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IVUS-Guided Stent Implantation to Improve Outcome: A Promise Waiting to be Fulfilled.

Rogacka R, Latib A, Colombo A - Curr Cardiol Rev (2009)

Bottom Line: The use of intravascular ultrasound (IVUS) to improve acute angiographic results was already shown in the prestent era.With the introduction of drug-eluting stents (DES) the rate of restenosis has been significantly reduced but a new concern, the risk of stent thrombosis, has emerged.Universal and easily applicable IVUS criteria for optimization of stent implantation as well as randomized studies on IVUS-guided DES implantation are necessary to minimize stent malapposition and underexpansion, which in turn can positively influence the rates of stent restenosis and thrombosis.

View Article: PubMed Central - PubMed

Affiliation: Interventional Cardiology Unit, Desio Hospital, Milan, Italy.

ABSTRACT
The use of intravascular ultrasound (IVUS) to improve acute angiographic results was already shown in the prestent era. Various studies demonstrated the efficacy of IVUS in balloon sizing and estimating the extent of positive remodeling. With the introduction of drug-eluting stents (DES) the rate of restenosis has been significantly reduced but a new concern, the risk of stent thrombosis, has emerged. The association of stent underexpansion with stent thrombosis was observed for bare metal stents (BMS) and DES. Until now, the criteria for IVUS optimization used in different studies have relied on distal reference or on mean reference vessel for stent or postdilatation balloon sizing. Furthermore, an important recent innovation not available in previous studies is the use of noncompliant balloons to perform high pressure post-dilatation. Universal and easily applicable IVUS criteria for optimization of stent implantation as well as randomized studies on IVUS-guided DES implantation are necessary to minimize stent malapposition and underexpansion, which in turn can positively influence the rates of stent restenosis and thrombosis.

No MeSH data available.


Related in: MedlinePlus

Cumulative frequency curves for baseline RVD and final ballon size in matched lesions optimized with IVUS versus angiography.
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Figure 2: Cumulative frequency curves for baseline RVD and final ballon size in matched lesions optimized with IVUS versus angiography.

Mentions: The size of this balloon was calculated using the median vessel media-to-media diameters at different sites in the stent segment. The CSA of the stent was measured at the most narrowed zones and stent underexpansion was defined as CSA below 70% of the postdilating balloon that matched the median vessel-vessel diameter at the underexpanded zone. The stent was then postdilated with a non-compliant balloon at any site where the stent CSA was below the 70% criteria, and if needed several different sized balloons were used in long-overlapping stents where the vessel diameter varied in size. Using these criteria, we were able to achieve a minimal stent CSA ≥ 70% of the postdilation balloon in 78% of lesions that underwent IVUS optimization. We then compared the final MLD in 93 IVUS optimized lesions with a group of angiographically-guided lesions matched according to diabetes, vessel type, reference vessel diameter (RVD), MLD and lesion length. Baseline RVD, MLD and lesion lengths were not statistically different between the two matched groups. However, final MLD was significantly larger in the IVUS compared to the angiographic guided group (3.09 ± 0.50 v 2.67 ± 0.54; p < 0.0001). From a practical point of view, we noted that despite a similar baseline angiographic RVD, the use of IVUS gave the operator the confidence to select a larger postdilating balloon size (3.26 ± 0.50 vs. 2.98 ± 0.42 mm; p<0.001) and safely inflate the balloon to higher pressures (24.4 ± 4.6 vs. 16.1 ± 5.0 atmospheres; p<0.001), Fig. (2).


IVUS-Guided Stent Implantation to Improve Outcome: A Promise Waiting to be Fulfilled.

Rogacka R, Latib A, Colombo A - Curr Cardiol Rev (2009)

Cumulative frequency curves for baseline RVD and final ballon size in matched lesions optimized with IVUS versus angiography.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2805818&req=5

Figure 2: Cumulative frequency curves for baseline RVD and final ballon size in matched lesions optimized with IVUS versus angiography.
Mentions: The size of this balloon was calculated using the median vessel media-to-media diameters at different sites in the stent segment. The CSA of the stent was measured at the most narrowed zones and stent underexpansion was defined as CSA below 70% of the postdilating balloon that matched the median vessel-vessel diameter at the underexpanded zone. The stent was then postdilated with a non-compliant balloon at any site where the stent CSA was below the 70% criteria, and if needed several different sized balloons were used in long-overlapping stents where the vessel diameter varied in size. Using these criteria, we were able to achieve a minimal stent CSA ≥ 70% of the postdilation balloon in 78% of lesions that underwent IVUS optimization. We then compared the final MLD in 93 IVUS optimized lesions with a group of angiographically-guided lesions matched according to diabetes, vessel type, reference vessel diameter (RVD), MLD and lesion length. Baseline RVD, MLD and lesion lengths were not statistically different between the two matched groups. However, final MLD was significantly larger in the IVUS compared to the angiographic guided group (3.09 ± 0.50 v 2.67 ± 0.54; p < 0.0001). From a practical point of view, we noted that despite a similar baseline angiographic RVD, the use of IVUS gave the operator the confidence to select a larger postdilating balloon size (3.26 ± 0.50 vs. 2.98 ± 0.42 mm; p<0.001) and safely inflate the balloon to higher pressures (24.4 ± 4.6 vs. 16.1 ± 5.0 atmospheres; p<0.001), Fig. (2).

Bottom Line: The use of intravascular ultrasound (IVUS) to improve acute angiographic results was already shown in the prestent era.With the introduction of drug-eluting stents (DES) the rate of restenosis has been significantly reduced but a new concern, the risk of stent thrombosis, has emerged.Universal and easily applicable IVUS criteria for optimization of stent implantation as well as randomized studies on IVUS-guided DES implantation are necessary to minimize stent malapposition and underexpansion, which in turn can positively influence the rates of stent restenosis and thrombosis.

View Article: PubMed Central - PubMed

Affiliation: Interventional Cardiology Unit, Desio Hospital, Milan, Italy.

ABSTRACT
The use of intravascular ultrasound (IVUS) to improve acute angiographic results was already shown in the prestent era. Various studies demonstrated the efficacy of IVUS in balloon sizing and estimating the extent of positive remodeling. With the introduction of drug-eluting stents (DES) the rate of restenosis has been significantly reduced but a new concern, the risk of stent thrombosis, has emerged. The association of stent underexpansion with stent thrombosis was observed for bare metal stents (BMS) and DES. Until now, the criteria for IVUS optimization used in different studies have relied on distal reference or on mean reference vessel for stent or postdilatation balloon sizing. Furthermore, an important recent innovation not available in previous studies is the use of noncompliant balloons to perform high pressure post-dilatation. Universal and easily applicable IVUS criteria for optimization of stent implantation as well as randomized studies on IVUS-guided DES implantation are necessary to minimize stent malapposition and underexpansion, which in turn can positively influence the rates of stent restenosis and thrombosis.

No MeSH data available.


Related in: MedlinePlus