive oct....

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