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

Age-specific sex differences in intravascular ultrasound based coronary atherosclerotic plaque characteristics

Insights in age- and sex-specific coronary atherosclerotic plaque characteristics may contribute to a better understanding of coronary artery disease and, ultimately, to its prevention and treatment. In 307 women and 406 men aged 20 to 90 years undergoing intravascular ultrasound imaging, sex-based differences in coronary atherosclerotic plaque characteristics were mainly present in younger patients, while these differences were less pronounced at advanced age.

Adjunctive Utilization of Intravascular Ultrasound in Peripheral Arterial Disease Treatment

BACKGROUND

The utility and benefit of intravascular ultrasound (IVUS) has been well established in coronary interventions, however widespread adoption for peripheral interventions has lagged. The objectives of this review article were to discuss the technical components of IVUS, describe key learning pearls for IVUS utilization, and review the literature describing the clinical outcomes of endovascular peripheral arterial interventions using IVUS.

METHODS

A scoping review of the current literature utilizing Pubmed. Terms used to search the literature included "intravascular ultrasound (IVUS)" in conjunction with "peripheral arterial disease (PAD)," "endovascular interventions," "chronic limb threatening ischemia," "balloon angioplasty" "stenting," "percutaneous coronary intervention," and "outcomes." All types of articles were reviewed including review articles, retrospective reviews, meta-analyses, and prospective observational and randomized studies.

RESULTS

Published literature regarding IVUS use in peripheral arterial interventions is heterogeneous and limited to mainly retrospective studies, registry analyses and metanalyses. Outcomes are generally favorable with the adjunct of IVUS compared to traditional angiography-driven peripheral interventions. The addition of IVUS improves stent expansion, stent patency, and reduces reintervention rates, particularly in infrainguinal arterial lesions. Long-term costs may also be lower with IVUS-guided procedures.

CONCLUSIONS

Expert consensus largely supports the implementation of IVUS in endovascular interventions for peripheral arterial disease. However, more robust high-quality data evaluating the efficacy, durability, and cost of IVUS in peripheral arterial disease are still needed.

Shining light on neurovascular disease

Tortuosity and fragility of the intracranial vasculature have precluded the application of novel intravascular imaging modalities during the treatment of cerebrovascular pathologies. In other circulatory beds, these technologies have transformed clinical and therapeutic decision-making. A new report demonstrates the clinical use of high-resolution intravascular imaging in the human cerebrovasculature using neuro optical coherence tomography. This technology provides an unprecedented opportunity to examine the luminal dimensions of cerebrovascular disease. We expect that the neurointerventional community will rapidly adopt this technology-similar to wider adoptions by other vascular specialties-for both a better understanding of underlying disease and clarity of endovascular therapeutic safety and effectiveness.

Clinical outcomes of percutaneous coronary intervention for severely calcified lesions: comparison between the morphologies of severely calcified coronary lesions

Existing studies evaluating the comparison of clinical outcome of percutaneous coronary intervention (PCI) for severe calcified coronary lesions are limited, and the clinical outcomes of PCI for different morphologies of calcified lesions are controversial. Overall, consecutive 576 lesions with severe calcification that were treated with PCI from 2010 to 2021 at Nagoya Heart Center were investigated. All lesions were assessed using invasive coronary angiogram (CAG) or computed tomography-CAG at 12 months after DES implantation. We divided the patients into three groups based on the results of intravascular ultrasound (IVUS) imaging (concentric calcified lesion [CC] n = 273, eccentric calcified lesion [EC] n = 217, calcified nodule [CN] n = 86). The clinical and angiographic outcomes of each group were investigated retrospectively to compare the prognosis between the three groups and identify predictive factors for the device-oriented composite end points (DoCE). There were no differences in patient characteristics among the three groups, except that there were significantly more patients on dialysis in the CN group. The incidence of DoCE was significantly higher in the CN group than in the other groups (CC; 18.3% vs. EC; 23.5% vs. CN; 36.0%; Log-Rank test; p = 0.001). Cox regression analysis showed that the independent predictors of DoCE were CN, insulin use, hemodialysis, right coronary artery lesions, and calcium cracks. The incidence of DoCE was significantly higher in the CN group. Calcium cracks are crucial for improving outcomes in severely calcified lesions, being key predictors of DoCE.

EQUATOR Network Mapping Review for Dysphagia Research

PURPOSE

The EQUATOR Network is an international initiative aimed at improving published health research through use of reporting guidelines. We conducted a review to determine the extent to which EQUATOR Network guidelines contain recommendations relevant for dysphagia research in human subjects.

METHOD

We downloaded all 542 EQUATOR Network guidelines on November 8, 2022. Each guideline was reviewed by two independent raters and judged for relevance to dysphagia and related fields (e.g., otolaryngology, gastroenterology). Dysphagia-relevant guidelines pertaining to quantitative human subjects research were further inspected to identify reporting guidance regarding (a) general research elements (e.g., data collection, statistical methods), (b) participant characteristics (e.g., demographics, accrual, randomization), (c) screening and clinical/noninstrumental assessments, (d) videofluoroscopic examinations, (e) flexible endoscopic examinations, (f) other instrumentation in swallowing research, (g) dysphagia treatment, (h) patient-/care provider-reported outcome measures, and (i) any other narrowly specified focus relevant for research on swallowing. Discrepancies were resolved by consensus.

RESULTS

Of 542 guidelines, 156 addressed quantitative research in human subjects relevant to dysphagia. Of these, 104 addressed general research elements and 108 addressed participant characteristics. Only 14 guidelines partially addressed the other topics of interest, and none addressed elements relevant to reporting videofluoroscopic or endoscopic assessments of swallowing.

CONCLUSIONS

We were unable to find guidelines with specific relevance to reporting key methods in dysphagia research. This lack of guidance illustrates a gap that hinders the critical appraisal of research quality in the field of dysphagia. Our review highlights the need to develop dysphagia-specific tools for critical appraisal and guidance regarding adequate research reporting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25014017.

Clinical impact of deep learning-derived intravascular ultrasound characteristics in patients with deferred coronary artery

Prognostic markers for long-term outcomes are lacking in patients with deferred (nonculprit) coronary artery lesions. This study aimed to identify the morphological criteria for predicting adverse outcomes and validate their clinical impact. Using deep learning models, we extracted geometrical parameters and maximal attenuation (or calcium) burden index (ABI-max or CBI-max) from the intravascular ultrasound (IVUS) images of nonculprit vessels in 1115 patients. The endpoints included cardiac death, myocardial infarction, and target vessel revascularization of nonculprit vessel. Cardiac death occurred in 27 (2.4 %) patients at 3 years and 39 (3.5 %) patients at 5 years. At 5 years, the cardiac death-free survival rate was significantly lower with ABP-max ≥11.37 % vs. < 11.37 % (90.0 % vs. 98.7 %), CBI-max ≥13.40 % vs. < 13.40 % (92.8 % vs. 98.4 %), and percent atheroma volume ≥ 51.35 % vs. < 51.35 % (94.0 % vs. 97.7) (all log-rank p < 0.001). The independent predictors of 5-year cardiovascular mortality were age (hazard ratio [HR] 1.21), female sex (HR 0.33), history of heart failure (HR 6.06), chronic kidney disease (HR 18.28), ABI-max (HR 1.04), and CBI-max (HR 1.05). The independent determinants of 5-year target vessel revascularization of nonculprit vessel were fractional flow reserve (HR 0.95 per 0.01 increase), minimal lumen area (HR 0.63), and plaque burden (HR 1.15). In patients with nonculprit coronary artery lesions, a large burden of attenuated or calcified plaques predicted cardiac mortality, while IVUS geometry was associated with repeat revascularization. Thus, deep learning-based IVUS analysis of the whole target vessel may help clinicians identify high-risk lesions.

Comparison of intravascular ultrasound-guided with optical coherence tomography-guided percutaneous coronary intervention for left main distal bifurcation lesions: Rationale and design of the ISOLEDS trial

BACKGROUND

Percutaneous coronary intervention (PCI) can provide benefits for anatomically suitable left main coronary artery (LMCA) lesions. When compared to traditional coronary angiography (CAG) -guided PCI, the use of intravascular ultrasound (IVUS) guidance has shown significant long-term prognostic improvements in LMCA PCI. Optical coherence tomography (OCT) offers a higher axial resolution than IVUS. However, there is currently a lack of relevant randomized controlled trials investigating the use of OCT specifically for left main distal bifurcation lesions.

