Optimizing PCI with IVUS Guidance

Pre-Intervention Assessment

The American College of Cardiology recommends IVUS for pre-intervention assessment of plaque composition, lesion characteristics, and identification of optimal reference segments and landing zones for stent placement 2
IVUS helps select optimal stent length and diameter, preventing systematic undersizing of stents, according to the American College of Cardiology 2
The American College of Cardiology suggests performing IVUS after administration of intracoronary nitroglycerine, beginning at least 20mm distal to the area of interest and ending at the vessel ostium 2
IVUS identifies vulnerable plaques at risk of future rupture, guiding intensification of medical therapy, as recommended by the American College of Cardiology 2, 3

The American College of Cardiology recommends using IVUS to improve detection, localization, and characterization of coronary calcification, guiding appropriate adjunctive therapies 1, 2
IVUS-based scoring systems help identify calcified stenoses at risk for stent under-expansion, requiring adjunctive modification before stent implantation, according to the American College of Cardiology 1
Stent lengths should be selected to cover from the most normal distal segment to the most normal proximal segment, as suggested by the American College of Cardiology 1, 4
The American College of Cardiology advises avoiding stenting into reference segments with restricted lumen areas and plaque burden >50% or segments with large lipid plaque or significant calcification 4

The American College of Cardiology recommends a minimum lumen area (MLA) in the IVUS-stented segment >5.0 mm² or 90% of the MLA at the distal reference segments 1, 5
The American College of Cardiology suggests <50% plaque burden within 5mm proximal or distal to the stent edge 1, 5
No edge dissection involving the media with a length >3mm is recommended by the American College of Cardiology 1, 5

Post-procedure IVUS confirms optimal procedural endpoints and identifies complications requiring correction, according to the American College of Cardiology 4, 6
The American College of Cardiology recommends identifying key complications, including stent underexpansion, deformation, and malapposition 5, 6
Edge dissection, hematoma, and tissue protrusion should be identified and addressed, as suggested by the American College of Cardiology 5, 6

For left main interventions, IVUS is particularly important with specific cut-off values, according to the American College of Cardiology 4
IVUS helps resolve proximal cap ambiguity and guides true-lumen wiring in chronic total occlusions, as recommended by the American College of Cardiology 4
The American College of Cardiology suggests using IVUS to determine optimal stenting strategy and proper stent sizing in tapering vessels, such as bifurcations 4
IVUS guides appropriate lesion preparation strategies before stent deployment in calcified lesions, according to the American College of Cardiology 2

Despite proven benefits, IVUS is used in <15% of all PCI procedures due to unfamiliarity with equipment and knowledge gaps in interpretation, as noted by the American College of Cardiology 7
The American College of Cardiology advises using IVUS cautiously in spontaneous coronary artery dissection due to risks of manipulating the dissected artery 2
Air bubbles between the catheter sheath and IVUS transducer can degrade image quality, according to the American College of Cardiology 7
Stent malapposition should be distinguished from stent underexpansion, as most acute malapposition resolves over time without affecting long-term stent failure rates, as suggested by the American College of Cardiology 6