IVUS with Volacano machine and basics

1. Cardiac Catheterization
Laboratry
08-June-2013
MuhammadNaveedSaeed
Cardio Vascular Technologist (Cath Lab)
King Faisal Specialist Hospital & Research Center,
Riyadh, KSA

2. Defination
Intravascular ultrasound (IVUS) is a medical
imaging methodology using a specially
designed catheter with a
miniaturized ultrasound probe attached to the distal
end of the catheter. The proximal end of
the catheter is attached to
computerized ultrasound equipment. It allows the
application of ultrasound technology to see from
inside blood vessels out through the
surrounding blood column, visualizing
the endothelium (inner wall) of blood vessels in
living individuals.

3. Digital gray scale IVUS for
fast, plug and play imaging

4. VH® IVUS tissue characterisation to identification
of necrotic core

5. ChromaFlo® stent apposition assessment to quickly
confirm desired stent expansion and placement

6. PrimeWire™ FFR functionality for reliable identification
of ischemic lesions as seen in FAME

7. Revolution™ high frequency rotational IVUS
for longer pullbacks and clinical study design

8. What is VH IVUS?
Previously, assessment of atherosclerotic
disease was limited to 2D views of symptom-
causing narrowing of the coronary arteries by
way of contrast agent-enhanced X-Ray imaging.
More recently, grayscale IVUS allowed for
quantification of atherosclerotic plaque build-up,
in addition to providing precise measurements of
vessel anatomy to guide optimal angioplasty or
stent-based treatment.

12. Vulnerable Plaque ?
 Functional Definition
 A plaque, often non-stenotic, that has a high likelihood of
becoming disrupted and forming a thrombogenic factor
after exposure to an acute risk factor
 Histological Definition
 Plaque containing a thin fibrous cap, lipid pools and
macrophages
 Prospective Definition
 A signature that has been proven in a prospective study
to identify a plaque that is prone to disrupt and can be
recognised and measured in the cath lab
James Muller

13. Vulnerable Plaque
The impact of early
“vulnerable” plaque
detection and therapy
would be a major
breakthrough in the
management of
patients with coronary,
peripheral and
neurovascular
disease!!!
Thin fibrous cap + lipid
core + dense
macrophages
Plaque rupture

15. Calcified noduleRupture
Erosion
ThTh NCTh
Rupture
Site Calcified
Nodule
FC
Th
NC
Th Th
Th
Th
Causes of Coronary Thrombosis
Virmani R, et al. Arterioscler Thromb Vasc Biol 2000;20:1262

16. Morphology vs. Activity Imaging
Inactive
and non-
inflamed
plaque
Active
and
inflamed
plaque
IVUS
OCT
MRI
w/o
CM
Morphology
Activity
Thermography,
Spectroscopy, MRI with
targeted CM

17. Necrotic Core
Necrotic core with an overlying thin fibrous cap.
They are covered by a thin fibrous cap, which is
inflamed with macrophages, and the smooth
muscle cell content of the cap is scarce. the cap
thickness is <65 µm such plaques have been
referred to as thin-cap fibroatheromas (TCFA).
TCFAs are more common in patients with high
serum total cholesterol (TC) and a high TC to
high density cholesterol ratio.

18. Calcium
Coronary artery calcification is more
prevalent in men in this young adult population.
Coronary risk factors measured in children and
young adults are associated with the early
development of coronary artery calcification.
Increased body mass index measured during
childhood and young adult life and increased
blood pressure and decreased HDL cholesterol
levels measured during young adult life are
associated with the presence of coronary
artery calcification in young adults.

