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Intravascular Ultrasound (IVUS) Consensus Guidelines

Author Ronak Patel covers Intravascular Ultrasound (IVUS) Consensus Guidelines on BackTable VI

Ronak Patel • Jun 15, 2023 • 374 hits

Intravascular Ultrasound (IVUS) has become a critical tool in coronary and peripheral vascular interventions, enabling an in-depth understanding of lesion length, vessel diameter, and plaque composition - valuable information necessary for the selection of balloons and stents. Furthermore, the utilization of IVUS post-stent placement has the potential to affirm accurate positioning and expansion of stents, mitigating the risk of dissection. In this article, interventional cardiologist Dr. Eric Secemsky explores key findings from IVUS consensus guidelines in coronary and peripheral interventions, emphasizing its importance in achieving optimal outcomes in tibial interventions and its common use for post-procedural optimization in iliac interventions. This article features excerpts from the BackTable Vascular & Interventional Podcast. We’ve provided the highlight reel here, and you can listen to the full episode below.

The BackTable Brief

• IVUS usage has significantly increased in coronary procedures since its inception, guiding 70% to 80% of interventions. IVUS assessment in coronary procedures includes measuring lesion length, vessel diameter, plaque composition, and stent optimization.

• IVUS sizing differs between coronary and peripheral arteries, with the former sized to the elastic membrane and the latter to the luminal diameter or slightly larger.

• A global survey on the appropriateness of IVUS use in different peripheral applications revealed that experts felt that IVUS is most useful in tibial and iliofemoral interventions during the procedure and post-procedure respectively.

Intravascular Ultrasound (IVUS) Consensus Guidelines

Table of Contents

(1) IVUS in Coronary vs Peripheral Interventions

(2) IVUS Consensus Guidelines

IVUS in Coronary vs Peripheral Interventions

Dr. Eric Secemsky highlights the use of IVUS imaging in vascular procedures. IVUS is commonly used in coronary interventions, with its use being considered a 'badge of honor’ according to Dr. Secemsky. The routine use of IVUS in such interventions provides key information like lesion length, vessel diameter, and plaque composition, crucial for the optimal selection of balloons and stents, and ensuring safe, improved outcomes. When used post-stent placement, IVUS imaging confirms stent position, expansion, and absence of dissection, giving clinicians confidence in the procedural outcome. Transiting this technology to peripheral procedures in regards to vessel sizing, the consensus is to size to the elastic membrane for coronary procedures, while for peripheral arteries, the luminal diameter or slightly larger is the typical measurement. These strategies help optimize balloon or stent selection, potentially improving procedural efficiency and patient outcomes.

[Dr. Sabeen Dhand]
Let's talk about IVUS. I personally used to use IVUS sporadically when I first started my practice, and about a year and a half ago, we upgraded our system and got a really much more newer generation of IVUS, which has been a lot better. Are you using IVUS for both artery and veins and everything far in between?

[Dr. Eric Secemsky]
Yeah, it's always interesting to talk to an interventional cardiologist about IVUS, because most interventionists in training right now, or in practice, have a specific focus on intravascular imaging during coronary procedures. We use IVUS liberally. I mean I would say in my own practice, 70% to 80% of my coronary interventions are performed by IVUS guidance. In the world of coronary intervention, you're applauded when you use IVUS.

It's something that you wear as a badge of honor, for having taken the extra time to use a device that is making the procedure safer and outcomes better. I spent a lot of time using IVUS in the coronary. When I trained on venous work, we did a lot of IVUS on venous work, and then we had a smattering of IVUS during our peripheral artery interventions. That wasn't as routine back when I was training, years ago now.

But again, as you use this device more and more, you get more comfortable with it, to the point where I don't even feel comfortable doing some procedures without IVUS. It started to become kind of light bulb to say, "I should be thinking about this more in my arterial interventions, doing a little bit more on the venous interventions, exploring where else this device can really help optimize care for patients."

Really, the goal, obviously, is to make our procedures durable, and particularly in the endovascular world, I think this was really a moment for me to say, "I think I can do better with this device as a guidance."

[Dr. Sabeen Dhand]
When you're using it for coronary, I mean what are you looking at in IVUS? Are you just looking at sizing? Tell me, what are the things that are going through your head one, two, three, four, five, when you're looking at an IVUS image?

[Dr. Eric Secemsky]
Yeah, in the coronary space, it's pretty well regimented into how we perform IVUS. On the normal case, you cross the lesion with the wire, and you IVUS. On your IVUS, you get a couple of things. You get lesion length, so you get healthy to healthy reference. You get the vessel diameter so that you can size your pre-do balloon, and then we always stent in the coronary, so our coronary stent. Then you get an understanding of the plaque composition.

