1. Saqib Chowdhary Wythenshawe Hospital STENT THROMBOSIS How Do IVUS & OCT Help

2. NO CONFLICT OF INTEREST TO DECLARE

3. Optimise the implant. Understand the predisposing pathology – stent healing. Guide & optimise the repeat intervention. Angiography Moderate Poor How Can Imaging Tackle The Problem Of Stent Thrombosis?

4. IVUS Assessment of DES SAT Fuji, Mintz et al. JACC 2005; 45:995-8 15 Cypher ST @ av of 14 days 4.3 6.2 mm 2 CSA 2.5 mm 2 80% 29% >70% <4mm 2

5. 0 10 20 30 40 50 60 Percentage Expansion <80% %DS>0 Malapposition Inflow-outflow disease Thrombus Filling defect Edge tear/ dissection Plaque protrusion IVUS Angio Uren et al, EHJ 2002 53 ST – Retrospective examination of implant IVUS vs Angio The POST Registry IVUS and prediction of SAT

6. All ST Bifurcations (non-LMS) p=0.03 VLST only Angio IVUS ALL Lesions Roy et al. EHJ (2008) 29, 1851 IVUS - guided Not IVUS - guided p < 0.014 884 propensity-matched pairs 758 pts - propensity scored Kim et al. Am J Cardiol 2010;106:612 IVUS Guidance and risk of ST in DES ST free survival

7. All Cause Death Park et al. Circ Cardiovasc Intervent. 2009;2:167-177 145 propensity-matched pairs Bifurcations – Non LMSLMS PCI 758 pts - propensity scored SH Kim et al. Am J Cardiol 2010;106:612– 618 IVUS Guidance in DES

8. VLST – Correlates with ISA Late acquired ISA due to +ve arterial remodelling Vessel Area

9. Copyright ©2007 American Heart Association Finn, A. V. et al. Circulation 2007;115:2435-2441 A and B, Heterogeneity of neointimal healing after DES placement Strongest predictor of LST 30% uncovered struts (in any section) Late Stent Thrombosis

10. Stent coverage in vivo? Murata et al. JACC. Img. 2010;3;76-84 1 mm 4 - 5 endothelial cell thickness 100  m 10mm Tissue Penetration Resolution Intravascular Ultrasound (IVUS) 10  m 1-2 mm Optical Coherence Tomography (OCT)

11. In-vivo mechanisms of DES late and VLST

12. Acute Re-Intervention Stent under-expansion primary Incomplete stent apposition Acquired or Persistent Min Stent CSA = 2.5 mm 2 OCT – Thrombus & ISA IVUS can image through dense thrombus, OCT cannot IVUS – Thrombus & ISA

13. TVF & Normal/Equivocal Angiogram 7 Patient Series Lifted struts + thrombus Crush C. APPLEBY, D. SARAVANAN, J. SARMA, S. CHOWDHARY - Paris 2010 Adherent micro-thrombus Gross thrombus Laminated thrombus Lipid Ruptured cap

14. Lipidic Plaque in BMS Cavity Flap Thrombus Lipid Rich Plaque Presentation with NSTEMI 7 yrs after implant of BMS

15. OptimisationHealingST treatment Expansion. Vessel sizing. Plaque coverage. Limited resolution for neointimal detection. Images pathology (e.g. ISA & under- expansion) through thrombus. Limited penetration. Too much detail! High res neointimal detection. Surrogate safety EP? Cannot image past heavy thrombus. Improves diagnosis in equivocal cases. Conclusions The ST problem – How IVUS and OCT help