Intravascular Ultrasonography Procedures

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Intravascular ultrasonography (IVUS) is an invasive imaging procedure that provides intravascular images of the coronary arteries and other blood vessels. Intravascular ultrasonography has played a critical role in enhancing the understanding of coronary atherosclerosis pathophysiology and has facilitated the refinement of diagnostic and therapeutic strategies for various vascular pathologies. Intravascular ultrasonography has become increasingly important in both clinical and research applications, ^[1] and it has played an integral role in the evolution of interventional cardiology. ^{[2, 3]} Intravascular ultrasonography in interventional cardiology is an adjunctive procedure to coronary angiogram; as such, any contraindication to coronary angiography applies to intravascular ultrasonography as well.

In general, risks and discomforts involved in IVUS include those associated with all catheterization procedures. Major complications, including dissection or vessel closure, are rare (<0.5%). The most frequently reported complication is transient coronary spasm (occurring in 1-3% of examinations), which responds to intracoronary glyceryl trinitrate.

(See the image below.)

An expert consensus committee commissioned by the American College of Cardiology, in collaboration with the European Society of Cardiology, has provided a framework for standardization of nomenclature, methods of measurement, and reporting of intravascular ultrasonography results. ^[4]

Preinterventional intravascular ultrasonography imaging allows the assessment of plaque distribution, ostial involvement, lumen and vessel area and diameters, extent of calcification, and the presence of thrombi or dissections. ^{[5, 6, 7]} It can alter strategy and the decision to use a particular device.

Two major trials, the Strategy for Intracoronary Ultrasound-Guided PTCA and Stenting (SIPS) trial and the Balloon Equivalent to Stent (BEST) study evaluated the potential benefit and demerits between ultrasound-guided balloon angioplasty and routine stenting. ^{[8, 9]} In the SIPS trial, approximately 50% of patients in each group received a stent at the time of the index procedure. Acute gain was greater in the IVUS-guided group than in the angiography-guided group, but angiographic 6-month follow-up revealed no difference in the primary endpoint of minimum lumen diameter. Although no difference was noted in the secondary endpoint of short-term target lumen revascularization, long-term clinical follow-up showed a significant decrease in clinically driven target lumen revascularization in the ultrasound group compared with the angiography group. In the BEST trial, at 6 months, 20 of 119 patients in the aggressive balloon angioplasty group and 21 of 116 patients in the routine stent implantation group had restenosis, along with no statistical difference in minimal luminal diameter or lumen cross-sectional area, thus fulfilling the prespecified criteria for noninferiority.

Although intravascular ultrasound-guided balloon angioplasty is a noninferior alternative to routine stenting, this approach is certainly more time consuming and requires meticulous attention to detail and expertise in intravascular ultrasonography image acquisition and interpretation. These studies have made apparent that the crossover rate is high, with more than 50% of patients requiring adjunctive stent implantation. In routine clinical practice, stent implantation has gained preference over intravascular ultrasound-guided balloon angioplasty. ^[10]

The Multicenter Ultrasound Stenting in Coronaries (MUSIC) study established the safety and feasibility of intravascular ultrasound-guided stent implantation. ^[11] Fitzgerald et al evaluated whether routine ultrasound guidance of stent implantation improved clinical outcome as compared to angiographic guidance alone in the Can Routine Ultrasound Influence Stent Expansion (CRUISE) trial. ^[12] Although no clinical outcome benefits were demonstrated with routine use of intravascular ultrasonography, a more effective stent expansion was noted when compared with angiographic guidance alone .

Casella et al conducted a meta-analysis of studies done on this topic and demonstrated that intravascular ultrasound-guided stent implantation has a neutral effect on long-term death and nonfatal myocardial infarction compared with an angiographic optimization. ^[13] However, it was noted that intravascular ultrasound-guided stenting significantly lowers 6-month angiographic restenosis and target vessel revascularizations.

