Providing state-of-the-art guidance and clarification concerning IC imaging

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Providing state-of-the-art guidance and clarification concerning IC imaging

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Paris, France, 21 May 2019. Intra-coronary (IC) imaging has been available for over two decades. Technological advances, with the development of new modalities and improvements in the software to facilitate "real-time" analysis and decision making, have seen an increased use for both diagnostic assessment and the guidance of percutaneous coronary interventions (PCI).

However, significant regional and institutional differences in the use of IC imaging have been observed.

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In an attempt to provide the interventional community with guidance, the EAPCI has generated consensus statements detailing the clinical utility of IC imaging, based on existing clinical evidence and contemporary best practice.

The first document focused on the role of IC imaging for PCI guidance and optimisation as well as the important function it plays in understanding the mechanisms of stent failure. These indications have subsequently gained strengthened recommendations in the ESC revascularisation guidelines.

The second document focuses on the role of IC imaging in clarifying angiographic ambiguity, delineating the extent of coronary artery disease and guiding decision making on lesion severity.

The following statements outline the consensus:

Complex patients (e.g., diabetes, ACS) and lesion subsets (e.g., left main stem, long lesion, CTO) benefit from IVUS guided PCI with reduced MACE, primarily driven by a reduction in TVR. Recent randomised data confirming clinical benefit from IVUS guided approach.
IVUS assessment of LMS facilitates assessment of functional significance with an ML<4.5mm2 requiring consideration for revascularisation and an MLA>6mm2 supporting a conservative therapy approach with OMT.
Left main stem intervention benefits significantly from IC-imaging-based guidance to understand the anatomical complexity, plan and optimise PCI.
IC imaging pre-PCI is essential to understand the underlying lesion substrate and guide appropriate lesion preparation/stent selection concerning size and length.
Imaging facilitates characterisation of calcification - calcific arc >180° with thickness >0.5mm and longitudinal length >5mm is predictive of stent under-expansion. There is an expanding role for IC imaging to assess and guide modification strategies for high-burden calcification.
Equivalence of IVUS and OCT has been confirmed in 2 rigorously designed RCTs (OPINION & ILUMIEN III)
Challenging angiographic assessment - aneurysmal/ectatic disease, aorto-ostial lesions and cardiac allograft vasculopathy - can be overcome by use of IC imaging.
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