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“IVUS Image

Interpretation and Analysis”


Dr Arindam Pande
Consultant Cardiologist,
Academic Coordinator: DNB Cardiology and
PGDCC Training
Apollo Gleneagles Hospital, Kolkata
Introduction to Intravascular
Ultrasound – IVUS

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Image by Boston Scientific Corporation

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Comparing Angiography and IVUS

In angiography, angle of view determines what we see.

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Clinical Utility for IVUS

• Stenting of smaller vessels


– Vessels ≤ 3mm
• Intra-stent restenosis
– Visualize the stent
• Difficult to assess lesions
– More sensitive plaque detection

1. Moussa C, et al J Am Coll Cardiol 1997; 29 (Suppl A) 60A

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Image Interpretation

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Lower Density Plaques

Eccentric fibrous plaque Concentric fibro-fatty plaque

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Lower Density Plaques
Concentric
fibro-fatty
plaque Media
Lumen Lumen

Guidewire
artifact
IVUS Eccentric IVUS
catheter fibrous catheter
plaque

Eccentric fibrous plaque Concentric fibro-fatty plaque

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Mixed Plaque

Mixed eccentric plaque Thin concentric fibrous plaque


(fibrous, fibro-fatty, and calcified) mixed with calcium

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Mixed Plaque
Fibrous
plaque IVUS
catheter Fibrous
Guidewire plaque
artifact Guidewire
artifact

Fibrous Fibro-fatty
plaque plaque Media

Calcified IVUS
plaque catheter
Calcified plaque

Mixed eccentric plaque Thin concentric fibrous plaque


(fibrous, fibro-fatty, and calcified) mixed with calcium

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Calcified Plaque

90° arc (one quadrant) Mixed deep and superficial


of deep calcium calcified plaque

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Calcified Plaque
Calcified Shadowing (IVUS signal
plaque does not pass through Reverberations Deep calcium
Fibrous
plaque calcified plaque)
Shadowing

Superficial
Fibrous calcium
plaque

Superficial
calcium Fibrous
Fibrous plaque
IVUS plaque IVUS
catheter Guidewire
catheter artifact

90° arc (one quadrant) Mixed deep and superficial


of deep calcium calcified plaque

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Calcified Plaque (continued)

180° arc of eccentric superficial 270° arc of superficial


calcified plaque calcified plaque

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Calcified Plaque (continued)

Calcified plaque
Reverberations Calcified plaque

Lumen

IVUS catheter
IVUS catheter

180° arc of eccentric superficial 270° arc of superficial


calcified plaque calcified plaque

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Stents

Fully apposed stent Incompletely apposed stent

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Stents
Concentric mixed fibrous
and fibro-fatty plaque
IVUS
catheter
Apposed

Stent
struts Apposed

Stent
struts Unopposed
IVUS
catheter Unopposed
Vessel wall

Fully apposed Incompletely apposed


stent stent

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Stents (continued)

Stent deployment in a heavily calcified vessel

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Stents (continued)

Stent struts
Guidewire artifact

Stent struts

IVUS catheter

Stent struts Calcified plaque

Stent deployment in a heavily calcified vessel

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Dissections

Fibrous plaque dissection Deep fibro-fatty plaque dissection


extending into the intima extending into the media

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Dissections
IVUS
catheter Dissection arm Media
Dissection
Fibro-fatty arm
plaque Fibrous
plaque

Fibro-fatty
Lumen plaque
Fibrous Fibro-fatty
plaque plaque
IVUS
catheter

Fibrous plaque dissection Deep fibro-fatty plaque dissection


extending into the intima extending into the media

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Dissections (continued)

Horseshoe dissection of fibrous Horseshoe dissection of


plaque extending into the media calcified plaque

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Dissections (continued)

Calcified Dissection IVUS Superficial


plaque arm catheter calcium

Blood Dissection
IVUS speckle arm: calcified
catheter plaque

Horseshoe dissection of fibrous Horseshoe dissection of


plaque extending into the media calcified plaque

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Measurement and Analysis

Lumen border
Maximum plaque
thickness Maximum lumen Maximum plaque thickness
diameter Eccentricity =
Minimum plaque thickness

Plaque CSA* = MA CSA – Lumen CSA

Measurements
Plaque CSA
required % Plaque area =
for analysis MA CSA
of IVUS
images Reference lumen CSA –
% Area stenosis =Lesion lumen CSA
Reference lumen CSA
Minimum lumen
Media-adventitia diameter
(MA) border * Plaque CSA includes variable amounts
of smooth muscle from media

Minimum plaque Lumen CSA


thickness

Plaque CSA

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Measurement and Analysis

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Calculating – Area

D(mm) = 0.0
A1 = 5.9mm2

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Lumen Diameter Measurements

2.5

3.0

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IVUS-Guided Stenting
• Measurement and Analysis
Lumen Diameters vs. Cross Sectional Areas (CSA)
Lumen Diameter Lumen CSA 90% of Lumen Lumen Diameter at
(mm) (mm )
2
CSA (mm ) 2
90% of CSA (mm)
2.5 4.9 4.4 2.4
3.0 7.0 6.4 2.8
3.2 8.0 7.2 3.0
3.4 9.0 8.2 3.2

“The Predictive Value of Different Intravascular Ultrasound


Criteria for Restenosis After Coronary Stenting”1
Minimum Lumen Cross
Potential Restenosis Rate
Sectional Area
The incidence of <5mm2 46%
restenosis has an 5.0-5.9mm2 33%
inverse relationship to 6.0-7.9mm2 27%
post-procedure absolute 8.0-8.9mm2 21%
IVUS lumen CSA. ≥9mm2 8%

1 Moussa et al., ACC 97: 707-6. Data did not include DES.

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39 years RTA patient with sudden
chest pain and VT in ER

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IVUS: Dissection

FL

TL
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Take Home Messages

• How to determine lesion length morphology

• How to identify dissections

• Determining appropriate stent placement

• Determining lesion size

• Understanding the shortfalls of angiography

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Thank You