Targeting new interventionalist generation could boost IVUS use

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Washington, D.C.—Despite studies that attest to the efficacy of intravascular ultrasound (IVUS) during PCI, the technology is “way underused,” according to Gary S. Mintz, MD, chief medical officer of the Cardiovascular Research Foundation in New York City, who discussed the topic with Cardiovascular Business News last week at the Cardiovascular Researcher Therapies (CRT) 2009 conference.  

Mintz said that efforts to increase use of IVUS should be directed toward the younger generation because “busy senior interventionalists have made up their minds not to use the technology.”  

Whatever their “excuses”—whether it’s the difficulty of interpreting the images, the difficulty of using the technology (which has gotten easier in the last several years), or inadequate reimbursement—the minds of older interventionalists are essentially closed, Mintz said.  

In the last several years, vendors have successfully integrated the IVUS platform into the cath lab, making it easier to employ the technology during a procedure. “People will still find excuses why they can’t use it,” he said. Someone with 10 labs might need an IVUS system for each lab, which means he might want to buy the wheel-around system, however that iteration is cumbersome, so he might not buy it at all.  

“I don’t know how to solve this problem,” he said. “I’ve encouraged the companies to stop trying to convince senior interventionalists who have staked their careers on never needing IVUS to start to use the technology, because that’s a losing proposition. I’ve encouraged the companies to train the fellows and junior interventionalists because they are the future, but for some reason all the manufacturers are unwilling to go in that direction.” 

Mintz said he tried to organize an IVUS training program last summer but had very little interest—either from the companies to support it or people to register. “For some reason, people think that they shouldn’t have to learn IVUS, that it should be intuitively obvious to them as interventionalists.”

Regarding reimbursement, Mintz said low reimbursement probably has some impact, but 50 percent of that complaint is spurious because physicians routinely do things where they are not reimbursed. In addition, IVUS allows real cost savings in terms of proper stent sizing so that only one stent need be deployed. 

Clinically, the best data show that IVUS helps reduce complications after stent implantation, those complications being stent thrombosis and either restenosis or revascularization. IVUS does this by helping to ensure full expansion of the stent and by imaging potential inflow and outflow track problems, such as large plaque burdens or residual dissections at either the proximal or distal edge. “Those are the only two things that have consistently been shown to have an impact on events within the first year,” Mintz said. 

IVUS should not be used with every stent implantation, only those procedures that pose a high risk of complications, such as stenting longer lesions, smaller vessels or diabetics, he said.  

While the current integration of the IVUS platform into the x-ray system is an improvement over the wheel-around product, the technology could still use an overhaul in design, Mintz said. “The current systems, regardless of who makes them, are essentially Band-Aids upon Band-Aids upon technology that is 15 years old.” 

In the best of all possible worlds, if someone would redesign an IVUS system from the ground up, with the goal of optimizing every single step of the process: transducer, drive shaft, catheter design, interface to the console and signal processing, this could give IVUS utilization the boost it needs across all interventionalist age brackets, he said.