Intravascular Imaging During PCI

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Due to angiography limitations, intra-coronary imaging can be used to guide coronary stent implantation, especially in patients with left main coronary artery involvement or complex lesions.^[1]
Intravascular ultrasound (IVUS) and optical coherence tomography (OCT are two imaging methods that can be used to assess vasculature conditions before and after PCI.
Both imaging methods can assist in evaluating the need for lesion preparation, stent sizing, diminishing geographic-related errors, confirming stent expansion, identifying complications, and causes of stent failure.^[2]

ACA 2021 Revascularization Guideline

Class 2a Recommendation, Level of Evidence: B-R^[1]
1.Intravascular ultrasound (IVUS) can be used as a procedural guidance in patients undergoing coronary stent implantation, particularly in those with left main or complex coronary artery stenting in order to diminish ischemic events. 2.Optical coherence tomography (OCT is a reasonable alternative to IVUS as an procedural guidance in patients undergoing coronary stent implantation, except in those with ostial left main disease.

Class 2a Recommendation, Level of Evidence: C-LD^[1]
If stent failure occurs, both IVUS and OCT can be used to determine the mechanism of stent failure.

Intravenous Ultrasound

Multiple meta-analyses have shown that intravascular ultrasound-guided PCI is more successful in reducing major adverse cardiovascular events (MACE) compared to angiographic-guided PCI.^[3]^[4]^[5]^[6]^[7]
Furthermore, based on a trial named ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in “All-Comers” Coronary Lesions), intravascular ultrasound-guided PCI is more successful in reducing target-vessel failure compared to angiographic-guided PCI.^[8]
The following are the list of pre-PCI evaluations that can be done with intravascular ultrasound:^[9]^[10]
- Full-thickness evaluation of the vessel wall
- Plaque burden
- Calcification extent
- Length of lesion
- External elastic lamina diameter for stent sizing
The following are the list of post-PCI evaluations that can be done with intravascular ultrasound:^[9]^[10]
- Assessment of stent area
- Stent malposition
- Stent underexpansion
- Tissue protrusion
- Edge disease and dissection

Optical Coherence Tomography

Optical coherence tomography (OCT) is capable of generating high-resolution images of vessel walls by using infrared light. This imaging method has particular advantages in the evaluation of the following:^[2]
- Calcium thickness
- Lipid, thrombus, fibroatheroma, and plaque rupture
- Stent strut neointimal thickness
- Stent malposition
- Edge dissections
The following are some of the limitations of optical coherence tomography (OCT):^[1]
- Limited depth of imaging
- Usage of OCT is limited in ostial left main disease since blood clearance through the use of contrast injection is necessary for performing OCT

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).
↑ ^2.0 ^2.1 Maehara A, Matsumura M, Ali ZA, Mintz GS, Stone GW (2017). “IVUS-Guided Versus OCT-Guided Coronary Stent Implantation: A Critical Appraisal”. JACC Cardiovasc Imaging. 10 (12): 1487–1503. doi:10.1016/j.jcmg.2017.09.008. PMID 29216976.
↑ Buccheri S, Franchina G, Romano S, Puglisi S, Venuti G, D’Arrigo P; et al. (2017). “Clinical Outcomes Following Intravascular Imaging-Guided Versus Coronary Angiography-Guided Percutaneous Coronary Intervention With Stent Implantation: A Systematic Review and Bayesian Network Meta-Analysis of 31 Studies and 17,882 Patients”. JACC Cardiovasc Interv. 10 (24): 2488–2498. doi:10.1016/j.jcin.2017.08.051. PMID 29153502.
↑ Elgendy IY, Mahmoud AN, Elgendy AY, Bavry AA (2016). “Outcomes With Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis of Randomized Trials in the Era of Drug-Eluting Stents”. Circ Cardiovasc Interv. 9 (4): e003700. doi:10.1161/CIRCINTERVENTIONS.116.003700. PMID 26980883.
↑ Zhang YJ, Pang S, Chen XY, Bourantas CV, Pan DR, Dong SJ; et al. (2015). “Comparison of intravascular ultrasound guided versus angiography guided drug eluting stent implantation: a systematic review and meta-analysis”. BMC Cardiovasc Disord. 15: 153. doi:10.1186/s12872-015-0144-8. PMC 4647753. PMID 26577590.
↑ Nerlekar N, Cheshire CJ, Verma KP, Ihdayhid AR, McCormick LM, Cameron JD; et al. (2017). “Intravascular ultrasound guidance improves clinical outcomes during implantation of both first- and second-generation drug-eluting stents: a meta-analysis”. EuroIntervention. 12 (13): 1632–1642. doi:10.4244/EIJ-D-16-00769. PMID 27840327.
↑ Ahn JM, Kang SJ, Yoon SH, Park HW, Kang SM, Lee JY; et al. (2014). “Meta-analysis of outcomes after intravascular ultrasound-guided versus angiography-guided drug-eluting stent implantation in 26,503 patients enrolled in three randomized trials and 14 observational studies”. Am J Cardiol. 113 (8): 1338–47. doi:10.1016/j.amjcard.2013.12.043. PMID 24685326.
↑ Zhang J, Gao X, Kan J, Ge Z, Han L, Lu S; et al. (2018). “Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: The ULTIMATE Trial”. J Am Coll Cardiol. 72 (24): 3126–3137. doi:10.1016/j.jacc.2018.09.013. PMID 30261237.
↑ ^9.0 ^9.1 Steinberg DH, Mintz GS, Mandinov L, Yu A, Ellis SG, Grube E; et al. (2010). “Long-term impact of routinely detected early and late incomplete stent apposition: an integrated intravascular ultrasound analysis of the TAXUS IV, V, and VI and TAXUS ATLAS workhorse, long lesion, and direct stent studies”. JACC Cardiovasc Interv. 3 (5): 486–94. doi:10.1016/j.jcin.2010.03.007. PMID 20488404.
↑ ^10.0 ^10.1 Kobayashi N, Mintz GS, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL; et al. (2016). “Prevalence, Features, and Prognostic Importance of Edge Dissection After Drug-Eluting Stent Implantation: An ADAPT-DES Intravascular Ultrasound Substudy”. Circ Cardiovasc Interv. 9 (7): e003553. doi:10.1161/CIRCINTERVENTIONS.115.003553. PMID 27402854.

