Cath Lab Digest - March 2008 - (Page 44)

44 CLINICAL UPDATE MARCH 2008 Note an innocuous-appearing lucency in the mid right coronary artery on proximal edge of a Cypher stent. The IVUS examination of this same region discloses a severe proximal edge dissection with a flap of plaque inside the stent. Left untreated, this patient would have been at high risk of stent thrombosis. main lesions — essentially those higher-risk, complex interventions where we know, even with DES technology, that you are likely to see higher rates of restenosis or a higher risk of stent thrombosis. To my knowledge, national use of IVUS in this country is somewhere between 5%-15%, which in my mind is way too low. The Japanese are at about 70%. Depending on the types of cases people are doing, anywhere between a 30-50% level of use is a more appropriate number. What have been some of the technological developments that have made IVUS easier to use? To me, the most critical is integration into the lab. Any interventionalist may have a natural resistance to bringing in a standalone device, whether a Rotablator, an AngioJet, etc., where you have to drag another piece of equipment that takes up space into the room, then have personnel turn it on and run it. It is an understandable and very natural impediment to using any technology, and it obviously takes a lot of time. Integrating IVUS into the cath lab, where it is always on and ready, means IVUS use is just a matter of grabbing an extra catheter and turning on a button. Integration is the most important development we have seen in the 14 years since I have been doing IVUS. We have not had this absolute luxury of integrated equipment in cath labs until the last year or two. It has certainly made the procedure much more pleasant for me and for my staff. It’s quicker and has dramatically reduced the resistance staff have to doing IVUS. Times in the past, you could almost hear people’s eyes roll around in their heads when you’d say, “Well, bring in the IVUS machine, let’s take a look at that.” They just knew it was going to be an extra 10 or 15 minute process. So the level of staff resistance, which I think in many cases has affected interventionalists’ judgment on whether to use it in a procedure, really evaporated in our lab. Our staff now often perceives IVUS as a time-saver. We have timed it and it takes about a minute and a half to do a baseline IVUS run in our lab. With that image, I can make a definitive judgment on the size of the stent I need and whether I will need to perhaps post-dilate with a larger balloon to upsize the stent. In some cases, I will look at a lesion and conclude that it doesn’t even need to be done at all. With integration, IVUS doesn’t prolong the procedure and may ultimately be a time-saver. I can even predict with a high degree of certainty from the baseline IVUS whether a lesion will require a pre-dilatation to get a good result. Virtual histology (VH) is a fascinating advancement; I think it is an advancement. At this point, in routine practice, it doesn’t have a clear-cut niche or indication. I use it, it’s part of the system we have, so I routinely look at IVUS with VH. I do gain a lot of insight into the nature of the lesion. Sometimes I make decisions to extend extra stents in adjacent disease. Sometimes VH points to a culprit it area of disease proximal to the area of the most severe stenosis. Recent studies indicate lesions with high necrotic core content appear to be more likely to embolize debris, and it might lead me to a decision to place a distal protection device. At this point we are still learning about VH. The PROSPECT trial should provide insight into the ability of VH to detect vulnerable plaque; this trial is entering the third year of follow up. If VH proves to be useful in vulnerable plaque detection, we may one day be able treat lesions before they cause potentially catastrophic clinical sequlae. At this point, however, we are still learning about VH. As you noted, is important to place the ends of the stent in a normal, undiseased part of the artery if possible.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - March 2008

Cath Lab Digest - March 2008 Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals Saint Joseph’s Hospital Invasive Imaging Tools for Optimizing Coronary Stent Deployment Contents Clinical Editor’s Corner A Workflow Revolution in Cath Lab Reporting Advantages of a New Digital Lab at Baystate Medical Center Cardiac Computed Tomography: What Does it Mean for the Cath Lab? The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cellular Cardiomyoplasty and Cardiac Regeneration Intravascular Ultrasound in the Cath Lab: A Powerful — and Underutilized — Tool to Improve Patient Outcomes The Stentplus™ Patient Success Program Cardiac Cath Lab Clutter — or, Spring into Action! Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A List of Relevant Issues Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab What Do You Think? Experience with a New Guidewire: The Terumo Runthrough NS The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Precious Minutes The Ten-Minute Interview with…Mark Bowles, BSN, CCRN Vascular Care in the Cath Lab: Planning a Smooth Transition Cath Laughs CMS 2008 OPPS Final Rule Review An Extensive Set of Review Courses for the CCI Basic Science, Non-Invasive Echocardiography and Vascular, and ARDMS Ultrasound Exams Meetings Calendar CEU Education Center Clinical & Industry News STEMI Interventions Classifieds Advertisers Index

Cath Lab Digest - March 2008

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