Watch this presentation to find out how the routine use of IVUS can lead to more precise PCIs, better outcomes and economic benefit in the treatment of CAD patients.
Advance your knowledge on the benefits of using intravascular imaging from Dr. Kevin Croce of Brigham and Women’s Hospital (Boston). His presentation outlines the shortcomings of angio-guided PCI and the growing list of trial evidence on how imaging-guided PCI can show clear benefit for patients.
Good morning, everybody. Thanks for being with us. Nice and early. Welcome to our in person attendees and the numerous people online, it's been neat to see such a good online presence and lots of good questions coming in both from our in person audience and from the people who are out there watching. So I was asked to charge with what is the reading, what is the evidence for routine international imaging? And so I kind of frame this in terms of why would I want to use inter-voucher imaging in my mind. You know, you'd hope to be able to improve PC outcomes, make it more precise, make it faster easier and then eventually show an economic benefits. So we'll take each of these in some quick fashion over the next 8 to 10 minutes. You know, there's a lot of misconceptions about the draft imaging, which I think are in part the reason why it's not used more. You know, there has been a long held belief that we've been doing pcr the same way for a long time and he was good enough. We'll look at the data on outcomes, you know, I'm busy, it takes too long and to get home for my kid's soccer game and then the procedure will cost too much if I use some of these adjectives adjunctive therapy support tools and so we'll look at each of these and details, you know, we we even went through this yesterday in the case, I think that Andrew showed or Justin showed or Bruce showed, you know, we talked a little about what the angiogram looked like and I called it a 50. Justin called it a 60 this slide just shows the fact that even as interventionist if we look at the same angiogram compared to Q. C. A. We don't agree in terms of the percent stenosis but yet we still think it's ok to use and geographic estimate of severity by eyeball to make decisions for patients. And so they're potentially is a better way. We've known for a long time that the NGO compared to physiology does not in any way correlate in an important way. People that are angio 50 to 70% stenosis bike. You see a large part of them actually where we differ normally would be undertreated because the frs are abnormal. And then the range we usually treat patients 70 to 90% by an Geographics to notice this. 20% of people actually have normal FFR values. So in many ways the anagram is not a great way to make decisions and who to treat and similarly thinking about, you know, how we treat patients and sizing and other aspects of looking angiograms. There really is a better way to do this. Looking at data which we participated in some part lead looking at the role of imaging and routine practice looking to see how it influenced decision making is in a project called Light Lab. I'll tell you, you know, when they came to me and said, hey we're gonna look at how you make decisions based on the angiogram kevin and then you're gonna do interventional imaging. Gonna see how it changes your decision making. I said to the team like hey I've been doing this a long time. I know I've retrained my eye so I'm hopefully better at reading angiograms. This is my personal data from Light Lab. If I do interventional imaging, it changes my stent sizing into either in terms of length or diameter, 76% of the time. So My premise that I didn't image for a while and I've gotten better was absolutely wrong. I thought to myself just and maybe it's time for me to go back to fellowship and really relearn how to read the instagrams. I felt a little bit better because the entire aggregate population of interventionists also got it wrong. About 40% of the time imaging change diameter both increased and decreased, showing that we're not really able to size are as well with imaging. This is Alan Jeremiah's study when we use an angiogram to guide our pc. I we leave a quarter of patients ischemic at the end of the case. This is defined P. C. I. And my chip fellow made the slide for me, I just put this to illustrate that 38% of the abnormal I. F. R. Values were in the stent that was just placed meaning it has an opportunity to be optimized further. And so other misconceptions about is you know there's really no proof that intravascular imaging impacts outcome. This is no longer true. There's a mountain of evidence that imaging helps us do a better job in PC. I patients to randomized trials done two years apart on different continents. I have a sex appeal and ultimate show conclusively that the interaction between cuts stent failure in half. It's amazing when two trials are done and they give you numerically the same benefit of mace on different continents. There's a lot to that. I think in terms of the veracity of the data. This is a meta analysis which included sex appeal and ultimate shows that there is a reduction in cardiovascular death when imaging is used to guide PC. I. Several registries tracked the same way UK registry and 6000 patients and misguided Pc I again associated with a reduction in an endpoint we really care about mortality. Additional to that. I think this is gonna be reviewed later syntax too, although it was a single arm study that looked at complex patients and compared them to syntax one we see when you use physiology imaging and good cto technique with modern stents, we were able to get outcomes as shown on the right side that approximate bypass surgery and so I think modern physiology and image guided P. C. I all the arrows pointing the same direction towards getting better outcomes for patients with regard to left main Pc. I think it's really uncomfortable in the current era to do left Main PC. I without image guidance. This is meta analysis. Looking at left Main PC. I benefit again. The benefit and mortality when left Main PC I is image guided. This is a slide I love to borrow from Gary Mintz where he shows the mountain of evidence randomized trials, meta analyses and registry is its support imaging. It's not meant to be read, it just meant to overwhelm you with the strength of the data and the amount