So, in any of our interventions, IVUS makes us better operators. We know in the coronary space, we always underestimate the size of the vessel and the amount of calcium. The more you use it, the more your staff is familiar, they can get it set up for you very, very quickly, and the better you are at interpreting the data, and it gives us a lot of information as we go through cases that can help us tremendously. So here's Chris's use of IVUS from head to toe. I always use it in some circumstances, for vertebral interventions or mesenteric where I want to know what size stent to put in, for big vein intervention, if I'm going to put a Viabond stent graft, or if I'm borderline, whether DES or bare metal stent for borderline size lesions in those important vessels listed. I use it selectively in the fem pop, which we'll look some if I need information as we're going, as well as some of the other territories listed. I only use it in quadids, and if I do it, I'm going to do it with protection and never for intracranials. A couple, real quick, this is a live case we did. You can see mesenteric severe stenosis. You can see the collaterals. Here's the SMA from the arm, and our strategy is the same every time, balloon, 4-0, IVUS, just get this vessel size, mark the ostium, and use that information to put the right size stent in. There was the SMA, same case, same story with the celiac, balloon, IVUS, get the right stent and put it in. And I think if you IVUS guide these, these will have a lot better patency than what you've seen out there in the literature, which is not very good, and final result in the celiac as well. Similar approach to vertebrals. This is somebody who's severely symptomatic. The right vert you can see is out. Left vert was tight. Even more relevant because there were no posterior communicating arteries. So again, strategy for all verts is something like this, an O1-4 wire, a 4-0 balloon, IVUS to mark the ostium and pick the right stent size, and it's usually bigger than what you think. This was a 6-millimeter stent, and deploy and flare it, and nice endographic result and IVUS result as well. Now let's go down lower extremity. This is a very complex, long SFA intervention. It comes back for a little bit, and then there's a popliteal trifurcation disease involving the anterior tibial. Here there was a little nub, so it crossed into the trulumen here and then took a picture, and I'll call this a geniculate octopus. I couldn't see where to go. So in a bunch of different views. So here's tibial, surprisingly difficult from the anterior tibial, kept deflecting. So we went posterior tibial. You can see the two wires there. We were able to cross pretty easily with the posterior tibial artery and then externalize it and then do some simple just balloon to reestablish flow, and then we could get the anterior tibial wire up. So now we, again, externalize that. So now we just did a lot of atherotomy and kind of reassessed. And June, you'll be happy with me on this one, I think. So here we get nice flow in the SFA, but not so nice flow down at the trifurcation. All right. So this is where I think IVUS is your best friend. All right. So we've got two wires in. So here's IVUS into each of these vessels and tells us a problem. In the popliteal, there's that flap. It's a significant flap, and there was a brief flap in the anterior tibial artery as well. So armed with that information, we use a ruler. We mark where the two ends of the dissection are so I know where to stent. Then we did DCB throughout, long inflations. We put a DES, drug-eluting stent in the intertibial, and one interwoven stent where the dissections were marked by IVUS. And nice result throughout that long occlusion, throughout the pop, throughout the trifurcation, down to the foot. And IVUS here identified where the problem points were, and there were only two. The rest was okay, and allowed us to just spot stent where it was needed with the right kind of stent, the right size, etc. Here's somebody with subacute limb ischemia. They came in with a popliteal occlusion, got a lytic canthar. Next day, come back, and this is what we have. IVUS to mark where I'm going to put the biobarn stent and what size. Here's the IVUS. Again, it's up to an 8-millimeter vessel. We marked where a good landing zone, above and below, and put a 9-0 biobarn stent graft and ballooned it and got a nice result. Now even with that IVUS guided therapy and triple anticoagulation, it came back again, which these guys and gals sometimes do. So another lytic canthar, another, open it up, another IVUS. Back then, this was before we had the larger separa, so it was too big for separa. So, okay, let's triple anticoagulation, add plate tall. Here we go. It didn't work. So here we go with round three. Same song and dance, but the nice thing is guided by IVUS. Now we have 7.5-millimeter separas, so we cleaned it out and put large separas. And this is... It was two and a half years ago. It's actually the father of one of our nurse practitioners, so I know him very well and see him routinely and good result, guided by the IVUS. Briefly, sometimes above the belt, this is somebody who came in with a clear-cut left hemispheric small stroke and had the left hemispheric TIAs and a benign workup, and even the angiograms look pretty benign. But there was no other etiology on extensive workup, including intracranial. So with protection, IVUS. And here's what the IVUS showed of this carotid, vulnerable, soft plaque, up to 80% answer for the stroke. This is one of the few times I'll ever primary stent a carotid. This was a primary stent with a big closed cell, 10x8x40 exact, and aspiration and final results. And finally, here's somebody with severe cerebrovascular disease. You can see that little nub is the included native abnominate. They had a graft placed elsewhere, and they have severe disease and symptoms in there. Went into both the common carotid artery and subclavian and through that Dacron graft. Again, if we're going to do the cerebral, we use protection. IVUS gave us invaluable information on the size of the disease and that there was definitely disease in the proximal subclavian. So DCB from the graft into the subclavian, and then a balloon expandable, obviously non-covered stent into the common carotid and final results in both territories and good cerebral flow. So in conclusion, I think IVUS is an essential part of our armamentarium for arterial venous circulation. I use it all the time if we need precision for the stent size selection and then selectively if we have problems along the way that need additional information. Thank you very much for your attention.

intravascular ultrasound

IVUS

medical interventions

vessel size

calcium presence