Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Optimization of Stent Deployment by Intravascular Ultrasound

Optimization of Stent Deployment by Intravascular Ultrasound review ORIGINAL ARTICLE korean j intern med 2012;27:30-38 pISSN 1226-3303 eISSN 2005-6648 http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Optimization of Stent Deployment by intravascular Ultrasound Hyuck-Jun Yoon and Seung-Ho Hur Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea Intravascular ultrasound (IVUS) is a useful diagnostic method that provides valuable information in addition to angiog- raphy regarding the coronary vessel lumen, dimensions, plaque burden, and characteristics. The major use of IVUS in coronary intervention is to guide interventional strategies and assess optimal stent deployment. Since the introduction of the drug-eluting stent (DES), concerns about restenosis have decreased. However, high-risk lesion subsets are being routinely treated with DESs, and the incidence of suboptimal results after stent deployment, such as stent underexpan- sion, incomplete stent apposition, edge dissection, geographic miss, and the risk of stent thrombosis, have correspond- ingly increased. Thus, optimization of stent deployment under IVUS guidance may be clinically important. In this review, we focus on the potential role of IVUS in stent optimization during percutaneous coronary intervention and its clinical benetfis. Keywords: Angioplasty, balloon; Coronary stenosis; Mortality; Stents; Therapy; Ultrasonography [1,2]. Int Ro Du Ct Ion IVUS is an invasive imaging technique used to visualize The coronary angiogram (CAG) remains the gold-stan- coronary cross-sectional anatomy and is superior to CAG dard method for assessing coronary artery disease (CAD). in assessing vessel size, calcium content, and lesion sever- However, the CAG has inherent pitfalls, such as only show- ity [3]. It also provides complementary procedural infor- ing the vessel lumen as an X-ray shadow image, created by mation in lesions requiring percutaneous coronary inter- the injection of contrast medium, and of often visualizing vention (PCI) when determining adequate stent sizing, a “side-view.” Thus, the apparent degree of coronary ste- and conr fi ming optimal stent deployment and apposition nosis can be affected by the projection angle due to lesion without edge tearing in real time. Thus, a growing number eccentricity. Additionally, diffuse coronary disease, lesion of interventional cardiologists attain optimal procedural foreshortening, angulations, calcic fi ation, and vessel over - results with reduced complications when using IVUS in lap can be challenges in the angiographic assessment of le- PCI. sion severity. In some cases, an angiographically normal- Although the routine use of IVUS in daily PCI remains looking coronary artery actually shows various degrees of controversial, stent optimization by IVUS during stenting atherosclerotic plaque by intravascular ultrasound (IVUS) procedures, especially in the era of drug-eluting stents Received : January 31, 2012 Accepted : February 2, 2012 Correspondence to Seung-Ho Hur, M.D. Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu 700-712, Korea Tel: 82-53-250-7998, Fax: 82-53-250-7034, E-mail: shur@dsmc.or.kr Copyright © 2012 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Yoon HJ and Hur SH. IVUS-guided stent optimization 31 (DESs), may have an important role in improving long- under 12-atmosphere pressure dilation and only 36% even term clinical outcomes such as stent restenosis and stent with higher deployment pressures (> 14 atmospheres) [9]. thrombosis [4]. In this review, we focus on the potential Another IVUS study with an early-generation DES in 200 roles of IVUS in stent optimization during PCI and its patients assessed stent expansion depending on the manu- clinical benet fi s. facturer’s compliance chart as a guideline. In that study, the DES obtained only 75% of predicted minimal stent di- ameter and 66% of the predicted minimal stent area (MSA) [10] (Fig. 1). Based on these observations, angiographic Re Al Ity o f Stent Ing p Ro Ce Du Re S In success cannot always be linked with optimal stent ex- DAIy l p RACt ICe pansion, despite higher pressure balloon ina fl tion during PCI has been the fastest growing method for the treat- the stenting procedure. In turn, stent optimization using ment of ischemic CA D over t he past t hree dec ades. a high-pressure balloon without IVUS guidance also has Coronary stents have emerged as the predominant form been associated with an increased risk of arterial perfora- of PCI and are currently used in more than 90% of PCI tion, probably secondary to vessel-balloon mismatch [11]. procedures. Procedural success of PCI is usually deter- Thus, the operator should consider using IVUS guidance mined by visual estimation by the operator, and usually, for high-pressure balloon inf lation during stent deploy- angiographic success after PCI is defined as the attain- ment. ment of residual diameter stenosis of less than 30%, which Apposition of stent struts to the vessel wall is also an is generally associated with at least a 20% improvement in important facet of stent optimization. Adequate stent diameter stenosis and relief of ischemia [5]. However, such expansion and adequate stent strut apposition have been subjective estimation of the severity of coronary artery ste- reported to be important factors in reducing repeated re- nosis is thought to be of limited reliability. Previous IVUS vascularization due to stent restenosis or stent thrombosis studies have demonstrated that visual estimation or quan- [12,13]. In the DES era, incomplete stent apposition has titative angiographic analyses of vessel dimension for stent been regarded as an important local factor in DES failure, deployment appear inaccurate [6-9]. The post-dilatation probably due to reduced drug delivery to the vessel wall clinical comparative (POSTIT) trial was designed to assess [14-17]. In a recent report, incomplete stent apposition was the achievement of optimal stent deployment by IVUS, signic fi antly associated with vessel/stent mismatch rather according to normal-to-high pressure balloon dilation than stent underexpansion immediately after stent im- after bare metal stent implantation. Among 256 patients, plantation [18]. Thus, adequate stent sizing by IVUS may only 14% of cases achieved optimal stent deployment with be clinically important in preventing incomplete stent ap- A b 4.5 3.5 SES SES PES PES 2.5 1.5 1 1.5 2 2.5 3 3.5 4 4.5 2 4 6 8 10 12 14 Manufacturer’s predicted stent diameter, mm Manufacturer’s predicted stent area, mm Figure 1. Intravascular ultrasound (IVUS)-measured minimum stent diameter (MSD, A) and minimum stent area (MSA, B) vs. pre- dicted measurements from each manufacturer’s compliance charts. SES, sirolimus-eluting stent; PES, paclitaxel-eluting stent. Reprint with permission from Elsevier Health Science Journals [10]. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr IVUS measured MSD, mm IVUS measured MSD, mm 32 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 position and in optimizing initial stent deployment. disease, are now being treated routinely with DESs [34,35]. Thus, the risk of stent underexpansion, incomplete stent apposition, and incomplete lesion coverage increases and these suboptimal stent deployment conditions have been IMpo Rt An Ce o f Stent opt IMIz At Ion reported to be potent IVUS predictors of stent resteno- IVUS has been used to detect suboptimal results after sis and stent thrombosis [13,17,24], suggesting that stent apparently angiographically successful stent deployment implantation under IVUS guidance still has a pivotal role in both the DES and bare metal stent (BMS) eras (Fig. 2). even in the DES era. An important aspect of IVUS is de- IVUS predictors that are associated with increased ad- termining appropriate reference segments that provide verse outcomes include smaller MSA, stent underexpan- the landing zone for stent deployment. IVUS examination sion, stent edge dissection, incomplete stent apposition, typically reveals a considerable amount of plaque, even in and incomplete lesion coverage [19-26]. In the BMS era, a segments of the vessel that appear “normal” on the angio- major problem after stent implantation was stent resteno- gram, known as “reference vessel” disease. Quantitative sis, and the main mechanism of this phenomenon was a IVUS studies have demonstrated that the segment chosen smaller MSA or stent underexpansion [21,26-30]. Several as the “normal” reference site for the calculation of angio- studies in the BMS era showed a benec fi ial effect of IVUS graphic percent stenosis has an average of 30-50% of its guidance on post-procedural angiographic results and cross-sectional area occupied by plaque [36]. By IVUS, the stent restenosis during long-term follow-up, resulting from den fi ition of reference segment is a cross-sectional image a larger MSA with a higher post-dilation balloon pressure adjacent to the lesion that has < 40% plaque burden [37]. [7,19,27,31]. Stent underexpansion, identie fi d by IVUS, can A previous study reported the association between clinical be treated with appropriate post-balloon dilation. IVUS outcomes and longitudinal positioning of the stent in 162 allows more