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[pmid34895950-1] 1.0 ^1.1 ^1.2 ^1.3 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).

[pmid29216976-2] 2.0 ^2.1 Maehara A, Matsumura M, Ali ZA, Mintz GS, Stone GW (2017). “IVUS-Guided Versus OCT-Guided Coronary Stent Implantation: A Critical Appraisal”. JACC Cardiovasc Imaging. 10 (12): 1487–1503. doi:10.1016/j.jcmg.2017.09.008. PMID 29216976.

[pmid29153502-3] Buccheri S, Franchina G, Romano S, Puglisi S, Venuti G, D’Arrigo P; et al. (2017). “Clinical Outcomes Following Intravascular Imaging-Guided Versus Coronary Angiography-Guided Percutaneous Coronary Intervention With Stent Implantation: A Systematic Review and Bayesian Network Meta-Analysis of 31 Studies and 17,882 Patients”. JACC Cardiovasc Interv. 10 (24): 2488–2498. doi:10.1016/j.jcin.2017.08.051. PMID 29153502.

[pmid26980883-4] Elgendy IY, Mahmoud AN, Elgendy AY, Bavry AA (2016). “Outcomes With Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis of Randomized Trials in the Era of Drug-Eluting Stents”. Circ Cardiovasc Interv. 9 (4): e003700. doi:10.1161/CIRCINTERVENTIONS.116.003700. PMID 26980883.

[pmid26577590-5] Zhang YJ, Pang S, Chen XY, Bourantas CV, Pan DR, Dong SJ; et al. (2015). “Comparison of intravascular ultrasound guided versus angiography guided drug eluting stent implantation: a systematic review and meta-analysis”. BMC Cardiovasc Disord. 15: 153. doi:10.1186/s12872-015-0144-8. PMC 4647753. PMID 26577590.

[pmid27840327-6] Nerlekar N, Cheshire CJ, Verma KP, Ihdayhid AR, McCormick LM, Cameron JD; et al. (2017). “Intravascular ultrasound guidance improves clinical outcomes during implantation of both first- and second-generation drug-eluting stents: a meta-analysis”. EuroIntervention. 12 (13): 1632–1642. doi:10.4244/EIJ-D-16-00769. PMID 27840327.

[pmid24685326-7] Ahn JM, Kang SJ, Yoon SH, Park HW, Kang SM, Lee JY; et al. (2014). “Meta-analysis of outcomes after intravascular ultrasound-guided versus angiography-guided drug-eluting stent implantation in 26,503 patients enrolled in three randomized trials and 14 observational studies”. Am J Cardiol. 113 (8): 1338–47. doi:10.1016/j.amjcard.2013.12.043. PMID 24685326.

[pmid30261237-8] Zhang J, Gao X, Kan J, Ge Z, Han L, Lu S; et al. (2018). “Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: The ULTIMATE Trial”. J Am Coll Cardiol. 72 (24): 3126–3137. doi:10.1016/j.jacc.2018.09.013. PMID 30261237.

[pmid20488404-9] 9.0 ^9.1 Steinberg DH, Mintz GS, Mandinov L, Yu A, Ellis SG, Grube E; et al. (2010). “Long-term impact of routinely detected early and late incomplete stent apposition: an integrated intravascular ultrasound analysis of the TAXUS IV, V, and VI and TAXUS ATLAS workhorse, long lesion, and direct stent studies”. JACC Cardiovasc Interv. 3 (5): 486–94. doi:10.1016/j.jcin.2010.03.007. PMID 20488404.

[pmid27402854-10] 10.0 ^10.1 Kobayashi N, Mintz GS, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL; et al. (2016). “Prevalence, Features, and Prognostic Importance of Edge Dissection After Drug-Eluting Stent Implantation: An ADAPT-DES Intravascular Ultrasound Substudy”. Circ Cardiovasc Interv. 9 (7): e003553. doi:10.1161/CIRCINTERVENTIONS.115.003553. PMID 27402854.

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Intravascular Imaging During PCI

ACA 2021 Revascularization Guideline

Intravenous Ultrasound

Optical Coherence Tomography

References

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