Pre intervention IVUS.pdf

8/11/2019 Pre intervention IVUS.pdf

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Cardiovascular Research FoundationCardiovascular Research Foundation

New York, NYNew York, NY

Pre-Intervention IVUSPre-Intervention IVUS

Gary S. Mintz, MDGary S. Mintz, MD


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Weigh otential ro!le"s #i$e$ %& disease, signi'icantWeigh otential ro!le"s #i$e$ %& disease, signi'icantro(i"al or distal disease)ro(i"al or distal disease)

*ssess lesion severit+*ssess lesion severit+ *ssess unusual lesion "orholog+ #i$e$, aneur+s"s,*ssess unusual lesion "orholog+ #i$e$, aneur+s"s,calciu", thro"!i, high-risk "orholog+, in-stentcalciu", thro"!i, high-risk "orholog+, in-stentrestenosis, etc$)restenosis, etc$)

&easure vessel sie&easure vessel sie

&easure lesion length&easure lesion length eter"ine and 'ine-tune the resultseter"ine and 'ine-tune the results *ssess co"lications*ssess co"lications

&ost o' the concets used in IVUS-guided intervention are&ost o' the concets used in IVUS-guided intervention areno di''erent 'ro" those used in angiograh+-guidedno di''erent 'ro" those used in angiograh+-guided

intervention$ .owever, unlike angiograh+, IVUS is actuall+intervention$ .owever, unlike angiograh+, IVUS is actuall+a!le to "ake recise "easure"ents and assess lesiona!le to "ake recise "easure"ents and assess lesion

"orholog+$"orholog+$


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// 0""0"" 12""12""

Pro(i"alPro(i"alRe'erenceRe'erence

%esion%esionSiteSite

istalistalRe'erenceRe'erence

33& CS* 4 21$533& CS* 4 21$5%u"en CS* 4 6$7%u"en CS* 4 6$7

&a(i"u" lu"en dia"eter 4 02$8&a(i"u" lu"en dia"eter 4 02$8&% 4 2$0&% 4 2$0

P9& CS* 4 33&-%u"en 4 1:$1P9& CS* 4 33&-%u"en 4 1:$13ccentricit+ 4 &a(i"u";"ini"u" P9& 4 0$/;/$13ccentricit+ 4 &a(i"u";"ini"u" P9& 4 0$/;/$1

PlaPla*rea stenosis 4 re'erence-lesion;re'erence lu"en area 4 72>*rea stenosis 4 re'erence-lesion;re'erence lu"en area 4 72>


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0 10 50mm

b

a

c

6% 74%

69%

67%

a

b

c

Mintz et al. J Am Coll Cardiol 1995;25:1479-85Mintz et al. J Am Coll Cardiol 1995;25:1479-85

In 886 native coronar+ arteries, the la

and :2A12> o' la


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Coronar+ Re"odeling .+othesisCoronar+ Re"odeling .+othesis

Co"enator+ 3(ansion&aintains Consistant %u"en

3(ansion

Bverco"e%u"en Narrows

Nor"al

Vessel

&ini"al

C*

&oderate

C*

Severe

C*


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* D

3'

'E

C

F

distal

%u"en

e

!

eE

!E

%u"en

Positive Re"odelingPositive Re"odeling

Negative Re"odelingNegative Re"odeling

c

cE

distal

33&33&

33&33&


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Re"odeling is not ust acade"ic$Re"odeling is not ust acade"ic$Positive re"odeling is associated withPositive re"odeling is associated with

Acute coronary syndrome at presentationAcute coronary syndrome at presentation CK-MB elevation after percutaneous coronary interventionCK-MB elevation after percutaneous coronary intervention No reflow in primary infarct angioplastyNo reflow in primary infarct angioplasty Recurrent ischemia within one month after thrombolysisRecurrent ischemia within one month after thrombolysis

for acute myocardial infarctionfor acute myocardial infarction

arget lesion revasculari!ation in patients undergoingarget lesion revasculari!ation in patients undergoingnonstent intervention and intimal hyerplasia in patientsnonstent intervention and intimal hyerplasia in patientsundergoing bare metal stent interventionundergoing bare metal stent intervention

Ma"or adverse coronary events in patients with unstableMa"or adverse coronary events in patients with unstableangina undergoing any form of revasculari!ationangina undergoing any form of revasculari!ation

#n-hospital complications$ ma"or adverse coronary events$#n-hospital complications$ ma"or adverse coronary events$restenosis$ and new lesion formation in patients withrestenosis$ and new lesion formation in patients with

stable angina undergoing single vessel intervention%stable angina undergoing single vessel intervention%


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%esion Calci'ication #n41177)%esion Calci'ication #n41177)

Calci'ication

&o

fangiographiclesions

#'() *uadrants of calcium

Suer'icial calci'ication

&o


#'() *uadrants ofsuperficial calcium

Mintz et al. Circlation1995;91:1959-65.Mintz et al. Circlation1995;91:1959-65.

