Intravascular ultrasound (IVUS) - Elias Hanna, Univ of Iowa

***Please review under Comments my comment and update regarding stent sizing and post-stent IVUS criteria, using ULTIMATE trial and the new RENOVATE COMPLEX PCI trial. Also, review my talk on IVUS stent guidance: • IVUS/OCT stent guidanc...
00:00 Image interpretation
12:18 Positive remodeling and measuring area of stenosis vs plaque burden- IVUS measurements
23:34 Blood stasis/speckles artifact
25:36 Unstable plaque cases and illustrations: ruptured plaque, thrombus, lipid rich plaque
48:38 Optimal stent deployment- IVUS features and endpoints: proper expansion, edge plaque shift or dissection, and apposition
56:14 Indications for IVUS and data
1:00:00 Suboptimal stent optimization, as per ULTIMATE trial algorithm
1:02:00 IVUS for assessing lesion significance
1:05:37 Additional tips and questions

[@eliashanna8248]

We have now 2 major randomized trials proving the value of IVUS in reducing target vessel failure, mainly target vessel MI and target vessel revascularization: ULTIMATE trial, which used IVUS, and the more recently published COMPLEX-RENOVATE PCI trial, which allowed both IVUS or OCT (NEJM 2023). Additional note regarding stent sizing:
***PRE-STENT sizing: Stent is typically sized according to the distal REFERENCE LUMEN (eg, 100% of the distal reference lumen). EEM area can be used, but only at the REFERENCE site, not the LESION site. DO NOT use EEM at the LESION site. The proximal and distal references are defined as segments with 100% the smallest reference lumen [usually distal] or >90% the average proximal+distal reference lumens). This is what was used in the original MUSIC trial and in the landmark ULTIMATE and IVUS-XPL trials, including for post-stent optimization. Stent is considered underexpanded if 80% of the average reference lumens.
Absolute values for stent expansion were also allowed as an alternative in both trials: non-left main stent minimal area >5.5 mm2, left main stent >7 mm2 (distally) or 8 mm2 (proximally). The 2 trials consider the stent properly expanded if you meet either the relative or absolute values, not necessarily both, but I believe the relative value is more relevant.
Regarding edge dissection, in order to be considered significant and to warrant further therapy both trials mandated that the dissection extends deep to the media, and to be additionally either longer than > 3 mm or arc >60 degrees. A shallow dissection at the intima level did not warrant further stenting regardless of length.
Regarding edge disease, ULTIMATE recommended that stent edges have

[@vvasavvat]

Thank you so much. This is really helpful!!!!

[@Coocoocachoo809]

Fantastic job, Dr. Hanna. Please post more, if able. This is an excellent learning resource.

[@Nikesnipe]

please keep those videos they are golden!! greetings from cardiology, germany

[@areenal-taie6836]

Thank you Dr Hanna
Very useful illustrations and great teaching as usual
Please continue to teach us

[@ibraheemghulman2812]

thanks a lot for simplifying and make it easily understandable for an undergraduate like me ❤️

[@ahmeddaoud9901]

Awesome Job , Deeply Thanks Dr Hanna

[@healthyheart-dr.hanumanthr978]

Excellent Academic teaching videos.
Thanks sir

[@faysalalkaki6079]

Thank you very much , the best lecture ever . 🙏🏻🙏🏻🙏🏻

[@munfatema6234]

Very nice demonstration of IVUS.

[@ahmedsabbar9049]

Thank you very much for sharing this fruitful lecture

[@leesiuki]

thanks for the lecture!

[@ukaszukasz4589]

Great. Thanks you a lot. Best wishes from Poland.

[@user-ov8sj1qe8v]

the best lecture ever .

[@adeel2169]

Excellent presentation

[@anuppusate2559]

Thank you Sir

[@valeriasantos3476]

Thank you so much.

[@wahabanwar8201]

Its a great lecture ❤

[@samiulislamalahi1659]

Best lecturer 😍

[@alirhayim]

Hands down one of the best IVUS lectures online.

[@BarrieLouis]

thank you!

[@aroojzahid3138]

Great talk like aleays

[@kelvinernest6738]

IVUS-ACS trial another major RCT showcase improved clinical outcomes of IVUS guided PCI compared to Angio guided in ACS patients

[@vijayasekaran5243]

Very nice

[@bilalwazzaz9820]

Thanks

[@SGSJR]

Great video!
Thank you!

[@abdullahlsharaf2264]

Excellent, can you do another Talk about OCT?

[@cliffoguk7679]

I love this. I love this. How can i be certified to do this procedure?

[@rodolfolanocita]

Thanks so much for this lecture. Have you got experience on liver transplant arteries? I'm looking to improve our service on that.

[@drhinasohail]

You should write a book on interventional cardiology..

[@marcop3038]

Hello, where can I get this presentation? Thanks a lot for this comprehensive presentation

[@nghethuatsong]

how to download the IVUS dataset? I tried many time but not yet...Thanks

[@ruxandrasava9703]

Thanks a lot for this great lecture!
I have one question regarding lumen size estimation for the purposes of establishing the stent diameter
You make the case that one should Never use the EEL-EEL measurement to determine stent size, however there is an aboundance of sources claming the superiority of stent diameter estimation by IVUS vs OCT strictly because of the ability to estimate the lumen diameter by EEL-EEL measurement at the level of the reference segments, which is considered the "true vessel lumen" - and then downsizing the stent by 0.5 from there. What's your comment on this topic?

[@eliashanna8248]

That is a great question, thank you! I agree that EEM area can be used, but only at the REFERENCE site, not at the LESION site; and even then, this is not the standard or referred method. The proximal and distal references being defined as segments with 100% the smallest reference lumen [usually distal] or >90% the average proximal+distal reference lumens). This is what was used in the original MUSIC trial and in the landmark ULTIMATE and IVUS-XPL trials, including for post-stent optimization.
2-A more aggressive approach consists of what you describe (EEL or EEM diameter at the distal reference, downsized 0.25-0.5 mm). This method was mainly used for OCT sizing in ILUMien III trial of OCT vs IVUS vs angio guidance. Only recently, it was applied to both OCT and IVUS in the iSIGHT trial, with some modification (circulation 2021).
Another EEM method was allowed in the IVUS ULTIMATE: use 80% of the media diameter at the reference (downsize the EEM diameter by 20% rather than absolute number).
You see that the exact reference EEM method used varies between studies. Since the stent is landing over the reference lumen, not the EEM, it makes sense to me to make it match the size of that reference lumen, as oversizing can cause edge dissection and edge plaque shift, particularly in diffusely diseased vessels, and particularly when you have to land in a reference with >40% plaque burden, hence the reason I prefer method 1. Method 1 has also been recommended by the expert consensus of the European Association of PCI (2018). Also, while it is established that method 2 results in larger stent size, it remains to be proven whether this results in better clinical outcomes.

[@ruxandrasava9703]

@@eliashanna8248 thanks for this very informative answer !

[@rangaarunachalam5759]

@@eliashanna8248 That was one of the best IVUS lectures I have heard and this answer is also the best response. Excellent job Dr. Hanna.