aggressive intervention using a larger diam- consecutive patients with 180 lesions treated with siroli- eter balloon with cond fi ence in terms of safety; thus, BMS mus-eluting stent (SES) implantation [38]. In that study, implantation under IVUS guidance can provide a bigger stepwise IVUS criteria primarily targeting plaque burden MSA and more favorable clinical outcomes compared < 50% were shown to be feasible and improved the rates of with angiography-guided PCI. DESs have led to a marked stent restenosis and target lesion revascularization (TLR) reduction in the rate of stent restenosis and the need for at 8 months follow-up. repeated revascularization compared with BMSs [32,33]. Because of their efficacy, high-risk lesions and clinical conditions, including bifurcation lesions, long lesions, cal- How to opt IMIe z Stent Depo l y Ment cie fi d lesions, left main disease, diabetes, and multivessel IVUS is used frequently in PCI, but the use of IVUS cannot be directly related to stent optimization. Defini- tive guidelines for IVUS-guided stent optimization are not available and it is still performed at the operator’s dis- cretion. So, how do we perform stent optimization using IVUS, and what IVUS criteria are acceptable for current practice? Although many IVUS criteria for stent optimization have been suggested, the basic concepts underlying them can be summarized briey fl as minimizing the occurrence of IVUS-related predictors of adverse events after PCI, including stent underexpansion, incomplete stent apposi- Incomplete Stent Edge tion, edge dissection, and lesion undercoverage. stent apposition underexpansion dissection Stent underexpansion is defined as an area of inad- equate stent expansion compared with the adjacent refer- Figure 2. Stent-related complications after stent deployment. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 33 A b 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 10 15 20 25 30 35 40 45 50 55 60 65 70 Stent CAS, mm Stent length, mm Figure 3. Sensitivity and specificity curves identified optimal cut-off values of final minimum stent cross-sectional area (CSA, A) and stent length (B) that predicted angiographic restenosis after sirolimus-eluting stent implantation: 5.5 mm for final minimum stent CSA and 40 mm for intravascular ultrasound-measured stent length. Triangle, sensitivity; circles, specic fi ity. Reprinted with permission from Oxford University Press [22]. ence segments. However, a consensus definition of “ad- only 56% of stents met all three MUSIC criteria. Many equate” expansion is still lacking. other trials in the BMS era used similar IVUS criteria, and two meta-analyses showed better outcomes of IVUS- In the BMS era, several randomized trials used various IVUS criteria for stent deployment optimization, yield- guided PCI than angiography-guided PCI, especially in ing mixed results. The r fi st large multicenter study, called terms of in-stent restenosis and target vessel revascular- MUSIC (multicenter ultrasound stenting in coronaries ization (TVR), but not in mortality or myocardial infarc- study), sought to define specic fi criteria for optimal stent tion [43,44]. deployment and demonstrate the feasibility and safety of In contrast to the BMS era, for IVUS-guided PCI with IVUS-guided stent optimization [39]. In the MUSIC cri- DES, few randomized studies showing clinical efficacy, teria, “adequate” expansion was defined as > 90% of the preventing TVR or restenosis, or stent optimization under average reference cross-sectional area (CSA), or > 100% IVUS guidance have been carried out. In the HOME DES of a smaller reference CSA with complete apposition and trial, optimal stent deployment was defined as complete symmetric expansion. Another large multicenter trial was apposition of the stent struts, no edge dissection, and ad- AVID (angiographic versus IVUS direct stent placement); equate stent expansion, den fi ed as either MSA > 5.0 mm its defined IVUS optimization required complete stent or > 90% of the distal reference lumen area [45]. In that apposition with stent CSA > 90% of the distal reference study, no significant benefit in terms of TVR or clinical lumen area [40]. The results of the AVID trial showed a events was reported. A similar finding was also noted in signic fi ant benet fi of IVUS guidance in vessels 2.5-3.5 mm the AVIO (angiography versus IVUS optimization) study in size and in saphenous vein graf t PCI. The TULIP in which optimal stent expansion was > 70% of the CSA of (thrombotic activity evaluation and effects of ultrasound the chosen balloon [46]. However, attention should be paid guidance in long intracoronary stent placement) Study to avoid stent underexpansion. Increasing evidence indi- also showed signic fi ant angiographic and clinical benet fi s cates that IVUS-guided PCI may reduce the risk of stent of IVUS guidance using criteria such as stent CSA > distal thrombosis (ST) [47]. Stent underexpansion was demon- reference lumen [41]. In contrast to the results mentioned strated to be one of the major causes of this disastrous above, the OPTICUS trial (optimization with IVUS to re- complication, although the cause of ST is multifactorial duce stent restenosis) using the MUSIC criteria for IVUS [13,24,48,49]. In a substudy of the SIRIUS trial, adequate guidance did not show a significant difference in 6- or patency was den fi ed as a follow-up IVUS MSA > 4.0 mm . 12-month clinical outcomes [42]. However, in this study, When the adequate post-interventional MSA of SESs was http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Angiographic restenosis, % 34 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 den fi ed as > 5.0 mm , the positive predictive value of pa- trials, the rates of 6-month angiographic restenosis and tency was 90%, but the optimal cutoff value of BMS was target vessel revascularization were signic fi antly lower in defined as 6.5 mm [50]. Another study concerning SES the IVUS-guided PCI group than the angiography-guided 2 2 failure also supported that MSA < 5.5 mm and < 5.0 mm group (22% vs. 29%, p = 0.02 and 13% vs. 18%, p < 0.001, were the most important predictors of SES failure (Fig. respectively), with no difference in the rates of death (2.4% 3) [22,51]. Even if SES had a considerably lower optimal vs. 1.6%, p = 0.18) or MI (3.6% vs. 4.4%, p = 0.51) [44], MSA threshold than BMS, these studies showed that un- consistent with a previous meta-analysis [43]. derexpansion remained the main cause of stent failure in To date, few studies have investigated the clinical ben- DESs; at least a MSA < 5.0 mm should be avoided in non- et fi s of DES optimization under IVUS guidance compared -left main (LM) lesions. In LM lesions, optimal MSA was with that of BMSs. The HOME DES IVUS (long-term reported in the MAIN-COMPARE (revascularization for health outcome and mortality evaluation after invasive unprotected left main coronary artery stenosis: compari- coronar y treatment using drug-eluting stents with or son of percutaneous coronary angioplasty versus surgical without IVUS guidance) study was a randomized trial to revascularization) study to be > 8.7 mm to prevent TLR investigate clinical outcomes of IVUS-guided PCI with [34]. DESs. Although the IVUS-guided strategy resulted in the Edge dissection, which is complicated by lumen nar- frequent use of adjunctive balloons and a larger size bal- rowing < 4 mm or dissection angle ≥ 60°, has been as- loon with higher pressure, no significant difference was sociated with an increased incidence of early ST [49]; thus, observed in major adverse cardiac events or stent throm- additional stents may be needed to prevent ST. However, a bosis in the study [45]. A similar retrospective study of minor dissection, detected by IVUS, may not be associated IVUS-guided stent optimization also showed no signifi- with an increased incidence of ST [52,53]. Although no cant difference in the incidence of in-stent restenosis or consensus exists on an optimal strategy, in minor dissec- neointimal volume between IVUS- versus angiography- tion, careful observation without stenting can be helpful. guided PCI [54]. Conversely, a study with a propensity- Overall, the results discussed above encourage ensuring matched analysis in 884 patients treated w ith DESs good apposition of stent struts to the vessel wall, such that showed a signic fi ant reduction in the stent thrombosis rate the stent struts are not surrounded by lumen, adequate at both 30 days (0.5% vs. 1.4%, p = 0.046) and 12 months stent expansion to obtain MSA at least > 6.5 mm for (0.7% vs. 2.0%, p = 0.014) in the IVUS-guided PCI group BMSs and > 5.0 mm for DESs or MSA > 90% of the distal [47]. reference lumen CSA, and lack of major dissections, intra- Recently, a large “real world” registry from two Korean mural hematomas, and geographic misses. centers reported long-term outcomes of both IVUS- and angiography-guided PCI using BMS or DES implantation [55]. In total, 8,371 patients who underwent coronary stenting under IVUS guidance (4,627 patients) or angi- o ut Co Me S o f IV u S-gu IDe D Ve RSu S ography guidance (3,744 patients) were consecutively Ang Iog RApHy-gu IDe D pCI enrolled, and 3-year adverse clinical outcomes were com- Numerous studies have evaluated the clinical benet fi s of pared between the groups using a Cox regression