The Case for More Imaging in PCI and How to Get There Intravascular - - PowerPoint PPT Presentation

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The Case for More Imaging in PCI and How to Get There Intravascular - - PowerPoint PPT Presentation

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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

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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

Wednesday, May 22, 2019 12:47-12:55 pm

Prashant Kaul, MD, FACC, FSCAI Director, Cardiac Catheterization Laboratory Piedmont Heart Institute, Atlanta, GA Adjunct Associate Professor of Medicine, University of North Carolina-Chapel Hill

@KaulP #SCAI2019 #RadialFirst #ACCIC

LAS VEGAS, NV MAY 19-22

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Disclosures

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the

  • rganization(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

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Dattilo PB et al. JACC 2012; 60(12): 2335-42

61,874 Attempted PCIs of Intermediate lesions April 2009- Sept 2010

  • FFR Use:

3,763 (6.1%)

  • IVUS Use:

12,589 (20.3%)

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SLIDE 4

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

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Inpatient Utilization of OCT and IVUS (NIS)

David W. Lee, Szymon Wiernek , Prashant Kaul, Joseph S. Rossi

2012 2013 2014 PCI 1,036,390 965,760 899,230 OCT (%) 1,385 (0.13) 1,525 (0.16) 1,415 (0.16) IVUS (%) 45,980 (4.44) 40,915 (4.24) 36,725 (4.08)

0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% 2012 2013 2014

IVUS OCT % Utilization

Catheter Cardiovasc Interv. 2018;91:S23– S225. doi: 10.1002/ccd.27553

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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

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SLIDE 7

Hong S-J et al. JAMA 2015; (20): 2155-2163

5.8% 2.9% 1400 Patients MACE:

  • Cardiac Death
  • Target Lesion MI
  • TLR 1 year *
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SLIDE 8

Elgendy IY et al. Circulation: Cardiovasc Interventions 2016; 9:e003700

  • 7 RCTs
  • 3192 Patients
  • Mean Lesion 32 mm

Favors IVUS-guidance Favors Angiography-guidance

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SLIDE 9

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

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SLIDE 10
  • 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.

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SLIDE 11

Kaplan-Meier Survival Curves: 2 Years

MACE Definite Or Probable Stent Thrombosis

Maehara A et al. Circ Cardiovasc Interv. 2018;11:e006243. 1.16%

Angiographic Guidance Angiographic Guidance

7.5

HR 0.65 CI 0.54-0.78 P <0.001 HR 0.47 CI 0.28-0.80 P = 0.004 able ST (%)

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Kaplan-Meier Survival Curves: 2 Years

Maehara A et al. Circ Cardiovasc Interv. 2018;11:e006243.

MI TLR

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ULTIMATE

A Multicenter, Prospective, Randomized Trial Comparing Intravascular Ultrasound-guided versus Angiography-guided Implantation of Drug-Eluting Stent in All-comers

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

Jun-Jie Zhang, MD, PhD

NCT02215915

ULTIMATE

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SLIDE 14

Zhang J et al. J Am Coll Cardiol 2018;72(24):3126–37.

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Study Design

1448 all-comer patients

1:1 Randomization

Angiography guidance (n=724)

ULTIMATE

Primary endpoint: TVF at 12 months IVUS guidance (n=724)

Powered for Superiority

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SLIDE 16

ULTIMATE Primary Endpoint: TVF at 12 Months

Zhang J et al. J Am Coll Cardiol 2018;72(24):3126–37.

5.4% 2.9%

IVUS guided PCI Angio guided PCI

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SLIDE 17

Adapted from: Ali, ZA et al. JACC: Interventions 2017;10(24):2473–87

Intravascular Imaging

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Expected Impact of Intracoronary Imaging for PCI Guidance

Burzotta, F and Trani C. Circulation: Cardiovascular Interventions. 2018;11

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2011 ACCF/AHA/SCAI Guidelines for PCI

IVUS is reasonable for the assessment of angiographically indeterminant LM CAD.

I IIa IIb III

IVUS and coronary angiography are reasonable 4 to 6 weeks and 1 year after cardiac transplantation to exclude donor CAD, detect rapidly progressive cardiac allograft vasculopathy, and provide prognostic information.

I IIa IIb III

Levine GN et al. JACC 2011; 58(24): E44-122.

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2011 ACCF/AHA/SCAI Guidelines for PCI

IVUS is reasonable to determine the mechanism

  • f stent restenosis.

I IIa IIb III

IVUS may be reasonable for the assessment of non-LM coronary arteries with angiographically intermediate coronary stenoses (50% - 70%) diameter stenosis.

I IIa IIb III

Levine GN et al. JACC 2011; 58(24): E44-122.

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2011 ACCF/AHA/SCAI Guidelines for PCI

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.

I IIa IIb III

Levine GN et al. JACC 2011; 58(24): E44-122.

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2018 ESC Guidelines on Myocardial Revascularization

Neumann F-J et al. EHJ 2019; 40: 87-165

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FFR

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Before Post-Dilation After Post-Dilation

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When to Use Intracoronary Imaging?

Anatomical/Procedural Factors:

  • Aorto-ostial/Left Main disease
  • Bifurcation stenting
  • 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

a) Large territory at risk if there is stent failure OR b) Scenarios associated with high risk of stent failure

Patient Factors:

  • Diabetes Mellitus
  • End Stage Renal Disease
  • Co-morbidity necessitating the use of BMS
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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