METHODS

The ISOLEDS trial is an ongoing multicenter study that aims to compare IVUS-guided PCI with OCT-guided PCI for patients with true LMCA distal bifurcation lesions. This prospective, randomized, controlled, non-inferiority trial will enroll a total of 664 patients with visually-defined Medina 1,1,1 or 0,1,1 classification of left main distal bifurcation lesions. The patients will be randomly assigned in a 1:1 ratio to either IVUS-guided or OCT-guided PCI. The primary endpoint is to assess the occurrence of target lesion failure (TLF) within 12 months after the procedure. After undergoing PCI, patients are required to visit the hospital for a 12-month clinical follow-up. During this clinical assessment, CAG can be performed to evaluate the status of target lesions.

DISCUSSION

The ISOLEDS trial represents the first attempt to compare two distinct intracoronary imaging techniques for guiding PCI in patients with true LMCA distal bifurcation lesions. By evaluating and comparing the outcomes of these two imaging techniques, the trial results will aid operators in selection of the most effective approach for guiding PCI in these patients.

NIRS-IVUS Assessment of OCT-Derived Healed Coronary Plaques

AIMS

Healed plaque (HP) is associated with rapid plaque growth and luminal narrowing. Thin-cap fibroatheroma (TCFA) is recognized as a precursor lesion to plaque rupture. The aim of the present study was to compare the lipid size among optical coherence tomography (OCT)-derived HP, TCFA, and thick-cap fibroatheroma (ThCFA) using near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS).

METHODS

The present study included 173 patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention. Non-culprit lesions with angiographically intermediate stenosis were assessed by both OCT and NIRS-IVUS.

RESULTS

The frequency of TCFA, HP, and ThCFA was 35 (20%), 53 (30%), and 85 (49%), respectively. Minimum lumen area was not significantly different between TCFA and HP, but was smaller in TCFA and HP than in ThCFA (4.6 [interquartile range {IQR}: 3.5-6.4] mm2 vs. 4.3 [3.4-5.3] mm2 vs. 6.5 [4.8-8.6] mm2, P＜0.001). Plaque burden was not significantly different between TCFA and HP, but was larger in TCFA and HP than in ThCFA (72 [IQR: 66-80] % vs. 75 [67-80] % vs. 62 [54-69] %, P＜0.001). Maximum lipid core burden index in 4mm (maxLCBI4mm) was largest in TCFA, followed by HP and ThCFA (493 [IQR: 443-606] vs. 446 [347-520] vs. 231 [161-302], P＜0.001). The frequency of lipid rich plaque with maxLCBI4mm ＞400 was highest in TCFA, followed by HP and ThCFA (89% vs. 60% vs. 7%, P＜0.001).

CONCLUSIONS

Based on NIRS-IVUS findings, non-culprit coronary HP in AMI was associated with vulnerable plaque characteristics, but not as much as TCFA.

Intravascular Ultrasound Use is Associated with Improved Patency in Lower Extremity Peripheral Arterial Interventions

BACKGROUND

Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVIs) for peripheral arterial disease. This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI).

METHODS

The VQI-PVI modules were reviewed (2016-2020). All patients with available 1-year follow-up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Intersociety Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches.

RESULTS

There were 56,633 procedures (non-IVUS PVI = 55,302 vs. IVUS-PVI = 1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. Lower extremity revascularization for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15 cm in length (46.6% vs. 43.3%) and for aortoiliac disease (31.8% vs. 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs. 16.8%), while balloon angioplasty was less common (13.5% vs. 24.4%). One-year patency was better with IVUS-PVI (97.7% vs. 95.2%, P = 0.004). On subgroup analysis, IVUS (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.29-3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15 cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95% CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95% CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95% CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year.

CONCLUSIONS

IVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15 cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.

Comparison of angiography-guided vs. intra-vascular imaging-guiding percutaneous coronary intervention of acute myocardial infarction: a real world clinical practice

Background

The role of routine intravascular imaging in percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) remains unclear. This study evaluated the clinical outcomes of PCI guided by different imaging modalities in AMI patients.

Materials and methods

Data from AMI patients who had undergone PCI between 2012 and 2022 were analyzed. The mean follow-up was 12.9 ± 1.73 months. The imaging modality-either intravascular ultrasound (IVUS), optical coherence tomography (OCT), or angiography alone-was selected at the operator's discretion. The primary endpoint was major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), target vessel revascularization.

Results

Of the 1,304 PCIs performed, 47.5% (n = 620) were guided by angiography alone, 37.0% (n = 483) by IVUS, and 15.4% (n = 201) by OCT. PCI guided by intravascular imaging modalities was associated with lower 1-year rates of MI (1.3%, P = 0.001) and MACE (5.2%, P = 0.036). OCT-guided PCI was linked to lower rates of 1-year CV death (IVUS vs. OCT: 6.2% vs. 1.5%, P = 0.016) and MACE (IVUS vs. OCT: 6.4% vs. 2.5%, P = 0.032). Intravascular imaging modalities and diabetes were identified as predictors of better and worse 1-year MACE outcomes, respectively.

Conclusion

PCI guided by intravascular imaging modalities resulted in improved 1-year clinical outcomes compared to angiography-guided PCI alone in AMI patients. OCT-guided PCI was associated with lower 1-year MACE rates compared to IVUS-guided PCI. Therefore, intravascular imaging should be recommended for PCI in AMI, with OCT being particularly considered when appropriate.

Deep learning model for intravascular ultrasound image segmentation with temporal consistency

This study was conducted to develop and validate a deep learning model for delineating intravascular ultrasound (IVUS) images of coronary arteries.Using a total of 1240 40-MHz IVUS pullbacks with 191,407 frames, the model for lumen and external elastic membrane (EEM) segmentation was developed. Both frame- and vessel-level performances and clinical impact of the model on 3-year cardiovascular events were evaluated in the independent data sets. In the test set, the Dice similarity coefficients (DSC) were 0.966 ± 0.025 and 0.982 ± 0.017 for the lumen and EEM, respectively. Even at sites of extensive attenuation, the frame-level performance was excellent (DSCs > 0.96 for the lumen and EEM). The model (vs. the expert) showed a better temporal consistency for contouring the EEM. The agreement between the model- vs. the expert-derived cross-sectional and volumetric measurements was excellent in the independent retrospective cohort (all, intra-class coefficients > 0.94). The model-derived percent atheroma volume > 52.5% (area under curve 0.70, sensitivity 71% and specificity 67%) and plaque burden at the minimal lumen area site (area under curve 0.72, sensitivity 72% and specificity 66%) best predicted 3-year cardiac death and nonculprit-related target vessel revascularization, respectively. In the stented segment, the DSCs > 0.96 for contouring lumen and EEM were achieved. Applied to the 60-MHz IVUS images, the DSCs were > 0.97. In the external cohort with 45-MHz IVUS, the DSCs were > 0.96. The deep learning model accurately delineated vascular geometry, which may be cost-saving and support clinical decision-making.

Predictor of left main coronary artery size: an intravascular ultrasound study in Southeast Asia population

Left main (LM) percutaneous coronary intervention (PCI) has expanded rapidly in the past decade, with up to fourfold increase annually. Recent trials found that intravascular imaging (IVI)-guided LM PCI resulted in lower risks of cardiac death and stent failure due to suboptimal PCI compared to angiography-guided PCI. IVI usage has increased in recent years; however, its utilization remains variable across regions and is still incredibly low in developing countries. Furthermore, to date, there is no data about LM size in the Southeast Asian population. This study aims to determine the mean external elastic membrane (EEM) diameter, cross-sectional area (CSA) of LM, and its predictor. This is a cross-sectional observational study on 100 patients with coronary artery disease (CAD) who underwent IVUS-guided PCI with a pullback to LM in Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from January 2020 until December 2022. Linear regression was used to determine the predictors of LM size. There were 100 segments of LM. LM's mean EEM diameter and CSA were 5.02 ± 0.43 mm and 19.93 ± 3.48 mm2. Body surface area (BSA) is an independent predictor of EEM diameter and CSA with a positive linear relationship (p 0.001 and p 0.0001). Hypertension is an independent predictor of EEM diameter with a positive linear relationship (p 0.034). The linear equation to predict EEM diameter and CSA were (2.741 + 1.272BSA(m2) + 0.165 hypertension (yes)) and (2.745 + 9.601BSA(m2)), respectively. The LM coronary artery size of the Southeast Asian population was comparable with the previous studies. BSA and hypertension are independent predictors of EEM diameter, with BSA being stronger than hypertension. Neither sex nor other cardiovascular risk factors affect the LM size. The knowledge of coronary artery size will help the clinician have a reference for intervention, especially when no intravascular imaging is available.

