Intravascular Ultrasound: From Acquisition to Advanced Quantitative Analysis

Intravascular Ultrasound

From Acquisition to Advanced Quantitative Analysis

First Edition

Simone Balocco

Table of Contents

Cover image

Title page

Copyright

Contributors

Editor Biography

Book_frontside

Acknowledgments

Chapter 1: Introduction

Abstract

Section I: Clinical Ivus

Chapter 2: Clinical Utility of Intravascular Ultrasound

Abstract

1 Introduction

2 Basic Principles of Imaging Acquisition

3 IVUS in Clinical Practice

4 IVUS Applications

5 IVUS Assessment of Plaque Progression

6 IVUS in Complex Coronary Lesions

7 IVUS Pitfalls

8 IVUS Complications

9 Future Perspectives

Chapter 3: Convenience of Intravascular Ultrasound in Coronary Chronic Total Occlusion Recanalization

Abstract

1 Innovation Chronology on CTO Coronary Intervention Guided by IVUS

2 Why and When IVUS Is Used in CTO Recanalization

3 Case Examples

Chapter 4: Intracardiac Ultrasound

Abstract

1 Introduction

2 ICE Devices and Case Studies

3 Rotational System

4 Phased Array System

5 Position and Image Examples of Phased Array System³

6 Case Examples

7 Patent Foramen Ovale⁷

8 Atrial Septum Defect

9 Hypertrophic Obstructive Cardiomyopathy⁸

10 Left Atrial Appendage Closure⁹

11 3D/4D Developments (Phased Array Only)

12 Transseptal Puncture

13 Cryoablation; Positioning of the Cryoballoon

14 PFO Closure

Chapter 5: Quantitative Virtual Histology for In Vivo Evaluation of Human Atherosclerosis—A Plaque Biomechanics-Based Novel Image Analysis Algorithm: Validation and Applications to Atherosclerosis Research

Abstract

Funding

Summary

1 Introduction

2 Methodology

3 Results

4 Discussion

Section II: Ivus Image Analysis

Chapter 6: A State-of-the-Art Intravascular Ultrasound Diagnostic System

Abstract

Acknowledgment

1 Introduction

2 IVUS Imaging Catheter

3 System Configuration

4 Signal Processing

5 Concluding Remarks

Chapter 7: Multimodality Intravascular Imaging Technology

Abstract

1 Introduction

2 Hybrid IVUS-OCT Imaging Technology

3 Near-Infrared Spectroscopy

4 Intravascular Photoacoustics

5 Near-Infrared Fluorescence

6 Fluorescence Lifetime Imaging

7 Multimodality Imaging: Clinical Outlook

Chapter 8: Quantitative Assessment and Prediction of Coronary Plaque Development Using Serial Intravascular Ultrasound and Virtual Histology

Abstract

Acknowledgments

1 Introduction

2 Graph-Based IVUS Segmentation

3 Baseline/Follow-Up Registration

4 Morphology Assessment: Remodeling

5 Prediction of Plaque Development

6 Conclusions

Glossary

Chapter 9: Training Convolutional Nets to Detect Calcified Plaque in IVUS Sequences

Abstract

Acknowledgment

1 Introduction

2 Methodology

3 Experiments and Discussion

4 Conclusions

Chapter 10: Computer-Aided Detection of Intracoronary Stent Location and Extension in Intravascular Ultrasound Sequences

Abstract

Acknowledgments

1 Introduction

2 Stent Shape Estimation

3 Longitudinal Stent Location

4 General Conclusion

Chapter 11: Real-Time Robust Simultaneous Catheter and Environment Modeling for Endovascular Navigation

Abstract

1 Introduction

2 Vessel Modeling in SCEM

3 Methods

4 Results

5 Conclusion

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

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ISBN: 978-0-12-818833-0

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Contributors

The editor would like to acknowledge and offer grateful thanks for the input of all contributors, without whom this first edition would not have been possible.