Ghe onl+ redictor o' IVUS calciu" was angiograhic calci'icationGhe onl+ redictor o' IVUS calciu" was angiograhic calci'icationelsewhere in the coronar+ tree$elsewhere in the coronar+ tree$ +u!cu et al% , AM Coll Cardiol ../0123451-46+u!cu et al% , AM Coll Cardiol ../0123451-46

0

5

1 0

1 5

2 0

2 5

3 0

N o n eO n e T w o T h r e eF o u r

S ev e r e

M od e r a t e

N o n e / M il d

0

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

N o n eO n e T w o T h r e eF o u

S ev e r e

M od e r a t e

N o n e / M il d


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%esion 3ccentricit+ #n41665)%esion 3ccentricit+ #n41665)

Mintz et al. Circlation 1996;9!:924-9!1Mintz et al. Circlation 1996;9!:924-9!1

0

1 0

2 0

3 0

4 0

5 0

6 0

1 . 0 - 3. 0 3 . 0 - 5. 0 5 . 0 - 7. 0 > 7. 0

Y es

N o

3ccentricit+

&o


#'() Ma78Min

9:M hic;ness


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&a(i"u" la


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Unusual %esion &orholog+Unusual %esion &orholog+

*ngiograhic 'illing de'ects*ngiograhic 'illing de'ects Ghro"!iGhro"!i Calci'ied nodulesCalci'ied nodules

*ngiograhic aneur+s"s*ngiograhic aneur+s"s Grue aneur+s"sGrue aneur+s"s Pseudoaneur+s"sPseudoaneur+s"s Co"le(;rutured la


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B


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0?/31/->0?/31/->

@istance from coronary ostium +mm6@istance from coronary ostium +mm6

of ruptured pla*ues of ruptured pla*ues


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IVUS Classi'ication o'*ngiograhic *neur+s"s

B' :: angiograhic aneur+s"s 21 #2:>) true aneur+s" 0 #6>) seudoaneur+s" 12 #15>) co"le( la) nor"al seg"ent adacent to one or "ore

stenoses

Grue*neur+s"

PS* Co"le(Pla


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0 2.5 10.0mm


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0 3.5 17.5mm


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0 1.5 7.5mm


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Ghree Vessel IVUS I"aging in 26Ghree Vessel IVUS I"aging in 26Pts with *CS and Positive GnPts with *CS and Positive Gn

7/ rutured la


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Rutured la


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%ocation o' 2:0 rutured la


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Co"arison o' Culrit Non-Culrit Ruture Sites inCo"arison o' Culrit Non-Culrit Ruture Sites in*CS Patients and Ruture Sites in Non-*CS Patients*CS Patients and Ruture Sites in Non-*CS Patients

4/$//14/$//1 4/$//14/$//1

ACS Culprit PlaqueACS Culprit Plaque

Ruptures (N=35)Ruptures (N=35)

ACS NonCulprit PlaqueACS NonCulprit Plaque

Ruptures (N=!")Ruptures (N=!")

NonACS PlaqueNonACS Plaque

Ruptures (N=!)Ruptures (N=!)

(mm!)

(nde)endent )redictor* o+ AC, ere MA and t$rom/* #/ot$ )0.01%(nde)endent )redictor* o+ AC, ere MA and t$rom/* #/ot$ )0.01%

Fuji et al. Circulation 2003;108:2473-8Fuji et al. Circulation 2003;108:2473-8


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2""2"" 5""5""//


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00 1.01.0 6.0mm6.0mm

' ' '


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What is the 'ate o' non-'low-li"itingWhat is the 'ate o' non-'low-li"itingrutured la) vs

no statin-treated atient #4/$11)$no statin-treated atient #4/$11)$

%esions re


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Su!clinical la


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0 3.0 12.0mm


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0 8 40mm


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The HCI SCAD Registry

)CA@ N15

Med R7 without stent or CAB

N?

