Analysis of Target Lesion Length Before Coronary Artery Stenting Using Angiography and Near-Infrared Spectroscopy Versus Angiography Alone

Dixon, Simon; Grines, Cindy L.; Ahmad, Mahmood; Madder, Ryan D.; Safian, Robert D.; Hanzel, George; Pica, Mark; Goldstein, James A.

doi:10.1016/j.amjcard.2011.07.068

Cited by 43 publications

(28 citation statements)

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“…79 An analysis of 75 lesions with NIRS demonstrated LCP extending beyond the angiographic margins in 16% of cases, which may potentially allow for more optimal selection of stent length and lesion coverage. 80 However, the low specificity of these modalities for the prediction of distal embolization and periprocedural MI, coupled with a measurable, albeit low, risk of complications with additional coronary instrumentation, suggests that routine intracoronary imaging may be a low-yield strategy. If a selective imaging strategy is chosen, patients presenting with ACS and those with long or thrombotic lesions represent the highest risk group for distal embolization or periprocedural MI, and hence the group is likely to derive the greatest benefit from coronary imaging.…”

Section: Discussionmentioning

confidence: 99%

Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention

Patel

Brayton

Mintz

et al. 2013

Circ: Cardiovascular Imaging

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T he incidence of periprocedural myocardial infarction (MI) after percutaneous coronary intervention (PCI) ranges from 2% to 50%, depending on the clinical presentation, type of procedure, choice of biomarker (creatine kinase [CK]-MB or troponin), and the threshold used to qualify the diagnosis. 1 Because of this heterogeneity of definition, the prognostic implications of periprocedural MI are controversial. However, several studies have demonstrated that periprocedural MI is associated with worse in-hospital, short-term, and long-term clinical outcomes, including death, recurrent MI, and need for revascularization. [3][4][5] Various mechanisms can lead to periprocedural MI, such as side branch occlusion or vessel spasm; however, distal embolization of atheroma or thrombus seems to be a dominant cause. 6 In a cardiac MRI (cMRI) study of patients undergoing complex native coronary PCI, elevated troponin levels post-PCI correlated with new myocardial enhancement because of side branch occlusion in 43% of cases and in the apical myocardium distal to the stent in 57% of cases, as would be expected with distal embolization. 7Numerous studies have documented the occurrence of distal embolization during both elective and urgent PCI and have characterized its histopathologic substrate. In an analysis of catheter-retrieved materials from human studies of patients undergoing PCI for acute coronary syndrome (ACS), 8 those with no-reflow had significantly higher amounts of visible atheroma and microscopic components such as platelet-fibrin complexes, cholesterol crystals, and macrophages. 8 In another study of 37 lesions in 35 patients undergoing elective PCI, microscopic particles were captured by embolic protection devices (EPDs) in 28 (75.6%) lesions.9 Thrombotic components (fibrin strand-entrapped platelets, leukocytes, and red cells) accounted for the majority (≈75%) of captured debris, whereas plaque components (fibrous tissue, calcium spots, acellular amorphous material, macrophages, foam cells, and cholesterol clefts) accounted for the minority (≈25%).9 Similar findings were demonstrated among 33 patients undergoing either native or saphenous vein graft PCI.10 Supporting these in vivo findings, in a postmortem analysis of patients who died of ischemic heart disease, many had evidence of coronary microemboli, composed of cholesterol crystals, hyaline, and platelet aggregates. 11Clinically, distal embolization can result in asymptomatic biomarker elevation or symptomatic ischemia; angiographically, it can present as visually undetectable silent embolization, macroembolization resulting in epicardial coronary obstruction, or severe microvascular obstruction resulting in no-reflow.Coronary angiography has limited capacity to assess the risk for distal macro-or microembolization. The development of advanced intracoronary imaging techniques and noninvasive imaging techniques, such as coronary computed tomography angiography (CCTA) and cMRI, provides an opportunity for detailed analysis of plaque composition, which can pot...

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Section: Discussionmentioning

confidence: 99%

Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention

Patel

Brayton

Mintz

et al. 2013

Circ: Cardiovascular Imaging

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“…4) document that placement of the ends of a stent over an LCP could result in high frequency of stent thrombosis [5,6]. Employing NIRS, Dixon et al demonstrated that in 16 % of cases, LCP extended beyond the angiographic margins of the target lesion [29]. A subsequent study employing NIRS-IVUS documented significant plaque burden (by IVUS) and LCP (by NIRS) beyond the angiographic margins in 80 % of target coronary lesions (Hanson et al, unpublished) (Fig.…”

Section: Nirs-ivus: Bvalue Added^clinical Applicationsmentioning

confidence: 98%

Present Status and Future Direction of NIRS-IVUS Multimodality Direct Coronary Imaging