Simone Balocco

Department of Mathematics and Informatics, University of Barcelona, Barcelona

Computer Vision Center, Bellaterra, Spain

R. Pawel Banys

Department of Radiology, John Paul II Hospital

Department of Physics and Applied Informatics, AGH University of Science and Technology, Krakow, Poland

Stéphane Carlier     UMONS & CHU Ambroise Paré, Mons, Belgium

Xavier Carrillo     University Hospital Germans Trias i Pujol, Badalona, Spain

Maria Elena de Ceglia     InspireMD, Tel-Aviv, Israel

Zhi Chen

Electrical and Computer Engineering

Iowa Institute for Biomedical Imaging, University of Iowa, Iowa City, IA, United States

Francesco Ciompi     Diagnostic Image Analysis Group, Pathology Department, Radboud University Medical Center, Nijmegen, The Netherlands

Wladyslaw Dabrowski

Jagiellonian University, Department of Cardiac & Vascular Diseases

Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland

Stamatia Giannarou     Hamlyn Center for Robotic Surgery, Imperial College London, London, United Kingdom

Joan Antoni Gomez-Hospital     Interventional Cardiology Unit, Hospital de Bellvitge, Barcelona, Spain

Josep Lluís Gómez-Huertas     InspireMD, Tel-Aviv, Israel

Akira Iguchi     Terumo Corporation, Tokyo, Japan

Tomas Kovarnik     Second Department of Internal Medicine, Charles University, Prague, Czech Republic

Su-Lin Lee     EPSRC Center for Interventional and Surgical Sciences, University College London, London, United Kingdom

Jurgen M.R. Ligthart     Erasmus MC, Rotterdam, The Netherlands

John J. Lopez     Stritch School of Medicine, Loyola University, Maywood, IL, United States

Josepa Mauri     University Hospital Germans Trias i Pujol, Badalona, Spain

Adam Mazurek     Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland

Piotr Musialek     Jagiellonian University, Department of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland

Ricardo Ñanculef     Federico Santa María Technical University, Valparaíso, Chile

Eric A. Osborn     Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States

Lukasz Partyka     InspireMD, Tel-Aviv, Israel

Petia Radeva

Department of Mathematics and Informatics, University of Barcelona, Barcelona

Computer Vision Center, Bellaterra, Spain

Fernando Ramos     Department of Mathematics and Informatics, University of Barcelona, Barcelona, Spain

Josep Rigla     Department of Mathematics and Informatics, University of Barcelona, Barcelona, Spain

Juan Rigla

InspireMD, Tel-Aviv, Israel

Department of Mathematics and Informatics, University of Barcelona, Barcelona, Spain

InspireMD, Boston, MA, United States

Yuki Sakaguchi     Terumo Corporation, Tokyo, Japan

Elias Sanidas     Department of Cardiology, LAIKO General Hospital, Athens, Greece

Yusuke Seki     Terumo Corporation, Tokyo, Japan

Milan Sonka

Electrical and Computer Engineering

Iowa Institute for Biomedical Imaging, University of Iowa, Iowa City, IA, United States

Justyna Stefaniak     Data Management and Statistical Analysis (DMSA), Krakow, Poland

Lukasz Tekieli

Jagiellonian University, Department of Cardiac & Vascular Diseases

Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland

Giovanni J. Ughi     New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States

Beatriz Vaquerizo     Interventional Cardiology Unit, Hospital del Mar, Barcelona, Spain

Andreas Wahle

Electrical and Computer Engineering

Iowa Institute for Biomedical Imaging, University of Iowa, Iowa City, IA, United States

Karen Th. Witberg     Erasmus MC, Rotterdam, The Netherlands

Guang-Zhong Yang     Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China

Honghai Zhang

Electrical and Computer Engineering

Iowa Institute for Biomedical Imaging, University of Iowa, Iowa City, IA, United States

Ling Zhang

Electrical and Computer Engineering

Iowa Institute for Biomedical Imaging, University of Iowa, Iowa City, IA, United States

Liang Zhao     Center for Autonomous Systems, University of Technology Sydney, Ultimo, NSW, Australia

Editor Biography

Dr. Balocco Simone is an associate professor in the Department of Mathematics and Informatics at the University of Barcelona, and a senior researcher at the Computer Vision Center, Bellaterra. He earned his PhD in acoustics from the CREATIS Laboratory, Lyon and in Electronic and Telecommunication from MSD Laboratory, University of Florence (Italy). He conducted a postdoctoral research at the CISTIB Laboratory, Pompeu Fabra University. Dr. Balocco’s main research interests include pattern recognition and computer vision methods for the computer-aided detection of clinical pathologies. In particular, his research focuses on ultrasound and magnetic imaging applications and vascular modeling.

