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[Intracoronary ultrasound changes the therapeutic approach in ambivalent angiography findings]
J Bruchhäuser1, U Sechtem, H W Höpp
1Klinik III für Innere Medizin, Universität zu Köln.
Insights
Intravascular ultrasound (IVUS) clarifies ambiguous coronary angiography findings, changing treatment strategies for many patients. This improved management led to excellent clinical outcomes, avoiding unnecessary interventions.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Coronary angiography can provide ambiguous results regarding lesion severity.
- Accurate assessment of coronary artery stenosis is crucial for guiding revascularization decisions.
Purpose of the Study:
- To evaluate the impact of intravascular ultrasound (IVUS) on revascularization treatment strategies for patients with angiographically ambiguous coronary findings.
- To assess the clinical efficacy of IVUS-guided management over a one-year follow-up period.
Main Methods:
- Retrospective review of 31 patients (34 lesions) with equivocal angiographic findings who underwent additional IVUS.
- Intervention was indicated if IVUS showed area stenosis >50% in the left main or >75% in other major coronary arteries.
- Clinical follow-up was performed at one year to assess outcomes.
Main Results:
- IVUS changed therapy in 21 of 31 patients, leading to intervention cancellation in 19 cases and revascularization in two.
- Angiography overestimated lesion severity in several cases (e.g., ostial lesions, non-significant proximal lesions).
- At follow-up, 17 of 21 patients with changed management were symptom-free; interventions guided by IVUS in two patients with persistent angina resolved symptoms.
Conclusions:
- Intravascular ultrasound (IVUS) is clinically valuable for clarifying ambiguous coronary angiographic findings.
- IVUS-guided management significantly altered treatment strategies, reducing unnecessary interventions and improving clinical outcomes.
- IVUS provides crucial anatomical detail, aiding in precise decision-making for coronary interventions.
Abstract:
Despite careful evaluation of multiple projections, coronary angiography may give ambiguous results of lesion severity. The purpose of this study was to analyze the impact of ultrasound imaging on revascularization treatment strategy in angiographically ambiguous findings. We reviewed our experience with such equivocal angiographic findings before intervention in 31 patients (34 lesions) who had additional intravascular ultrasound (IVUS) to clarify coronary anatomy. Intervention was felt to be indicated if area stenosis by IVUS exceeded 50% in the left main or 75% in other major coronary arteries. To evaluate the clinical efficacy of IVUS based management strategies, all patients had clinical follow-up after 1 year. Seven of nine ostial lesions were overestimated by angiography, but two of three left main lesions were found to be significant. Seven lesions in one of the proximal coronary arteries whose significance was difficult to judge by angiography were found not to be significant by IVUS, whereas in the other four severe obstruction was confirmed. Membranes by angiography corresponded to remnants of ruptured plaques by IVUS in all five patients. However, significant narrowing was found in only two patients. Side branch ostial lesions were ruled out by IVUS in all four instances. Two patients with unstable angina but normal angiograms showed complex atherosclerotic plaques in the left coronary artery. IVUS led to a change of therapy in 21 patients (revascularization instead of conservative treatment in two and cancellation of initially intended intervention in 19). At follow-up examination, 17 of these 21 patients were free of cardiac symptoms. Interventions at the site thought not severely diseased by IVUS had to be performed in two patients with persistent angina who were afterwards free of symptoms. One patient with persistent chest pain had a second coronary angiogram during the follow-up period, but conservative therapy was continued. Evaluation was impossible in one patient because of bypass surgery due to another coronary lesion. In conclusion, IVUS was clinically useful in patients with angiographically ambiguous findings and resulted in a change of therapy in 21/31 patients obviating interventions in 19 patients with excellent clinical results.