In particular, for coronary, it's calcium. How much calcium? What's the arc? If it's 360 degrees, we know that we probably have to do something to modify that calcium, to get a stent in. So every coronary intervention that uses IVUS kinda follows that same routine. We're very regimented in the coronary. When you look at coronary cases, you could be across the country, or even the world, we do things almost the same, in Boston as in the Netherlands, or where else.

It's really interesting because in the peripheral, we know that's not the same, and we'll talk a little bit about that later. Then you do your ballooning. Usually, if you feel comfortable with how your balloon looks, you put in your stent, and then you IVUS again. When you IVUS again, you're trying to optimize the stent at position. You want to make sure that there's no malposition, or under-expansion.

Then, for me, you're looking at the edges of the stent and make sure there's no dissection. When I walk away from a coronary procedure with a clear IVUS run, showing a good stent, no problems, I'm sleeping better. I always joke about this to my fellows, because we always get these calls, "Oh, they're having a little bit of chest pain, or their blood pressures--" Listen, I feel very confident based on how I left the lab, that that stent's looking good.

[Dr. Sabeen Dhand]
That stent is perfect, basically.

[Dr. Eric Secemsky]
That stent's per area. Got my stamp on it.

[Dr. Sabeen Dhand]
Now, a little bit of a peculiarity, because now I'm using IVUS almost on every intervention, too. When you're measuring the size in a coronary, or what we're going to extrapolate to peripheral soon, I mean you see the round ring of calcium. Usually, most arteries are calcified, what we're treating. Are you measuring on the outside of the ring, on the inside, in the middle? It makes a difference. I mean, we're talking about 0.5 mm, or a millimeter, which makes a difference in our sizing. So where exactly are you measuring?

[Dr. Eric Secemsky]
Yeah, that’s a continued debate about what's the right way. I think we're both on the same page for arterial sizing. Ideally, you're trying to identify the three layers of the vessel wall. In the coronary, we're really looking to size to that black stripe that happens behind the intima. That's the elastic membrane, and you want to size to that. Now, again, in the corner, though, it's a balloon-mounted stent and you deploy it, that's where you deploy that.

If you're sizing to the elastic membrane, that's fine, but you're doing that differently than when you have an outward force from a self-expanding stent, or if you're not stenting, just ballooning. A lot of times, minus the calcium, if I'm making a measurement of the arterial vessel in the periphery, I'm usually doing a luminal diameter, or extending it maybe a quarter millimeter longer than the luminal diameter of a healthy reference. That's pretty much how I do my measurements.

Keeping in mind that, again, a lot of the self-expanding stents we'll use, but even for one-to-one sizing, or 1.2-to-one sizing for balloon angioplasty.

[Dr. Sabeen Dhand]
Sometimes, I'm a little confused, like, "Oh, should I go--? What part of the vessel should I measure?" Now it's nice, I can measure myself on the system that I have, where I have the tablet in my sterile field. Before, I was using this trackball, and not I was, my techs would use it, and they would measure from the thigh skin to the middle of the vessel. There was no control of it.

[Dr. Eric Secemsky]
It makes a world of difference, how much easier you can do it. Again, I'm a little bit spoiled, because I have a fellow that's usually doing the pullback, and I'm just making bookmarks. I'm telling them to stop, I’ll fluoro-save a healthy reference or section on IVUS. The whole thing goes really quickly when you get used to it. My humble opinion is that I make a smarter device selection after that.

Usually, I don't necessarily dilate anymore. I'm just using one balloon that sized off IVUS. It definitely makes my procedure more efficient.

Listen to the Full Podcast

Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus with Dr. Eric Secemsky on the BackTable VI Podcast)
Ep 320 Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus with Dr. Eric Secemsky
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IVUS Consensus Guidelines

Dr. Eric Secemsky discusses the key findings from IVUS consensus guidelines in peripheral interventions. The survey, which involved arterial and venous specialists from different specialties and countries, aimed to determine the appropriateness and significance of IVUS in various procedural scenarios. The results revealed a strong consensus among experts that IVUS is now considered a mainstay in peripheral interventions. Specifically, for tibial interventions, IVUS was deemed crucial for achieving optimal outcomes. In iliac interventions, IVUS was more commonly used for post-procedural optimization, given the availability of standardized sizing methods such as CT scans. In the venous realm, IVUS was unanimously viewed as an integral part of iliofemoral interventions, both for obstructive and thrombotic venous disease. These findings provide important guidance for clinicians, highlighting the areas where IVUS can significantly enhance procedural success and patient outcomes.

[Dr. Sabeen Dhand]
What are the take-home points of your consensus guideline, then? Tell me what are the major things that you guys found.