model IVUS-guided PCI compared with angiography-guided PCI and propensity score matching. In the overall population, in the BMS era [41-44]. The OPTICUS trial showed no sig- the 3-year adjusted incidence of mortality was signifi- nic fi ant difference between IVUS- and angiography-guid - cantly lower in the IVUS-guided PCI group compared ed PCI groups in terms of 6- and 12-month rates of death, with the angiography-guided PCI group (hazard ratio myocardial infarction (MI), and TLR in 550 patients [HR], 0.70; 95% confidence interval [CI], 0.56 to 0.87; meeting the MUSIC criteria [42]. In contrast, the TULIP p = 0.001) (Fig. 4). In 2,715 matched pairs of the overall study demonstrated favorable angiographic and clinical population, the IVUS-guided PCI group also had a lower outcomes in patients with long coronary lesions (> 20 mm) mortality risk (HR, 0.71; 95% CI, 0.56 to 0.90; p = 0.005). treated with a BMS (> 3 mm) under IVUS guidance [41]. In However, IVUS-guided PCI did not influence the rates of a meta-analysis of 2,193 patients from seven randomized myocardial infarction, target-vessel revascularization, or http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 35 Death Myocardial infarction 99.2 ± 0.1 99.2 ± 0.1 100 100 99.0 ± 0.2 99.0 ± 0.2 98.8 ± 0.2 98.8 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 97.3 ± 0.2 97.3 ± 0.2 96.4 ± 0.3 96.4 ± 0.3 99.0 ± 0.2 99.0 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 98.4 ± 0.2 98.4 ± 0.2 95 96.8 ± 0.3 96.8 ± 0.3 95 95.1 ± 0.4 95.1 ± 0.4 93.6 ± 0.4 93.6 ± 0.4 90 90 L Log-rank test, og-rank test, pp < 0.001 < 0.001 L Log-rank test, og-rank test, pp = 0.205 = 0.205 85 85 80 80 IVUS IVUS guidance guidance PCI PCI IVUS IVUS guidance guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI 0 0 0 0 12 12 24 24 36 36 0 0 12 12 24 24 36 36 Months after initial procedure Months after initial procedure No. at risk No. at risk No. at risk No. at risk IVUS IVUS 4627 4627 4492 4492 4355 4355 3898 3898 IVUS IVUS 4627 4627 4451 4451 4307 4307 3846 3846 Angioraphy Angioraphy 3744 3744 3508 3508 3363 3363 3013 3013 Angioraphy Angioraphy 3744 3744 3471 3471 3320 3320 2967 2967 Stent thrombosis Target vesssel revascularization 98.9 ± 0.2 98.9 ± 0.2 100 100 98.6 ± 0.2 98.6 ± 0.2 98.3 ± 0.2 98.3 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 98.2 ± 0.2 98.2 ± 0.2 97.8 ± 0.3 97.8 ± 0.3 95 95 92.0 ± 0.4 92.0 ± 0.4 90.4 ± 0.4 90.4 ± 0.4 80.0 ± 0.5 80.0 ± 0.5 90 90 91.2 ± 0.5 91.2 ± 0.5 90.0 ± 0.5 90.0 ± 0.5 L Log-rank test, og-rank test, pp = 0.131 = 0.131 89.0 ± 0.5 89.0 ± 0.5 L Log-rank test, og-rank test, pp = 0.8 = 0.8 IVUS IVUS guidance guidance PCI PCI IVUS IVUS guidance guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI 0 0 0 0 12 12 24 24 36 36 0 0 12 12 24 24 36 36 Months after initial procedure Months after initial procedure No. at risk No. at risk No. at risk No. at risk IVUS IVUS 4627 4627 4100 4100 301 3011 1 3453 3453 IVUS IVUS 4627 4627 4463 4463 4320 4320 3860 3860 Angioraphy Angioraphy 3744 3744 3208 3208 3026 3026 2668 2668 Angioraphy Angioraphy 3744 3744 3485 3485 3337 3337 2986 2986 Figure 4. Kaplan-Meier event-free 3-year survival curves for death, myocardial infarction, target-vessel revascularization, and stent thrombosis in 8,371 patients following intravascular ultrasound (IVUS)- (n = 4,627) or angiography- (n = 3,744) guided percutaneous coronary intervention (PCI). Reprinted with permission from John Wiley and Sons [55]. stent thrombosis in the overall or in the 2,715 matched- noted in the IVUS-guided PCI group compared with the pair populations. In the DES subpopulation, IVUS guid- angiography-guided PCI group (4.7% vs. 13.6%, p = 0.048), ance significantly reduced the 3-year adjusted mortality but no significant difference was detected in the rates of rate (HR, 0.55; 95% CI, 0.36 to 0.78; p = 0.001), which was TVR or MI. Notably, this benet fi was found only for DES, not the case in the BMS subpopulation (HR, 0.79; 95% CI, and the benet fi in mortality appeared to be primarily as - 0.59 to 1.05; p = 0.10). A propensity score matching analy- sociated with reduced sudden cardiac death related to sis of 201 matched patients from the MAIN-COMPARE late stent thrombosis. Similar n fi dings were also observed study also demonstrated the importance of IVUS-guided in patients undergoing PCI of non-left main bifurcations PCI in unprotected left main disease [34]. In this analy- with DESs [35]. Taken together, the benet fi of IVUS guid - sis, significantly lower incidence of 3-year mortality was ance contributed primarily to decreased rates of stent http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Event-free survival, % Event-free survival, % Event-free Survival, % Event-free survival, % 36 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 • Apposition of stent • MSA at least struts to the vessel wall, - 5.0-5.5 mm (non-LM) Complete not surrounded by Well & 8.7 mm (LM): DES lumen - 6.5-7.5 mm : BMS expansion apposition (not in small vessels) - > 90% of distal ref. lumen area or or > 80% of ave. ref. lumen area IVUS No • Post-procedure IVUS • Detection of reference Full for evaluation of edge site with plaque burden edge dissection of < 50% lesion dissection coverage Figure 5. The possible intravascular ultrasound criteria for optimal stent deployment. LM, left main; DES, drug-eluting stent; BMS, bare metal stent . restenosis and repeated revascularization in the BMS era, Ree f Ren Ce S whereas reduction of the stent thrombosis rate with pos- 1. Nissen SE, Gurley JC, Grines CL, et al. Intravascular ultra- sible improvement in mortality have predominated in the sound assessment of lumen size and wall morphology in normal DES era. subjects and patients with coronary artery disease. Circulation 1991;84:1087-1099. 2. Nissen SE, Gurley JC. Application of intravascular ultrasound Con Cu l SIon S for detection and quantitation of coronary atherosclerosis. Int J Card Imaging 1991;6:165-177. IVUS can provide direct cross-sectional images as well 3. Waller BF, Pinkerton CA, Slack JD. Intravascular ultrasound: a as longitudinal images of the coronary vessel wall. It has histological study of vessels during life: the new ‘gold standard’ also contributed to our understanding of mechanisms for vascular imaging. Circulation 1992;85:2305-2310. in coronary atherosclerotic plaques and provided real- 4. Schiele F, Meneveau N, Seronde MF, et al. Medical costs of time information at stented segments af ter coronar y intravascular ultrasound optimization of stent deployment: interventions. Possible criteria for optimal stent deploy- results of the multicenter randomized ‘REStenosis after Intra- ment by IVUS are complete stent apposition to the vessel vascular ultrasound STenting’ (RESIST) study. Int J Cardiovasc Intervent 2000;3:207-213. wall, adequate stent expansion, and full lesion coverage 5. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/ without edge dissection (Fig. 5). Recent data suggest that SCAI 2005 Guideline Update for Percutaneous Coronary Inter- IVUS-guided PCI may reduce long-term mortality when vention-summary article: a report of the American College of compared with angiography-guided PCI, particularly after Cardiology/American Heart Association Task Force on Practice DES implantation; thus, the clinical importance of IVUS- Guidelines (ACC/AHA/SCAI Writing Committee to Update the guided PCI raised in the BMS era persists in the DES era. 2001 Guidelines for Percutaneous Coronary Intervention). Cir- Optimization of stent deployment by IVUS during PCI culation 2006;113:156-175. may be considered as a routine practice in daily PCI, espe- 6. Nakamura S, Colombo A, Gaglione A, et al. Intracoronary ul- cially for complex lesion intervention. trasound observations during stent implantation. Circulation 1994;89:2026-2034. Conifl ct of interest 7. Gorge G, Haude M, Ge J, et al. Intravascular ultrasound after low and high ina fl tion pressure coronary artery stent implanta - No potential conf lict of interest relevant to this article tion. J Am Coll Cardiol 1995;26:725-730. was reported. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 37 8. Mudra H, Klauss V, Blasini R, et al. Ultrasound guidance of 23. Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute Palmaz-Schatz intracoronary stenting with a combined intra- stent thrombosis: results of a systematic intravascular ultra- vascular ultrasound balloon catheter. Circulation 1994;90:1252- sound study. Circulation 2003;108:43-47. 1261. 24. Fujii K, Carlier SG, Mintz GS, et al. Stent underexpansion and 9. Brodie BR, Cooper C, Jones M, Fitzgerald P, Cummins F; Post- residual reference segment stenosis are related to stent throm- dilatation Clinical Compartative Study (POSTIT) Investigators. bosis after sirolimus-eluting stent implantation: an intravascu- Is adjunctive balloon postdilatation necessary after coronary lar ultrasound study. J Am Coll Cardiol 2005;45:995-998. stent deployment? Final results from the POSTIT trial. Catheter 25. Kimura M, Mintz GS, Carlier S, et al. Outcome after acute in- Cardiovasc Interv 2003;59:184-192. complete sirolimus-eluting stent apposition as assessed by se- 10. de Ribamar Costa J Jr, Mintz GS, Carlier SG, et al. Intravascu- rial intravascular ultrasound. Am J Cardiol 2006;98:436-442. lar ultrasound assessment of drug-eluting stent expansion. Am 26. Hong MK, Lee CW, Kim JH, et al. Impact of various intra- Heart J 2007;153:297-303. vascular ultrasound criteria for stent optimization on the six- 11. Alfonso F, Goicolea J, Hernandez R, et al. Arterial perforation month angiographic restenosis. Catheter Cardiovasc Interv during optimization of coronary stents using high-pressure bal- 2002;56:178-183. loon ina fl tions. Am J Cardiol 1996;78:1169-1172. 