Stent boost subtract imaging for the assessment of optimal stent deployment in coronary ostial lesion intervention: comparison with intravascular ultrasound

Value of stent boost imaging in decision making after coronary stenting

BACKGROUND

Several studies reported the comparability of digital stent enhancement techniques (including stent boost imaging) in detecting suboptimal results of coronary stenting with Intra Vascular Ultrasound and optical coherence tomography.

AIMS

to assess results of stent deployment and determine the incidence of suboptimal results requiring changing final decision using stent boost imaging.

METHODS

This cross-sectional study included 120 patients eligible for PCI were recruited during a period of one year (January 2021 to 2022) using DES.

RESULTS

Suboptimal results were found in 38% of the PCI cases with stents (angiography guided). Importantly it was found that improper lesion preparation in our practice could not help improving stent optimization. Also, angiography guided PCI has significant incidence of suboptimal results. Digital stent enhancement techniques like stent boost have significant and important value in better decision making. After adjusting for age and sex, six factors were identified as independent predictors for final decision change (stent length, LAD/RCA affection, proximal segment affection, calcification, and optical coherence tomography.

CONCLUSION

This study has confirmed the utility of stent boost for the optimization of PCI in daily practice. Stent Boost is a simple and costless technique that provides an accurate assessment of a deployed stent without extending the procedure time and without more risk. It appears to be useful for the immediate evaluation of stent expansion and optimization of PCI by additional post-dilatation, when appropriate. Future studies are needed to determine whether Stent Boost data will correlate with adverse long-term clinical outcomes in patients undergoing PCI.

Image-based visualization of stents in mechanical thrombectomy for acute ischemic stroke: Preliminary findings from a series of cases

BACKGROUND

Mechanical thrombectomy is the most effective treatment for great cerebral artery embolization within a set time window. Typically, an arteriogram does not show the localization of the stent after release and whether a thrombus is captured or not. Thus, improving the visualization of a stent in interventional therapy will be helpful for clinicians.

AIM

To analyze stent imaging findings to enhance clinicians' understanding of a special circumstance, wherein a Solitaire AB retrievable stent was visible during the imaging of a thrombus capture that improved the success rate of stent-based mechanical thrombectomy.

METHODS

This was a retrospective study with four acute ischemic stroke (AIS) patients who underwent stent-based mechanical thrombectomy.

RESULTS

Patient 1 was a 64-year-old man admitted after 5 h of confusion; angiography revealed basilar artery occlusion. We inserted a stent into the left posterior cerebral artery-P2 segment and visualized the expanded stent that successfully captured a thrombus. Patient 2 was a 74-year-old man admitted with confusion, which lasted approximately 3 h. Angiography revealed a left middle cerebral artery (MCA)-M1 segment occlusion. A stent was deployed in the distal M2 segment, and we could visualize the stent by capturing the thrombus. Patient 3 was a 74-year-old woman admitted after experiencing left hemiplegia for 3 h. We deployed a stent at the distal right MCA-M2 segment, and the developing stent captured a large thrombus. Patient 4 was an 82-year-old man who presented with confusion for 3 h. A developing stent was placed in the distal left MCA-M1 segment, which captured a large thrombus and several fragmented thrombi.

CONCLUSION

To the best of our knowledge, this is the first report of stent imaging in patients with AIS. We demonstrated the usefulness and substantial potential of stent imaging in stent-based mechanical thrombectomy for AIS.

Optical coherence tomography: evaluating the effects of stent boost subtract imaging on stent underexpansion in STEMI patients

Background

To evaluate the effect of stent boost subtract (SBS) imaging on stent underexpansion during percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) by optical coherence tomography (OCT).

Methods

One hundred thirty-eight STEMI patients who underwent drug-eluting stent (DES) implantation were prospectively recruited and divided into the SBS group (69 cases) and the CAG group (69 cases) according to whether SBS was used to guide PCI. Finally, OCT was performed on all enrolled patients, and the OCT results were used as the gold standard to evaluate the impact of standard SBS technology on stent underexpansion immediately after DES implantation.

Results

SBS identified 51 patients (24%) with stent underexpansion while OCT identified 56 patients (27.2%). SBS has a sensitivity of 80%, a specificity of 96%, a positive predictive value of 88%, and a negative predictive value of 93% for identifying stent underexpansion.

Conclusion

Compared with OCT, SBS technology is a rapid stent imaging evaluation method that can accurately quantify the stent expansion level and is time-saving and economical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02498-9.

Stent visualization methods to guide percutaneous coronary interventions and assess long-term patency

Evaluation of acute percutaneous coronary intervention (PCI) results and long-term follow-up remains challenging with ongoing stent designs. Several imaging tools have been developed to assess native vessel atherosclerosis and stent expansion, improving overall PCI results and reducing adverse cardiac events. Quantitative coronary analysis has played a crucial role in quantifying the extent of coronary artery disease and stent results. Digital stent enhancement methods have been well validated and improved stent strut visualization. Intravascular imaging remains the gold standard in PCI guidance but adds costs and time to the procedure. With a recent shift towards non-invasive imaging assessment and coronary computed tomography angiography imaging have shown promising results. We hereby review novel stent visualization techniques used to guide PCI and assess stent patency in the modern PCI era.