#nitial 9C# attempted

N5

Coronary stenting without CAB

N5

#nitial med R7 attempted

N4

#nitial CAB

N5

9C# after initial med R7

N1

CAB after 9C# attempt

N

CAB after initial med R7N

Med R7 after failed

thrombectomy

N

CAB

N/

9C# attempted otal

N>

hrombolysis N1

Coronary AngiogramsN15

#(to et al. JACC Cardio3a*clar (nter3ention* in )re**%#(to et al. JACC Cardio3a*clar (nter3ention* in )re**%


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WrinklingWrinkling


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0 1.5 9.0mm

Attenuated 9la*ueAttenuated 9la*ue

Dee et al% ,ACC Cardiovasc #nterv% 1==.013/>-21

Eu et al$ Am , Cardiol 1==0=>3?4->5

Attenuated pla*ues were observed in 5.%/& of )FM#$ 2%/& of N)FM#$ and =&

of stable angina%

Attenuate pla*ues were associated with more fibroatheromas and a larger necroticcore +on '


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Validation o' IVUS assess"ent o' ische"ia-Validation o' IVUS assess"ent o' ische"ia-


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Validation o' IVUS assess"ent o' ische"ia-Validation o' IVUS assess"ent o' ische"ia-roducing stenoses #oler FloWire,roducing stenoses #oler FloWire,

SP3CG, and Pressure Wire)SP3CG, and Pressure Wire)

??5.5.CHRCHR 1%=1%=

121211CHR G 1%=CHR G 1%=

#'() MDAG?%=mm1

#'() MDAI?%=mm1

@iagnostic accuracy .1&%@iagnostic accuracy .1&%Abi!aid et al% Am , Cardiol ..40413?1-4Abi!aid et al% Am , Cardiol ..40413?1-4

1=1=- )pect- )pect

?1?1??J )pectJ )pect

#'() MDAG?%=mm1

#'() MDAI?%=mm1

@iagnostic accuracy .5&%@iagnostic accuracy .5&%Nishio;a et al% , Am Coll Cardiol ...055342=-4Nishio;a et al% , Am Coll Cardiol ...055342=-4

a;agi$ et al% Circulationa;agi$ et al% Circulation...0==31>=->...0==31>=->


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85 ts

Nishioka G,

M*CC 1===

Gakagi et al

Cir$ 1===

*!iaid et al

*MC 1==8

:/ lesions

62 ts

&%* #""2) 0$092$0 0$=A2$/ 6$6A2$/

&V* #""2) 10$2A6$6

*rea stenosis> 77A26 60A26

Cut-o'' o' &%*

#""2)

6$/

#Ghalliu" 9)

0$/

#FFR /$:7)

J 6$/

#CFR J2$/)

OC* V #"")S #>)

IVUS vs FFR in 2/1 ts #205


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Sensitivit+4=/>Seci'icit+45/>

PPV40:>

NPV4=5>

*ccurac+458>

IVUS vs FFR in 2/1 ts #205inter"ediate lesions)

= 1= ?= /= 4= ==

==-)pecificity

==

4=

/=

?=

1=

=

)ens

itivity

Cut-o'' 42$62""2

A(C=%4==

.>& C#=%2?1-=%4?4

"an' et al. Circlation Cardio3a*clar (nter3ention* in )re**


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&%* ""2

/>?51=

=%4

FFR J/$8

2$6 ""2

FFR /$8

V3RICG Pil tV3RICG Pil t


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V3RICG PilotV3RICG Pilot

9rospective$ multicenter$ non-randomi!ed$ non-blinded study in

5== intermediate coronary lesions

+@) ?=& - G4=&$ R'@ 1%2> L ?%= mm6

HHR and '


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C$ ctober ? th $ 1==4C$ ctober ? th $ 1==4

Nico


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*NIB-grou

N46=5

FFR-grou

N47/=

9-value9-value

# indicated lesions per patient# indicated lesions per patient 2$: A /$= 2$8 A 1$/ =%5?=%5?

FFR resultsFFR results

Desions succesfully measured$Desions succesfully measured$ No +&6No +&6 - 102= #=8>) --