27. Albiero R, Rau T, Schlüter M, et al. Comparison of immediate 12. Mintz GS, Weissman NJ. Intravascular ultrasound in the drug- and intermediate-term results of intravascular ultrasound ver- eluting stent era. J Am Coll Cardiol 2006;48:421-429. sus angiography-guided Palmaz-Schatz stent implantation in 13. Cook S, Wenaweser P, Togni M, et al. Incomplete stent apposi- matched lesions. Circulation 1997;96:2997-3005. tion and very late stent thrombosis after drug-eluting stent im- 28. Hoffmann R, Mintz GS, Mehran R, et al. Intravascular ultra- plantation. Circulation 2007;115:2426-2434. sound predictors of angiographic restenosis in lesions treated 14. Hwang CW, Wu D, Edelman ER. Physiological transport forces with Palmaz-Schatz stents. J Am Coll Cardiol 1998;31:43-49. govern drug distribution for stent-based delivery. Circulation 29. Kasaoka S, Tobis JM, Akiyama T, et al. Angiographic and intra- 2001;104:600-605. vascular ultrasound predictors of in-stent restenosis. J Am Coll 15. Papafaklis MI, Chatzizisis YS, Naka KK, Giannoglou GD, Mi- Cardiol 1998;32:1630-1635. chalis LK. Drug-eluting stent restenosis: Effect of drug type, 30. Moussa I, Moses J, Di Mario C, et al. Does the specific intra- release kinetics, hemodynamics and coating strategy. Phar- vascular ultrasound criterion used to optimize stent expansion macol Ther 2011 Dec 22 [Epub]. http://dx.doi.org/10.1016/ have an impact on the probability of stent restenosis? Am J Car- j.pharmthera.2011.12.006. diol 1999;83:1012-1017. 16. Hwang CW, Edelman ER. Arterial ultrastructure inf luences 31. Blasini R, Neumann FJ, Schmitt C, Bokenkamp J, Schomig transport of locally delivered drugs. Circ Res 2002;90:826-832. A. Comparison of angiography and intravascular ultrasound 17. Windecker S, Meier B. Late coronary stent thrombosis. Circula- for the assessment of lumen size after coronary stent place- tion 2007;116:1952-1965. ment: impact of dilation pressures. Cathet Cardiovasc Diagn 18. Kume T, Waseda K, Ako J, et al. Intravascular ultrasound as- 1997;42:113-119. sessment of postprocedural incomplete stent apposition. J In- 32. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents vasive Cardiol 2012;24:13-16. versus standard stents in patients with stenosis in a native coro- 19. Fitzgerald PJ, Oshima A, Hayase M, et al. Final results of the nary artery. N Engl J Med 2003;349:1315-1323. Can Routine Ultrasound Inu fl ence Stent Expansion (CRUISE) 33. Colombo A, Drzewiecki J, Banning A, et al. Randomized study study. Circulation 2000;102:523-530. to assess the effectiveness of slow- and moderate-release poly- 20. Uren NG, Schwarzacher SP, Metz JA, et al. Predictors and out- mer-based paclitaxel-eluting stents for coronary artery lesions. comes of stent thrombosis: an intravascular ultrasound regis- Circulation 2003;108:788-794. try. Eur Heart J 2002;23:124-132. 34. Park SJ, Kim YH, Park DW, et al. Impact of intravascular ul- 21. Doi H, Maehara A, Mintz GS, et al. Impact of post-intervention trasound guidance on long-term mortality in stenting for un- minimal stent area on 9-month follow-up patency of paclitaxel- protected left main coronary artery stenosis. Circ Cardiovasc eluting stents: an integrated intravascular ultrasound analysis Interv 2009;2:167-177. from the TAXUS IV, V, and VI and TAXUS ATLAS Workhorse, 35. Kim SH, Kim YH, Kang SJ, et al. Long-term outcomes of intra- Long Lesion, and Direct Stent Trials. JACC Cardiovasc Interv vascular ultrasound-guided stenting in coronary bifurcation 2009;2:1269-1275. lesions. Am J Cardiol 2010;106:612-618. 22. Hong MK, Mintz GS, Lee CW, et al. Intravascular ultrasound 36. Mintz GS, Painter JA, Pichard AD, et al. Atherosclerosis in an- predictors of angiographic restenosis after sirolimus-eluting giographically “normal” coronary artery reference segments: an stent implantation. Eur Heart J 2006;27:1305-1310. intravascular ultrasound study with clinical correlations. J Am http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr 38 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 Coll Cardiol 1995;25:1479-1485. 46. Colombo A, Caussin C, Presbitero P, Chieffo A. AVIO: a pro- 37. Weissman NJ, Palacios IF, Nidorf SM, Dinsmore RE, Weyman spective, randomized trial of intravascular-ultrasound guided AE. Three-dimensional intravascular ultrasound assessment compared to angiography guided stent implantation in complex of plaque volume after successful atherectomy. Am Heart J coronary lesions [abstract]. J Am Coll Cardiol 2010;56:xvii. 1995;130:413-419. 47. Roy P, Steinberg DH, Sushinsky SJ, et al. The potential clinical 38. Morino Y, Tamiya S, Masuda N, et al. Intravascular ultrasound utility of intravascular ultrasound guidance in patients under- criteria for determination of optimal longitudinal positioning of going percutaneous coronary intervention with drug-eluting sirolimus-eluting stents. Circ J 2010;74:1609-1616. stents. Eur Heart J 2008;29:1851-1857. 39. de Jaegere P, Mudra H, Figulla H, et al. Intravascular ultra- 48. Okabe T, Mintz GS, Buch AN, et al. Intravascular ultrasound sound-guided optimized stent deployment: Immediate and 6 parameters associated with stent thrombosis after drug-eluting months clinical and angiographic results from the Multicenter stent deployment. Am J Cardiol 2007;100:615-620. Ultrasound Stenting In Coronaries Study (MUSIC Study). Eur 49. Choi SY, Witzenbichler B, Maehara A, et al. Intravascular Heart J 1998;19:1214-1223. ultrasound findings of early stent thrombosis after primary 40. Russo RJ, Silva PD, Teirstein PS, et al. A randomized controlled percutaneous intervention in acute myocardial infarction: a trial of angiography versus intravascular ultrasound-directed Harmonizing Outcomes with Revascularization and Stents in bare-metal coronary stent placement (the AVID Trial). Circ Car- Acute Myocardial Infarction (HORIZONS-AMI) substudy. Circ diovasc Interv 2009;2:113-123. Cardiovasc Interv 2011;4:239-247. 41. Oemrawsingh PV, Mintz GS, Schalij MJ, Zw inderman AH, 50. Sonoda S, Morino Y, Ako J, et al. Impact of final stent dimen - Jukema JW, van der Wall EE. Intravascular ultrasound guid- sions on long-term results following sirolimus-eluting stent ance improves angiographic and clinical outcome of stent im- implantation: serial intravascular ultrasound analysis from the plantation for long coronary artery stenoses: final results of a sirius trial. J Am Coll Cardiol 2004;43:1959-1963. randomized comparison with angiographic guidance (TULIP 51. Takebayashi H, Kobayashi Y, Mintz GS, et al. Intravascular Study). Circulation 2003;107:62-67. ultrasound assessment of lesions with target vessel failure 42. Mudra H, di Mario C, de Jaegere P, et al. Randomized compari- af ter sirolimus- elut ing stent implantat ion. A m J Cardiol son of coronary stent implantation under ultrasound or angio- 2005;95:498-502. graphic guidance to reduce stent restenosis (OPTICUS Study). 52. Hong MK, Park SW, Lee NH, et al. Long-term outcomes of mi- Circulation 2001;104:1343-1349. nor dissection at the edge of stents detected with intravascular 43. Casella G, Klauss V, Ottani F, Siebert U, Sangiorgio P, Brac- ultrasound. Am J Cardiol 2000;86:791-795, A9. chetti D. Impact of intravascular ultrasound-guided stenting on 53. Liu X, Tsujita K, Maehara A, et al. Intravascular ultrasound long-term clinical outcome: a meta-analysis of available studies assessment of the incidence and predictors of edge dissections comparing intravascular ultrasound-guided and angiographi- after drug-eluting stent implantation. JACC Cardiovasc Interv cally guided stenting. Catheter Cardiovasc Interv 2003;59:314- 2009;2:997-1004. 321. 54. Park SM, Kim JS, Ko YG, et al. Angiographic and intravascular 44. Parise H, Maehara A, Stone GW, Leon MB, Mintz GS. Meta- ultrasound follow up of paclitaxel- and sirolimus-eluting stent ana lysis of randomized st udies compar ing intravascular after poststent high-pressure balloon dilation: from the post- ultrasound versus angiographic guidance of percutaneous coro- stent optimal stent expansion trial. Catheter Cardiovasc Interv nary intervention in pre-drug-eluting stent era. Am J Cardiol 2011;77:15-21. 2011;107:374-382. 55. Hur SH, Kang SJ, Kim YH, et al. Impact of intravascular ul- 45. Jakabcin J, Spacek R, Bystron M, et al. Long-term health out- trasound-guided percutaneous coronary intervention on long- come and mortality evaluation after invasive coronary treat- term clinical outcomes in a real world population. Catheter Car- ment using drug eluting stents with or without the IVUS guid- diovasc Interv 2011 Jul 29 [Epub]. http://dx.doi.org/10.1002/ ance. Randomized control trial: HOME DES IVUS. Catheter ccd.23279. Cardiovasc Interv 2010;75:578-583. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Korean Journal of Internal Medicine Pubmed Central

Optimization of Stent Deployment by Intravascular Ultrasound

The Korean Journal of Internal Medicine , Volume 27 (1) – Feb 28, 2012

Loading next page...