of data in the space. Looking at how image guided PC. I changes decision making. This is more data from light lab. We looked at how a prescriptive strategy which is gonna be reviewed later today. Andrew's gonna teach us how to do an image guided divers Pc. I think the next couple of talks if you look at the impact of imaging compared the angiogram based decision making, it changes what we do 88% of the time. And if you plan the case based on the imaging, it actually the majority of impacts on the left slide. The left part of the slide is in pre PC. I. Planning so it helps us to do a better job and understand exactly what we need to do to treat patients. We know that small stents are the main predictor of stent failure. This is oh cT data but there are several studies survivalists in terms of whether we don't make our stents bigger. We have under expansion. It's one of the main things that causes students to fail. So it's not surprising that when you use imaging and makes sense bigger we start to harness the outcome benefits I alluded to earlier. It's been clearly shown again another meta analysis and imaging increases minimal luminary of stents by about 1.6 millimeters squared. Considering that the freedom from may survive, this starts to be positive after 5.5 millimeters, 1.6 millimeters is a big change in terms of stent area. So based on the data, everyone should get an image guided P. C. I. Right. Unfortunately us we're running about 24% of our pcs are currently image guided compared to japan which is 95%. So you could look at this as half empty and say, hey we've got to go a long way. But the cool part about this is in the prior couple of years leading up to last year, imaging only grew about a percent per year and after ultimate was published, it actually went up substantially the following year in response to the data. And so we're on I hope the beginning of a precipice of rapid growth in imaging because the data really is prime time in terms of supporting it and we're hoping that guidelines and other things will start to track as we get more randomized trials in this space which I'm sure we're gonna point in the same direction if you look at this. However it's not that every hospital does 24% imaging. This is data from the national inpatient database. Most hospitals do none or very little and that number 24% is driven by a number of centers to the right part of the screen doing sort of 60 80%. And so there is a lot of hydrogenated in terms of how we practice in the United States regarding image adoption of PC. I. I'm busy it takes too long to do imaging more data from light lab. When you actually take this prescriptive image based strategy and apply it for pre peace and imaging and post piece and watching how much longer does it take? We presented this at T. C. T. About a month ago. It takes nine extra minutes to do an MLD max guided P. C. I. If I'm getting a stent in my LED please take nine minutes to make sure it's implanted. Well so I can live longer. Additional to that is procedure cost. What's the cost of not using international imaging extent failure additional. This is data from light live from the efficiency phase which is the third phase that we've gone into. That demonstrates if you do prescriptive image based stenting you actually use less stents because you stand normal to normal have less edge dissections and plan your case appropriately. Additional to that. The cost of not using international imaging is substantial. Currently 12.6% of all us pc either done to treat incident restenosis, I can tell you these cases are expensive. We talked about things like laser rodeo, shockwave to deal with under expanded stance. If you get it right the first time and cut tlf in half, we're gonna be doing a lot less work for I. S. Are in the current era and I said I was gonna be reviewed as part of one of the later sessions in terms of how to optimally treated using imaging additional to that instead, restenosis has a major hazard of mortality. It kills people. A study from bobby a from last year on the left and again a list of all on the bottom ds restenosis is associated with bad outcomes for patients. So if you connect the dots, imaging cuts down Tl R. I. S. R kills people and people live along with imaging, it's not too hard to understand how aggregate all arrows point in the same direction. This is a nice opinion piece that Sunil Rao published about a year and a half ago, comprehensive use of physiology testing to identify ischemia lesions and imaging not to my standing results or contemporary features of high quality Pc. I we need to get our guidelines to attract the same way and I agree with Sunil Holy regarding that statement. So we now at our hospital tracked this monthly at our quality conference in terms of a quality initiative. We look monthly to see how many cases we do with PCR supported by imaging typically run between 80 and 90%. This didn't happen overnight. We put decision support tools in place. We trained our team, we trained our text and really work on this as an initiative because we believe in the data. So a final thought here. You know, we all believe in the fact that elective elective P CI doesn't show a benefit of mace. We never compete well against bypass surgery for target vessel failure. But if we use modern tools such as physiology and imaging that we know way better in the Andrea. Um what if we actually weren't under treating and over treating patients by deciding how to treat them basically angiogram? What if we weren't leaving a quarter of the ischemic at the end of the case? Especially half of those were in the stent that was displaced. What if we were cutting stent failure down in half which has been shown in all the imaging studies? And what if we had outcomes that we're approximating those in syntax to using modern stance. Modern physiology. Modern image guidance. I wonder if we might actually be able to show improving hard endpoints were actually compete with bypass surgery regarding target vessel failure. So by way of summary the angiogram of the blunt tied diagnostic tools to poor predictive ischemia. The angiogram is a bad way to assess PC. I success shown by alan Study, image guided PCR reduce the stent failure by 50% and likely saved lives. And intravascular imaging, I firmly believe is underutilized and PC. I. Thanks very much.