WHY 9% IS NOT ENOUGH: The Case for More Imaging in PCI and How to Get There Intravascular Imaging and Coronary Physiology: Current State of the Art Satellite Symposium LAS VEGAS, NV Wednesday, May 22, 2019 12:47-12:55 pm MAY 19-22 Prashant Kaul, MD, FACC, FSCAI Director, Cardiac Catheterization Laboratory @KaulP Piedmont Heart Institute, Atlanta, GA Adjunct Associate Professor of Medicine, University of North Carolina-Chapel Hill #SCAI2019 #RadialFirst #ACCIC
Disclosures Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below Affiliation/Financial Relationship Company Grant/Research Support None Consulting Fees/Honoraria Abbott Vascular Cardiovascular Systems Inc Boston Scientifc Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None
61,874 Attempted PCIs of Intermediate lesions April 2009- Sept 2010 • FFR Use: 3,763 (6.1%) • IVUS Use: 12,589 (20.3%) Dattilo PB et al. JACC 2012; 60(12): 2335-42
Effect of PSP and other Elements of Technique on 3 Year Outcomes Among Metallic Everolimus-Eluting Stent -Treated Patients in the ABSORB Trials • 1223 patients and 1284 lesions treated with EES • ABSORB II, ABSORB III, ABSORB China and ABSORB Japan trials • 3-year TLF and stent thrombosis (ST) were correlated with PSP PSP: Pre-dilatation, appropriate vessel sizing and post-dilatation All 3 elements performed in only 2.7% patients
Inpatient Utilization of OCT and IVUS (NIS) David W. Lee, Szymon Wiernek , Prashant Kaul, Joseph S. Rossi 10.00% 9.00% 8.00% 7.00% 6.00% % 5.00% Utilization IVUS 4.00% 3.00% 2.00% 1.00% OCT 0.00% 2012 2013 2014 Catheter Cardiovasc Interv . 2018;91:S23 – S225. doi: 10.1002/ccd.27553 2012 2013 2014 1,036,390 965,760 899,230 PCI 1,385 (0.13) 1,525 (0.16) 1,415 (0.16) OCT (%) 45,980 (4.44) 40,915 (4.24) 36,725 (4.08) IVUS (%)
Inpatient Utilization of OCT and IVUS (NIS) David W. Lee, Szymon Wiernek , Prashant Kaul, Joseph S. Rossi David W. Lee, Szymon Wiernek , Prashant Kaul, Joseph S. Rossi Teaching Hospitals Non-Teaching Hospitals Catheter Cardiovasc Interv . 2018;91:S23 – S225. doi: 10.1002/ccd.27553
5.8% 1400 Patients MACE: • Cardiac Death 2.9% • Target Lesion MI • TLR 1 year * Hong S-J et al. JAMA 2015; (20): 2155-2163
• 7 RCTs • 3192 Patients • Mean Lesion 32 mm Favors Angiography-guidance Favors IVUS-guidance Elgendy IY et al. Circulation: Cardiovasc Interventions 2016; 9:e003700
IVUS-guided PCI was associated with: 1. Significantly larger post-intervention MLD 2. Greater reduction in the diameter stenosis 3. Reduction in the risk of MACE (NNT=26) * 4. Borderline lower risk of stent thrombosis and cardiovascular mortality * primarily due to a reduction in ischemia or clinically driven TLR (NNT=40) at a mean follow-up of 15 months. Elgendy IY et al. Circulation: Cardiovasc Interventions 2016; 9:e003700
• Prospective, multicenter, nonrandomized all-comers study • 8582 consecutive patients • 11 US and German Sites • Propensity-adjusted multivariable analysis • Impact of IVUS guidance on 2-year outcomes Maehara A et al. Circ Cardiovasc Interv. 2018;11:e006243.
Kaplan-Meier Survival Curves: 2 Years MACE Definite Or Probable Stent Thrombosis HR 0.65 CI 0.54-0.78 HR 0.47 CI 0.28-0.80 able ST (%) P <0.001 P = 0.004 7.5 Angiographic Guidance Angiographic Guidance 1.16% Maehara A et al. Circ Cardiovasc Interv. 2018;11:e006243.
