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Intravascular Ultrasound (IVUS) Imaging: Benefits & Drawbacks

Author Ronak Patel covers Intravascular Ultrasound (IVUS) Imaging: Benefits & Drawbacks on BackTable VI

Ronak Patel • Jun 15, 2023 • 174 hits

Intravascular ultrasound (IVUS) is a medical imaging technique that utilizes a catheter with an ultrasound probe to provide detailed images of blood vessels from within. IVUS has shown benefits such as improved vessel assessment, enhanced procedural efficiency, reduced need for additional imaging and radiation exposure, and potential long-term durability of interventions. However, challenges in implementation, including cost, learning curve, and time constraints, need to be addressed to facilitate wider adoption of IVUS. According to interventional cardiologist, Dr. Secemsky, IVUS imaging can take up to 8-10 minutes extra, but can also help ensure optimal outcomes during the procedures.

IVUS imaging has been extensively studied and its application has recently been summarized in a consensus document that emphasizes the importance of independence from external industry relationships and aims to serve as a guide for all medical practitioners incorporating IVUS into their procedures.

Throughout this article, Dr. Secemsky, discusses the benefits and barriers of implementing the IVUS procedure and the more widespread adoption of this technique. This article features excerpts from the BackTable Podcast. You can listen to the full episode below.

The BackTable Brief

• Overcoming initial barriers and implementing a standardized IVUS procedure can enhance vascular interventional procedures overall.

• Consistent application of IVUS imaging may improve the long-term durability of vascular interventions due to better luminal gains.

• The IVUS consensus document was developed by a 12-person steering committee, including experts from vascular surgery, interventional cardiology, interventional radiology, and vascular medicine specialists. It outlines three phases of IVUS use: (1) Pre-intervention: Evaluate the healthy reference vessel, diameter, and presence of clot or mixed plaque. (2) Procedural: Enables real-time decisions during the intervention, such as the decision to stent or evaluate the result of an atherectomy. (3) Post-procedural optimization: Assesses the outcome of the intervention, checks stent placement, and verifies if there are complications like dissection.

Intravascular Ultrasound (IVUS) Imaging: Benefits & Drawbacks

Table of Contents

(1) Standardizing the IVUS Procedure for Improved Outcomes

(2) Addressing Barriers to IVUS Imaging Utilization in Peripheral Interventions

Standardizing the IVUS Procedure for Improved Outcomes

Dr. Eric Secemsky elaborates on the development and implications of a consensus document aimed at harmonizing the use of Intravascular Ultrasound (IVUS) imaging across multiple medical specialties. The document, a result of a robust collaboration involving a 12-member steering committee comprised of diverse vascular experts, outlines a procedural framework for IVUS, establishing a clear, standardized methodology that can be applied across arterial and venous beds. The document's key contribution is the establishment of three main procedural phases where IVUS can be employed — pre-intervention, during the procedure, and post-procedural optimization — providing a comprehensive guide for both seasoned practitioners and newcomers alike. The consensus document represents a significant stride towards unifying and standardizing peripheral vascular interventions.

[Dr. Sabeen Dhand]
Absolutely. It's been a whole difference to me now, the past year, having this new system, and it's just been tremendously helpful having that fellow or doing it yourself, rather than just relying on nothing. You've released an article last year, about the benefit of IVUS. Tell me how you organized the data, and what it really said. Just give us a little summary first, and we'll dive into it.

[Dr. Eric Secemsky]
Yeah so, I think the big question we ran into is-- We've got a lot of great studies that have come out, supporting IVUS, use is up, in particular, in the venous side, use is very high in the venous side, but we've got many specialties performing procedures in different ways, for different indications. So, this is one of those situations where we step back, and we all love randomized trials. I love randomized trials. This is such a mature field. It's a safe device.

Again, as you even speak about in your own experience, once you start using it, you see the benefit of it, was-- How do we harmonize this across specialties, across arterial and venous beds? Harmonize the data, harmonize expert opinion, and create a little bit of a guide for new users to follow, and feel that they are doing things in line with more experienced users. I think that was really the origin of how we put together this consensus document.

[Dr. Sabeen Dhand]
Exactly, how many people did you have? Tell me about your data.

