1. IVUS, FFR, OCT- Which Should I Use For PCI?
Ramesh Daggubati, MD FACC FSCAI
Director of Interventional Cardiology
East Carolina University

2. Nothing to disclose

3. Angiogram is gold standard for imaging
It provides 2 dimensional information similar to a roadmap

4. Angiography Has Major Limitation in Assessing in Complicated Lesions

5. IVUS IVUS provides 3 dimensional detail of what lies ahead
It provides additional information not visualized on the angio map

6. IVUS: Pre PCI indication
When IVUS?
Decide strategy & sizing
Why IVUS?
Vessel reference & % stenosis
Length of lesion
Plaque composition

7. IVUS: Post PCI Indication
When IVUS?
Evaluate stent result
Why IVUS?
Final lumen
Expansion
Apposition
Dissection or plaque shift

8. IVUS Guided LMCA Stenting
Assessment of lesion
Selection of PCI technique
Optimization of technique
Assessment of DES failure

9. Treat or Not Treat EEM=14.04 sq mm Lumen= 4.0 sq mm
Area stenosis=71.5%

10. Plaque Characterization
Lesion preparation: need of rotablation
Fibrous plaque
Plaque rupture
Thrombus
Calcification

11. How IVUS Helps?

12. Significant LMCA ostial disease
Mild LCX ostial disease
Normal- LAD, bifurcation, shaft

13. Post Stenting

14. No Malapposition, No Touch on Ostial LAD or LCX

15. Impact of IVUS on all Cause Mortality With LMCA DES

16. Procedural Optimization

17. Unstable Angina, Significant LMCA, LAD, Mild LCX Ostial Disease

18. SB Assessment

19. Final Result After Crush

20. Final IVUS After Crush Ostial LCX 6.2 mm2 Ostial LAD 7 mm2 Distal LMCA

21. Other Uses of IVUS
DES failure: In-stent restenosis & thrombosis (under expansion, incomplete apposition, strut fracture)
Vulnerable plaque

22. IVUS: Impacts Clinical Outcomes
IVUS improves clinical outcomes (Zhang et al, EuroIntervention 2012.
Reduces stent thrombosis & mortality
For LMCA stenosis, IVUS is an important adjunct pre and post intervention

23. FFR Threshold For IschemiaNo
ischemia
Yes
ischemia
FFR
1.00
0.75
0.00
Bovendien is er een drempewaarde van 0.75 die onderscheid maakt tussen wel of geen induceerbare ischaemie.
FFR <  inducible ischemia (spec. 100 % )
FFR >  no inducible ischemia (sens. 90 % )
Pijls, De Bruyne et al, NEJM 1996

24. Event – free Survival (%)
100 75
78.8
72.7
64.4 50
Defer
p=0.52
Perform
p=0.03
p=0.17 25
Reference
(FFR < 0.75) 1 2 3 4 5
Years of Follow-up
No. at risk
Defer group 90 85 82 74 73 72
Perform group 88 78 70 67 65
Reference gr
135
105
103 96

25. Cardiac Death And Acute MI After 5 Years
P< 0.03 % 20
P< 0.005
15.7 15
P=0.20 10
7.9 5
3.3
DEFER PERFORM REFERENCE
FFR > FFR < 0.75

26. FAME
FFR allowed elimination of a third of the lesions that might have been stented
Outcomes at 1yr for the FFR group showed a 28% lower incidence of MACE

27. FAME: 2Yr Surival Free of MACE (Death, MI, Repeat Revascularization)
FFR Guided
Angio Guided
Tonino et al NEJM 2008

28. Only 35% of lesions with 50-70% stenosis have FFR< .80
Tonino JACC 2010

29. Anatomic vs Functional Revascularization Only 14% Anatomical 3 VD are Functional 3 VD
Tonino JACC 2010

30. Only 27% Lesions With Angiographically Stenosis of > 75% Are Significant by FFR
Koo et al. Euro Heart J 2008

31. FFR Guided Provisional SB PCI

32. FFR Guided LMCA Crossover Stenting (FILM)
Real functional status of LCX could be widely different from that apparent by angiography : NAM CW

33. FILM Study

34. Ostial and Shaft LMCA PCI
FFR is crucial
FFR works
Akiko Maehara

35. FFR with Concomitant LAD and LCx Disease
FFR LM apparently rises with severe downstream lesion
A downstream FFR of 0.6 is associated with a 0.05 overestimation of FFR LM true.
Daneils, et al. J Am Coll Cardiol Intv 2012;5:1021–5

36. Single Stent Cross-Over
IVUS Guided Stent cross over based on LCX disease status , stent size selection, stent optimization.
FFR Guided decision making for further treatment about the side branch.