19. Fibrous
Myofibroblasts (myoFb) are cells responsible for fibrous
tissue formation in injured systemic organs such as the
heart. Cultured myoFb, obtained from rat cardiac scar
tissue, express genes that encode components requisite
for angiotensin (Ang) II generation, which in turn
regulates myoFb collagen turnover in an
autocrine/paracrine manner..
Coronary artery with atherosclerosis (fibrous
plaque). The atheromatous fibrous plaque is localized in
the intima of the artery, beneath the endothelium,
producing the thickening of the wall and, secondary, the
narrowing of the lumen and the atrophy of the muscular
layer by compression. The fibrous plaque
contains collagen fibres(eosinophilic), precipitates of
calcium (hematoxylinophilic) and rare lipid-laden cells.
(H&E, ob. x4)

20. Fibro-Fatty
The atheromatous fibro-fatty plaque is
characterized by the accumulation of lipids in the
intima of the arteries, narrowing the lumen and
compressing the muscular layer.

21. When I use
IVUS

22. Diagnostic Applications of IVUS
 Identify specific disease
- left main stem, ostial lesions
 Detect angiographically silent disease - transplant
vasculopathy
 Identify plaque morphology
 Examine vessel when angiography is inconclusive
- hazy lesions, presence or absence of thrombus or dissection
 Measure plaque load
 Measure true vessel size

23. Angiography versus IVUS
ANGIOGRAPHY
2 dimensional
Planar
Shadow of lumen
Wall structures not imaged
Intermittent snapshots or
repeat contrast injections
necessary
QCA measurements prone to
magnification errors
IVUS
360º view
Tomographic and sagittal
Visualisation of shape and
location
Visualisation of inner wall
structures and
morphology
Continuous image
Precise measurements

24. IVUS Transducers
Mechanical Transducer – 40 MHz Atlantis Pro (BosSci)
Solid-State Transducer – 25 MHz Eagle Eye (Volcano)

25. Lumen
Area
Vessel Area
Atheroma Area
IVUS Determination of Atheroma Area
Precise Planimetry of EEM and Lumen Borders
with Calculation of Atheroma Cross-sectional Area
Vessel Diameter
Lumen Diameter

26. In-Stent Restenosis

28. Interventional Indications of IVUS
PRE-INTERVENTION
 Accurate quantitation
 Assessment of reference segment disease
 Interventional strategy & device selection
 In-stent restenosis
 Plaque composition
 Length of lesion
POST-INTERVENTION
 Recognition of an ambiguous appearance
 Optimal balloon angioplasty
 IVUS-guided stenting
 Plaque shifting
 Dissection

29. IVUS & Stent Expansion

30. Minimum Stent Area & Restenosis
0
5
10
15
20
25
30
35
40
<6 6-7.9 8-9.9 >10
Angio restenosis
TVR
Minimum Stent Area (mm2)
%
After Moussa et al, Mintz et al, CRUISE 2000

31. Stent Malapposition

32. Left Main Stenting
PRE-INTERVENTION
 Confirm length of left main stem
= pullback time (0.5 mm/s) ÷ 2
 Confirm lesion length
 Assess for ostial disease in LAD or CFX
 Measure TVS (true vessel size)
= [maximum + minimum vessel diameter] ÷ 2

33. IVUS & Left Main Stenting
POST-INTERVENTION
 Confirm optimal stent deployment
 Recognition of an ambiguous appearance
 Maximise stent expansion
- clinical experience MLA ≥7 mm2
- parent vessel MLA should be 1.5x daughter (4mm2)

36. IVUS & Unprotected LMS Stenting
 18 LMS vs. 60 non-LMS PCI
 Additional high-pressure or larger size balloon
dilatations were more frequently performed in
LMS stenting vs. non-LMS stenting (p <0.05)
 After IVUS-guided stent implantation, MLA was
≥9 mm2 in 88% of LMS patients vs. 19% of
non-LMS (p<0.001)
Hong MK et al, AJC 1998;82:670-3

37. IVUS & Unprotected LMS Stenting
0
5
2.5
15
5
25
MLD (mm)
Debulk/Stent
Stent
0
10
20
Angiographic
Restenosis (%)
p<0.05
p<0.01
4.2
4.0
Reference artery size = only independent predictor (not IVUS)
99.2% procedural success, 97% 2 year survival
8.3
25.0
IVUS
Angio
n=127
non-randomised
77 50 40 87
Park SJ et al, JACC 2001;38:1054-60