[Dr. Eric Secemsky]
Yeah. Most important thing was, it had to be representative of all specialties practicing in our field and that was the number one key for this. It had to be completely independent of any external industry relationships. How this started was a conversation, honestly, with Phillips in Boston, about how do we create a better template, a better format for incorporating IVUS, and the appropriateness of IVUS in lower extremity interventions.

Myself, Sahil Parikh at Columbia, Ken Rosenfield at Mass General, created a 12-person steering committee. This is all on the JACC Interventions publication that, hopefully, we'll be able to link to the podcast, but we had 12 members who were a mix of vascular surgeons, interventional cardiologists, interventional radiologists, and vascular medicine specialists, from both the US and abroad. We really had a well-rounded group of experts who were really experienced users, but also balanced, in terms of their perspective.

Some people felt like IVUS is important, but not for every case. Some people were more like me, where I felt like IVUS, if I could, I'd use it in every case. We tried to get a number of opinions, a number of backgrounds represented, and we dove in. Again, when someone says to you, "You should do a consensus document," I'm one of those headfirst people. I'm like, "We're doing it, I'm in," I get home and I'm smiling, I'm like, "We're doing this consensus document," I sit down on my computer, I'm like, "How do we do this?"

We went back to other consensus documents that were done. In the cardiology side, we had the American College of Cardiology, that has done several AUC, and then a society called Sky, as well. We looked at how they did that. Again, we set up some basic rules. We had to set up the framework for how the survey would be put together, and we had to create criteria, including that anybody on the writing committee can't vote. On the voting committee, no one could be, obviously, reimbursed, no one could know each other.

I had to go through several rounds to meet consensus. Then, it came down to-- How do you structure an appropriate use criteria for IVUS? And then I can probably pull 10 people in a room and say how to use IVUS, and everybody uses IVUS differently. So, one of the secret sauces in the whole project was creating three phases where we were like, "Let's focus on three important procedural parts of your intervention, where IVUS is utilized, could be utilized, or should be utilized, and we'll use it as a framework.

That was probably what I was most proud of out of this, because we created this pre-intervention phase, which was a step through on the corner side, you get the wire crossed, and then you IVUS, and now, you're evaluating again, where's a healthy reference vessel, what's the diameter? Is there a clot in the mixed plaque? That's a pre-intervention phase. We have the procedural phase, which was-- Okay, I'm going to balloon, and if it doesn't yield, I'm going to IVUS, see what I want to do next, if I want to stent.

If I debulked with atherectomy, I may go back in and make sure I did a sufficient job. Then, the post-procedural optimization phase is-- I put a stent in, let's just make sure that stent's well opposed, no complications. I've got a small dissection, let's just take a look at it, make sure it's not extending back into the media or adventitia, that I feel like I need to cover. That was probably the breakthrough with the whole document. That is probably the most under-recognized out of the whole thing.

[Dr. Sabeen Dhand]
Is that format, or that form-- You can say, is that available to other people? Could I go in my practice and have a little regimented way of how I use IVUS? You're right, all eight IRS in my practice, either some of them don't use IVUS, some of them do, and then there's some, like me, who use it all the time, but variable, even within myself.

[Dr. Eric Secemsky]
Yes, absolutely. I mean, if I could say I have one career goal, is to get all of us, me, you, all of our colleagues, vascular surgery, vascular medicine, to do superficial anything that we do in the peripheral vascular space, to get it to be done a little bit more consistently in the more standardized approach. One of the table in there, in the consensus document, walks through these three phases, and it talks about different clinical scenarios that you're looking for in each phase.

Honestly, out of all, you can cite the appropriateness, and we'll get into that in a minute, but if anything, if you're a new user, just following that first part is really helpful to standardize how you use it. Again, that's how I use almost every one of my IVUS cases now. There's always somewhere-- something happens, and I vary from it, but I would say 80%, 90% of the time, I'm doing the pre-intervention run, I'm doing the middle run, I'm doing my post and that's how I use IVUS. I think everyone in that committee agreed on it.

