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      Intravascular Ultrasound–Guided Percutaneous Coronary Intervention: An Updated Review

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          Abstract

          Common practice dictates the performance of percutaneous coronary intervention under conventional angiographic guidance. With studies suggesting the high incidence of intraobserver variability, especially in angiographic borderline lesions, new modalities such as intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention have surfaced. Multiple studies have shown improved outcomes with IVUS guidance, mainly driven by a decrease in ischemia-driven target lesion revascularization. In the past two decades, a multitude of studies have investigated the uses and clinical outcomes associated with this technology. In this review, we highlight the utility, advantages, economic implications, and clinical outcomes of IVUS guidance over standard angiographic guidance, with emphasis on data as they pertain to IVUS-guided stent implantation.

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          Most cited references 53

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          Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI.

          Coronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave-free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR.
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            Long-Term Safety of Drug-Eluting and Bare-Metal Stents: Evidence From a Comprehensive Network Meta-Analysis.

            Previous meta-analyses have investigated the relative safety and efficacy profiles of different types of drug-eluting stents (DES) and bare-metal stents (BMS); however, most prior trials in these meta-analyses reported follow-up to only 1 year, and as such, the relative long-term safety and efficacy of these devices are unknown. Many recent studies have now reported extended follow-up data.
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              Intravascular ultrasound: novel pathophysiological insights and current clinical applications.

               P G Yock,  Mark Nissen (2001)
              Intravascular ultrasound (IVUS) is a valuable adjunct to angiography, providing new insights in the diagnosis of and therapy for coronary disease. Angiography depicts only a 2D silhouette of the lumen, whereas IVUS allows tomographic assessment of lumen area, plaque size, distribution, and composition. The safety of IVUS is well documented, and the assessment of luminal dimensions represents an important application of this modality. Comparative studies show the greatest disparities between angiography and ultrasound after mechanical interventions. In young subjects, normal intimal thickness is typically approximately 0.15 mm. With IVUS, lipid-laden lesions appear hypoechoic, fibromuscular lesions generate low-intensity echoes, and fibrous or calcified tissues are echogenic. Calcium obscures the underlying wall (acoustic shadowing). The extent and severity of disease by angiography and ultrasound are frequently discrepant. Arterial remodeling refers to changes in vascular dimensions during the development of atherosclerosis. At diseased sites, the external elastic membrane may actually shrink in size, contributing to luminal stenosis. The interpretation of IVUS relies on simple visual inspection of acoustic reflections to determine plaque composition. However, different tissue components may look quite similar, and artifacts may adversely affect ultrasound images. IVUS commonly detects occult disease in angiographically "normal" sites. In ambiguous lesions, ultrasound permits lesion quantification, particularly for left main coronary disease. IVUS has emerged as the optimal method for the detection of transplant vasculopathy. An important potential application of ultrasound is the identification of atheromas at risk of rupture. The mechanisms of action of interventional devices have been elucidated using IVUS, and ultrasound is used by some operators to select the most suitable interventional device. IVUS-derived residual plaque burden is the most useful predictor of clinical outcome. In restenosis after balloon angioplasty, negative remodeling is a major mechanism of late lumen loss. IVUS is not routinely used for stent optimization, and there is no consensus regarding optimal procedural end points. Ultrasound has proven useful in evaluating brachytherapy. New and emerging applications for IVUS are continuing to evolve, particularly in atherosclerosis regression-progression trials.
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                Author and article information

                Journal
                CVIA
                Cardiovascular Innovations and Applications
                CVIA
                Compuscript (Ireland )
                2009-8782
                2009-8618
                July 2018
                August 2018
                : 3
                : 2
                : 127-136
                Affiliations
                1Department of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
                2Division of Cardiovascular Diseases, Department of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
                Author notes
                Correspondence: Islam Y. Elgendy, MD, Division of Cardiovascular Medicine, Department of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA, E-mail: iyelgendy@ 123456gmail.com
                Article
                cvia20170029
                10.15212/CVIA.2017.0029
                Copyright © 2018 Cardiovascular Innovations and Applications

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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