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FFR
I was wondering if anyone knows why FFR (Fractional flow reserve) isn't used in all cath labs? I read about a good example last year where a man was having a heart attack. In the Cath lab they used FFR which in his right artery showed a large restriction to be still giving a good flow (89%) but in the left artery a smaller obstruction seemed to be reducing flow to 20%. They stented the left artery and his symptoms immediately stopped. Now, without FFR, the Cardiologist would have stented the right artery and not the left, for obvious observation reasons. FFR has a sensor on the tip of the catheter registering pressure, temperature and flow. So, you can take readings in front of an obstruction and behind it to see the difference. It would appear bigger isn't necessarily worse. I honestly believed this technique was going to be rolled out to all hospitals, which would also cut the cost in stenting.
Maybe next time anyone here has an angiogram, we should just say to the cardiologist "please make sure you use FFR please" :)
Interesting article and thanks for sharing: The reason why many hospital cardiac labs do not use the procedure may reduce their bottom line income....fewer stent implants.
For context, "an angiogram is a shadow image of the coronary artery, produced by X-rays and contrast dye to show if any blockages exist. When a cardiologist sees a blockage greater than 50%, he or she often decides to open the artery using balloon angioplasty and places a stent to hold the artery open. (I agree!)
Criticism has been leveled at this diagnostic method and has been labeled as the "oculo-stenotic reflex" -- if you see a blockage (stenosis) you automatically assume it needs to be stented. However, this is not always the case. (I agree, prior interventional cardiologist wanted to stent 72% occlusion of ICX...no symptoms).
The FAME study refuted this methodology for patients with multivessel coronary disease (narrowings in more than one artery). Using a catheter to measure the blood pressure on both sides of the blockage, called the fractional flow reserve (FFR), cardiologists were able to determine more accurately whether the plaque build-up was actually causing significant ischemia (loss of blood flow). When guided by FFR, less stents were placed and outcomes for the patients were better by 28%, when compared to stent placement guided only by the angiogram.
What the authors of this week's JACC paper have shown is that the advantage of FFR-guided stent placement exists not only in what might be called "intermediate lesions" of 50-70% (as measured by angiography) but also in more severe blockages. Two-thirds of the coronary narrowings in the 50-70% range were measured by FFR as being functionally insignificant. In other words, only one out of three blockages in this range was causing ischemia; placing a stent in two-thirds of these lesions was not only unnecessary, but could result in more adverse events. (stent recoil, stent migration, clots, etc.)
However, even in the more severe range of 71-90% blockages, one out of five stenoses were measured by FFR as being functionally insignificant -- no stent needed. It was only in the range of 91% or greater narrowing that virtually all of the lesions were significant and the patient would benefit from stenting. (that may depend whether or not there are collateral vessel development. To stent a lesion that has collaterals reduces or stops the blood flow through the collaterals).
For context, "an angiogram is a shadow image of the coronary artery, produced by X-rays and contrast dye to show if any blockages exist. When a cardiologist sees a blockage greater than 50%, he or she often decides to open the artery using balloon angioplasty and places a stent to hold the artery open. (I agree!)
Criticism has been leveled at this diagnostic method and has been labeled as the "oculo-stenotic reflex" -- if you see a blockage (stenosis) you automatically assume it needs to be stented. However, this is not always the case. (I agree, prior interventional cardiologist wanted to stent 72% occlusion of ICX...no symptoms).
The FAME study refuted this methodology for patients with multivessel coronary disease (narrowings in more than one artery). Using a catheter to measure the blood pressure on both sides of the blockage, called the fractional flow reserve (FFR), cardiologists were able to determine more accurately whether the plaque build-up was actually causing significant ischemia (loss of blood flow). When guided by FFR, less stents were placed and outcomes for the patients were better by 28%, when compared to stent placement guided only by the angiogram.
What the authors of this week's JACC paper have shown is that the advantage of FFR-guided stent placement exists not only in what might be called "intermediate lesions" of 50-70% (as measured by angiography) but also in more severe blockages. Two-thirds of the coronary narrowings in the 50-70% range were measured by FFR as being functionally insignificant. In other words, only one out of three blockages in this range was causing ischemia; placing a stent in two-thirds of these lesions was not only unnecessary, but could result in more adverse events. (stent recoil, stent migration, clots, etc.)
However, even in the more severe range of 71-90% blockages, one out of five stenoses were measured by FFR as being functionally insignificant -- no stent needed. It was only in the range of 91% or greater narrowing that virtually all of the lesions were significant and the patient would benefit from stenting. (that may depend whether or not there are collateral vessel development. To stent a lesion that has collaterals reduces or stops the blood flow through the collaterals).
I believe you are referring to an implication regarding right coronary artery dominance and/or left dominance. Consideration is the area supplied by its configuration, etc. and FFR determined the lesion's significance applicability. Lesion significance is the only redeeming asset, but effective for multi-lesion arteries.
But a competing company IVUS claims a better product and has the following that FFR doesn't and may explain why all labs may not be using FFR.
Stent Expansion X
Stent Placement X
Stent Apposition X
Stent Diameter Sizing X
Stent Length Sizing X
Plaque Burden X
Plaque Tissue Type X
% Stenosis X
Stent Placement X
Lesion Morphology
IVUS Is Clinically Relevant¹
One-year data from theWashington Hospital Center (WHC) IVUS vs. No IVUS DES Study show that patients in the IVUS group had:
65% lower stent thrombosis
29% lower TLR
The study concluded that using IVUS during DES implantation has the potential to influence treatment strategy and affect both DES thrombosis and the need for repeat procedures
But a competing company IVUS claims a better product and has the following that FFR doesn't and may explain why all labs may not be using FFR.
Stent Expansion X
Stent Placement X
Stent Apposition X
Stent Diameter Sizing X
Stent Length Sizing X
Plaque Burden X
Plaque Tissue Type X
% Stenosis X
Stent Placement X
Lesion Morphology
IVUS Is Clinically Relevant¹
One-year data from theWashington Hospital Center (WHC) IVUS vs. No IVUS DES Study show that patients in the IVUS group had:
65% lower stent thrombosis
29% lower TLR
The study concluded that using IVUS during DES implantation has the potential to influence treatment strategy and affect both DES thrombosis and the need for repeat procedures
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