Desions with HHR I =%4=$Desions with HHR I =%4=$ No +&6No +&6 - 8:6 #50>) --

Desions with HHR P =%4=$Desions with HHR P =%4=$ No +&6No +&6 - 710 #0:>) --

Stents per patientStents per patient 2$: A 1$2 1$= A 1$0 G=%==G=%==

Desions succesfully stentedDesions succesfully stented +&6+&6 =2> =6> --

@F)$ total$@F)$ total$ NoNo 107= =8/ --

HAMF study3HAMF study3 9rocedural Results9rocedural Results

HAMF t dHAMF t d F t f ) i lF t f ) i l


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HHR-guided

5= days1%.& .= days

5%4& 4= days

?%.& 5/= days

>%5&

Angio-guided

absolute difference in MACF-free survival

HAMF study3HAMF study3 Fvent-free )urvivalFvent-free )urvival

B' all the coronar+ seg"ents, the %&C* hasB' all the coronar+ seg"ents, the %&C* has


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Hisher et al% Cathet Cardiovasc @iagn .41043>/>-2>

Comparison between percent stenosisComparison between percent stenosisassessment from the *uality control +QC6 lab vsassessment from the *uality control +QC6 lab vs

the clinical site in the CA)) )tudythe clinical site in the CA)) )tudy

area of the s*uare is proportional to the number of casesarea of the s*uare is proportional to the number of cases

QC labQC lab

Clinical siteClinical site

====

== ======

B' all the coronar+ seg"ents, the %&C* hasB' all the coronar+ seg"ents, the %&C* hasthe greatest angiograhic assess"entthe greatest angiograhic assess"ent

varia!ilit+ - Ivaria!ilit+ - I

B' all the coronar+ seg"ents, the %& hasB' all the coronar+ seg"ents, the %& has


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B' all the coronar+ seg"ents, the %& hasB' all the coronar+ seg"ents, the %& hasthe greatest angiograhic assess"entthe greatest angiograhic assess"ent

varia!ilit+ - IIvaria!ilit+ - II

Cameron et al% Circulation .450/43?4?-?4.

Hive grades of DMHive grades of DM

severityseverity

33 =-1?& @) =-1?& @)1313 1>-?.& @)1>-?.& @)

5353 >=-2?& @)>=-2?& @)

?3?3 2>-4.& @)2>-4.& @)

>3>3 .=-==&@).=-==&@)

of grades of difference in assessment of grades of difference in assessment

of DM severityof DM severity

=3=3 no differenceno differenceJ or -3J or -3 grade difference grade difference

J1 or -13J1 or -13 1 grades of difference1 grades of difference

J5 or -53J5 or -53 5 grades of difference5 grades of difference

J? or -?3J? or -?3 ? grades of difference? grades of difference

Clinical site vsClinical site vs

Quality controlQuality control

Clinical site vsClinical site vs

)tudy roup)tudy roup

)tudy roup vs)tudy roup vs

Quality controlQuality control

Dut surel+ we are !etter toda+ IQDut surel+ we are !etter toda+ IQ


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Lindstaedt et al. Int J Cardiol 200!"202$%&'"

Dut surel+ we are !etter toda+ - IQDut surel+ we are !etter toda+ - IQ

> intermediate or e*uivocal DM lesions were evaluated by> intermediate or e*uivocal DM lesions were evaluated byHHR and angiography% Hour e7perienced interventionalHHR and angiography% Hour e7perienced interventional

cardiologists visually classified lesions as SsignificantT$ Snotcardiologists visually classified lesions as SsignificantT$ Snot

significantT$ or Sunsure%TsignificantT$ or Sunsure%T he ? e7perienced interventional cardiologists achievedhe ? e7perienced interventional cardiologists achieved

correct lesion classification in no more thancorrect lesion classification in no more than UU>=& of each>=& of each

case regardless of the HHR threshold +I=%2> or I=%4=6%case regardless of the HHR threshold +I=%2> or I=%4=6% #nterobserver variability was large$ resulting in unanimous#nterobserver variability was large$ resulting in unanimous

correct lesion classification in only 1.&Vcorrect lesion classification in only 1.&V

Which o' these %&C* lesions isWhich o' these %&C* lesions is


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Which o' these %&C* lesions isWhich o' these %&C* lesions issigni'icant and, there'ore, should !esigni'icant and, there'ore, should !e

treated *nd which is nottreated *nd which is not


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0 1.5 6.0mm


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0 3.0 9.0mm


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0 2.0 5.0mm

&%*46$5""2


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0 2.0 8.0mm


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0 1.0 4.0mm

IVUS deter"inants o' %&C* FFRIVUS deter"inants o' %&C* FFR


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IVUS deter"inants o' %&C* FFRIVUS deter"inants o' %&C* FFR/$:7/$:7