Book_frontside

Acknowledgments

Benjamin Franklin

I am deeply grateful to Captain Juan Rigla, PhD, MD, a great friend who coordinated the clinical part of the manuscript. Without his help, this book would not be possible.

I would like to thank all the contributors of this book for making possible this legacy for the new generation. Thanks go to those who participated and those who wanted but couldn’t. Some of them have been working day and night, stealing time from their personal life, and putting aside work, family duties, patients for delivering the best result ever.

My special thanks go to Petia Radeva, the founder of this research line in IVUS, for letting me complete the work that she started so many years ago.

Thanks are due to Fina Mauri and Xavier Carrillo, who were the true motivators of most of this research.

My heartfelt thanks to uncles Carlo Gatta and Francesco Ciompi for being true brothers.

Thanks go to Phillippe Delachartre, who transferred to me his passion for the research in IVUS so many years ago. Thanks are due to Piero Tortoli, Christian Cachard, and Olivier Basset, my mentors now and forever.

I would also like to thank my family, Sara, Giampiero, and Gaetano, for encourage me all along this long journey.

…Tell me and I forget, teach me and I may remember, involve me and I will learn….

Chapter 1

Introduction

Simone Baloccoa,b    a Department of Mathematics and Informatics, University of Barcelona, Barcelona, Spain

b Computer Vision Center, Bellaterra, Spain

Abstract

This book focuses on imaging, treatment, and computer-assisted technological advances in diagnostic and intraoperative vascular imaging and stenting in intravascular ultrasound (IVUS). The book brings together the advanced knowledge of scientific researchers, medical experts, and industry partners working in the field of IVUS in different anatomical regions. The context of the book is transversal to several disciplines, and specifically it covers several technological fields, such as clinical intervention, catheter and IVUS system design, biomechanics, 3D visualization, tissue characterization, segmentation, plaque evolution and rupture analysis, stent deployment, and planning.

Keywords

Atherosclerosis; Cardiovascular diseases; Imaging; Biomechanics; Clinical workflow

Atherosclerosis, a disease of the vessel walls that causes vessel narrowing and obstruction, is the major cause of cardiovascular diseases such as heart attack or stroke. Intravascular ultrasound (IVUS) is an intraoperative imaging tool that allows visualizing internal vessel structures, quantifying and characterizing coronary plaque, and is useful for diagnostic purposes and image-guided intervention.

The book focuses on imaging, treatment, and computer-assisted technological advances in diagnostic and intraoperative vascular imaging and stenting in IVUS. Such techniques offer increasingly useful information regarding vascular anatomy and function and are poised to have dramatic impact on the diagnosis, analysis, modeling, and treatment of vascular diseases. Computational vision techniques designed to analyze images for modeling, simulating, and visualizing anatomy and medical devices such as stents as well as the assessment of interventional procedures therefore play an important role and are currently receiving significant interest.

The book brings together the advanced knowledge of scientific researchers, medical experts, and industry partners working in the field of IVUS in different anatomical regions.

The book is organized into two sections: the first one includes a clinical perspective of the vascular disease, the current clinical workflow, and the main challenges faced by the research community across anatomical boundaries, including cerebral, coronary, and cardiac interventions. In particular, an introduction for the nonexpert readers recalls the basics of this image modality. Special care was taken to describe the relevance of these problems, and to identify the locks that currently hinder their realization.

The second section provides a deep overview of intravascular ultrasound imaging systems analysis. It includes topics of the whole imaging pipeline, ranging from the definition of the clinical problem and image acquisition systems, to the image processing and analysis, including the assisted clinical decision-making procedures and the treatment planning (stent deployment and follow-up). The book will conclude with new research horizons and open questions.

The context of the book is transversal to several disciplines, and specifically it covers several technological fields such as clinical intervention, catheter and IVUS system design, biomechanics, 3D visualization, tissue characterization, segmentation, plaque evolution and rupture analysis, stent deployment, and planning.

For these reasons, the book will be a compendium of the current state of the art in this research field and will be a perfect resource to get updated on the advances of the intravascular ultrasound and stent analysis topics.

Finally, our sincerest thanks go to the authors of all chapters for their dedication to this project and to Elsevier for their support.