In their appraisal of intravascular ultrasonography and its application in routine angioplasty, Oxford et al have noted that intravascular ultrasonography is better than contrast angiography in key procedural variables, such as measurement of postdeployment stent dimensions, confirming complete stent apposition, and excluding edge dissections that may predispose to both early and late complications, including in-stent restenosis. ^[14] At present, no guidelines exist on the routine use of intravascular ultrasound-guided angioplasty, but the interventionist should weigh the risks and benefits of this procedure before its application. The clinical usefulness of ultrasound guidance in stent deployment maintains its value. Particularly in small vessels, bifurcation stenting, ostial lesions, long segments, and in left main stenting, ultrasound can provide beneficial guidance. ^{[15, 16]}

Intravascular ultrasound plays a vital role in characterization of plaque structures and planning of debulking (atherectomy) procedures by differentiating between superficial (intimal) and deep calcium deposits . ^[17] Intravascular ultrasonography has emerged as superior to routine angiography at guiding selective plaque removal. ^[18] Rotational atherectomy is preferred over directional atherectomy in superficial calcification. ^[19]

Intravascular ultrasonography consists of a miniature ultrasound-mounted catheter that is connected to an electronics console to reconstruct the images transmitted by sound waves. The ultrasound signal is produced by passing an electrical current through the piezoelectric (pressure-electric) crystalline material of the transducer that expands and contracts when electrically excited.

After reflection from tissue, part of the ultrasound energy returns to the transducer. The received signal is converted to electrical energy and sent to an external signal processing system for amplification, filtering, scan conversion, user-controlled modification, and graphic presentation. The ultrasound beam upon reflection remains fairly parallel for a distance (near field) and then begins to diverge (far field). The quality of ultrasound images is greater in the near field because the beam is narrower and more parallel, the resolution is greater, and the characteristic backscatter (reflection of ultrasound energy) from a given tissue is more accurate.Therefore, larger transducers with lower frequencies are used for examination of large vessels because they create a deeper near field.

(See the video below.)

Di Mario C, Görge G, Peters R, Kearney P, Pinto F, Hausmann D. Clinical application and image interpretation in intracoronary ultrasound. Study Group on Intracoronary Imaging of the Working Group of Coronary Circulation and of the Subgroup on Intravascular Ultrasound of the Working Group of Echocardiography of the European Society of Cardiology. Eur Heart J. 1998 Feb. 19(2):207-29. [Medline].

Serruys PW, de Jaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N Engl J Med. 1994 Aug 25. 331(8):489-95. [Medline].

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Mintz GS, Nissen SE, Anderson WD, Bailey SR, Erbel R, Fitzgerald PJ, et al. American College of Cardiology Clinical Expert Consensus Document on Standards for Acquisition, Measurement and Reporting of Intravascular Ultrasound Studies (IVUS). A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2001 Apr. 37(5):1478-92. [Medline].

Chung H, Lee SJ, Park JK, Choi IS, Won HY, Kim S, et al. Spontaneous coronary artery dissection mimicking coronary spasm diagnosed by intravascular ultrasonography. Korean Circ J. 2013 Jul. 43(7):491-6. [Medline]. [Full Text].

Choi YH, Hong YJ, Ahn Y, Park IH, Jeong MH. Relationship between Neutrophil-to-Lymphocyte Ratio and Plaque Components in Patients with Coronary Artery Disease: Virtual Histology Intravascular Ultrasound Analysis. J Korean Med Sci. 2014 Jul. 29(7):950-6. [Medline]. [Full Text].

Chang M, Kang SJ, Yoon SH, Ahn JM, Park DW, Lee SW, et al. Plaque composition and morphologic characteristics in significant left main bifurcation disease; virtual histology intravascular ultrasound study. Coron Artery Dis. 2016 Dec. 27 (8):623-628. [Medline].

Frey AW, Hodgson JM, Müller C, Bestehorn HP, Roskamm H. Ultrasound-guided strategy for provisional stenting with focal balloon combination catheter: results from the randomized Strategy for Intracoronary Ultrasound-guided PTCA and Stenting (SIPS) trial. Circulation. 2000 Nov 14. 102(20):2497-502. [Medline].

Schiele F, Meneveau N, Gilard M, Boschat J, Commeau P, Ming LP. Intravascular ultrasound-guided balloon angioplasty compared with stent: immediate and 6-month results of the multicenter, randomized Balloon Equivalent to Stent Study (BEST). Circulation. 2003 Feb 4. 107(4):545-51. [Medline].