,asti,astiet al% Circulationet al% Circulation1==?0=3145-/1==?0=3145-/

IVUS Criteria 'or aIVUS Criteria 'or a Signi'icantT %&C*Signi'icantT %&C*


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IVUS Criteria 'or aIVUS Criteria 'or a Signi'icantT %&C*Signi'icant %&C*StenosisStenosis

&ost IVUS %&C* studies show either insigni'icant disease&ost IVUS %&C* studies show either insigni'icant diseaseor critical diseaseor critical disease

*!solute lu"en CS* 5$/""*!solute lu"en CS* 5$/""22#or &% 0$/"") is the#or &% 0$/"") is the

suggested criterion 'or a signi'icant %&C* stenosissuggested criterion 'or a signi'icant %&C* stenosis

Correlates with a %&C* FFR/$:7Correlates with a %&C* FFR/$:7

oes not deend on 'inding a disease-'ree re'erenceoes not deend on 'inding a disease-'ree re'erence

seg"entseg"ent

%ong ter" data #%IGRB registr+)%ong ter" data #%IGRB registr+)

It is not clear whether the sa"e criteria should !e used 'orIt is not clear whether the sa"e criteria should !e used 'or

ostial %& lesions as 'or "id-sha't;distal !i'urcation lesionsostial %& lesions as 'or "id-sha't;distal !i'urcation lesionsand 'or ositivel+ vs negativel+ re"odeled lesionsand 'or ositivel+ vs negativel+ re"odeled lesions

#'() assessment of DM disease#'() assessment of DM disease


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9la*ue burden +9:M8FFM6 /4&9la*ue burden +9:M8FFM6 /4&

MDA2%1mmMDA2%1mm11

#'() assessment of DM disease#'() assessment of DM diseasesignificance is based on lumensignificance is based on lumendimensions$ not pla*ue burdendimensions$ not pla*ue burden

??S"all@ %& 4 i''use %&C* diseaseS"all@ %& 4 i''use %&C* disease


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S"all %& 4 i''use %&C* diseaseS"all %& 4 i''use %&C* disease

&urra+&urra+Ts %awTs %aw

%&C*%&C*rr00

44 %*%*rr00

99 %C%Crr00

Fractal eo"etr+Fractal eo"etr+

%&C*%&C* 4 /$5:8 # 4 /$5:8 #%*%* 9 9 %C%C))

(C) DS *+

Fractal (C) DS *+/

2/

:/

/

2/

:/

Matreff et al% Furointervention 1==0>32=.->

-rospectie application o/ prede/ined I1S criteria /or-rospectie application o/ prede/ined I1S criteria /or


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-rospectie application o/ prede/ined I1S criteria /orospect e app cat o o p ede ed 1S c te a oreascularization o/ interediate le/t ain coronary arteryreascularization o/ interediate le/t ain coronary artery

lesions Results at 2 years /ro t3e LI4R5 studylesions Results at 2 years /ro t3e LI4R5 study

5>? patients5>? patients

MDAMDA /%=mm/%=mm11

+n4/6+n4/6MDA G/%=mmMDA G/%=mm11

+n/46+n/46

2 revasculari!ed2 revasculari!ed

No DMCA revasculari!ationNo DMCA revasculari!ation

+n2.$ ./&6+n2.$ ./&6DMCA revasculari!ationDMCA revasculari!ation

+n>1$ .=&6+n>1$ .=&6

/ not revasculari!ed/ not revasculari!ed

>/& 9C# of other vessels>/& 9C# of other vessels>>& CAB>>& CAB

?>& 9C# +J other vessels in /1&?>& 9C# +J other vessels in /1&

@e Da orre


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reascularization *ML) 7'reascularization *ML) 7'22

Surial /ree o/ cardiac

deat3, MI and anyreascularization

-80.22

De/er *n8"9

Reascularization *n8"$2


deat3-80.20

De/er

Reascularization


deat3, MI and LMC)reascularization at 2

years 9%.2+

Surial /ree o/ LMC)

reascularization at 2years 9'.$+

Surial /ree o/ cardiacdeat3 at 2 years 9.++

@e Da orre


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@e Da orre =

?=

5=

1=

-=

=

ime

De/er *edical t3erapy 6it3 ML) :'2*n8"9

De/er *edical t3erapy 6it3 ML) ;'2


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IVUS vs FFR in %&C* iseaseIVUS vs FFR in %&C* isease

here is probably more agreement between #'() and HHR inhere is probably more agreement between #'() and HHR in

assessing DMCA lesion significance than in assessing non-assessing DMCA lesion significance than in assessing non-