Hanson

Goldstein

Dixon

et al. 2015

Curr Cardiovasc Imaging Rep

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Intracoronary near-infrared spectroscopy (NIRS)-IVUS is a direct coronary imaging catheter for the identification and quantification of lipid core plaque (LCP). NIRS is combined with traditional grayscale IVUS in a hybrid catheter that provides co-registered architectural and compositional plaque characterization data. The novel capability of the NIRS catheter component is its ability to directly identify LCP, which underlies the majority of vulnerable and unstable plaques. NIRS-IVUS has potential to optimize percutaneous coronary intervention (PCI) by delineating precise lesion length, assuring adequate stent expansion and apposition, detection of stent edge dissection, and predicting periprocedural myocardial infarction (PMI). NIRS-IVUS may also be important in the identification of vulnerable plaques at risk to cause future events.Catheterization laboratory decision-making in individual patients requires challenging decisions regarding revascularization strategies (i.e., percutaneous coronary intervention (PCI) versus bypass surgery) and performance of PCI (e.g., choosing target lesions, identifying length of vessel to treat, optimization of stent deployment, and prevention of distal embolization and PMI).Based on first principles, optimal stenting would fully cover the target lesion, landing stent edges in normal zones of the vessel. However, atherosclerosis is typically a diffuse process, with disease often extending beyond the critical stenosis. Failure to cover the full length of the target diseased coronary arterial segment with drug-eluting stent (DES) has been associated with increased rates of sub-acute stent thrombosis and late restenosis [1, 2, 3••, 4••], particularly if the uncovered lesion segment is composed of lipid core plaque (LCP) [5,6]. Unfortunately, coronary angiography alone is inadequate. Although important to delineate the presence of disease and quantification of lumen stenosis, angiography underestimates the magnitude of atherosclerosis, particularly in early disease when positive vascular remodeling maintains Bnormal^lumen caliber despite substantial plaque in the vascular wall. In addition, angiography does not provide data on chemical composition of plaque.

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“…Potential clinical strategies to mitigate this risk include vasodilator administration (nicardipine is the authors' preferred medication due to longer half-life and modest hypotensive effect), aggressive anticoagulation (with addition of a glycoprotein IIb/IIIa inhibitor, which is usually given as bolus only without post-PCI infusion), attempts for plaque "vaporization" (e.g., by using laser), and deployment of an embolic protection device (usually a filter that can capture both embolized plaque and/or thrombus) (12). Although these steps are logical, their Third, fibroatheroma detection within a lesion treated with PCI may allow for optimal stent selection (13). Using a long-enough stent to completely cover the fibroatheroma may reduce the rate of acute stent thrombosis (14), and possibly restenosis.…”

Section: Fibroatheroma Detected: Now What?mentioning

confidence: 99%

How to Detect and Treat Coronary Fibroatheromas

Brilakis

Banerjee

2015

JACC: Cardiovascular Imaging

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As you set out for Ithaka hope the voyage is a long one, full of adventure, full of discovery.-Constantine P. Cavafy, Ithaka (1) C oronary fibroatheromas can cause a wide spectrum of adverse events, such as sudden death, acute coronary syndromes, and procedural complications during percutaneous coronary interventions (PCI) (2). Accurate fibroatheroma detection could significantly enhance our ability to treat these lesions and prevent complications. FIBROATHEROMA DETECTION DURING CARDIAC CATHETERIZATION Fibroatheromas can be detected noninvasively with coronary computed tomography angiography. Three imaging modalities are currently available for fibroatheroma detection during cardiac catheterization: intravascular ultrasonography (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy (NIRS) (3) (Figure 1).Grayscale IVUS, which is the oldest and most widely available intravascular imaging modality, was not developed specifically for the detection of fibroatheroma. However, IVUS-attenuated plaque (attenuation of the ultrasound beam in the absence of calcification), especially when superficial (closer to the lumen than the media), is a specific (but not sensitive) fibroatheroma "signature" (4,5).Analysis of the backscattered radiofrequency IVUS signals (virtual histology IVUS and integrated backscatter IVUS) also allows plaque characterization, but it is challenging to perform in real time during the procedure because it requires accurate segmentation of the IVUS images, which is a time-consuming and labor-intensive process (3).OCT identifies fibroatheromas as signal-poor regions with ill-defined borders (6), but OCT image interpretation is subjective and highly dependent on operator experience (3). Moreover, deep fibroatheromas may be harder to detect due to poor penetration of the near-infrared light beam.NIRS was developed to specifically detect lipid core plaque in coronary arteries, on the basis of the specific chemical signature of the fibroatheroma (7).Near-infrared light is directed to the coronary artery wall, and the reflected light is collected and analyzed using algorithms developed based on histological analyses (7). NIRS is currently available as a combination catheter with IVUS (TVC, Infraredx, Burlington, Massachusetts)-the only such catheter currently in clinical use. In this issue of iJACC, Kang et al. (8) advance our understanding of fibroatheroma detection with IVUS and NIRS, compared with the gold standard, histology. In an autopsy study of 103 coronary arteries from 56 autopsied hearts, they compared superficial IVUS attenuation (for IVUS) and a yellow or tan block chemogram (for NIRS) with the histopathology obtained from 1,943 sections. Superficial IVUS attenuation had excellent specificity, yet low sensitivity for fibroatheroma detection, which was significantly improved by NIRS. The addition of NIRS significantly increased SEE PAGE 184 *Editorials published in JACC: Cardiovascular Imaging reflect the views of the authors and do not necessarily represent the views of JACC:...

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Analysis of Target Lesion Length Before Coronary Artery Stenting Using Angiography and Near-Infrared Spectroscopy Versus Angiography Alone

Cited by 43 publications

References 17 publications

Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention

Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention

Present Status and Future Direction of NIRS-IVUS Multimodality Direct Coronary Imaging

How to Detect and Treat Coronary Fibroatheromas

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