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Title: Is quantitative angiography sufficient to guide stent implantation? A comparison with three-dimensional reconstruction of intracoronary ultrasound images.
Author: Prati F, Gil R, Di Mario C, Ozaki Y, Bruining N, Camenzind E, de Feyter PJ, Roelandt JR, Serruys PW.
Journal: G Ital Cardiol; 1997 Apr; 27(4):328-36. PubMed ID: 9199951.
Abstract:
Intracoronary ultrasound (ICUS) frequently reveals stent underexpansion despite a satisfactory angiographic result by visual assessment. Whether on-line quantitative coronary angiography (QCA) alone can guide optimal stent deployment is still unknown. The aim of the study was to assess the usefulness of quantitative coronary angiography in the evaluation of optimal stent expansion, confirmed with a new on-line system of 3-D reconstruction of ICUS. The results obtained with 3-D ICUS were compared with the measurements achieved with QCA analyses in 49 patients (70 stents: 31 Palmaz-Schatz, 22 Wallstent, 7 Cordis, 6 Micro-stent, 2 Gianturco-Roubin, 2 Multi-Link). Following delivery of the stent, high pressure intrastent balloon inflation (14.2 +/- 3.3 atmospheres) was performed in all 70 stents. Optimal stent implantation by QCA was defined as minimal lumen diameter post-stenting > or = 90% of the reference diameter preintervention. Percent diameter stenosis (% DS) post-stenting was defined as minimal lumen diameter divided by the reference diameter post-stenting. The on-line 3-D ICUS reconstructions and measurements were performed processing the images on-line in the catheterization laboratory with an automated contour detection algorithm based on acoustic quantification. ICUS criteria for optimal stent expansion were defined as: 1) complete apposition of stent struts to vessel wall; 2) minimal stent lumen cross-sectional area > or = 80% of the average lumen area of the proximal and distal reference segments; 3) symmetry index (minimum divided by maximum lumen diameter) > 0.7. Ninety-seven percent of the deployed stents met the QCA criteria. Whilst 3-D ICUS documented complete stent apposition to the vessel wall in all cases and a symmetric expansion in 65 of 70 lesions (93%), the stent minimal lumen area was > or = 80% only in 30 out of 70 stents (43%). The diagnostic sensitivity and specificity at 10% residual diameter stenosis provided by QCA for optimal stent expansion compared to 3-D ICUS criteria were 86 and 45%, respectively. In conclusion 3-D ICUS criteria of adequate stent expansion were achieved only in 43% of patients despite the application of aggressive strategies of stent deployment leading to optimal results with quantitative angiography. Ten percent residual diameter stenosis provided by QCA may be an acceptable alternative for optimal stent deployment in clinical practice. The clinical benefit of an ICUS guided approach of stent deployment and of a lower cost strategy using on-line QCA guidance should be compared in large prospective randomized studies.

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