The uric acid/HDL-C ratio may predict significant coronary stenosis in moderate left main coronary artery lesions: an intravascular ultrasonography study

BACKGROUND

There may be severe difficulties in determining the severity of LMCA (left main coronary artery) lesions. The use of intravascular ultrasound (IVUS) facilitates decisions about lesion severity in these patients. The aim of this study was to investigate the relationship between the UHR (uric acid to HDL-C ratio) and lesion severity in patients who underwent LMCA IVUS.

METHODS

This study included 205 patients with ICS (intermediate coronary stenosis) in the LMCA who underwent IVUS. In the IVUS measurements of these patients, the plaque burden (PB) and the minimal lumen area (MLA) showing lesion severity were measured.

RESULTS

The patients were separated into two groups according to plaque burden (< 65% and ≥ 65%). The UHR was significantly greater in the high plaque burden group (479.5 vs. 428.6, P = 0.001). When the patients were separated into two groups according to the MLA (< 6mm2 and ≥ 6mm2), the UHR was determined to be significantly greater in the group with low MLA (476.8 vs. 414.9, P < 0.001). In the ROC analysis performed according to the MLA and plaque burden values, the UHR cutoff value of 450 was found to have similar sensitivity and the same specificity for both parameters.

CONCLUSIONS

The results of this study suggested that there is a relationship between UHR and MLA < 6mm2 and plaque burden ≥ 65%, which are independently evaluated as critical in IVUS, and this could predict anatomically significant lesions in patients with a moderate degree of LMCA stricture.

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence (AI)-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The 2 identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The AI model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to 1 of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our AI model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the AI-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

Innovations in Intracoronary Imaging: Present Clinical Practices and Future Outlooks

Engaging intracoronary imaging (IC) techniques such as intravascular ultrasound or optical coherence tomography enables the precise description of vessel architecture. These imaging modalities have well-established roles in providing guidance and optimizing percutaneous coronary intervention (PCI) outcomes. Furthermore, IC is increasingly recognized for its diagnostic capabilities, as it has the unique capacity to reveal vessel wall characteristics that may not be apparent through angiography alone. This manuscript thoroughly reviews the contemporary landscape of IC in clinical practice. Focused on current methodologies, the review explores the utility and advancements in IC techniques. Emphasizing their role in clarifying coronary pathophysiology, guiding PCI, and optimizing patient outcomes, the manuscript critically evaluates the strengths and limitations of each modality. Additionally, the integration of IC into routine clinical workflows and its impact on decision-making processes are discussed. By synthesizing the latest evidence, this review provides valuable insights for clinicians, researchers, and healthcare professionals involved in the dynamic field of interventional cardiology.

Scale Mutualized Perception for Vessel Border Detection in Intravascular Ultrasound Images

Vessel border detection in IVUS images is essential for coronary disease diagnosis. It helps to obtain the clinical indices on the inner vessel morphology to indicate the stenosis. However, the existing methods suffer the challenge of scale-dependent interference. Early methods usually rely on the hand-crafted features, thus not robust to this interference. The existing deep learning methods are also ineffective to solve this challenge, because these methods aggregate multi-scale features in the top-down way. This aggregation may bring in interference from the non-adjacent scale. Besides, they only combine the features in all scales, and thus may weaken their complementary information. We propose the scale mutualized perception to solve this challenge by considering the adjacent scales mutually to preserve their complementary information. First, the adjacent small scales contain certain semantics to locate different vessel tissues. Then, they can also perceive the global context to assist the representation of the local context in the adjacent large scale, and vice versa. It helps to distinguish the objects with similar local features. Second, the adjacent large scales provide detailed information to refine the vessel boundaries. The experiments show the effectiveness of our method in 153 IVUS sequences, and its superiority to ten state-of-the-art methods.

Randomized Trial of Cholesterol Lowering With Evolocumab for Cardiac Allograft Vasculopathy in Heart Transplant Recipients

BACKGROUND

Cardiac allograft vasculopathy is characterized by increased coronary intimal thickness and is a leading cause of death in heart transplant (HTx) recipients despite the routine use of statins. The experience with inhibitors of proprotein convertase subtilisin-kexin type 9 in HTx recipients is limited. Our hypothesis was that lowering cholesterol with the proprotein convertase subtilisin-kexin type 9inhibitor evolocumab would reduce coronary intimal thickness in these patients without compromising safety.

OBJECTIVES

This double blind, randomized trial was conducted to test whether evolocumab reduces the burden of cardiac allograft vasculopathy.

METHODS

Patients who had received a cardiac allograft at one of the Nordic transplant centers within the prior 4 to 8 weeks were randomized to monthly subcutaneous injections of evolocumab 420 mg or matching placebo. The primary endpoint was the baseline-adjusted maximal intimal thickness as measured by intracoronary ultrasound after 12 months' treatment.

RESULTS

The trial enrolled 128 patients between June 2019 and May 2022. Matched pairs of coronary ultrasound images were available for 56 patients assigned to evolocumab and 54 patients assigned to placebo. At 12 months, the adjusted mean difference in the maximal intimal thickness between the 2 arms was 0.017 mm (95% CI: -0.006 to 0.040; P = 0.14). The mean reduction in low-density lipoprotein cholesterol with evolocumab compared with placebo was 1.11 mmol/L (95% CI: 0.86-1.37 mmol/L). The use of evolocumab was not associated with an increase in adverse events.

CONCLUSIONS

Twelve months of treatment with evolocumab substantially reduced low-density lipoprotein cholesterol but did not reduce maximal coronary intimal thickness in HTx recipients. (Cholesterol Lowering With EVOLocumab to Prevent Cardiac Allograft Vasculopathy in De-novo Heart Transplant Recipients [EVOLVD]; NCT03734211).

Procedural characteristics and cardiovascular outcomes in patients undergoing drug-coated balloon angioplasty for de novo lesions in large coronary arteries: an observational study

Limited data exist regarding drug-coated balloon (DCB) treatment in de novo large coronary arteries. We sought to demonstrate procedural characteristics, residual stenosis, and clinical outcomes following DCB angioplasty for de novo lesions in large versus small coronary arteries. The study included 184 consecutive patients with 223 de novo coronary lesions undergoing paclitaxel DCB angioplasty between January 2019 and August 2020, who were divided according to whether the DCB diameter was ≥ 3.0 mm (large group, n = 58) or < 3.0 mm (small group, n = 125). The large group had a higher proportion of acute coronary syndrome more commonly with ostial, bifurcation, and calcified lesions in large vessels and received lesion preparation with more frequent use of scoring or cutting balloons and atherectomy devices compared to the small group. Postprocedural angiographic diameter stenosis was smaller in the large group compared to the small group (31% [22-37] vs. 35% [26-42], p = 0.032), and intravascular ultrasound revealed no significant difference in postprocedural area stenosis between the groups (66.2 ± 7.7% vs. 67.9 ± 7.8%; p = 0.26). The median follow-up duration was 995 days. The incidence of a composite of all-cause death, myocardial infarction, stroke, or target lesion revascularization was similar between the groups (log-rank p = 0.41) and was influenced by the presence of acute coronary syndrome and anemia but not by DCB diameter. The rate of cardiovascular outcomes after DCB treatment was comparable in de novo large and small coronary arteries. Notably, well-planned lesion preparation with intravascular imaging guidance was prevalent in large vessels.

Effect of ezetimibe-statin combination therapy vs. statin monotherapy on coronary atheroma phenotype and lumen stenosis in patients with coronary artery disease: a meta-analysis and trial sequential analysis

Background

Evidence indicates that the addition of ezetimibe to statin therapy reduces cardiovascular events. However, the impact of ezetimibe-statin combination therapy on coronary plaque regression, plaque stabilization, and diameter stenosis remains a matter of controversy.

Methods

We performed electronic searches in PubMed, Web of Knowledge, and the Cochrane Central Register of Controlled Trials to identify eligible trials assessing the effects of ezetimibe-statin combination therapy versus statin monotherapy reporting at least one outcome among total atheroma volume (TAV), minimum fibrous cap thickness (FCT), lumen volume (LV), and lumen area (LA) derived from intravascular imaging modalities of intravascular ultrasound (IVUS) and optical coherence tomography (OCT). We used the random-effects model and performed trial sequential analysis (TSA) during this meta-analysis.