37. LMCA: 2 Stent Technique
IVUS guided stent optimization is needed irrespective of any 2 stent technique used

38. FFR vs IVUS: LMCA Stenosis
FFR has better correlation with IVUS in LM stenosis due to limited variability in length, diameter, and amount of supplied myocardium.

39. FFR vs IVUS MLA IVUS MLA < 6 sq mm is matched with FFR <0.75
Jasti V et al. Circulation 2004

41. Angiographic 30-60% diameter stenosis (Intermediate LMCA Stenosis)
MLA≥ 6.0 mm2
MLA<6.0 mm2
FFR or non-invasive
stress test
Defer
revascularization
J Am Coll Cardiol Interv 2011

42. Angiographic 40-70% diameter stenosis
( Intermediate non-LMCA Stenosis)
MLA≥ 4.0 mm2
MLA<4.0 mm2
FFR or non-invasive stress test
If unavailable consider revasc if:
Area stenosis≥60-70%
Plaque burden ≥80%
Lesionl ength ≥20 mm
Defer
revascularization
J Am Coll Cardiol Interv 2011

43. OCT Plaque Characterization
Normal arterial wall with
mild intimal thickening
Fibro fatty plaque
Calcified plaque

44. OCT Plaque Characterization: TCFA

45. Plaque Erosion

46. OCT Post PCI Immediately post: Malapposition, dissection, thrombus
Intermediate F/U: DES Strut surface coverage
Chronic F/U: BMS after 5 years
DES after 2 years
Neoatherosclerosis

47. OCT- Immediately Post PCI

48. Stent Strut Coverage. Apposition
A: well apposed and covered
B: well apposed, not covered
C: malapposed, not covered
D: malapposed, but covered D
Takano, Jang AJC 2007

49. Comparison of IVUS & OCT
Grey Scale IVUS VH
OCT
Axial Resolution (µm)
100
200 20
PCI ++
+/- +
TCFA
Necrotic Core
Thrombus -
Stent Coverage

50. Comparison of OCT and IVUS Findings Post Stenting35 29 30
Number of stents 25 18 18 20
OCT 15
IVUS 12
Comparison of OCT and IVUS finding post stenting, obtained in 39 patients including 42 stents. 10 8 7 3 5 2
Dissection
Tissue
Incomplete
Irregular
prolapse
apposition
struts
Bouma, Jang, Heart 2003

51. Will OCT Replace IVUS?
It has limitations (penetration, true vessel sizing, assessment of plaque burden, etc) and really does not add important information.
A good IVUS study provides all the information needed to optimize stenting . OCT only will have a niche role.
There is simply not enough data to say for sure.

52. Why OCT Would Succeed? The images are seductive.
OCT provides additional information in specific situations . . .
?Follow-up imaging – especially in clinical trials – may belong to OCT

53. Conclusion (1) I will choose the right tool for the right job
None of the tools is a single, all-in-one solution
IVUS, FFR & OCT have complementary role
All of them are important in specific situations.

54. Conclusion (2)
I would use FFR to know if PCI is indicated & beneficial (Shift from anatomical revascularization to physiological revascularization)
Targeted PCI/CABG rather than conventional would be of focus in based on FFR
IVUS is useful for optimization of stenting
IVUS could be used to apprise of significance of LMCA stenosis.

55. Conclusion (3)
OCT determines optimal stent deployment (sizing, apposition, and lack of edge dissection) with improved resolution
However, clinical implications need to be determined
?Follow-up imaging – especially in clinical trials – may belong to OCT

56. THANK YOU FOR ATTENTION