[Dr. Eric Secemsky]
After we created those phases, we had to write the whole survey. We tried to really take clinical scenarios that we encounter in our daily practice. We focused on Iliofemoral obstructive, venous obstructive disease, and then we broke up lower extremity arterial disease by iliac, fem pop, and tibial, just because they have three different-- Those are all different procedural, in the approaches. We created this really robust survey that was originally about 180 questions, for the arterial side, so 60 per vascular bed.

Then we took the survey and it took three and a half hours. Then we were like, "No one's going to do this," so we randomly picked two questions out of-- We wrote five for each scenario, so two questions. It was about a four to five minutes arterial survey, and about a little over 40 questions on the venous side, it was a little bit shorter for that one. Then we voted and nominated, and identified 15 arterial experts, who did not know each other, or at least did not know they were all participating, and then 15 venous experts.

No overlap. None of them were on the writing committee, and we sent them the survey.

[Dr. Sabeen Dhand]
That's awesome.

[Dr. Eric Secemsky]
We sent them the survey and what we get back-- I remember when we unveiled, it was September of 2021, right before we were planning to have a meeting on this, at VIVA. It was like-- Wow, everybody on this survey-- Again, we didn't know how people's IVUS experience necessarily were. We were just looking for representation from different specialties, different countries, whatnot. It was really remarkable how much people were on the same page about using IVUS, and in particular for tibial intervention.

If you look at the tables that go through the appropriateness, it is kind of green, yellow, red, appropriate, may be appropriate, not appropriate. Pretty much the whole survey is green and yellow. There's really no red, and it's all green for tibial. Everybody there who did extensive or advanced tibial work felt like IVUS was a necessary tool to get a good outcome. On the iliac side, a lot of people looked at IVUS as important for later in the procedural, so those optimization phases.

Again, I get that, there's a little bit more standardized sizing on iliacs. A lot of people use CT scans to size.

[Dr. Sabeen Dhand]
You have a CT. Yes. Exactly.

[Dr. Eric Secemsky]
Exactly. It makes more sense that it would be more of a post-procedure thing. The fem pop, it was more consistently appropriate throughout the procedure scenarios, a touch less on the pre-procedure side, where a few scenarios were maybe appropriate, but really, the take-home on this was-- Each photo contributes to score, then we take the median of all the scores. Could be seven to nine to be appropriate, all them, the medians, were eight or nine.

Just showing you that people really felt passionately about where IVUS should be used. I think we came out of it with two things. One is really a consensus, probably the first time, by multiple specialty, multiple providers, that IVUS is a mainstay in peripheral intervention now. Then the second thing was-- It did give you some granularity about where IVUS is particularly helpful, where you really should be honing in if you're a new user, or you're dabbling a little bit, where this should be the right first space to move into.

If you're doing tibial, grab the coronary IVUS from their partners in the cath lab, stick it down there, see what we've been talking about on this podcast for the last half hour, and you'll really see the value.

[Dr. Sabeen Dhand]
Yes. Exactly. I'm sure in venous, where was the most appropriate-- Probably iliofemoral, probably iliac. I mean, that one is a little different, right? I think everyone says you got to IVUS the common iliac vein.

[Dr. Eric Secemsky]
Yes. We came off at the right time with the survey, because we had the stent recall in one of the newer stents that were on the market. I had actually looked at this in Medicaid data, we were looking at deep venous stenting with IVUS, and it was like 70% of deep venous stents placed in the US for Medicaid patients, older patients had IVUS use. We focused only really on the iliofemoral disease, both nerval and thrombotic.

It was unanimous, the IVUS was an integral part of any venous intervention. I know you feel strongly, I feel strongly, that is the appropriate way to do venous work. That was less unexpected, and again, very consistent, in terms of the recommendation.

[Dr. Sabeen Dhand]
Yes, no, it's great work. It's a very good article. We will link to it in our podcast now. I don't think it's available for free. I don't know. I actually tried searching it, and I think it's on EuroInterventions, but I think they should just have this posted and available. It'd be awesome.

Podcast Contributors

Dr. Eric Secemsky discusses Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus on the BackTable 320 Podcast

Dr. Eric Secemsky

Dr. Eric A. Secemsky, MD, MSc, RPVI, FACC, FSCAI, FSVM is the Director of Vascular Intervention and an Interventional Cardiologist within the CardioVascular Institute at Beth Israel Deaconess Medical Center (BIDMC).

Dr. Sabeen Dhand discusses Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus on the BackTable 320 Podcast

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Cite This Podcast

BackTable, LLC (Producer). (2023, May 8). Ep. 320 – Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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