 
/lp/pubmed-central/optimization-of-stent-deployment-by-intravascular-ultrasound-rC7UfwRkmQ

References (65)

Publisher
Pubmed Central
Copyright
Copyright © 2012 The Korean Association of Internal Medicine
ISSN
1226-3303
eISSN
2005-6648
DOI
10.3904/kjim.2012.27.1.30
Publisher site
See Article on Publisher Site

Abstract

review ORIGINAL ARTICLE korean j intern med 2012;27:30-38 pISSN 1226-3303 eISSN 2005-6648 http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Optimization of Stent Deployment by intravascular Ultrasound Hyuck-Jun Yoon and Seung-Ho Hur Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea Intravascular ultrasound (IVUS) is a useful diagnostic method that provides valuable information in addition to angiog- raphy regarding the coronary vessel lumen, dimensions, plaque burden, and characteristics. The major use of IVUS in coronary intervention is to guide interventional strategies and assess optimal stent deployment. Since the introduction of the drug-eluting stent (DES), concerns about restenosis have decreased. However, high-risk lesion subsets are being routinely treated with DESs, and the incidence of suboptimal results after stent deployment, such as stent underexpan- sion, incomplete stent apposition, edge dissection, geographic miss, and the risk of stent thrombosis, have correspond- ingly increased. Thus, optimization of stent deployment under IVUS guidance may be clinically important. In this review, we focus on the potential role of IVUS in stent optimization during percutaneous coronary intervention and its clinical benetfis. Keywords: Angioplasty, balloon; Coronary stenosis; Mortality; Stents; Therapy; Ultrasonography [1,2]. Int Ro Du Ct Ion IVUS is an invasive imaging technique used to visualize The coronary angiogram (CAG) remains the gold-stan- coronary cross-sectional anatomy and is superior to CAG dard method for assessing coronary artery disease (CAD). in assessing vessel size, calcium content, and lesion sever- However, the CAG has inherent pitfalls, such as only show- ity [3]. It also provides complementary procedural infor- ing the vessel lumen as an X-ray shadow image, created by mation in lesions requiring percutaneous coronary inter- the injection of contrast medium, and of often visualizing vention (PCI) when determining adequate stent sizing, a “side-view.” Thus, the apparent degree of coronary ste- and conr fi ming optimal stent deployment and apposition nosis can be affected by the projection angle due to lesion without edge tearing in real time. Thus, a growing number eccentricity. Additionally, diffuse coronary disease, lesion of interventional cardiologists attain optimal procedural foreshortening, angulations, calcic fi ation, and vessel over - results with reduced complications when using IVUS in lap can be challenges in the angiographic assessment of le- PCI. sion severity. In some cases, an angiographically normal- Although the routine use of IVUS in daily PCI remains looking coronary artery actually shows various degrees of controversial, stent optimization by IVUS during stenting atherosclerotic plaque by intravascular ultrasound (IVUS) procedures, especially in the era of drug-eluting stents Received : January 31, 2012 Accepted : February 2, 2012 Correspondence to Seung-Ho Hur, M.D. Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu 700-712, Korea Tel: 82-53-250-7998, Fax: 82-53-250-7034, E-mail: shur@dsmc.or.kr Copyright © 2012 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Yoon HJ and Hur SH. IVUS-guided stent optimization 31 (DESs), may have an important role in improving long- under 12-atmosphere pressure dilation and only 36% even term clinical outcomes such as stent restenosis and stent with higher deployment pressures (> 14 atmospheres) [9]. thrombosis [4]. In this review, we focus on the potential Another IVUS study with an early-generation DES in 200 roles of IVUS in stent optimization during PCI and its patients assessed stent expansion depending on the manu- clinical benet fi s. facturer’s compliance chart as a guideline. In that study, the DES obtained only 75% of predicted minimal stent di- ameter and 66% of the predicted minimal stent area (MSA) [10] (Fig. 1). Based on these observations, angiographic Re Al Ity o f Stent Ing p Ro Ce Du Re S In success cannot always be linked with optimal stent ex- DAIy l p RACt ICe pansion, despite higher pressure balloon ina fl tion during PCI has been the fastest growing method for the treat- the stenting procedure. In turn, stent optimization using ment of ischemic CA D over t he past t hree dec ades. a high-pressure balloon without IVUS guidance also has Coronary stents have emerged as the predominant form been associated with an increased risk of arterial perfora- of PCI and are currently used in more than 90% of PCI tion, probably secondary to vessel-balloon mismatch [11]. procedures. Procedural success of PCI is usually deter- Thus, the operator should consider using IVUS guidance mined by visual estimation by the operator, and usually, for high-pressure balloon inf lation during stent deploy- angiographic success after PCI is defined as the attain- ment. ment of residual diameter stenosis of less than 30%, which Apposition of stent struts to the vessel wall is also an is generally associated with at least a 20% improvement in important facet of stent optimization. Adequate stent diameter stenosis and relief of ischemia [5]. However, such expansion and adequate stent strut apposition have been subjective estimation of the severity of coronary artery ste- reported to be important factors in reducing repeated re- nosis is thought to be of limited reliability. Previous IVUS vascularization due to stent restenosis or stent thrombosis studies have demonstrated that visual estimation or quan- [12,13]. In the DES era, incomplete stent apposition has titative angiographic analyses of vessel dimension for stent been regarded as an important local factor in DES failure, deployment appear inaccurate [6-9]. The post-dilatation probably due to reduced drug delivery to the vessel wall clinical comparative (POSTIT) trial was designed to assess [14-17]. In a recent report, incomplete stent apposition was the achievement of optimal stent deployment by IVUS, signic fi antly associated with vessel/stent mismatch rather according to normal-to-high pressure balloon dilation than stent underexpansion immediately after stent im- after bare metal stent implantation. Among 256 patients, plantation [18]. Thus, adequate stent sizing by IVUS may only 14% of cases achieved optimal stent deployment with be clinically important in preventing incomplete stent ap- A b 4.5 3.5 SES SES PES PES 2.5 1.5 1 1.5 2 2.5 3 3.5 4 4.5 2 4 6 8 10 12 14 Manufacturer’s predicted stent diameter, mm Manufacturer’s predicted stent area, mm Figure 1. Intravascular ultrasound (IVUS)-measured minimum stent diameter (MSD, A) and minimum stent area (MSA, B) vs. pre- dicted measurements from each manufacturer’s compliance charts. SES, sirolimus-eluting stent; PES, paclitaxel-eluting stent. Reprint with permission from Elsevier Health Science Journals [10]. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr IVUS measured MSD, mm IVUS measured MSD, mm 32 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 position and in optimizing initial stent deployment. disease, are now being treated routinely with DESs [34,35]. Thus, the risk of stent underexpansion, incomplete stent apposition, and incomplete lesion coverage increases and these suboptimal stent deployment conditions have been IMpo Rt An Ce o f Stent opt IMIz At Ion reported to be potent IVUS predictors of stent resteno- IVUS has been used to detect suboptimal results after sis and stent thrombosis [13,17,24], suggesting that stent apparently angiographically successful stent deployment implantation under IVUS guidance still has a pivotal role in both the DES and bare metal stent (BMS) eras (Fig. 2). even in the DES era. An important aspect of IVUS is de- IVUS predictors that are associated with increased ad- termining appropriate reference segments that provide verse outcomes include smaller MSA, stent underexpan- the landing zone for stent deployment. IVUS examination sion, stent edge dissection, incomplete stent apposition, typically reveals a considerable amount of plaque, even in and incomplete lesion coverage [19-26]. In the BMS era, a segments of the vessel that appear “normal” on the angio- major problem after stent implantation was stent resteno- gram, known as “reference vessel” disease. Quantitative sis, and the main mechanism of this phenomenon was a IVUS studies have demonstrated that the segment chosen smaller MSA or stent underexpansion [21,26-30]. Several as the “normal” reference site for the calculation of angio- studies in the BMS era showed a benec fi ial effect of IVUS graphic percent stenosis has an average of 30-50% of its guidance on post-procedural angiographic results and cross-sectional area occupied by plaque [36]. By IVUS, the stent restenosis during long-term follow-up, resulting from den fi ition of reference segment is a cross-sectional image a larger MSA with a higher post-dilation balloon pressure adjacent to the lesion that has < 40% plaque burden [37]. [7,19,27,31]. Stent underexpansion, identie fi d by IVUS, can A previous study reported the association between clinical be treated with appropriate