(Circulation. 2001;103:604.)
© 2001 American Heart Association, Inc.
Clinical Cardiology: New Frontiers |
Intravascular Ultrasound
Novel Pathophysiological Insights and Current Clinical Applications
From the Cleveland Clinic Foundation, Cleveland, Ohio (S.E.N.), and Stanford University, Palo Alto, Calif (P.Y.).
Correspondence to Steven E. Nissen, MD, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. E-mail nissens{at}ccf.org
Abstract
Abstract—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 
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.
Key Words: ultrasonics • imaging • stents
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