Listen to the Full Podcast

Ep 320 Appropriate Use of IVUS in Lower Extremity Interventions: Expert Consensus with Dr. Eric Secemsky
00:00 / 01:04

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Addressing Barriers to IVUS Imaging Utilization in Peripheral Interventions

Dr. Eric Secemsky and Dr. Sabeen Dhand discuss the time constraints that come with the frequent use of Intravascular Ultrasound (IVUS) in peripheral artery disease (PAD) interventions. While acknowledging that the need to deploy IVUS multiple times per procedure can be seen as a barrier due to the potential increase in procedural time, they highlight the offsetting efficiencies brought about by its use. Utilizing IVUS often leads to increased procedure efficacy, with less contrast, radiation, and device utilization. They agree that the initial extra minutes spent on IVUS imaging are justified by improved patient outcomes and the reduction of potential procedure complications.

[Dr. Sabeen Dhand]
That's three times you're pulling up the IVUS catheter. How much time is that adding to your intervention now? You said you have a well-oiled machine, I realize that some people don't have that. What would you say is the average time you're adding to an intervention?

[Dr. Eric Secemsky]
Yes, it's a really important question. There's a couple we recognize as barriers to implementation costs. We're lucky in the US, our reimbursement's pretty good for these devices. It's not, outside the US, and that's big trouble. Then it's the, "How do I learn how to use IVUS?" That's a big one. I got lucky because that was part of my coronary training. In peripheral, we don't really have a lot of peripheral tracks for intravascular imaging, which, hopefully, will be available in the near future.

Then the third is, "God, I have eight cases booked, and you want me to pull out IVUS three times?"

[Dr. Sabeen Dhand]
Per case, that's 24 times, we put in that rapid exchange catheter on.

[Dr. Eric Secemsky]
We did this study on the coronary side, where we have a similar technology called OCT, Optical Coherence Tomography. We did this study with Abbott, called the Light Lab, where you started to ease and increase their use of OCT to guide your coronary intervention. Then they checked metrics, how much time it took to take that, you would do one or two runs, how many devices, radiation, contrast, exposure. Everything about your procedure became more efficient when you were using intravascular imaging, compared to before.

Again, it's back to-- I only pulled one balloon, I didn't take that extra shot at contrast, because I had that great run there, and I didn't need another image. Going back to the peripheral, I can't say that it's completely time neutral, but it's in the order of minutes. I spend more time sometimes just sitting there, asking my techs to run upstairs and try to find another balloon that wasn't on my shelf or something than I'd do doing three IVUS runs.

If you're counting minutes like that, I would say this is minutes well spent because, again, you can cut down device utilization, you can cut down contrast, cut down radiation, do something better for the patient, and, potentially, improve their outcomes. I would say maybe 8 to 10 minutes I could add, if I'm doing three IVUS runs, at most.

[Dr. Sabeen Dhand]
Yes. I agree. Again, too, when I upgraded my system-- Before, it used to be a 20-minute fiasco of trying to get this, or measure, and now it's just-- It's a streamlined machine, where I think it adds a couple minutes, but I do less runs. It's so fast, and I get so much more information. I'm literally probably opening IVUS for every single PAD case I do now. Whereas before, it was probably less than 10%. It was a big change in my practice, and I love it so far.

[Dr. Eric Secemsky]
It's really remarkable. Again, the things that you stumble across, also, where you're like, "Wow, I would normally guess there." [laughs] You know what I mean? Something like-- You got a prosthetic in the way, or it's just some weird angle, and you're like, "I'm just going to look on IVUS, it's not going to lie to me."

[Dr. Sabeen Dhand]
It's positive feedback. You're like, "Oh man, I thought that was like a five-vessel, and this is like eight. What the hell?"

[Dr. Eric Secemsky]
Oh, yes. That's the best.

[Dr. Sabeen Dhand]
Oh, man. I'll be honest, I've been getting-- I know I'm focusing on PAD, because that's a part of my practice, but I've been getting more palpable pulses now. I was getting them before, but now it's just much more often. I'm just using bigger devices, and doing better treatment.

[Dr. Eric Secemsky]
I think that the long-term durability of our procedures are based on the sizes, the diameter, that we get a vessel, and that's the same idea in the corner. If we're getting better luminal gain at the end, like you said, you're going to get a bigger bounding pulse, but hopefully, a better, long-term durability.

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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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