post-balloon dilation. IVUS outcomes and longitudinal positioning of the stent in 162 allows more aggressive intervention using a larger diam- consecutive patients with 180 lesions treated with siroli- eter balloon with cond fi ence in terms of safety; thus, BMS mus-eluting stent (SES) implantation [38]. In that study, implantation under IVUS guidance can provide a bigger stepwise IVUS criteria primarily targeting plaque burden MSA and more favorable clinical outcomes compared < 50% were shown to be feasible and improved the rates of with angiography-guided PCI. DESs have led to a marked stent restenosis and target lesion revascularization (TLR) reduction in the rate of stent restenosis and the need for at 8 months follow-up. repeated revascularization compared with BMSs [32,33]. Because of their efficacy, high-risk lesions and clinical conditions, including bifurcation lesions, long lesions, cal- How to opt IMIe z Stent Depo l y Ment cie fi d lesions, left main disease, diabetes, and multivessel IVUS is used frequently in PCI, but the use of IVUS cannot be directly related to stent optimization. Defini- tive guidelines for IVUS-guided stent optimization are not available and it is still performed at the operator’s dis- cretion. So, how do we perform stent optimization using IVUS, and what IVUS criteria are acceptable for current practice? Although many IVUS criteria for stent optimization have been suggested, the basic concepts underlying them can be summarized briey fl as minimizing the occurrence of IVUS-related predictors of adverse events after PCI, including stent underexpansion, incomplete stent apposi- Incomplete Stent Edge tion, edge dissection, and lesion undercoverage. stent apposition underexpansion dissection Stent underexpansion is defined as an area of inad- equate stent expansion compared with the adjacent refer- Figure 2. Stent-related complications after stent deployment. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 33 A b 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 10 15 20 25 30 35 40 45 50 55 60 65 70 Stent CAS, mm Stent length, mm Figure 3. Sensitivity and specificity curves identified optimal cut-off values of final minimum stent cross-sectional area (CSA, A) and stent length (B) that predicted angiographic restenosis after sirolimus-eluting stent implantation: 5.5 mm for final minimum stent CSA and 40 mm for intravascular ultrasound-measured stent length. Triangle, sensitivity; circles, specic fi ity. Reprinted with permission from Oxford University Press [22]. ence segments. However, a consensus definition of “ad- only 56% of stents met all three MUSIC criteria. Many equate” expansion is still lacking. other trials in the BMS era used similar IVUS criteria, and two meta-analyses showed better outcomes of IVUS- In the BMS era, several randomized trials used various IVUS criteria for stent deployment optimization, yield- guided PCI than angiography-guided PCI, especially in ing mixed results. The r fi st large multicenter study, called terms of in-stent restenosis and target vessel revascular- MUSIC (multicenter ultrasound stenting in coronaries ization (TVR), but not in mortality or myocardial infarc- study), sought to define specic fi criteria for optimal stent tion [43,44]. deployment and demonstrate the feasibility and safety of In contrast to the BMS era, for IVUS-guided PCI with IVUS-guided stent optimization [39]. In the MUSIC cri- DES, few randomized studies showing clinical efficacy, teria, “adequate” expansion was defined as > 90% of the preventing TVR or restenosis, or stent optimization under average reference cross-sectional area (CSA), or > 100% IVUS guidance have been carried out. In the HOME DES of a smaller reference CSA with complete apposition and trial, optimal stent deployment was defined as complete symmetric expansion. Another large multicenter trial was apposition of the stent struts, no edge dissection, and ad- AVID (angiographic versus IVUS direct stent placement); equate stent expansion, den fi ed as either MSA > 5.0 mm its defined IVUS optimization required complete stent or > 90% of the distal reference lumen area [45]. In that apposition with stent CSA > 90% of the distal reference study, no significant benefit in terms of TVR or clinical lumen area [40]. The results of the AVID trial showed a events was reported. A similar finding was also noted in signic fi ant benet fi of IVUS guidance in vessels 2.5-3.5 mm the AVIO (angiography versus IVUS optimization) study in size and in saphenous vein graf t PCI. The TULIP in which optimal stent expansion was > 70% of the CSA of (thrombotic activity evaluation and effects of ultrasound the chosen balloon [46]. However, attention should be paid guidance in long intracoronary stent placement) Study to avoid stent underexpansion. Increasing evidence indi- also showed signic fi ant angiographic and clinical benet fi s cates that IVUS-guided PCI may reduce the risk of stent of IVUS guidance using criteria such as stent CSA > distal thrombosis (ST) [47]. Stent underexpansion was demon- reference lumen [41]. In contrast to the results mentioned strated to be one of the major causes of this disastrous above, the OPTICUS trial (optimization with IVUS to re- complication, although the cause of ST is multifactorial duce stent restenosis) using the MUSIC criteria for IVUS [13,24,48,49]. In a substudy of the SIRIUS trial, adequate guidance did not show a significant difference in 6- or patency was den fi ed as a follow-up IVUS MSA > 4.0 mm . 12-month clinical outcomes [42]. However, in this study, When the adequate post-interventional MSA of SESs was http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Angiographic restenosis, % 34 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 den fi ed as > 5.0 mm , the positive predictive value of pa- trials, the rates of 6-month angiographic restenosis and tency was 90%, but the optimal cutoff value of BMS was target vessel revascularization were signic fi antly lower in defined as 6.5 mm [50]. Another study concerning SES the IVUS-guided PCI group than the angiography-guided 2 2 failure also supported that MSA < 5.5 mm and < 5.0 mm group (22% vs. 29%, p = 0.02 and 13% vs. 18%, p < 0.001, were the most important predictors of SES failure (Fig. respectively), with no difference in the rates of death (2.4% 3) [22,51]. Even if SES had a considerably lower optimal vs. 1.6%, p = 0.18) or MI (3.6% vs. 4.4%, p = 0.51) [44], MSA threshold than BMS, these studies showed that un- consistent with a previous meta-analysis [43]. derexpansion remained the main cause of stent failure in To date, few studies have investigated the clinical ben- DESs; at least a MSA < 5.0 mm should be avoided in non- et fi s of DES optimization under IVUS guidance compared -left main (LM) lesions. In LM lesions, optimal MSA was with that of BMSs. The HOME DES IVUS (long-term reported in the MAIN-COMPARE (revascularization for health outcome and mortality evaluation after invasive unprotected left main coronary artery stenosis: compari- coronar y treatment using drug-eluting stents with or son of percutaneous coronary angioplasty versus surgical without IVUS guidance) study was a randomized trial to revascularization) study to be > 8.7 mm to prevent TLR investigate clinical outcomes of IVUS-guided PCI with [34]. DESs. Although the IVUS-guided strategy resulted in the Edge dissection, which is complicated by lumen nar- frequent use of adjunctive balloons and a larger size bal- rowing < 4 mm or dissection angle ≥ 60°, has been as- loon with higher pressure, no significant difference was sociated with an increased incidence of early ST [49]; thus, observed in major adverse cardiac events or stent throm- additional stents may be needed to prevent ST. However, a bosis in the study [45]. A similar retrospective study of minor dissection, detected by IVUS, may not be associated IVUS-guided stent optimization also showed no signifi- with an increased incidence of ST [52,53]. Although no cant difference in the incidence of in-stent restenosis or consensus exists on an optimal strategy, in minor dissec- neointimal volume between IVUS- versus angiography- tion, careful observation without stenting can be helpful. guided PCI [54]. Conversely, a study with a propensity- Overall, the results discussed above encourage ensuring matched analysis in 884 patients treated w ith DESs good apposition of stent struts to the vessel wall, such that showed a signic fi ant reduction in the stent thrombosis rate the stent struts are not surrounded by lumen, adequate at both 30 days (0.5% vs. 1.4%, p = 0.046) and 12 months stent expansion to obtain MSA at least > 6.5 mm for (0.7% vs. 2.0%, p = 0.014) in the IVUS-guided PCI group BMSs and > 5.0 mm for DESs or MSA > 90% of the distal [47]. reference lumen CSA, and lack of major dissections, intra- Recently, a large “real world” registry from two Korean mural hematomas, and geographic misses. centers reported long-term outcomes of both IVUS- and angiography-guided PCI using BMS or DES implantation [55]. In total, 8,371 patients who underwent coronary stenting under IVUS guidance (4,627 patients) or angi- o ut Co Me S o f IV u S-gu IDe D Ve RSu S ography guidance (3,744 patients) were consecutively Ang Iog RApHy-gu IDe D pCI enrolled, and 3-year adverse clinical outcomes were com- Numerous studies have evaluated the clinical