Section I

Clinical Ivus

Chapter 2

Clinical Utility of Intravascular Ultrasound

Elias Sanidasa; Stéphane Carlierb    a Department of Cardiology, LAIKO General Hospital, Athens, Greece

b UMONS & CHU Ambroise Paré, Mons, Belgium

Abstract

Coronary angiography remains the gold standard imaging method for the detection of coronary artery disease (CAD) and its widespread clinical application has steered patients to a host of beneficial interventional medical therapies. Nonetheless, this approach only provides a two-dimensional image of the contrast-filled arterial lumen and does not visualize the arterial wall where largest atherosclerotic plaques are located. Consequently, angiography often underestimates the degree of intraluminal stenosis and does not gauge the size of the plaque burden itself (Topol and Nissen, 1995).

Keywords:

Coronary artery disease; Intravascular ultrasound (IVUS); Atherosclerosis

Disclosures

SC is a consultant for Boston Scientific and Terumo.

1 Introduction

Coronary angiography remains the gold standard imaging method for the detection of coronary artery disease (CAD) and its widespread clinical application has steered patients to a host of beneficial interventional medical therapies. Nonetheless, this approach only provides a two-dimensional image of the contrast-filled arterial lumen and does not visualize the arterial wall where largest atherosclerotic plaques are located. Consequently, angiography often underestimates the degree of intraluminal stenosis and does not gauge the size of the plaque burden itself.¹

Currently, intravascular ultrasound (IVUS) provides a more detailed assessment of CAD and has emerged as an essential diagnostic tool for understanding coronary lesion morphology, deploying stents, and solving postpercutaneous coronary intervention (PCI) complications.

Historically, the first medical ultrasound application was described in 1953 by Inge Edler and Carl Hertz, who introduced the recording of the motion pattern of cardiac structures along a single sound beam. This technique, known as supersonic reflectoscope, used short supersonic sound pulses that were generated by an electrically excited quartz crystal and delivered to the heart. Part of the sound was reflected back to the quartz crystal and the time difference between the emanation of the sound pulse and the reception of the echo was a measure of the distance between the crystal and the reflecting material. In 1971, the first true IVUS system was designed by Nicolaas Bom and Charles Lancée in Rotterdam. It was conceived as an improved technique for the continuous visualization of cardiac chambers and valves by a catheter with 32 elements with an outer diameter of 3 mm. However, the first transluminal images of human arteries were recorded by Paul Yock in 1988.²–⁴

IVUS is considered a diagnostic imaging method that delivers real-time, high-resolution images of the coronary arteries and provides a precise depiction of the morphology of atherosclerotic plaque.⁵ Its role begins with pre-PCI imaging targeted to (1) measure the diameter and the area of the lesion/reference segment, (2) measure the length of the lesion, (3) evaluate the distribution of plaque and presence of calcification, and (4) estimate in vivo plaque composition and burden, identifying plaque characteristics associated with increased vulnerability.⁶ In order to further guide percutaneous procedures, IVUS will also be performed poststenting in order to (1) evaluate stent expansion, (2) assess side branch compromise, (3) assess the presence of coronary dissection, and (4) determine the mechanism or stent restenosis or thrombosis (i.e., underexpansion).⁷–⁹

Notably, 2018 ESC/EACTS Guidelines on myocardial revascularization recommend the use of IVUS to detect stent-related mechanical problems in left main coronary artery (LMCA) as class IIa with level of evidence B.¹⁰ IVUS has also been shown to be an adjunctive imaging technique for the crossing of coronary chronic total occlusions (CTO), the performance of complex aortic, carotid, and peripheral artery endovascular procedures without excluding even vein intervention.

2 Basic Principles of Imaging Acquisition

In summary, the function of IVUS is based on the following general principles:

•conversion of electrical energy into sound waves via piezoelectric crystals;

•transmission and detection of sound waves reflected by tissues using the same piezoelectric crystals, the transducer, and converting back the received sound waves into an electrical signal;

•amplification and processing of this electrical signal and conversion to an image;

•projection of that image on the device's computer screen from where it can be analyzed or stored.⁵

There are two types of IVUS catheters: the mechanically rotated single-element transducer and the synthetic steered phased array system (Fig. 1). The mechanical catheter has a piezoelectric transducer placed at the edge of a flexible shaft that is rotated and advanced or withdrawn in order to scan the artery within a protective sheath. The systems that have been used lately are high-definition devices running at frequencies between 40 and 60 MHz. The 20-MHz synthetic aperture array catheter has 64 tiny transducers permanently embedded around the circumference of the catheter edge. Cross-sectional images are produced using an electronically phased-array rotating beam forming without any necessary mechanical rotation of the catheter while advanced or withdrawn within the artery.¹¹,¹² The main features of the IVUS catheters are summarized in Table 1.

