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IVUSGuidedCaseReviewCasePerformedbyFrankR.Arko III,MD
Charlotte,NC
Theopinionsandclinicalexperiencespresentedhereinareforinformationalpurposesonly.Dr.Arko isapaidconsultantforPhilipsVolcano.Theresultsfromthesecasestudymaynotbepredictiveforallpatients. Individualresultsmayvarydependingonavarietyof
patient-specificattributesandrelatedfactors.TrademarksarethepropertyofPhilipsVolcanoortheirrespectiveowners.
PatientPresentation
2
51year-oldAfricanAmericanmalepresentedwithrestpaininleftlegwithahistoryofpriorself-expandingstentinleftSFA.
Presentedwithrestpaininleftleg
Underwentnon-invasiveperipheralarterialstudiespriortoourassessmentwhichconfirmedin-stentrestenosis,and
indicatedfreshthrombusin-stent.
HistoryofstentinginleftSFA
Imageisamodel,notanactualpatient
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InitialAngiogram
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LeftProximalSFA LeftSFAMid-DistalOcclusion
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InitialIVUSPullback
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IVUSassistedindeterminingthe:
• Diameteroftreatmentarea
• Plaquemorphology
• Lengthofstenosis
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TherapyUsed
5
Basedoffthepatientpresentation,angiogramandIVUSthephysiciandecidedtotreatthepatientwith:
• Catheter-infused10mgoftPA toassistinresolvingthethrombusinsidethepreviouslystentedportionoftheSFA.
• A5x150mmViabahnstenttotreatthein-stentrestenosisinthemidtodistalSFA.
• A5x120mm(2each)and5x40mmMedtronicIN.Pact Admiraldrug-coatedballoontotreatthediseasedareaintheproximalSFA.
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IVUSGuidanceConclusions
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IVUSconfirmedin-stentrestenosisinthedistallesion.Also,IVUSimagedfreshthrombuswithinthein-stentrestenosis.
IVUSidentifiedthevesseldiameterthusassistingthephysiciantoappropriatelypre-dilatethedistallesionanddeterminepropersizedViabahnstenttotreatthein-stentrestenosissegment.
IVUSidentifiedtheproximalvesseldiameterandwherethenormalproximalsegmentofthevesseloccurred.Thisassistedthephysicianindeterminingtheappropriatesizeandlengthofdrugcoatedballoonneededtotreattheproximaldiseasedsegment.
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VIPERTrial-Results
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Theoverall1-yearprimarypatencyrateforcomplexlesionswithameanlengthof19cmwas73%.
The1-yearprimarypatencyratefordevicesthatwerenotoversized(≤20%)relativetotheproximallandingzonewas88%,significantlybetterthanthe70% 1-yearprimarypatencyratefordevicesthatwereoversized>20%(P=.047).
SaxonR.,MDet.al.Heparin-bonded,ExpandedPolytetrafluoroethylene- linedStentGraftintheTreatmentofFemoropopliteal ArteryDisease:1-YearResultsoftheVIPER(Viabahn Endoprosthesis withHeparinBioactiveSurfaceintheTreatmentofSuperficialFemoralArteryObstructiveDisease)Trial.JVasc Interv Radiol 2013;24:165–173.
VIPERTrial- SizeMatters
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Primarypatencyratewas88%intheVIPERtrialifthestentwassized≤20%relativetotheproximallandingzonetothevessel.
IntheVIPERTrialifthestentwasoversizedbymorethan20%thentheprimarypatencyratedroppedto70%(P<0.05)
Pertheinvestigators,“Mostoftheexcessiveoversizinginthistrialresultedfromoperators’overestimationofthediameterofthearteriallumen.Toavoidthis,cliniciansmayemployquantitativetechniquestooptimizestentgrafttreatment.”
SaxonR.,MDet.al.Heparin-bonded,ExpandedPolytetrafluoroethylene- linedStentGraftintheTreatmentofFemoropopliteal ArteryDisease:1-YearResultsoftheVIPER(Viabahn Endoprosthesis withHeparinBioactiveSurfaceintheTreatmentofSuperficialFemoralArteryObstructiveDisease)Trial.JVasc Interv Radiol2013;24:165–173.
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PostIVUSAfterTreatment
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PosttherapyIVUSpullbackperformedtoassessadequacyoftherapy.
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FinalAngiogram
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Finalangiogramperformedposttreatment.
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Conclusion
11
IVUSSolution:
• IVUSconfirmedin-stentrestenosis,aswellasdemonstratingfreshthrombusinthein-stentrestenosissegment.
• IVUSidentifiedthevesseldiameterthusassistingthephysiciantoappropriatelypre-dilatethedistallesionanddeterminepropersizedViabahnstenttotreatthein-stentrestenosissegment.
• IVUSidentifiedtheproximalvesseldiameterandwherethenormalproximalsegmentofthevesseloccurred.Thisassistedthephysicianindeterminingtheappropriatesizeandlengthofdrugcoatedballoonneededtotreattheproximaldiseasedsegment.
• Followingtherapy,IVUSwasusedtovisualizetheminimumluminalareaandlookforanyflowlimitingdissectionsthattheangiogrammayhavemissed.Thisassistedthephysicianindeterminingthatanadequateresultwasachievedforthepatient.
IVUSSolution:
600-0100.171/001
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