benet fi s of pared between the groups using a Cox regression model IVUS-guided PCI compared with angiography-guided PCI and propensity score matching. In the overall population, in the BMS era [41-44]. The OPTICUS trial showed no sig- the 3-year adjusted incidence of mortality was signifi- nic fi ant difference between IVUS- and angiography-guid - cantly lower in the IVUS-guided PCI group compared ed PCI groups in terms of 6- and 12-month rates of death, with the angiography-guided PCI group (hazard ratio myocardial infarction (MI), and TLR in 550 patients [HR], 0.70; 95% confidence interval [CI], 0.56 to 0.87; meeting the MUSIC criteria [42]. In contrast, the TULIP p = 0.001) (Fig. 4). In 2,715 matched pairs of the overall study demonstrated favorable angiographic and clinical population, the IVUS-guided PCI group also had a lower outcomes in patients with long coronary lesions (> 20 mm) mortality risk (HR, 0.71; 95% CI, 0.56 to 0.90; p = 0.005). treated with a BMS (> 3 mm) under IVUS guidance [41]. In However, IVUS-guided PCI did not influence the rates of a meta-analysis of 2,193 patients from seven randomized myocardial infarction, target-vessel revascularization, or http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 35 Death Myocardial infarction 99.2 ± 0.1 99.2 ± 0.1 100 100 99.0 ± 0.2 99.0 ± 0.2 98.8 ± 0.2 98.8 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 97.3 ± 0.2 97.3 ± 0.2 96.4 ± 0.3 96.4 ± 0.3 99.0 ± 0.2 99.0 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 98.4 ± 0.2 98.4 ± 0.2 95 96.8 ± 0.3 96.8 ± 0.3 95 95.1 ± 0.4 95.1 ± 0.4 93.6 ± 0.4 93.6 ± 0.4 90 90 L Log-rank test, og-rank test, pp < 0.001 < 0.001 L Log-rank test, og-rank test, pp = 0.205 = 0.205 85 85 80 80 IVUS IVUS guidance guidance PCI PCI IVUS IVUS guidance guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI 0 0 0 0 12 12 24 24 36 36 0 0 12 12 24 24 36 36 Months after initial procedure Months after initial procedure No. at risk No. at risk No. at risk No. at risk IVUS IVUS 4627 4627 4492 4492 4355 4355 3898 3898 IVUS IVUS 4627 4627 4451 4451 4307 4307 3846 3846 Angioraphy Angioraphy 3744 3744 3508 3508 3363 3363 3013 3013 Angioraphy Angioraphy 3744 3744 3471 3471 3320 3320 2967 2967 Stent thrombosis Target vesssel revascularization 98.9 ± 0.2 98.9 ± 0.2 100 100 98.6 ± 0.2 98.6 ± 0.2 98.3 ± 0.2 98.3 ± 0.2 98.6 ± 0.2 98.6 ± 0.2 98.2 ± 0.2 98.2 ± 0.2 97.8 ± 0.3 97.8 ± 0.3 95 95 92.0 ± 0.4 92.0 ± 0.4 90.4 ± 0.4 90.4 ± 0.4 80.0 ± 0.5 80.0 ± 0.5 90 90 91.2 ± 0.5 91.2 ± 0.5 90.0 ± 0.5 90.0 ± 0.5 L Log-rank test, og-rank test, pp = 0.131 = 0.131 89.0 ± 0.5 89.0 ± 0.5 L Log-rank test, og-rank test, pp = 0.8 = 0.8 IVUS IVUS guidance guidance PCI PCI IVUS IVUS guidance guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI A Angiography guidance ngiography guidance PCI PCI 0 0 0 0 12 12 24 24 36 36 0 0 12 12 24 24 36 36 Months after initial procedure Months after initial procedure No. at risk No. at risk No. at risk No. at risk IVUS IVUS 4627 4627 4100 4100 301 3011 1 3453 3453 IVUS IVUS 4627 4627 4463 4463 4320 4320 3860 3860 Angioraphy Angioraphy 3744 3744 3208 3208 3026 3026 2668 2668 Angioraphy Angioraphy 3744 3744 3485 3485 3337 3337 2986 2986 Figure 4. Kaplan-Meier event-free 3-year survival curves for death, myocardial infarction, target-vessel revascularization, and stent thrombosis in 8,371 patients following intravascular ultrasound (IVUS)- (n = 4,627) or angiography- (n = 3,744) guided percutaneous coronary intervention (PCI). Reprinted with permission from John Wiley and Sons [55]. stent thrombosis in the overall or in the 2,715 matched- noted in the IVUS-guided PCI group compared with the pair populations. In the DES subpopulation, IVUS guid- angiography-guided PCI group (4.7% vs. 13.6%, p = 0.048), ance significantly reduced the 3-year adjusted mortality but no significant difference was detected in the rates of rate (HR, 0.55; 95% CI, 0.36 to 0.78; p = 0.001), which was TVR or MI. Notably, this benet fi was found only for DES, not the case in the BMS subpopulation (HR, 0.79; 95% CI, and the benet fi in mortality appeared to be primarily as - 0.59 to 1.05; p = 0.10). A propensity score matching analy- sociated with reduced sudden cardiac death related to sis of 201 matched patients from the MAIN-COMPARE late stent thrombosis. Similar n fi dings were also observed study also demonstrated the importance of IVUS-guided in patients undergoing PCI of non-left main bifurcations PCI in unprotected left main disease [34]. In this analy- with DESs [35]. Taken together, the benet fi of IVUS guid - sis, significantly lower incidence of 3-year mortality was ance contributed primarily to decreased rates of stent http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Event-free survival, % Event-free survival, % Event-free Survival, % Event-free survival, % 36 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 • Apposition of stent • MSA at least struts to the vessel wall, - 5.0-5.5 mm (non-LM) Complete not surrounded by Well & 8.7 mm (LM): DES lumen - 6.5-7.5 mm : BMS expansion apposition (not in small vessels) - > 90% of distal ref. lumen area or or > 80% of ave. ref. lumen area IVUS No • Post-procedure IVUS • Detection of reference Full for evaluation of edge site with plaque burden edge dissection of < 50% lesion dissection coverage Figure 5. The possible intravascular ultrasound criteria for optimal stent deployment. LM, left main; DES, drug-eluting stent; BMS, bare metal stent . restenosis and repeated revascularization in the BMS era, Ree f Ren Ce S whereas reduction of the stent thrombosis rate with pos- 1. Nissen SE, Gurley JC, Grines CL, et al. Intravascular ultra- sible improvement in mortality have predominated in the sound assessment of lumen size and wall morphology in normal DES era. subjects and patients with coronary artery disease. Circulation 1991;84:1087-1099. 2. Nissen SE, Gurley JC. Application of intravascular ultrasound Con Cu l SIon S for detection and quantitation of coronary atherosclerosis. Int J Card Imaging 1991;6:165-177. IVUS can provide direct cross-sectional images as well 3. Waller BF, Pinkerton CA, Slack JD. Intravascular ultrasound: a as longitudinal images of the coronary vessel wall. It has histological study of vessels during life: the new ‘gold standard’ also contributed to our understanding of mechanisms for vascular imaging. Circulation 1992;85:2305-2310. in coronary atherosclerotic plaques and provided real- 4. Schiele F, Meneveau N, Seronde MF, et al. Medical costs of time information at stented segments af ter coronar y intravascular ultrasound optimization of stent deployment: interventions. Possible criteria for optimal stent deploy- results of the multicenter randomized ‘REStenosis after Intra- ment by IVUS are complete stent apposition to the vessel vascular ultrasound STenting’ (RESIST) study. Int J Cardiovasc Intervent 2000;3:207-213. wall, adequate stent expansion, and full lesion coverage 5. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/ without edge dissection (Fig. 5). Recent data suggest that SCAI 2005 Guideline Update for Percutaneous Coronary Inter- IVUS-guided PCI may reduce long-term mortality when vention-summary article: a report of the American College of compared with angiography-guided PCI, particularly after Cardiology/American Heart Association Task Force on Practice DES implantation; thus, the clinical importance of IVUS- Guidelines (ACC/AHA/SCAI Writing Committee to Update the guided PCI raised in the BMS era persists in the DES era. 2001 Guidelines for Percutaneous Coronary Intervention). Cir- Optimization of stent deployment by IVUS during PCI culation 2006;113:156-175. may be considered as a routine practice in daily PCI, espe- 6. Nakamura S, Colombo A, Gaglione A, et al. Intracoronary ul- cially for complex lesion intervention. trasound observations during stent implantation. Circulation 1994;89:2026-2034. Conifl ct of interest 7. Gorge G, Haude M, Ge J, et al. Intravascular ultrasound after low and high ina fl tion pressure coronary artery stent implanta - No potential conf lict of interest relevant to this article tion. J Am Coll Cardiol 1995;26:725-730. was reported. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr Yoon HJ and Hur SH. IVUS-guided stent optimization 37 8. Mudra H, Klauss V, Blasini R, et al. Ultrasound guidance of 23. Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute Palmaz-Schatz intracoronary stenting with a combined intra- stent thrombosis: results of a systematic intravascular ultra- vascular ultrasound balloon catheter. Circulation 1994;90:1252- sound study. Circulation 2003;108:43-47. 1261. 24. Fujii K, Carlier SG, Mintz GS, et al. Stent underexpansion and 9. Brodie BR, Cooper C, Jones M, Fitzgerald P, Cummins F; Post- residual reference segment stenosis are related to stent throm- dilatation Clinical Compartative Study (POSTIT) Investigators. bosis after sirolimus-eluting stent implantation: an intravascu- Is adjunctive balloon postdilatation necessary after coronary lar ultrasound study. J Am Coll Cardiol 2005;45:995-998. stent deployment? Final results from the POSTIT trial. Catheter 25. Kimura M, Mintz GS, Carlier S, et al. Outcome after acute in- Cardiovasc Interv 2003;59:184-192. complete sirolimus-eluting stent apposition as assessed by se- 10. de Ribamar Costa J Jr, Mintz GS, Carlier SG, et al. Intravascu- rial intravascular ultrasound. Am J Cardiol 2006;98:436-442. lar ultrasound assessment of drug-eluting stent expansion. Am 26. Hong MK, Lee CW, Kim JH, et al. Impact of various intra- Heart J 2007;153:297-303. vascular ultrasound criteria for stent optimization on the six- 11. Alfonso F, Goicolea J, Hernandez R, et al. Arterial perforation month angiographic restenosis. Catheter Cardiovasc Interv during optimization of coronary stents using high-pressure bal- 2002;56:178-183. loon ina fl tions. Am J Cardiol 1996;78:1169-1172. 