Results

Eleven articles with a total of 926 individuals (460 in the dual-lipid-lowering therapy group and 466 in the statin monotherapy group) were included in the final meta-analysis. Compared to statin monotherapy, ezetimibe-statin combination therapy was associated with significantly decreased TAV [WMD = -3.17, 95% CI (-5.42 to -0.92), and p = 0.006], with no effect on the LV of the coronary artery [WMD = -0.52, 95% CI (-2.24 to 1.21), and p = 0.56], the LA of the coronary artery [WMD = 0.16, 95% CI (-0.10-0.42), and p = 0.22], or minimum FCT thickness [WMD = 19.11, 95%CI (-12.76-50.97)].

Conclusion

In patients with coronary artery disease, ezetimibe-statin combination therapy resulted in a significant regression in TAV compared to statin monotherapy, whereas no overall improvements of minimum FCT or lumenal stenosis were observed.

A Comparison of Three-Layer and Single-Layer Small Vascular Grafts Manufactured via the Roto-Evaporation Method

This study used the roto-evaporation technique to engineer a 6 mm three-layer polyurethane vascular graft (TVG) that mimics the architecture of human coronary artery native vessels. Two segmented polyurethanes were synthesized using lysine (SPUUK) and ascorbic acid (SPUAA), and the resulting materials were used to create the intima and adventitia layers, respectively. In contrast, the media layer of the TVG was composed of a commercially available polyurethane, Pearlbond 703 EXP. For comparison purposes, single-layer vascular grafts (SVGs) from individual polyurethanes and a polyurethane blend (MVG) were made and tested similarly and evaluated according to the ISO 7198 standard. The TVG exhibited the highest circumferential tensile strength and longitudinal forces compared to single-layer vascular grafts of lower thicknesses made from the same polyurethanes. The TVG also showed higher suture and burst strength values than native vessels. The TVG withstood up to 2087 ± 139 mmHg and exhibited a compliance of 0.15 ± 0.1%/100 mmHg, while SPUUK SVGs showed a compliance of 5.21 ± 1.29%/100 mmHg, akin to coronary arteries but superior to the saphenous vein. An indirect cytocompatibility test using the MDA-MB-231 cell line showed 90 to 100% viability for all polyurethanes, surpassing the minimum 70% threshold needed for biomaterials deemed cytocompatibility. Despite the non-cytotoxic nature of the polyurethane extracts when grown directly on the surface, they displayed poor fibroblast adhesion, except for SPUUK. All vascular grafts showed hemolysis values under the permissible limit of 5% and longer coagulation times.

Serial longitudinal changes of coronary calcified plaques with clear outer borders under intensive lipid management: insights from optical coherence tomography

Percutaneous coronary intervention (PCI) for calcified lesions is one of the most challenging procedures related to worse clinical outcomes. To stabilize vulnerable plaques, intensive lipid management is recommended; however, the serial changes of calcified plaques under intensive lipid management are unknown. A total of 31 patients (mean age, 63 ± 10 years; men, 29 patients) who underwent PCI with intensive lipid management were retrospectively studied. We evaluated the serial longitudinal changes of calcified plaques with clear outer borders using optical coherence tomography (OCT) at two time points: at the time of PCI (baseline) and the chronic phase. The median interval from PCI to chronic phase was 287 (233-429) days. Twenty-eight patients (90.3%) had increased calcium volume at the chronic phase compared with those at baseline (2.6 [1.3-5.1] vs. 1.8 [0.7-4.3] mm2, p < 0.05), and the median increase rate of calcium volume was 27.4% at the chronic phase. According to the median increase rate of calcium volume (27.4%), patients were divided into the following two groups: rapid progression (≥ 27.4%, RP group) and non-rapid progression (< 27.4%, non-RP group). The RP group had more patients with diabetes, and diabetes was independently associated with rapid progression by multivariate analysis. Furthermore, patients with diabetes had significantly higher changes in calcium index and volume from the baseline to the chronic phase than those without diabetes. Coronary calcification progression during relatively short intervals was observed using OCT even under intensive lipid management. Diabetes was an independent predictor for rapid coronary calcification progression.

Optimal lesion preparation before implantation of a Magmaris bioresorbable scaffold in patients with coronary artery stenosis: Rationale, design and methodology of the OPTIMIS study

Introduction

Percutaneous coronary intervention with implantation of a bioresorbable scaffold (BRS) provide the vessel support for a limited period allowing the vessel to restore normal vasomotion after degradation of the BRS, opposed to treatment with drug-eluting stents where the metal persist in the vessel wall. Late lumen loss and reduction in lumen area after implantation have been reported. The purpose of this study was to investigate whether intense pre-dilatation before BRS implantation resulted in less reduction of minimal lumen area at 6- and 12-month follow-up after implantation of a Magmaris BRS (MgBRS). Coronary imaging with optical coherence tomography (OCT) and intravascular ultrasound (IVUS) was assessed to track changes in lumen and vessel dimensions.

Methods

The prospective Optimal lesion PreparaTion before Implantation of the Magmaris bioresorbable scaffold In patients with coronary artery Stenosis (OPTIMIS) study randomly assigned eighty-two patients with chronic coronary syndrome to two pre-dilatation treatment strategies. Patients were randomized in a 1:1 ratio to pre-dilatation with either a non-compliant scoring balloon or a standard non-compliant balloon prior to implantation of a MgBRS. The treated segment was evaluated with OCT and IVUS at baseline, after 6 and 12 months to assess changes in lumen and vessel dimensions. The hypothesis was that more intense pre-dilatation with a non-compliant scoring balloon before MgBRS implantation can reduce the risk of late lumen reduction compared to standard pre-dilatation. The power calculation used expected MLA after 6 months (6.22 mm2 for the scoring balloon and 5.01 mm2 for the standard non-compliant balloon), power of 80 %, significance level of 0.05 and expected drop-out rate of 15 %, requiring 82 patients to be enrolled.

Results

Eighty-two patients were included in the study. Enrollment was from December 2020 to September 2023.

Conclusion

The hypothesis was that more intense pre-dilatation with a non-compliant scoring balloon before MgBRS implantation can reduce the risk of late lumen reduction compared to standard pre-dilatation.

Serum secreted phosphoprotein 1 level is associated with plaque vulnerability in patients with coronary artery disease

Background

Vulnerable plaque was associated with recurrent cardiovascular events. This study was designed to explore predictive biomarkers of vulnerable plaque in patients with coronary artery disease.

Methods

To reveal the phenotype-associated cell type in the development of vulnerable plaque and to identify hub gene for pathological process, we combined single-cell RNA and bulk RNA sequencing datasets of human atherosclerotic plaques using Single-Cell Identification of Subpopulations with Bulk Sample Phenotype Correlation (Scissor) and Weighted gene co-expression network analysis (WGCNA). We also validated our results in an independent cohort of patients by using intravascular ultrasound during coronary angiography.

Results

Macrophages were found to be strongly correlated with plaque vulnerability while vascular smooth muscle cell (VSMC), fibrochondrocyte (FC) and intermediate cell state (ICS) clusters were negatively associated with unstable plaque. Weighted gene co-expression network analysis showed that Secreted Phosphoprotein 1 (SPP1) in the turquoise module was highly correlated with both the gene module and the clinical traits. In a total of 593 patients, serum levels of SPP1 were significantly higher in patients with vulnerable plaques than those with stable plaque (113.21 [73.65 - 147.70] ng/ml versus 71.08 [20.64 - 135.68] ng/ml; P < 0.001). Adjusted multivariate regression analysis revealed that serum SPP1 was an independent determinant of the presence of vulnerable plaque. Receiver operating characteristic curve analysis indicated that the area under the curve was 0.737 (95% CI 0.697 - 0.773; P < 0.001) for adding serum SPP1 in predicting of vulnerable plaques.

Conclusion

Elevated serum SPP1 levels confer an increased risk for plaque vulnerability in patients with coronary artery disease.

Emerging applications of single-cell profiling in precision medicine of atherosclerosis

Atherosclerosis is a chronic, progressive, inflammatory disease that occurs in the arterial wall. Despite recent advancements in treatment aimed at improving efficacy and prolonging survival, atherosclerosis remains largely incurable. In this review, we discuss emerging single-cell sequencing techniques and their novel insights into atherosclerosis. We provide examples of single-cell profiling studies that reveal phenotypic characteristics of atherosclerosis plaques, blood, liver, and the intestinal tract. Additionally, we highlight the potential clinical applications of single-cell analysis and propose that combining this approach with other techniques can facilitate early diagnosis and treatment, leading to more accurate medical interventions.