Fig. 1 Two types of IVUS imaging systems. (A) Mechanical system with a rotating element; (a) cross-sectional image provided by a mechanical system (Atlantis SR Pro Catheter iLab Ultrasound Imaging System). (B) Electronic system with a multielement array; (b) cross-sectional image given by an electronic system (Eagle Eye Gold Catheter S5 System).

Table 1

A gray-scale IVUS image is formed from a codification of the level of echogenicity of the radiofrequency signal that is reflected by the tissues. Signals with low echogenicity are coded as dark gray or black, while highly echogenic signals are coded as light gray or white. The strongest reflection of ultrasound comes from collagen and calcium. The adventitia of the coronary arteries is very rich in collagen and appears as the brightest structure in a noncalcified segment. The external elastic lamina (EEL) is lies between the adventitia and the media, mostly muscular, and typically echolucent (dark). In normal, nonatherosclerotic arteries, the thickness of the media is typically 200 μm. The internal elastic lamina (IEL) separates the media from the most inner structure of the artery, the intima, covered by a single layer of endothelial cells. Intimal thickness increases with age and it is typically 200 μm at 40 years of age producing the classical three-layer appearance of a normal coronary artery by IVUS. Intimal thickening is the first pathophysiological change related to atherosclerosis. With the accumulation of plaque, intima and IEL tend to merge and the separation from the media is difficult to assess.¹³,¹⁴

The definitions of reference segment along with the most common measurements using IVUS are presented in Table 2.¹⁵

Table 2

CSA, cross-sectional area; EEL, external elastic lamina.

3 IVUS in Clinical Practice

Atherosclerosis, from the Greek ἀθήρα, athêra, meaning gruel and σκλήρωσις, sclerosis or hardening, is by essence a disease of the arterial wall while the lumen will only lately be compromised.¹⁶–¹⁸ Thus, an atherosclerotic lesion can evolve during years without any clinical symptom or flow limitation. Previous studies have reported that a coronary angiography performed weeks before an acute myocardial infarction revealed that at the culprit lesion there was only a mild to moderate degree of stenosis in more than half of the patients and as such an angiogram does not provide adequate prognostic information concerning future ischemic events.¹⁹ Such conclusions have given rise to the notion that acute ischemic syndromes are the result of how vulnerable an atherosclerotic plaque is to rupture and are less dependent on the degree of luminal stenosis.²⁰ Several attempts of IVUS signal postprocessing have been reported to detect such vulnerable plaques²¹–²⁴; however, it is seldom used nowadays in a clinical setting. On the other side, numerous studies and metaanalyses compared the clinical outcomes between IVUS-guided and angiography-guided stent implantation with the latest results supporting the utility of IVUS to guide complex PCI procedures, yet remaining underused²⁵ (Table 3).

Table 3

NA, nonavailable; NS, no significant.

3.1 IVUS in Percutaneous Transluminal Coronary Angioplasty

IVUS could improve angiographic results by safely upsizing the largest balloon for angioplasty once vessel remodeling was taken into account, as demonstrated in the CLOUT trial.²⁶ Using balloons sized to the EEL diameter, some advocated aggressive percutaneous transluminal coronary angioplasty (PTCA) instead of systematic stent implantation.²⁷ Nowadays, with the advent of DES that solved the issues of (1) late lumen loss secondary to negative remodeling post balloon angioplasty,²⁸ and (2) in-stent restenosis process, such provisional angioplasty strategies based on IVUS or physiological measurements²⁹ are no more considered. On the other side, the importance of optimal lesion preparation before stenting, using rotational atherectomy, cutting balloons, or newer devices, has been identified and IVUS is a very important guidance tool to assess the results of these techniques.³⁰,³¹

3.2 IVUS in the Bare Metal Stent Era

Intimal hyperplasia is the major underlying mechanism of bare metal stent (BMS) restenosis. In BMS, percentage of intimal hyperplasia volume averages 30% of stent volume and is consistently greater in diabetics than in nondiabetics. In BMS that do not restenose, initial studies showed that