Clinical Use of Intracoronary Imaging

Räber L, Mintz GS, Koskinas KC, et al.
Clinical Use of Intracoronary Imaging. Part 1: Guidance and Optimization of Coronary Interventions. An Expert Consensus Document of the European Association of Percutaneous Cardiovascular Interventions. Eur Heart J 2018;May 22:[Epub ahead of print].

The following are key points to remember from this European Expert Consensus Document on Clinical Use of Intracoronary Imaging: Guidance and Optimization of Coronary Interventions:

  1. Intracoronary imaging by means of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) provides valuable incremental information that can be used clinically to optimize stent implantation and minimize stent-related problems.
  2. IVUS and OCT are equivalent (and superior to angiography) in guiding and optimizing most percutaneous coronary intervention (PCI) procedures. Both modalities can identify features of optimal stent implantation (expansion, apposition, and complications), as well as mechanisms of stent failure that cannot be captured using coronary angiography alone.
  3. OCT, in contrast to IVUS, can often assess calcium thickness. Total calcium arc >180° and increased calcium thickness >0.5 mm are associated with greater risk of stent underexpansion.
  4. Patients with left-main lesions should be considered for imaging-guided interventions by means of IVUS, or OCT in nonostial left main lesions, due to particular challenges in angiographic evaluation and procedural complexity, and because of the clinical sequelae of a suboptimal result in this context.
  5. There is stronger evidence on the advantages of intravascular imaging to guide stenting in complex lesion morphology and in patients presenting with acute coronary syndrome, with less benefit in simpler lesions or patients with more stable clinical presentation.
  6. Patients at high risk of developing contrast-induced acute kidney injury may benefit from IVUS-guided PCI due to the potential for lower volume of contrast.
  7. Analysis of stent restenosis and stent thrombosis by intracoronary imaging is essential to understand mechanisms of failure and is highly recommended.
  8. Intracoronary imaging should be mandatory in case of any investigational device failure to expedite the identification of potential safety concerns and is recommended for evaluation of any new drug-eluting stent or bioresorbable scaffolds.
  9. OCT findings from stent thrombosis registries propose the following correctable targets for PCI guidance: malapposition, residual disease burden at stent edge, dissections, and stent underexpansion.
  10. Refinements in imaging technology such as co-registration (angiography and intracoronary imaging [roadmap]), lower-profile and more deliverable catheters with faster pullbacks, higher resolution technology (IVUS), and fully automated software to support pre- and post-stent assessment are expected to further improve the ease of use and therefore penetration in daily clinical practice.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Absorbable Implants, Acute Coronary Syndrome, Acute Kidney Injury, Coronary Angiography, Diagnostic Imaging, Drug-Eluting Stents, Ischemia, Percutaneous Coronary Intervention, Stents, Secondary Prevention, Thrombosis, Tomography, Optical Coherence, Ultrasonography

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