Cath Lab Digest

Tell us about your lab.

The Medical University of South Carolina (MUSC) has 4 dedicated cath labs with 9 practicing interventionalists, 6 of whom are on faculty at MUSC. We do coronary, peripheral, and structural procedures.

How do you use intravascular ultrasound (IVUS)?

We use it primarily for optimization of the interventional technique, meaning vessel sizing and stent sizing, diameter, and length, and then to determine adequacy of stent deployment, which includes lesion coverage, stent expansion and apposition, and any edge injury.

What have you seen in terms of your outcomes with IVUS use?

Well, we certainly think we get better outcomes, but it’s hard to prove. It takes thousands of patients to truly show differences with regard to stent thrombosis, restenosis, or results with percutaneous coronary intervention (PCI) in general.

Does IVUS impact how you make decisions in the lab?

Absolutely. We use IVUS to determine stent length, diameter, and/or the need for adjunct therapy, meaning whether pretreatment of the lesion requires more aggressive pretreatment techniques, such as predilation with a cutting balloon or adjunctive treatment with rotational atherectomy. It gives us an idea of how the lesion will behave in response to direct stenting. If any adjunctive techniques are needed, we can optimize that, and make them more efficient.

What about after the stent is placed?

It’s always nice to see how you did! In our case, we would be looking specifically at lesion coverage, to make sure we didn’t miss anything, then also look at the edges, to make sure we didn’t cause any dissection, and then, of course, adequacy of stent expansion and apposition.

How frequently do you find that your post-stent IVUS prompts action?

I would say at least half the time we do something different. The question remains whether or not a simple post-dilation would have taken care of any issues. Some operators make the argument that if you are going to post dilate ½ mm up at high pressure throughout the whole stent, then you have, in many cases, covered whatever you would see on post-stent IVUS. Others argue that there is more still to be gained in terms of the edges and adequacy of lesion coverage, and that there is still benefit from routine IVUS post stent. Sometimes you may not even need to post dilate because IVUS shows the areas of coverage you have achieved are sufficient with the initial stent deployment.

So, in a sense, we need more data.

We can always say that. We always need more data. I would like to see a large-scale, randomized outcomes-based trial properly done that explores these techniques and evaluates outcomes. I think it’s difficult to do and those that have been done have had mixed results. I’m not sure there will be a definitive answer, but I certainly would like to see one. There is some evidence from a Washington Hospital series that was published in European Heart Journal that routine IVUS use in the drug-eluting stent era reduces the incidence of stent thrombosis.¹ While we recognize that there is more than one way to ‘skin the cat’, we believe that routine IVUS use optimizes our equipment choices, optimizes our treatment strategies and optimizes our outcomes, although admittedly, we and most of the IVUS camp has had difficulty proving that in the drug-eluting stent era.

Do you use IVUS every time you stent?

I try to, unless there is a reason not to. Across our lab, we are at least 50% pre and post IVUS. I tend to be on the side of 85-90%.

In what patients would it not be appropriate?

Sometimes the IVUS catheter just won’t go because of vessel tortuosity or size. I tend not to use IVUS in vein grafts or through internal mammary grafts, just because I want to minimize the amount of instrumentation in those territories.

How do you use IVUS and FFR differently in your practice?

There was a time when many believed that anatomic lesion assessment was a good way of determining whether or not a lesion was significant. In the past few years, what we have learned, especially with the publication of the FAME trial², is that FFR and the physiologic assessment it provides not only can reduce the number of stents that are implanted, but also improve outcomes. We don’t have that data with IVUS, and therefore, for the diagnosis of physiologically significant coronary disease that will benefit from treatment, an FFR-guided strategy is certainly preferred over an IVUS-guided strategy.

Today, we have come to the understanding that FFR and/or clinical reasoning tells us when to treat, while IVUS optimizes how we treat.

What about other imaging technologies, such as optical coherence tomography (OCT)?

OCT is a very exciting technology. It shows us things that, in truth, we haven’t seen before. What we still need to learn is whether routine strategy with OCT can provide the same information and/or better information than what can be provided by IVUS, and can further improve outcomes.

Do you think IVUS adds a significant amount of time to the procedure?