38. When I Use IVUS
CLINICAL PRACTICE
 Diagnostic uncertainty
 Assessment of in-stent restenosis
 Left main stenting
 Atherosclerosis research

39. IVUS can assess Risk of a
future Clinical Events
 Yes

40.  a new study Obstructive Coronary Artery
Disease Mechanisms of Myocardial
Infarction in Women Without
Angiographically Obstructive Coronary
Artery Disease" by researchers at the Cardiac &
Vascular Institute at NYU Langone Medical
Center. And this type of non-obstructive
myocardial infarction seems to happen more
frequently in women than in men.

41. Intravascular Ultrasound (IVUS) Imaging Reveals
Hidden Heart Attack Culprit In Women
a coronary artery may look completely normal using the standard two-dimensional "shadow" image of
coronary angiography. But when the same arterial segment is viewed cross-sectionally using
intravascular ultrasound, a "flap" of plaque can be seen hanging in the arterial lumen. This plaque
disruption, a rupture or ulceration of cholesterol plaque, was shown to be the mechanism behind
myocardial infarction (heart attack) in some women who were classified as having no significant coronary
artery disease (CAD).

42. Can I assess Bifurcation lesion
through IVUS

43. IVUS Pull-back

44. IVUS Pull-back
Proximal LM
Lesion
Catheter
Distal LM
Bifurcation
LAD-CX
14mm
Bif. LAD-CX
Prox. LM
Distal LM
Lesion

45. Ostium
Stent
Distal LM
Bifurcation
LAD-CX
Stent area: 12 mm2
Stent diameter: 4 mm
IVUS Pull-back

46. ChromaFlo imaging highlights
blood red at the touch of a button
,for the easiest assessment of
Stent apposition
Lumen size
Wall apposed stent
Thrombus
Dissection and
more.
Chromaflo

47. Lumen Sizing
Bifurcation Plaque
across Crania
Thrumbus
DissectionWall apposed stent
Stent Malapposed

48. OCT can provide a super high resolution tool to identify;
 Intraluminal thrombus
 Thin cap fibroatheromas (10-15 micron resolution)
 Other?
Stent with acute formation of white thrombus
Volcano OCT
Optical Coherence Tomography

49. OCT provides a super high resolution tool to guide;
 proper lumen sizing
 full stent apposition
 optimal stent expansion
Volcano OCT
Optical Coherence Tomography

50. Proposed Volcano OCT Components
 Super-fast Spectral Domain
imaging catheter
○ Does not require balloon occlusion for
blood clearance
○ Similar to rotational IVUS design
○ 10-15 micron axial resolution
 Bedside user controls
○ The same user interface controls IVUS
and FFR
 Image on existing monitor bank
The development, release and timing of any features or functionality described for our products remains at the sole discretion of the company.
Volcano OCT
Optical Coherence Tomography

51. Performance Comparison, OCT vs
IVUS
Spazial Resolution 12 - 15 mm 100 - 200 mm
Acquisition Time 20 mm/s 0.5 - 1 mm/s
Tissue Penetration 1.0 - 2.0 mm 10 mm
Contrast enjection
during acquisition
Every images No contrast
IVUSC7XR

52. Image Comparison
52
 Edge dissection
during stent
implantation
 Neointimal growth on
previously implanted
stent at follow-up
???
???