Laskey WK, Williams DO, Vlachos HA, Cohen H, Holmes DR, King SB 3rd. Changes in the practice of percutaneous coronary intervention: a comparison of enrollment waves in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry. Am J Cardiol. 2001 Apr 15. 87(8):964-9; A3-4. [Medline].

de Jaegere P, Mudra H, Figulla H, Almagor Y, Doucet S, Penn I. Intravascular ultrasound-guided optimized stent deployment. Immediate and 6 months clinical and angiographic results from the Multicenter Ultrasound Stenting in Coronaries Study (MUSIC Study). Eur Heart J. 1998 Aug. 19(8):1214-23. [Medline].

Fitzgerald PJ, Oshima A, Hayase M, Metz JA, Bailey SR, Baim DS. Final results of the Can Routine Ultrasound Influence Stent Expansion (CRUISE) study. Circulation. 2000 Aug 1. 102(5):523-30. [Medline].

Casella G, Klauss V, Ottani F, Siebert U, Sangiorgio P, Bracchetti D. Impact of intravascular ultrasound-guided stenting on long-term clinical outcome: a meta-analysis of available studies comparing intravascular ultrasound-guided and angiographically guided stenting. Catheter Cardiovasc Interv. 2003 Jul. 59(3):314-21. [Medline].

Orford JL, Lerman A, Holmes DR. Routine intravascular ultrasound guidance of percutaneous coronary intervention: a critical reappraisal. J Am Coll Cardiol. 2004 Apr 21. 43(8):1335-42. [Medline].

Tyczynski P, Chmielak Z, Pregowski J, Rewicki M, Karcz M. Intervention on the left main coronary artery. Importance of periprocedural and follow-up intravascular ultrasonography guidance. Postepy Kardiol Interwencyjnej. 2014. 10(2):130-2. [Medline]. [Full Text].

Li QH, Zhang Q, Li XL, Yin JF, Ji HG. A volumetric intracoronary ultrasonographic study of coronary bifurcation lesions. Eur Rev Med Pharmacol Sci. 2018 Feb. 22 (4):1094-1101. [Medline].

Li L, Dash D, Gai LY, Cao YS, Zhao Q, Wang YR, et al. Intravascular Ultrasound Classification of Plaque in Angiographic True Bifurcation Lesions of the Left Main Coronary Artery. Chin Med J (Engl). 2016 Jul 5. 129 (13):1538-43. [Medline]. [Full Text].

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Puri R, Nicholls SJ, Brennan DM, Andrews J, Liew GY, Carbone A, et al. Coronary atheroma composition and its association with segmental endothelial dysfunction in non-ST segment elevation myocardial infarction: novel insights with radiofrequency (iMAP) intravascular ultrasonography. Int J Cardiovasc Imaging. 2014 Oct 9. [Medline].

Alfonso F, Sandoval J, Pérez-Vizcayno MJ, Cárdenas A, Gonzalo N, Jiménez-Quevedo P, et al. Mechanisms of balloon angioplasty and repeat stenting in patients with drug-eluting in-stent restenosis. Int J Cardiol. 2014 Oct 23. 178C:213-220. [Medline].

Kartika Shetty, MD, FACP Chief Hospitalist, Sound Physicians

Kartika Shetty, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, Association of Program Directors in Internal Medicine, Medical Council of India

Disclosure: Nothing to disclose.

Nirmal Sunkara, MD Chief Resident, Department of Internal Medicine, University of Nevada School of Medicine

Nirmal Sunkara, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Subodh Raja Devabhaktuni, MD Resident Physician, Department of Internal Medicine, University of Nevada School of Medicine

Disclosure: Nothing to disclose.

Chowdhury H Ahsan, MD, PhD, MRCP, FSCAI Clinical Professor of Medicine, Director of Cardiac Catheterization and Intervention, Marlon Cardiac Catheterization Laboratory, Director of Cardiovascular Research, University Medical Center, University of Nevada School of Medicine

Chowdhury H Ahsan, MD, PhD, MRCP, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions, American Stroke Association

Disclosure: Received consulting fee from sanofi for consulting; Received honoraria from astra zeneca for speaking and teaching; Received honoraria from BI for speaking and teaching.

Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia

Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand

Disclosure: Nothing to disclose.

Intravascular Ultrasonography Procedures

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