Kaplan-Meier Survival Curves: 2 Years MI TLR Maehara A et al. Circ Cardiovasc Interv. 2018;11:e006243.
ULTIMATE ULTIMATE A Multicenter, Prospective, Randomized Trial Comparing Intravascular Ultrasound-guided versus Angiography-guided Implantation of Drug-Eluting Stent in All-comers Jun-Jie Zhang, MD, PhD Xiaofei Gao, Jing Kan, Zhen Ge, Leng Han, Shu Lu, Nailiang Tian, Song Lin, Qinghua Lu Xueming Wu, Qihua Li, Zhizhong Liu, Yan Chen, Xuesong Qian, Juan Wang, Dayang Chai, Chonghao Chen, Xiaolong Li, Bill D. Gogas, Tao Pan, Shoujie Shan, Fei Ye, Shao-Liang Chen NCT02215915
Zhang J et al. J Am Coll Cardiol 2018;72(24):3126 – 37.
ULTIMATE Study Design 1448 all-comer patients 1:1 Randomization IVUS guidance Angiography guidance (n=724) (n=724) Primary endpoint: TVF at 12 months Powered for Superiority
ULTIMATE Primary Endpoint: TVF at 12 Months 5.4% Angio guided PCI 2.9% IVUS guided PCI Zhang J et al. J Am Coll Cardiol 2018;72(24):3126 – 37.
Intravascular Imaging Adapted from: Ali, ZA et al. JACC: Interventions 2017;10(24):2473 – 87
Expected Impact of Intracoronary Imaging for PCI Guidance Burzotta, F and Trani C. Circulation: Cardiovascular Interventions. 2018;11
2011 ACCF/AHA/SCAI Guidelines for PCI I IIa IIb III IVUS is reasonable for the assessment of angiographically indeterminant LM CAD. IVUS and coronary angiography are reasonable 4 to 6 weeks and 1 year after cardiac transplantation to I IIa IIb III exclude donor CAD, detect rapidly progressive cardiac allograft vasculopathy, and provide prognostic information. Levine GN et al. JACC 2011; 58(24): E44-122.
2011 ACCF/AHA/SCAI Guidelines for PCI I IIa IIb III IVUS is reasonable to determine the mechanism of stent restenosis . IVUS may be reasonable for the assessment of I IIa IIb III non-LM coronary arteries with angiographically intermediate coronary stenoses (50% - 70%) diameter stenosis. Levine GN et al. JACC 2011; 58(24): E44-122.
2011 ACCF/AHA/SCAI Guidelines for PCI I IIa IIb III IVUS may be considered for guidance of coronary stent implantation, particularly in cases of LM coronary artery stenting I IIa IIb III IVUS may be reasonable to determine the mechanism of stent thrombosis. Levine GN et al. JACC 2011; 58(24): E44-122.
2018 ESC Guidelines on Myocardial Revascularization Neumann F-J et al. EHJ 2019; 40: 87-165
FFR
Before Post-Dilation After Post-Dilation
When to Use Intracoronary Imaging? a) Large territory at risk if there is stent failure OR b) Scenarios associated with high risk of stent failure Anatomical/Procedural Factors: Patient Factors: • Diabetes Mellitus • Aorto-ostial/Left Main disease • End Stage Renal Disease • Bifurcation stenting • Co-morbidity necessitating the use of BMS • Prior stent failure due to ISR or IST • Long Lesions (> 28 mm) Calcium Management • Lesion Assessment - Do I need to use Atherectomy? - Should I avoid Atherectomy? • Stent Optimization
How to Increase Intracoronary Imaging? 1. Improve Physician Education 2. Lack of Image Interpretation Skill is a barrier 3. Update Guideline Recommendations 4. Intracoronary Imaging should be a Quality Metric 5. Improve reimbursement
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