CVIT 2023 clinical expert consensus document on intravascular ultrasound

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this updated expert consensus document summarizes the methods of measurements and assessment of IVUS images and the clinical evidence of IVUS use in percutaneous coronary intervention.

Comparative Clinical Implications of Calcified versus Non-Calcified Tissue Protrusion After Coronary Stent Implantation

Purpose

The prognostic implications of calcified versus non-calcified tissue protrusions (TPs) following stent implantation remain undetermined. This study aimed to evaluate the differential clinical outcomes associated with calcified and non-calcified TP morphologies.

Patients and Methods

Employing intravascular ultrasound (IVUS), we identified calcified TPs as calcium fragment extrusions permeating the stent struts, while non-calcified TPs were characterized as plaque and/or thrombus extensions through the stent into the arterial lumen. The primary endpoint encompassed target lesion failure (TLF), comprising cardiac death, target vessel myocardial infarction, clinically driven target lesion revascularization (TLR), or stent thrombosis, assessed in patients with a follow-up period exceeding one year.

Results

Of 1033 patients subjected to pre- and post-intervention IVUS, 62 exhibited calcified TPs (6.0%), and 279 presented non-calcified TPs (27.0%), forming the basis of this analysis. Multivariable linear regression indicated calcified nodules as a significant predictor of calcified TP [Odds Ratio (OR) 2.47; 95% Confidence Interval (CI) 2.33 to 2.62; P <0.001], with ST-segment elevation myocardial infarction emerging as an inverse correlate [OR 0.82; 95% CI 0.73 to 0.93; P = 0.004]. Two-year data revealed a higher incidence of TLF in patients with calcified TPs versus their non-calcified counterparts (11.3% vs 2.2%, P <0.001), and a marked increase in clinically driven TLR (9.7% vs 1.4%, P <0.001). Calcified TPs were independently correlated with increased TLF risk in the adjusted model [Hazard Ratio (HR) 2.47; 95% CI 1.17 to 5.16; P = 0.027].

Conclusion

After drug-eluting stent implantation, IVUS-identified calcified TPs correlate with adverse clinical outcomes compared to non-calcified TP formations.

Rationale and design of the INVICTUS Registry: (Multicenter Registry of Invasive and Non-Invasive imaging modalities to compare Coronary Computed Tomography Angiography, Intravascular Ultrasound and Optical Coherence Tomography for the determination of Severity, Volume and Type of coronary atherosclerosiS)

BACKGROUND

Coronary CT angiography (CCTA) is a first-line noninvasive imaging modality for evaluating coronary artery disease (CAD). Recent advances in CCTA technology enabled semi-automated detection of coronary arteries and atherosclerosis. However, there have been to date no large-scale validation studies of automated assessment of coronary atherosclerosis phenotype and coronary artery dimensions by artificial intelligence (AI) compared to current standard invasive imaging.

METHODS

INVICTUS registry is a multicenter, retrospective, and prospective study designed to evaluate the dimensions of coronary arteries, as well as the characteristic, volume, and phenotype of coronary atherosclerosis by CCTA, compared with the invasive imaging modalities including intravascular ultrasound (IVUS), near-infrared spectroscopy (NIRS)-IVUS and optical coherence tomography (OCT). All patients clinically underwent both CCTA and invasive imaging modalities within three months.

RESULTS

Patients data are sent to the core-laboratories to analyze for stenosis severity, plaque characteristics and volume. The variables for CCTA are measured using an AI-based automated software and assessed independently with the variables measured at the imaging core laboratories for IVUS, NIRS-IVUS, and OCT in a blind fashion.

CONCLUSION

The INVICTUS registry will provide new insights into the diagnostic value of CCTA for determining coronary atherosclerosis phenotype and coronary artery dimensions compared to IVUS, NIRS-IVUS, and OCT. Our findings will potentially shed new light on precision medicine informed by an AI-based coronary CTA assessment of coronary atherosclerosis burden, composition, and severity. (ClinicalTrials.gov: NCT04066062).

Impact of prolonged drug-coated balloon inflation on residual stenosis and clinical outcomes in coronary artery disease patients: A propensity score matched analysis

BACKGROUND

There is a paucity of data regarding the optimal duration of drug-coated balloon (DCB) inflation for coronary lesions. We sought to explore the effect of DCB angioplasty with versus without long inflation time on residual stenosis and clinical outcomes in patients with coronary artery disease.

METHODS

This study included 314 consecutive patients with 445 lesions undergoing paclitaxel DCB angioplasty using different inflation time, divided according to whether the total inflation time of the DCB was ≥180 s (prolonged group) or <180 s (standard group). The primary clinical endpoint, defined as a composite of all-cause death, myocardial infarction, stroke, or target lesion revascularization, was examined in 92 propensity score matched pairs.

RESULTS

In the matched cohort, the median clinical follow-up period was 947 days. Postprocedural angiographic diameter stenosis was smaller in the prolonged group than in the standard group (30.0% [22.0-37.0] vs. 33.5% [25.5-40.5]; p = 0.042). Intravascular ultrasound measurements revealed that longer DCB inflation time resulted in smaller area stenosis (66.6 ± 7.8% vs. 69.4 ± 7.0%; p = 0.044) and a less mean increase in percent atheroma volume (-11.2 ± 7.1% vs. -7.4 ± 5.9%; p = 0.004) after angioplasty. The rate of the primary endpoint was lower in the prolonged group than in the standard group (log-rank p = 0.025). The efficacy of prolonged DCB inflation was prominent in patients with in-stent restenosis and longer lesions.

CONCLUSION

Prolonged DCB inflation was associated with reduced residual stenosis and improved clinical outcomes in patients with coronary artery disease undergoing percutaneous coronary intervention. Prospective randomized trials are warranted to validate the benefits of DCB angioplasty with long inflation time.

Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide, and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, has increased operators' confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications and the importance of adequate training and education.

Association of triglyceride glucose index levels ​​with calcification patterns and vulnerability of plaques: an intravascular ultrasound study

PURPOSE

High triglyceride glucose (TyG) index level is one of the risks for cardiovascular events. The purpose of this research was to examine the correlation of the triglyceride glucose (TyG) index levels with plaque characteristics and calcification types determined by intravascular ultrasound (IVUS) in acute coronary syndrome (ACS) patients.

METHODS

A total of 234 acute coronary syndromes (ACS) participants who completed intravascular ultrasound (IVUS) and coronary angiography (CAG) were finally enrolled.

RESULTS

Logistic regression analysis manifested that the TyG index was independently correlated with the occurrence of coronary calcification, minimum lumen area (MLA) ≤ 4.0 mm², plaque burden (PB) > 70%, and spotty calcification. Taking the lowest group as a reference, the risk of coronary calcification (OR, 2.57; 95%CI, 1.04-6.35; p = 0.040), MLA ≤ 4.0 mm² (OR, 7.32; 95%CI, 2.67-20.01; p < 0.001), PB > 70% (OR, 2.68; 95%CI, 1.04-6.91; p = 0.041), and spotty calcification (OR, 1.48; 95%CI, 0.59-3.71; p = 0.407) was higher in the highest TyG index group. TyG index was converted into a dichotomous variable or a continuous variable for analysis, and we found that a similar result was observed. In addition, optimal predictive models consisting of clinical variables and the TyG index distinctly improved the ability to predict the prevalence of coronary calcification and MLA ≤ 4.0 mm² (p < 0.05).

CONCLUSION

The TyG index may serve as a potential predictor for calcification patterns and plaque vulnerability.

Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial

BACKGROUND

Intravascular imaging-guided percutaneous coronary intervention (PCI) with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) showed superior clinical outcomes compared with angiography-guided PCI. However, the comparative effectiveness of OCT-guided and IVUS-guided PCI regarding clinical outcomes is unknown.

METHODS

In this prospective, multicenter, open-label, pragmatic trial, we randomly assigned 2008 patients with significant coronary artery lesions undergoing PCI in a 1:1 ratio to undergo either an OCT-guided or IVUS-guided PCI. The primary end point was a composite of death from cardiac causes, target vessel-related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year, which was powered for noninferiority of the OCT group compared with the IVUS group. Safety outcomes were also assessed.