Use of enhanced stent visualisation compared to angiography alone to guide percutaneous coronary intervention

OBJECTIVE

We aimed to assess the use of enhanced stent visualisation (ESV) on outcomes, after PCI with overlapping stents, specifically using CLEARstent technology.

BACKGROUND

Stent underexpansion and overlap are both significant risk factors for restenosis and stent thrombosis. Enhanced stent visualisation (e.g. CLEARstent) systems could provide important data to reduce under-expansion and stent overlap.

METHODS

This was a cohort study based on this institution's percutaneous coronary intervention (PCI) registry. A total of 2614 patients who had PCI for stable angina or acute coronary syndromes (ACS, excluding cardiogenic shock) with overlapping 2nd generation drug eluting stents (DES) in the same vessel between May 2015 and January 2018 were included in the analysis. Patients were divided into ESV (n = 1354) and no ESV guided intervention (n = 1260). The primary end-point was major adverse cardiovascular events (MACE: target vessel revascularisation, target vessel myocardial infarction and all-cause mortality) recorded at a median follow up of 2.4 years.

RESULTS

Groups were comparable for patient characteristics (age, diabetes mellitus, ACS presentation). A significant difference in MACE was observed between patients who underwent ESV-guided PCI (9.5%) compared with patients who underwent Standard PCI (14.4%, p = .018). This difference was mainly driven by reduced rates of target vessel revascularisation and recurrent myocardial infarction. Overall this difference persisted after multivariate Cox analysis (HR 0.86, 95% CI: 0.73-0.98) and propensity matching (HR = 0.88, 95% CI: 0.69-0.99).

CONCLUSION

We suggest that routine clinical use of ESV technology during PCI can be useful, and is associated with better medium-term angiographic and clinical outcomes. Further study is required to build on this promising signal.

Five-year Clinical Outcomes of CAD Patients Complicated with Diabetes after StentBoost-optimized Percutaneous Coronary Intervention

Objective To evaluate the instant effects and five-year clinical outcomes of coronary artery disease patients complicated with diabetes mellitus after StentBoost-optimized percutaneous coronary intervention (PCI). Methods From March 2009 to July 2010, 184 patients undergoing PCI at our hospital were found stent underexpansion or malapposition by StentBoost after stents implantation and were divided into the diabetic (n=73, 39.67%) and the non-diabetic group (n=111, 60.33%). All patients received StentBoost-guided post-dilatation after stent implantation. The instant procedural results were measured and clinical outcome after five-year follow-up was analyzed in each group. Between-group comparisons were performed using Chi-square test or Student's t test. Multivariate logistic regression analysis was carried out to reveal the independent predictors for long-term clinical outcomes of StentBoost-optimized PCI . Results After StentBoost-guided post-dilatation, the minimum diameter (MinLD), maximum diameter (MaxLD) and average diameter in both groups increased significantly than before (P<0.001), the (MaxLD-MinLD)/MaxLD ratio and the in-stent residual stenosis decreased accordingly (P<0.001). The five-year follow-up showed similar mortality rate (4.92% vs. 2.86%, P=0.67) and major adverse cardiac event rate (11.48% vs. 11.43%, P = 1.0) between the diabetic and the non-diabetic group, whereas the recurrence of angina pectoris was higher in the diabetic group compared to the non-diabetic group (47.54% vs. 29.52%; P=0.02). A multivariate logistic regression analysis revealed that age and left ventricular ejection fraction rather than diabetes mellitus were independent predictors for long-term clinical outcomes. Conclusions StentBoost could effectively improve instant PCI results; the long-term clinical outcomes of StentBoost-optimized PCI were similar between diabetic and non-diabetic patients. Age and left ventricular ejection fraction were the independent predictors for long-term clinical outcomes.

Use of Stent Enhancement Technique During Percutaneous Coronary Intervention - A Case Series

Stent enhancement allows clear visualisation of implanted stents. This method, originally intended to assess stent under-expansion, can prove extremely valuable in several other situations. We present three cases illustrating its potential uses in assessment of stent failure, intraprocedural stent disruption and treatment of aorto-ostial and bifurcation lesions. Whilst stent enhancement cannot replace intravascular imaging, compared to simple angiography it can significantly improve percutaneous coronary intervention outcomes with no additional cost and with minimal procedural time.

Stent boost enhancement compared to intravascular ultrasound in the evaluation of stent expansion in elective percutaneous coronary interventions

Background

Stent underexpansion is a major risk factor for in-stent restenosis and acute in-stent thrombosis¹Intravascular ultrasound (IVUS) is one of the standards for detection of stent underexpansion (de Feyter et al. 1999; Mintz et al., 2001). StentBoost (SB) enhancement allows an improved angiographic visualization of the stent (Koolen et al., 2005).