54. FFR= 0,74

55. COMPLEMENTARY ROLE IVUS FFR OCT
PRE INTERVENTION
IVUS vessel size lesion lenght
FFR Severity lesion
POST INTERVENTION Expansion
Apposition
Coverage
Complication Underexpansion
Edge problems
IVUS
OCT INDICATION
Immediatelly after stent
implantation
1 Year after DES
Implantation
1 Year after BMS
Implantation
Delayed healing; new intimal growth

56. Technical Specification of Volcano Catheters

57. Technical Specification of Volcano Catheters

58. Advancement in Volcano

59. IVUS Guided Therapy - VIBE
Combined IVUS and Balloon
•IVUS Platform : Eagle Eye Platinum
•Balloon semi- and non-compliant

60. Technical Specification
 Tip Entry profile
 Crossing Profile
 Nominal Compliance
 Rated Burst comp.
 Frequency
 Shaft outer diameter
 Crossing profile at transducer
 Maximum guide wire
Minimum guide catheter
 Usable length
0.017’’
0.025’’
8 atm
14 atm
20 Mhz
0.046”, 1.17 mm
0.046”, 1.17 mm
0.014” (0.36 mm)
6F (0.066” ID)
150 cm

61. Revolution® 45 MHz IVUS
Imaging Catheter
 High frequency rotational imaging
providing unmatched access and
accuracy

65. Forward Looking IVUS

66. Fractional flow reserve
 Technique used in coronary catheterization to
measure pressure differences across a coronary
artery stenosis (narrowing, usually due to
atherosclerosis) to determine the likelihood that the
stenosis impedes myocardial ischemia.
 Fractional flow reserve is defined as the pressure
behind (distal to) a stenosis relative to the pressure
before the stenosis. The result is an absolute
number; an FFR of 0.50 means that a given stenosis
causes a 50% drop in blood pressure. In other
words, FFR expresses the maximal flow down a
vessel in the presence of a stenosis compared to the
maximal flow in the hypothetical absence of the
stenosis.

68. FFR Limitation &
Disadvantage
 FFR assess of lesion
severity.
 FFR invasive test and
allows real-time estimation
of the effects of a
narrowed vessel.
 No plaque morphology
information.
 physical exercise or some
intravenous medication is
to increase the workload
and oxygen demand of the
heart muscle, and
ischemia is detected
using ECG changes
or Nuclear imaging.

70. Normal >0.8
Non significant 0.75 - 0.8
Significant <.75

71. Fractional flow reserve
Significant <0.75
Non significant 0.75 - 0.8
Normal > 0.8

73. Microvascular hyperemia
Drugs
Adenosine / Papaverin
 • Adenosine: 6mg/500cc NS (12mcg/cc)
 • IC boluses:
○ –60 mcg (5 cc)
○ –96 mcg (8 cc)
○ –120 mcg (10 cc)
 • IV drip 140 mcg/Kg/Min

74. DEFER study
 In the DEFER study, fractional flow reserve
was used to determine the need for stenting in
patients with intermediate single vessel
disease. In those patients with a stenosis with
a FFR of less than 0.75, outcome was
significantly worse. In patients with a FFR of
0.75 or more however, stenting did not
influence outcomes. This suggests that FFR is
a useful tool to gauge decision-making in this
setting.

75. Forward Looking IVUS
 PreView™
 Catheter-based
 1.5 mm imaging offset from
tip
 45 degree off-set forward
looking cone
 5 mm forward
 Imagine a funnel centred at
your eye and looking forward
 Mackinaw™
 Same image
 Pulsed RF energy delivered
to ‘red’ target
 Steering is enabled by
rotating the catheter and
moving the target
Ablation Region
Vessel
Lumen
New
Ultrasound
Lines
Intima
Media
Adventitia

76.  CTOs indication
 Successful product requires 3
attributes
 Visualization, Steering, Dissection
 Design Considerations
 Compatible with CTO guidewire of
choice
 Ability to visualize at 45 degrees when
catheter approaches vessel wall
 Passive version for visualization
only
 Preview™
 Active version equipped with RF
ablation
 Mackinaw™
These Volcano Products are not currently available for sale. This document implies no guarantee as to future delivery or timing of these programs, and is meant
only to highlight Volcano’s recent research & development efforts
Volcano FL.IVUS
Forward Looking IVUS to facilitate CTO crossing