RESULTS

At 1 year, primary end point events occurred in 25 of 1005 patients (Kaplan-Meier estimate, 2.5%) in the OCT group and in 31 of 1003 patients (Kaplan-Meier estimate, 3.1%) in the IVUS group (absolute difference, -0.6 percentage points; upper boundary of one-sided 97.5% CI, 0.97 percentage points; P<0.001 for noninferiority). The incidence of contrast-induced nephropathy was similar (14 patients [1.4%] in the OCT group versus 15 patients [1.5%] in the IVUS group; P=0.85). The incidence of major procedural complications was lower in the OCT group than in the IVUS group (22 [2.2%] versus 37 [3.7%]; P=0.047), although imaging procedure-related complications were not observed.

CONCLUSIONS

In patients with significant coronary artery lesions, OCT-guided PCI was noninferior to IVUS-guided PCI with respect to the incidence of a composite of death from cardiac causes, target vessel-related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year. The selected study population and lower-than-expected event rates should be considered in interpreting the trial.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique number: NCT03394079.

Culprit lesion plaque characteristics and angiopoietin like 4 in acute coronary syndrome: A virtual histology-intravascular ultrasound analysis

BACKGROUND

Thin-cap fibroatheroma is a rupture-prone vulnerable plaque that leads to acute coronary syndrome (ACS). However, its underlying mechanisms are not fully understood. Several studies have investigated the clinical association between angiopoietin-like protein 4 (ANGPTL4) and coronary artery disease. Therefore, this study aimed to investigate the correlation of plasma ANGPTL4 in culprit lesion of ACS patients using intravascular ultrasound (IVUS) and virtual-histology IVUS (VH-IVUS).

METHODS

Fifty patients newly diagnosed with ACS between March to September 2021 were selected. Blood samples for baseline laboratory tests, including ANGPTL4, were collected before percutaneous coronary intervention (PCI), and all pre- and post-PCI IVUS examinations were performed of the culprit lesions.

RESULTS

Linear regression analysis between plasma ANGPTL4 and grayscale IVUS/VH-IVUS parameters revealed that plasma ANGPTL4 was strongly correlated with the necrotic core (NC) of the minimal lumen site (r = -0.666, p = 0.003) and largest NC site (r = -0.687, p < 0.001), and patients with lower plasma ANGPTL4 levels showed a significantly higher proportion of TFCA.

CONCLUSION

The present study further demonstrated the protective role of ANGPTL4 in the spectrum of atherosclerotic development in patients with ACS by culprit lesion morphology analysis using IVUS and VH-IVUS.

Calcified plaque harboring lipidic materials associates with no-reflow phenomenon after PCI in stable CAD

Calcified atheroma has been viewed conventionally as stable lesion which less likely increases no-reflow phenomenon. Given that lipidic materials triggers the formation of calcification, lipidic materials could exist within calcified lesion, which may cause no-reflow phenomenon after PCI. The REASSURE-NIRS registry (NCT04864171) employed near-infrared spectroscopy and intravascular ultrasound imaging to evaluate maximum 4-mm lipid-core burden index (maxLCBI4mm) at target lesions containing small (maximum calcification arc < 180°: n = 272) and large calcification (maximum calcification arc ≥ 180°: n = 189) in stable CAD patients. The associations of maxLCBI4mm with corrected TIMI frame count (CTFC) and no-reflow phenomenon after PCI were analyzed in patients with target lesions containing small and large calcification, respectively. No-reflow phenomenon occurred in 8.0% of study population. Receiver-operating characteristics curve analyses revealed that optimal cut-off values of maxLCBI4mm for predicting no-reflow phenomenon were 585 at small calcification (AUC = 0.72, p < 0.001) and 679 at large calcification (AUC = 0.76, p = 0.001). Target lesions containing small calcification with maxLCBI4mm ≥ 585 more likely exhibited a greater CTFC (p < 0.001). In those with large calcification, 55.6% of them had maxLCBI4mm ≥ 400 [vs. 56.2% (small calcification), p = 0.82]. Furthermore, a higher CTFC (p < 0.001) was observed in association with maxLCBI4mm ≥ 679 at large calcification. On multivariable analysis, maxLCBI4mm at large calcification still independently predicted no-reflow phenomenon (OR = 1.60, 95%CI = 1.32-1.94, p < 0.001). MaxLCBI4mm at target lesions exhibiting large calcification elevated a risk of no-reflow phenomenon after PCI. Calcified plaque containing lipidic materials is not necessarily stable lesion, but could be active and high-risk one causing no-reflow phenomenon.

Plaque morphology and distribution in patients with and without myocardial bridge - an intravascular ultrasound study

BACKGROUND

Myocardial bridging (MB) is a common congenital cardiovascular anomaly. There are reported associations of MB with different clinical presentations like effort angina, acute coronary syndromes (ACS) and sudden cardiac death. Acceleration of atherosclerosis in proximal vessel is reported in patients with MB, while bridged segments are reported to be free of atherosclerosis.

METHODS

We assessed patients who underwent intravascular ultrasound (IVUS) guided percutaneous intervention (PCI) of left anterior descending (LAD) artery. Plaque characteristics derived from IVUS analysis were compared between those who displayed myocardial bridge versus those who did not harbour the anomaly.

RESULTS

One hundred and forty-seven (147) patients underwent IVUS guided PCI. Incidence of MB was 44/147 (29.9%). Mean age of patients who had MB {+} was higher (62.1 ± 10.3 vs. 57.8 ± 11.2 (p = .03). 142/147 (96.6%) patients presented with ACS. ST elevation myocardial infarction (STEMI) was the most common presenting diagnosis (110/147 to 74.8%). There were no differences in qualitative plaque characteristics - attenuated plaque, calcification or calcium score between two groups. Plaque burden and length of the lesion in the proximal vessel were not different. Among patients with MB {+}, atheromatous extension to segments underlying the bridge was seen in 31/44 (70.5%) cases.

CONCLUSIONS

In a series of patients who presented with advanced clinical atherosclerosis, plaque characteristics were not different in patients who harboured myocardial bridge vs. those who did not have the anomaly. Atheromatous involvement was seen extending into bridged segment contrary to previous reports.

State-of-art review: intravascular imaging in percutaneous coronary interventions

The history of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) reflects the relentless pursuit of innovation in interventional cardiology. These intravascular imaging technologies have played a pivotal role in our understanding of coronary atherosclerosis, vascular pathology, and the interaction of coronary stents with the vessel wall. Two decades of clinical investigations demonstrating the clinical efficacy and safety of intravascular imaging modalities have established these technologies as staples in the contemporary cardiac catheterization lab's toolbox and earning their place in revascularization clinical practice guidelines. In this comprehensive review, we will delve into the historical evolution, mechanisms, and technical aspects of IVUS and OCT. We will discuss the expanding evidence supporting their use in complex percutaneous coronary interventions, emphasizing their crucial roles in optimizing patient outcomes and ensuring procedural success. Furthermore, we will explore the substantial advances that have propelled these imaging modalities to the forefront of contemporary interventional cardiology. Finally, we will survey the latest developments in the field and explore the promising future directions that have the potential to further revolutionize coronary interventions.

Preventive PCI or medical therapy alone for vulnerable atherosclerotic coronary plaque: Rationale and design of the randomized, controlled PREVENT trial

BACKGROUND

Acute coronary syndromes are commonly caused by the rupture of vulnerable plaque, which often appear angiographically not severe. Although pharmacologic management is considered standard therapy for stabilizing plaque vulnerability, the potential role of preventive local treatment for vulnerable plaque has not yet been determined. The PREVENT trial was designed to compare preventive percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) with OMT alone in patients with functionally nonsignificant high-risk vulnerable plaques.

METHODS

The PREVENT trial is a multinational, multicenter, prospective, open-label, active-treatment-controlled randomized trial. Eligible patients have at least 1 angiographically significant stenosis (diameter stenosis >50% by visual estimation) without functional significance (fractional flow reserve [FFR] >0.80). Target lesions are assessed by intracoronary imaging and must meet at least 2 imaging criteria for vulnerable plaque; (1) minimal lumen area <4.0 mm2; (2) plaque burden >70%; (3) maximal lipid core burden index in a 4 mm segment >315 by near infrared spectroscopy; and (4) thin cap fibroatheroma as determined by virtual histology or optical coherence tomography. Enrolled patients are randomly assigned in a 1:1 ratio to either preventive PCI with either bioabsorbable vascular scaffolds or metallic everolimus-eluting stents plus OMT or OMT alone. The primary endpoint is target-vessel failure, defined as the composite of death from cardiac causes, target-vessel myocardial infarction, ischemic-driven target-vessel revascularization, or hospitalization for unstable or progressive angina, at 2 years after randomization.

RESULTS

Enrollment of a total of 1,608 patients has been completed. Follow-up of the last enrolled patient will be completed in September 2023 and primary results are expected to be available in early 2024.

