I would like to address the many responses I received regarding an intravascular ultrasound (IVUS) article I recently wrote (“Give Your Patient the Correct Stent”, CLD July 2012). Many people stated that it took too long to advance an IVUS catheter into a vessel for correct sizing, or one response I thought was interesting, “You use IVUS if you’re not confident with your ability in choosing the correct stent size.” Well, I would like to note it only takes us about 1-3 minutes to use IVUS in the coronary or peripheral vessels. As far as not being confident in your ability to choose the correct stent size, with all of the under-deployed stents that I have seen come into my lab from different areas, I am sure the people placing the stent were very confident in their ability at the time. If not, I hope they would not have placed a stent in the first place. I am not saying to IVUS every case that comes along. I hope people respect IVUS use when needed instead of saying it is only for people who aren’t confident in their ability or that it takes too long.
I would like to share a case we did a few weeks ago using an IVUS catheter. We were catheterizing an outpatient when I put up a JL4 catheter to reveal an 80 percent lesion in the mid left anterior descending coronary artery (LAD) area. The lesion was about 30 mm long by visual inspection with angiography. The cardiologist inserted a .014” wire across the lesion, then proceeded to insert an IVUS catheter. To our surprise, the lesion in question looked to be very patent with no blockages visible with the IVUS catheter. We removed the IVUS and proceeded to inject 200 mcg of nitro intracoronary. After visualizing our nitro effect through the slight drop in pressure, the vessel by angiography was normal, with no visible lesions. Essentially, the vessel had spasmed down with the first injection.
As of late, I have seen five under-deployed stents come into my lab from different labs. I am sure every team placing these stents was confident in their ability in choosing the correct stent size. Remember these under-deployed stents come with risks to the patients of which they are unaware. These patients could have a myocardial infarction just due to the stent not being correctly sized and apposed to the vessel wall. I know if it was me or my family, I would want the cath lab team to take an additional 1-3 minutes and IVUS the lesion for the correct size. Who knows? You might see that the patient doesn’t need a stent at all, and medical management would be the correct treatment.
As I said before, I am not saying you have to use IVUS in every case, but just keep an open mind and I know a few times you will be surprised at what IVUS shows. Please feel free to email me to discuss topics I write or topics you would like to see covered.
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