Aim of work

Comparison of stent expansion by IVUS and SB enhancement and detection of value of SB to guide dilatation post stent deployment.

Methodology

IVUS, SB enhancement and QCA were done in 30 patients admitted for elective stenting procedures .We compared measurements of mean ±standard deviations of (Max SD, Min SD, Mean SD, stent symmetry index) using IVUS, SB and QCA after stent deployment and after postdilatation whenever necessary to optimize stent deployment. The Stent symmetry index was calculated [(maximum stent diameter minus minimum stent diameter) divided by maximum stent diameter].

Results

The Max SD was (3.45 ± 0.62 vs 3.55 ± 0.56 vs 2.97 ± 0.59) by IVUS vs SB vs QCA respectively. Max SD was significantly higher by IVUS vs QCA (p .009) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .53). The Min SD was (2.77 ± 0.53 vs 2.58 ± 0.56 vs 1.88 ± 0.60) by IVUS vs SB vs QCA respectively. Min SD was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .07). The stent symmetry index was (0.24 ±0.09 vs 0.34 ± 0.09 vs 0.14 ±0.27) by IVUS vs SB vs QCA respectively. It was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .32). SB was positively correlated with IVUS measurements of Max SD (p < .0001 & r 0.74) and Min SD (p < .0001 & r 0.68). QCA was positively correlated with IVUS measurements of Max SD correlation (p < .0001 & r 0.69) and Min SD (p < .0001 & r 0.63). QCA was positively correlated with SB measurements of Max SD (p < .0001 & r 0.61) and Min SD (p .003 & r 0.49).

Conclusions

StentBoost enhancement has superior correlations for stent expansion measured by IVUS when compared with QCA. SB enhancement improved stent visualization and identification of stent underexpansion to guide stent postdilatation.

Stent deployment protocol for optimized real-time visualization during endovascular neurosurgery

Successful application of endovascular neurosurgery depends on high-quality imaging to define the pathology and the devices as they are being deployed. This is especially challenging in the treatment of complex cases, particularly in proximity to the skull base or in patients who have undergone prior endovascular treatment. The authors sought to optimize real-time image guidance using a simple algorithm that can be applied to any existing fluoroscopy system. Exposure management (exposure level, pulse management) and image post-processing parameters (edge enhancement) were modified from traditional fluoroscopy to improve visualization of device position and material density during deployment. Examples include the deployment of coils in small aneurysms, coils in giant aneurysms, the Pipeline embolization device (PED), the Woven EndoBridge (WEB) device, and carotid artery stents. The authors report on the development of the protocol and their experience using representative cases. The stent deployment protocol is an image capture and post-processing algorithm that can be applied to existing fluoroscopy systems to improve real-time visualization of device deployment without hardware modifications. Improved image guidance facilitates aneurysm coil packing and proper positioning and deployment of carotid artery stents, flow diverters, and the WEB device, especially in the context of complex anatomy and an obscured field of view.

Mechanical thrombectomy with the Trevo ProVue device in ischemic stroke patients: does improved visibility translate into a clinical benefit?

PURPOSE

To investigate the efficacy and safety of the Trevo ProVue (TPV) stent retriever in stroke patients with large artery occlusions, with particular attention to the full structural radiopacity of the TPV.

MATERIALS AND METHODS

Case files and images of TPV treatments were reviewed for clinical and technical outcome data, including revascularization rates, device and procedure related complications, and outcome at discharge and after 90 days.

RESULTS

76 patients were treated with TPV. Mean National Institutes of Health Stroke Scale (NIHSS) score was 18 and 68% had additional intravenous thrombolysis. 63 occlusions were in the anterior circulation: 44 M1 (58%), 8 M2 (11%), 8 internal carotid artery-terminus (11%), 2 internal carotid artery- left (3%), 1 A2 (1%), and 13 vertebrobasilar (17%). 58 of 76 (76%) were solely treated with TPV; the remainder were treated with additional stent retrievers. Mean number of passes in TPV only cases was 2.2 (SD 1.2). In rescue cases, 3.2 (SD 2.2) passes were attempted with the TPV followed by 2.6 rescue device passes (SD 2). TPV related adverse events occurred in 4/76 cases (5%) and procedural events in 6/76 cases (8%). Mean procedural duration was 64 min (SD 42). Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization was achieved in 69/76 patients (91%), including 50% TICI 3. Of 56 survivors (74%), 37 (49%) showed a favorable outcome at 90 days (Solitaire With the Intention for Thrombectomy trial criteria), statistically associated with age, baseline NIHSS, onset to revascularization time, and TICI 2b-3 reperfusion. TPV radiopacity allowed for visual feedback, changing the methodology of stent retriever use in 44/76 cases (58%).

CONCLUSIONS

Neurothrombectomy with TPV is feasible, effective, and safe. The recanalization rate compares favorably with reported data in the literature. Improved structural radiopacity may facilitate neurothrombectomy or influence the course of action during retrieval.