CONCLUSIONS

The PREVENT trial is the first large-scale, randomized trial to evaluate the effect of preventive PCI on non-flow-limiting vulnerable plaques containing multiple high-risk features that is appropriately powered for clinical outcomes. PREVENT will provide compelling evidence as to whether preventive PCI of vulnerable plaques plus OMT improves patient outcomes compared with OMT alone.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT02316886.

KEY POINTS

The PREVENT trial is the first, large-scale randomized clinical trial to evaluate the effect of preventive PCI on non-flow-limiting vulnerable plaque with high-risk features. It will provide compelling evidence to determine whether PCI of focal vulnerable plaques on top of OMT improves patient outcomes.

Accelerated stenotic flow in the left anterior descending coronary artery explains the causes of impaired coronary flow reserve: an integrated transthoracic enhanced Doppler study

Background

Accelerated stenotic flow (AsF) in the entire left anterior descending coronary artery (LAD), assessed by transthoracic enhanced color Doppler (E-Doppler TTE), can reveal coronary stenosis (CS) and its severity, enabling a distinction between the microcirculatory and epicardial causes of coronary flow reserve (CFR) impairment.

Methods

Eighty-four consecutive patients with a CFR <2.0 (1.5 ± 0.4), as assessed by E-Doppler TTE, scheduled for coronary angiography (CA) and eventually intracoronary ultrasounds (IVUS), were studied. CFR was calculated by the ratio of peak diastolic flow velocities: during i.v. adenosine (140 mcg/Kg/m) over resting; AsF was calculated as the percentage increase of localized maximal velocity in relation to a reference velocity.

Results

CA showed ≥50% lumen diameter narrowing of the LAD (critical CS) in 68% of patients (57/84) vs. non-critical CS in 32% (27/84). Based on the established CA/IVUS criteria, the non-critical CS subgroup was further subdivided into 2 groups: subcritical/diffuse [16/27 pts (57%)] and no atherosclerosis [11/27 pts (43%)]. CFR was similar in the three groups: 1.4 ± 0.3 in critical CS, 1.5 ± 0.4 in subcritical/diffuse CS, and 1.6 ± 0.4 in no atherosclerosis (p = ns). Overall, at least one segment of accelerated stenotic flow in the LAD was found in 73 patients (87%), while in 11 (13%) it was not. The AsF was very predictive of coronary segmental narrowing in both angio subgroups of atherosclerosis but as expected with the usage of different cutoffs. On the basis of the ROC curve, the optimal cutoff was 109% and 16% AsF % increment to successfully distinguish critical from non-critical CS (area under the curve [AUC] = 0.99, p < 0.001) and diffuse/subcritical from no CS (AUC = 0.91%, p < 0.001). Sensitivity and specificity were 96% and 100% and 82% and 100%, respectively.

Conclusion

E-Doppler TTE is highly feasible and reliable in detecting the CS of any grade of severity, distinguishing epicardial athero from microvascular causes of a severe CFR reduction.

Comparison of Atherosclerotic Plaque Compositions in Diabetic and Non-diabetic Patients

INTRODUCTION

Diabetes mellitus is one of the major risk factors for coronary artery disease. Intravascular ultrasound (IVUS) imaging has an important role in the evaluation of atherosclerotic coronary artery disease. The aim of the study was to investigate the potential link between diabetes mellitus and plaque vulnerability in patients with coronary artery disease.

METHODS

In total, 26 patients with acute coronary syndrome (eight with diabetes mellitus) and 34 with stable angina pectoris (16 with diabetes mellitus) constituted the study population. Patients underwent IVUS ultrasound and virtual histology (VH)-IVUS imaging during routine diagnostic catheterization procedures. A total of 70 plaques in 60 patients were examined.

RESULTS

Patients with diabetes mellitus had a significantly greater percentage of fibrofatty components in the minimal lumen area (MLA) (17 ± 12 in diabetics; 12 ± 6 in non-diabetics; p=0.06). Thin-cap fibroatheromas were more frequent in patients with diabetes mellitus (72% versus 45%; p=0.012). There was a positive correlation between the presence of attenuated plaque and hemoglobin A1C (HbA1c) levels as well (7.09 ± 1.66 versus 6.02 ± 1.00; p=0.011). Patients with HbA1C ≥7.5% also had the highest prevalence of attenuated plaque.

CONCLUSION

As shown by VH-IVUS, the prevalence of vulnerable plaques in patients with diabetes mellitus was much higher than that in non-diabetic patients. The presence of attenuated plaque detected in grayscale intravascular ultrasonography was associated with high HbA1C levels in diabetic patients. Diabetes mellitus may cause cardiovascular vulnerability by changing the plaque morphology.

Utilization of intravascular imaging in elective non chronic total occlusion percutaneous intervention and chronic total occlusion percutaneous intervention: Trends in utilization and impact on in-hospital mortality

OBJECTIVES

The objectives of this retrospective study include outcomes associated with and without intravascular imaging in cases of elective single vessel (SV) CTO PCI and in non-CTO PCI.

METHOD

We explored the NIS database from October 1, 2015 to December 31, 2018 to identify 317,090 adult admissions with elective SV PCI. Admissions with STEMI and NSTEMI were excluded to identify elective cases only. Using the ICD 10 diagnosis code for CTO, we identified 33,345 admissions that underwent SV CTO PCI. We classified the remaining cases as SV non-CTO PCI.

RESULTS

Intravascular imaging was utilized in 2930 (8.8%) cases in CTO PCI group and 23,710 (8.3%) cases in non-CTO PCI groups. The utilization of intravascular imaging (IVUS/OCT) significantly increased in elective SV CTO PCI, 6.4%-11.2%, p-trend<0.001 and non-CTO PCI group, 7.3%-9.0%, p-trend<0.001. There was no significance difference in mortality with and without intravascular imaging (combined IVUS/OCT vs no IVUS/OCT: 1.5% vs 1.3%, p = 0.195) in the CTO PCI group. But, in non-CTO PCI admissions, there was a significantly lower in-hospital mortality when intravascular imaging was used (0.7% vs 0.8%, p = 0.003). The cost of hospitalization was significantly higher when intravascular imaging was used in elective single vessel CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $27,427 vs $21,452, p < 0.001 and non-CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $23,620 vs $20,272, p < 0.001.

CONCLUSIONS

In conclusion, despite the cost, intravascular imaging use decrease mortality in non-CTO PCI groups but there is no difference in mortality in CTO PCI groups.

Associations of High-Density Lipoprotein Functionality with Coronary Plaque Characteristics in Diabetic Patients with Coronary Artery Disease: Integrated Backscatter Intravascular Ultrasound Analysis

High-density lipoprotein (HDL) functionality has been reported to be associated with coronary artery disease (CAD). However, little is known about the impact of HDL functionality on coronary atherosclerosis. Thirty-eight type 2 diabetic patients with CAD who underwent percutaneous coronary intervention were examined. Coronary atheroma burden and plaque composition of the culprit lesions were assessed using conventional gray-scale and integrated backscatter intravascular ultrasound. HDL-mediated cholesterol efflux capacity (HDL-CEC) and HDL antioxidant capacity, estimated as HDL inflammatory index (HII), were examined. The associations between HDL functionality and coronary plaques were analyzed using multivariate data analysis, including principal components analysis and orthogonal partial least squares (OPLS) models. Percent atheroma volume was correlated with HDL-CEC (r = 0.34, p = 0.04) but not with HII (p = 0.65). The OPLS model demonstrated that the percentage lipid volume was significantly associated with HDL functionality [coefficient (95% confidence interval); HDL-CEC: -0.26 (-0.49, -0.04); HII: 0.34 (0.08, 2.60), respectively]. HII exhibited the highest variable importance in projection score, indicating the greatest contribution. HDL functionality was associated with coronary plaque composition, a key component of plaque vulnerability. Our findings highlight the potential importance of HDL functionality for coronary plaque stabilization.

Assessment of the Severity of Left Anterior Descending Coronary Artery Stenoses by Enhanced Transthoracic Doppler Echocardiography: Validation of a Method Based on the Continuity Equation

BACKGROUND

To verify whether the severity of coronary stenosis could be non-invasively assessed by enhanced transthoracic coronary echo Doppler in convergent color Doppler mode (E-Doppler TTE) over a wide range of values (from mild to severe).