DMCA lesion significanceDMCA lesion significance Dimited variability in DMCA lengthDimited variability in DMCA length Dimited variability in amount of supplied myocardiumDimited variability in amount of supplied myocardium

Darge DMCA si!eDarge DMCA si!e Both have theoretical and practical limitationsBoth have theoretical and practical limitations

DA@ and8or DCW disease L HHRDA@ and8or DCW disease L HHR #t is necessary to image the DM from both the DA@ and#t is necessary to image the DM from both the DA@ and

DCW - #'()DCW - #'()


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#n 1>& of patients$ the left main MDA differed#n 1>& of patients$ the left main MDA differedby mmby mm11when imaged from a pullbac;when imaged from a pullbac;

beginning in the DA@ vs a pullbac; beginningbeginning in the DA@ vs a pullbac; beginning

in the DCW%in the DCW%

)ince #'() can artificially increase$ but not)ince #'() can artificially increase$ but notdecrease lumen dimensions$ the smallest MDAdecrease lumen dimensions$ the smallest MDA

is always the most accurateis always the most accurate


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00 1.01.0 4.0mm4.0mm

00 1.01.0 5.0mm5.0mm

LC=LC=

L)DL)D

#'() assessment of DCW ostium from the DA@-#'() assessment of DCW ostium from the DA@-


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3valuation o' the %* 'ro"

the %&-%C ull!ack

3valuation o' the %C 'ro"

the %&-%* ull!ack

-

i''erence!etweenesti"atedand

directl+"easuredlu"en

dia"eters#"")

-

i''erence!etweenesti"atedand

directl+"eas

uredlu"en

dia"eters#"")

DM +or vice versa6 - MD@DM +or vice versa6 - MD@

viedo et al% Am , Cardiol 1==0=>3.?4->?

#f you want to *uantify the degree of lumen compromise$ you

must image the daughter branches directly%

#'() assessment of DCW ostium from the#'() assessment of DCW ostium from the


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Sensitivit+ Seci'icit+

9la*ueburdenP?=&

>.& ?>&

9la*ueburdenP2=&

24& ?1&

3valuation o' the %* 'ro"

the %&-%C ull!ack

Sensitivit+ Seci'icit+

9la*ueburdenP?=&

/2& >>&

9la*ueburdenP2=&

44& ?1&

3valuation o' the %C 'ro"

the %&-%* ull!ack

#'() assessment of DCW ostium from the#'() assessment of DCW ostium from theDA@-DM +or vice versa6 L pla*ue burdenDA@-DM +or vice versa6 L pla*ue burden

#f you want to *uantify the pla*ue burden$ you must image the

daughter branches directly%

viedo et al% Am , Cardiol 1==0=>3.?4->?

IVUS la


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%C #1)%* #1)

%&C* #1;1)

52> 16> 16>

6> 0> 2> 1>

%C #1)%* #1) %C #/)%* #1)

%C #1)%* #1) %C #/)%* #1) %C #1)%* #1) %C #1)%* #/)

%&C* #1;/) %&C* #1;/)

%&C* #/;1) %&C* #/;/) %&C* #/;/) %&C* #/;1)

1;1,1,1 1;/,1,1 1;/,1,/

/;1,1,1 /;/,1,/ /;/,1,1 /;1,/,1

-1


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=& ==&

&edina 1,1,1#n421)

&edina 1,1,/#n4=)

&edina 1,/,1

#n45)&edina /,1,1

#n411)

&edina 1,/,/#n4:)

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viedo et al% Circ Cardiovasc #nterv% 1==053=>-1

Inter"ediate in-stent restenosis lesions IIInter"ediate in-stent restenosis lesions II


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'ree survival in atients 'ro" G*US IV, V, and VI'ree survival in atients 'ro" G*US IV, V, and VI

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&ini"u" lu"en area&ini"u" lu"en area /$:7/$:7 6$2""6$2""22

+@oi et al Circulation #nterventions 1==403-4%%


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Date post:	02-Jun-2018
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Pre intervention IVUS.pdf

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