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Morphology of chronic coronary occlusions and response to interventional therapy--a study by intracoronary ultrasound
G S Werner1, J Diedrich, A J Morguet
1Department of Cardiology, Georg-August-University Goettingen, Germany. gwerner1@gwdg.de
Insights
Intracoronary ultrasound reveals multi-layered plaques in chronic coronary occlusions, associated with recoil. Quantitative ultrasound optimizes balloon angioplasty, improving luminal area and guiding stent use for better outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Balloon angioplasty for chronic coronary occlusions (CCOs) faces challenges with low success and high recurrence rates.
- Improved understanding of lesion morphology is crucial for optimizing interventional strategies in CCOs.
Purpose of the Study:
- To investigate the utility of intracoronary ultrasound (ICUS) in characterizing the morphology of CCOs.
- To assess the impact of ICUS-guided lesion assessment on balloon angioplasty outcomes.
- To identify predictors of acute recoil and inform decisions on stent deployment.
Main Methods:
- Intracoronary ultrasound was employed during recanalization procedures in 45 CCOs.
- Luminal area, plaque burden, and lesion morphology were quantitatively assessed using ICUS.
- Ultrasonographic characteristics were compared between occlusive and non-occlusive lesions.
Main Results:
- Multi-layered plaque morphology was identified in 22% of CCOs, a feature absent in non-occlusive lesions.
- ICUS-guided balloon sizing increased luminal area significantly (3.51 to 5.08 mm², p < 0.001).
- Multi-layered plaques were associated with significantly higher acute recoil (49% vs. 34%, p < 0.05).
Conclusions:
- Intracoronary ultrasound effectively visualizes plaque morphology in CCOs, revealing multi-layered plaques linked to acute recoil.
- Quantitative ICUS assessment optimizes balloon sizing, leading to substantial luminal gain.
- Detection of significant acute recoil warrants consideration for stent deployment in CCOs.
Objectives:
Balloon angioplasty of chronic coronary occlusions has a low procedural success and a high recurrence rate. Better tomographic insights into the lesion morphology may improve the interventional strategy and results.
Methods:
Intracoronary ultrasound was used during the recanalizaton procedure of 45 chronic coronary occlusions (2 weeks to 14 months; average 3.4 months) to determine the lesion morphology and to assess the angioplasty result. The luminal area and the plaque burden were measured proximal and distal to the occlusion, and within the occlusion. The ultrasonographic characteristics of the occlusive lesions were compared to 45 nonocclusive lesions of age-matched patients with stable angina pectoris.
Results:
Occlusive lesions were more often echodense as compared to nonocclusive lesions (35% vs. 20%; p = 0.10). In chronic occlusions a multi-layered plaque morphology was observed in 22%, and this morphology was not found in nonocclusive lesions. Angiographic characteristics were not related to the ultrasonographic morphology of the lesion. Despite similar vessel areas in occlusive and nonocclusive lesions, the balloon size selected according to the angiographic image was underestimated in occlusive lesions. Based on the quantitative ultrasound measurement the balloon size was increased from 2.6 +/- 0.3 mm to 3.3 +/- 0.5 mm in 53% of the lesions. This resulted in an increase of the luminal area from 3.51 +/- 0.92 to 5.08 +/- 1.43 mm2 (p < 0.001). The acute recoil after balloon angioplasty was similar (34 +/- 18%) in hypodense and echodense plaques, but was significantly higher in lesions with a multi-layered plaque morphology (49 +/- 22%; p < 0.05). In 19 patients with severe dissections or extreme acute recoil (residual stenosis > 50%) the use of a stent increased the luminal area from 3.94 +/- 0.81 to 7.51 +/- 1.71 mm2 (p < 0.001).
Conclusions:
Intracoronary ultrasound demonstrated a multi-layered plaque morphology in one fourth of the chronic occlusions. This type of plaque was associated with a significant acute recoil. The presence of diffuse atherosclerosis in neighbouring segments of chronic coronary occlusions leads to underestimation of the balloon size. Quantitative assessment by intracoronary ultrasound helped to optimize the balloon size leading to a significant luminal area gain. The detection of excessive acute recoil should be considered an indication for stent deployment.