27. Albiero R, Rau T, Schlüter M, et al. Comparison of immediate 12. Mintz GS, Weissman NJ. Intravascular ultrasound in the drug- and intermediate-term results of intravascular ultrasound ver- eluting stent era. J Am Coll Cardiol 2006;48:421-429. sus angiography-guided Palmaz-Schatz stent implantation in 13. Cook S, Wenaweser P, Togni M, et al. Incomplete stent apposi- matched lesions. Circulation 1997;96:2997-3005. tion and very late stent thrombosis after drug-eluting stent im- 28. Hoffmann R, Mintz GS, Mehran R, et al. Intravascular ultra- plantation. Circulation 2007;115:2426-2434. sound predictors of angiographic restenosis in lesions treated 14. Hwang CW, Wu D, Edelman ER. Physiological transport forces with Palmaz-Schatz stents. J Am Coll Cardiol 1998;31:43-49. govern drug distribution for stent-based delivery. Circulation 29. Kasaoka S, Tobis JM, Akiyama T, et al. Angiographic and intra- 2001;104:600-605. vascular ultrasound predictors of in-stent restenosis. J Am Coll 15. Papafaklis MI, Chatzizisis YS, Naka KK, Giannoglou GD, Mi- Cardiol 1998;32:1630-1635. chalis LK. Drug-eluting stent restenosis: Effect of drug type, 30. Moussa I, Moses J, Di Mario C, et al. Does the specific intra- release kinetics, hemodynamics and coating strategy. Phar- vascular ultrasound criterion used to optimize stent expansion macol Ther 2011 Dec 22 [Epub]. http://dx.doi.org/10.1016/ have an impact on the probability of stent restenosis? Am J Car- j.pharmthera.2011.12.006. diol 1999;83:1012-1017. 16. Hwang CW, Edelman ER. Arterial ultrastructure inf luences 31. Blasini R, Neumann FJ, Schmitt C, Bokenkamp J, Schomig transport of locally delivered drugs. Circ Res 2002;90:826-832. A. Comparison of angiography and intravascular ultrasound 17. Windecker S, Meier B. Late coronary stent thrombosis. Circula- for the assessment of lumen size after coronary stent place- tion 2007;116:1952-1965. ment: impact of dilation pressures. Cathet Cardiovasc Diagn 18. Kume T, Waseda K, Ako J, et al. Intravascular ultrasound as- 1997;42:113-119. sessment of postprocedural incomplete stent apposition. J In- 32. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents vasive Cardiol 2012;24:13-16. versus standard stents in patients with stenosis in a native coro- 19. Fitzgerald PJ, Oshima A, Hayase M, et al. Final results of the nary artery. N Engl J Med 2003;349:1315-1323. Can Routine Ultrasound Inu fl ence Stent Expansion (CRUISE) 33. Colombo A, Drzewiecki J, Banning A, et al. Randomized study study. Circulation 2000;102:523-530. to assess the effectiveness of slow- and moderate-release poly- 20. Uren NG, Schwarzacher SP, Metz JA, et al. Predictors and out- mer-based paclitaxel-eluting stents for coronary artery lesions. comes of stent thrombosis: an intravascular ultrasound regis- Circulation 2003;108:788-794. try. Eur Heart J 2002;23:124-132. 34. Park SJ, Kim YH, Park DW, et al. Impact of intravascular ul- 21. Doi H, Maehara A, Mintz GS, et al. Impact of post-intervention trasound guidance on long-term mortality in stenting for un- minimal stent area on 9-month follow-up patency of paclitaxel- protected left main coronary artery stenosis. Circ Cardiovasc eluting stents: an integrated intravascular ultrasound analysis Interv 2009;2:167-177. from the TAXUS IV, V, and VI and TAXUS ATLAS Workhorse, 35. Kim SH, Kim YH, Kang SJ, et al. Long-term outcomes of intra- Long Lesion, and Direct Stent Trials. JACC Cardiovasc Interv vascular ultrasound-guided stenting in coronary bifurcation 2009;2:1269-1275. lesions. Am J Cardiol 2010;106:612-618. 22. Hong MK, Mintz GS, Lee CW, et al. Intravascular ultrasound 36. Mintz GS, Painter JA, Pichard AD, et al. Atherosclerosis in an- predictors of angiographic restenosis after sirolimus-eluting giographically “normal” coronary artery reference segments: an stent implantation. Eur Heart J 2006;27:1305-1310. intravascular ultrasound study with clinical correlations. J Am http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr 38 The Korean Journal of Internal Medicine Vol. 27, No. 1, March 2012 Coll Cardiol 1995;25:1479-1485. 46. Colombo A, Caussin C, Presbitero P, Chieffo A. AVIO: a pro- 37. Weissman NJ, Palacios IF, Nidorf SM, Dinsmore RE, Weyman spective, randomized trial of intravascular-ultrasound guided AE. Three-dimensional intravascular ultrasound assessment compared to angiography guided stent implantation in complex of plaque volume after successful atherectomy. Am Heart J coronary lesions [abstract]. J Am Coll Cardiol 2010;56:xvii. 1995;130:413-419. 47. Roy P, Steinberg DH, Sushinsky SJ, et al. The potential clinical 38. Morino Y, Tamiya S, Masuda N, et al. Intravascular ultrasound utility of intravascular ultrasound guidance in patients under- criteria for determination of optimal longitudinal positioning of going percutaneous coronary intervention with drug-eluting sirolimus-eluting stents. Circ J 2010;74:1609-1616. stents. Eur Heart J 2008;29:1851-1857. 39. de Jaegere P, Mudra H, Figulla H, et al. Intravascular ultra- 48. Okabe T, Mintz GS, Buch AN, et al. Intravascular ultrasound sound-guided optimized stent deployment: Immediate and 6 parameters associated with stent thrombosis after drug-eluting months clinical and angiographic results from the Multicenter stent deployment. Am J Cardiol 2007;100:615-620. Ultrasound Stenting In Coronaries Study (MUSIC Study). Eur 49. Choi SY, Witzenbichler B, Maehara A, et al. Intravascular Heart J 1998;19:1214-1223. ultrasound findings of early stent thrombosis after primary 40. Russo RJ, Silva PD, Teirstein PS, et al. A randomized controlled percutaneous intervention in acute myocardial infarction: a trial of angiography versus intravascular ultrasound-directed Harmonizing Outcomes with Revascularization and Stents in bare-metal coronary stent placement (the AVID Trial). Circ Car- Acute Myocardial Infarction (HORIZONS-AMI) substudy. Circ diovasc Interv 2009;2:113-123. Cardiovasc Interv 2011;4:239-247. 41. Oemrawsingh PV, Mintz GS, Schalij MJ, Zw inderman AH, 50. Sonoda S, Morino Y, Ako J, et al. Impact of final stent dimen - Jukema JW, van der Wall EE. Intravascular ultrasound guid- sions on long-term results following sirolimus-eluting stent ance improves angiographic and clinical outcome of stent im- implantation: serial intravascular ultrasound analysis from the plantation for long coronary artery stenoses: final results of a sirius trial. J Am Coll Cardiol 2004;43:1959-1963. randomized comparison with angiographic guidance (TULIP 51. Takebayashi H, Kobayashi Y, Mintz GS, et al. Intravascular Study). Circulation 2003;107:62-67. ultrasound assessment of lesions with target vessel failure 42. Mudra H, di Mario C, de Jaegere P, et al. Randomized compari- af ter sirolimus- elut ing stent implantat ion. A m J Cardiol son of coronary stent implantation under ultrasound or angio- 2005;95:498-502. graphic guidance to reduce stent restenosis (OPTICUS Study). 52. Hong MK, Park SW, Lee NH, et al. Long-term outcomes of mi- Circulation 2001;104:1343-1349. nor dissection at the edge of stents detected with intravascular 43. Casella G, Klauss V, Ottani F, Siebert U, Sangiorgio P, Brac- ultrasound. Am J Cardiol 2000;86:791-795, A9. chetti D. Impact of intravascular ultrasound-guided stenting on 53. Liu X, Tsujita K, Maehara A, et al. Intravascular ultrasound long-term clinical outcome: a meta-analysis of available studies assessment of the incidence and predictors of edge dissections comparing intravascular ultrasound-guided and angiographi- after drug-eluting stent implantation. JACC Cardiovasc Interv cally guided stenting. Catheter Cardiovasc Interv 2003;59:314- 2009;2:997-1004. 321. 54. Park SM, Kim JS, Ko YG, et al. Angiographic and intravascular 44. Parise H, Maehara A, Stone GW, Leon MB, Mintz GS. Meta- ultrasound follow up of paclitaxel- and sirolimus-eluting stent ana lysis of randomized st udies compar ing intravascular after poststent high-pressure balloon dilation: from the post- ultrasound versus angiographic guidance of percutaneous coro- stent optimal stent expansion trial. Catheter Cardiovasc Interv nary intervention in pre-drug-eluting stent era. Am J Cardiol 2011;77:15-21. 2011;107:374-382. 55. Hur SH, Kang SJ, Kim YH, et al. Impact of intravascular ul- 45. Jakabcin J, Spacek R, Bystron M, et al. Long-term health out- trasound-guided percutaneous coronary intervention on long- come and mortality evaluation after invasive coronary treat- term clinical outcomes in a real world population. Catheter Car- ment using drug eluting stents with or without the IVUS guid- diovasc Interv 2011 Jul 29 [Epub]. http://dx.doi.org/10.1002/ ance. Randomized control trial: HOME DES IVUS. Catheter ccd.23279. Cardiovasc Interv 2010;75:578-583. http://dx.doi.org/10.3904/kjim.2012.27.1.30 http://www.kjim.or.kr

Journal

The Korean Journal of Internal MedicinePubmed Central

Published: Feb 28, 2012

There are no references for this article.