METHODS

Color-guided pulsed wave Doppler sampling in the left anterior descending coronary artery (LAD) was performed in 103 diseased LAD segments (corresponding to 94 patients examined) as assessed by quantitative coronary angiography (QCA) or intracoronary ultrasound (IVUS). The E-Doppler TTE examinations consisted of measuring the velocity (vel) at the stenosis site and a reference adjacent segment. Then the continuity equation (C-Eq) was applied to calculate the percent cross-sectional area reduction (%CSA) at the stenosis site. The applied formula was: %CSA = 100 × (1 - [TVIref × 0.5]/TVIs). TVI = the time velocity integral at the stenosis [s] and the reference site [ref], respectively); 0.5 = the correcting factor for a parabolic profile was used only when the % accelerated stenotic flow was >122% (AsF = diastolic peak vel at first site - diastolic peak vel at second site/diastolic peak vel at second site × 100).

RESULTS

E-Doppler TTE feasibility was 100%. Doppler and QCA/IVUS-derived %CSA stenosis showed very good agreement over a large range of values (from mild to severe), with no significant bias; the maximum difference between QCA/IVUS and transthoracic Doppler %CSA was mostly around 20% with a few patients exceeding this limit (limits of agreement = -27.53 to 23.5%). The scattering was slightly larger for the non-significant stenoses. The correlation was strong (r = 0.89, p < 0.001).

CONCLUSION

E-Doppler TTE is a feasible and reliable method for assessing the severity of LAD stenosis by applying the C-Eq.

Clinical outcomes of acute myocardial infarction arising from non-lipid-rich plaque determined by NIRS-IVUS

Acute myocardial infarction (AMI) can rarely arise from non-lipid-rich coronary plaques. This study sought to compare the clinical outcomes after percutaneous coronary intervention (PCI) between AMI showing maximum lipid-core burden index in 4 mm (maxLCBI_4mm) < 400 and ≥ 400 in the infarct-related lesions assessed by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We investigated 426 AMI patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. Major adverse cardiovascular events (MACE) were defined as the composite of cardiac death, non-fatal MI, clinically driven target lesion revascularization (TLR), clinically driven non-TLR, and congestive heart failure requiring hospitalization. 107 (25%) patients had infarct-related lesions of maxLCBI_4mm < 400, and 319 (75%) patients had those of maxLCBI_4mm ≥ 400. The maxLCBI_4mm < 400 group had a younger median age at onset (68 years [IQR: 57-78 years] vs. 73 years [IQR: 64-80 years], P = 0.007), less frequent multivessel disease (39% vs. 51%, P = 0.029), less frequent TIMI flow grade 0 or 1 before PCI (62% vs. 75%, P = 0.007), and less frequent no-reflow immediately after PCI (5% vs. 11%, P = 0.039). During a median follow-up period of 31 months [IQR: 19-48 months], the frequency of MACE was significantly lower in the maxLCBI_4mm < 400 group compared with the maxLCBI_4mm ≥ 400 group (4.7% vs. 17.2%, P = 0.001). MaxLCBI_4mm < 400 was an independent predictor of MACE-free survival at multivariable analysis (hazard ratio: 0.36 [confidence interval: 0.13-0.98], P = 0.046). MaxLCBI_4mm < 400 measured by NIRS in the infract-related lesions before PCI was associated with better long-term clinical outcomes in AMI patients.

Reproducibility of Femoropopliteal Artery Intravascular Ultrasound Imaging in Patients With Peripheral Artery Disease

Despite increased use of intravascular ultrasound (IVUS) during peripheral artery interventions, evidence for reproducibility of IVUS measurements and its relation to angiography is lacking. Forty cross-sectional IVUS images of the femoropopliteal artery from 20 randomly selected patients enrolled in the XLPAD (Excellence in Peripheral Artery Disease) registry who underwent peripheral artery interventions and met criteria based on IVUS consensus guidelines were independently assessed by 2 blinded readers. IVUS images from 6 patients (40 images) were selected for angiographic correlation and met criteria for identifiable landmarks (e.g., stent edge and bifurcation). Lumen cross-sectional area (CSA), external elastic membrane (EEM) CSA, luminal diameter, and reference vessel diameter were repeatedly measured. The Lumen CSA and EEM CSA intra-observer agreement by Spearman rank-order correlation (ρ) was >0.993, intraclass correlation coefficient was >0.997, and repeatability coefficient was <1.34. For the interobserver measurement of luminal CSA and EEM CSA, the ρ = 0.742 and 0.764; intraclass correlation coefficient = 0.888 and 0.885; and repeatability coefficient = 7.24 and 11.34, respectively. A Bland-Altman plot for lumen and EEM CSA showed good reproducibility. For angiographic comparison, the ρ for luminal diameter, luminal area, and vessel area were 0.419, 0.414, and 0.649, respectively. Femoropopliteal IVUS measurements showed strong intra-observer and interobserver agreement; IVUS and angiographic measurements did not demonstrate a similar strong agreement.

Intravascular Ultrasound Guided Intervention in Calcified Coronary Lesions Showed Good Clinical Outcomes during One Year Follow-Up

BACKGROUND

Calcified coronary lesions can cause stent under-expansion, malapposition, and polymer degradation, hence increasing the risk of adverse clinical outcomes. Percutaneous coronary intervention (PCI) guided by intravascular ultrasound (IVUS) has been used regularly to improve outcomes. Our primary aim was to evaluate the clinical efficacy of IVUS-guided PCI in calcified coronary lesions.

METHODS

From August 2018 to December 2021, we prospectively included 300 patients in the CAPIRO study (CAlcified plaque in patients receiving Resolute Onyx®) at three educational hospitals in Jeonbuk Province. We studied 243 patients (265 lesions) who were followed up for over a year. Based on coronary calcification by IVUS analysis, the patient population was categorized into two groups (Group I: non/mild calcification; Group II: moderate/severe calcification (maximum calcium arc >180° and calcium length > 5 mm)). One-to-one Propensity Score Matching was used to match the baseline characteristics. The stent expansion rate was analyzed by recent criteria. The primary clinical outcome was Major Adverse Cardiac Events (MACE), which included Cardiac death, Myocardial Infarction (MI), and Target Lesion Revascularization (TLR).

RESULTS

After follow-up time, the MACE rate in Group I was 1.99%, comparable to Group II's 1.09% (p = 0.594). The components of MACE did not significantly differ between the two groups. Based on absolute MSA or MSA/MVA at MSA site criteria, the stent expansion rate in Group II was lower than that of Group I. Nevertheless, based on recent relative criteria, the stent expansion rate in both groups was comparable.

CONCLUSIONS

After more than a year of follow-up, IVUS-guided PCI in moderate/severe calcification lesions was associated with good clinical outcomes, which was comparable with non/mild calcification lesions. Future studies with a larger sample size and a more extended follow-up period are required to clarify our findings.

Impact of plaque and luminal morphology in balloon angioplasty of the femoropopliteal artery: an intravascular ultrasound analysis

Objective

To assess the effect of plaque and luminal morphologies in balloon angioplasty of femoropopliteal lesions using intravascular ultrasound (IVUS).

Methods

This retrospective, observational study analyzed 836 cross-sectional images using IVUS, from 35 femoropopliteal arteries of patients who underwent endovascular treatment between September 2020 and February 2022. Pre- and post-balloon angioplasty images were matched per 5 mm. Post-balloon angioplasty images were grouped into successful (n = 345) and unsuccessful (n = 491) groups. Plaque and luminal morphologies (such as severity of calcification, vascular remodeling, and plaque eccentricity) were extracted before the balloon angioplasty procedure to identify the predictors of unsuccessful balloon angioplasty. Additionally, 103 images with severe dissection were analyzed using IVUS and angiography.

Results

In univariate analyses, the predictive factors for unsuccessful balloon angioplasty were vascular remodeling (p < .001), plaque burden (p < .001), lumen eccentricity (p < .001), and balloon/vessel ratio (p = .01). Predictive factors for severe dissections were the guidewire route (p < .001) and balloon/vessel ratio (p = .04). In multivariate analysis, the predictive factors for unsuccessful balloon angioplasty included lumen eccentricity (odds ratio [OR]: 3.99, 95% confidence interval [CI]: 1.28-12.68, p = .02) and plaque burden (OR: 1.03, 95% CI: 1.02-1.04; p < .001). For severe dissections, the independent risk factor was an eccentric guidewire route (OR: 2.10, 95% CI: 1.22-3.65, p = .01).

Conclusion

High plaque burden and luminal eccentricity were risk factors for failed femoropopliteal artery balloon angioplasty. Additionally, eccentric guidewire routes predicted severe dissection.