Most Popular Angioplasty Web Site
supported by Volcano Corporation

Augusto ("Gus") Pichard, MD, specializes in Invasive Cardiology and is board certified in Internal Medicine, Cardiology and Interventional Cardiology. He joined Washington Hospital Center in 1983 as director of the Cardiac Catheterization Lab. He is also a Professor of Medicine at The George Washington University Medical Center.

Dr. Pichard has written more than 500 manuscripts for peer-reviewed journals on many topics in Invasive Cardiology, including innovative heart disease treatment techniques. He is also very active in national and international educational activities related to his specialty.

Prior to coming to the Hospital Center, Dr. Prichard directed the Cardiac Catheterization Lab at Mount Sinai Medical Center in New York, N.Y. He also completed a Cardiology fellowship at Cleveland Clinic and served on its staff until 1975.



Augusto D. Pichard, MD
Augusto D. Pichard, MD

Intravascular Ultrasound Image
Intravascular Ultrasound Image

Q. For what percentage of your cases do you use either IVUS or FFR?
Dr. Pichard: I use IVUS on all my angioplasties, always! The IVUS is already set before I come into the cath lab and I always image, both before and after. It keeps me humble. The IVUS teaches me so much; I change the strategy all the time based on IVUS. It makes angioplasty, easy, uncomplicated, and very successful.

I always say I save the hospital money because, by knowing exactly what I'm doing, I have less complications. I rarely need to add another stent. So that way, the hospital makes money: less complications and less need for a second stent, which is not reimbursed.

We use a lot of FFR. If the lesion is a difficult interpretation on the angio, and the IVUS gives me a borderline measurement, I do FFR. We used to stent everything with less than 4 mm square on IVUS, now I've learned that you can have 3.7, 3.8 and still not have a physiologically significant lesion. So now we've modified our strategy and do not stent those.

Q. The FAME study obviously had some impact there?
Dr. Pichard: Right. An abstract was presented at this past AHA: IVUS vs. FFR to better understand the correlation, and some of these new discrepancies. I am a great believer in the physiology; I think the FFR has the upper hand, especially now that we can manage, medically, the intermediate lesions. Five years ago, eight years ago, you had a 50% lesion that looked ugly, it was safer to stent it. But I think that's changed now, as a result of the enhanced medical therapy.

Q. This past year, the ACC/AHA/SCAI issued some new guidelines giving FFR a higher level of evidence in PCI and STEMI cases. It’s now a Class 2A indication. They’re recommending that FFR be used more, not in every lesion, but where there are questions, or intermediate lesions. Do you think this will have an affect on practice in the U.S.?

Dr. Pichard: It should give the physicians more confidence that they are using something that is approved that is in the guidelines. My concern still for some is the lack of reimbursement. If someone uses it a lot, the cath lab director is going to be after them for using so much of it. I don't seem to have that problem, because of proving to the hospital that we saved them money by doing optimal treatment to begin with.

    Fractional Flow Reserve (FFR) Wire
Fractional Flow Reserve
(FFR) Wire

Q. So do you think the reimbursement for IVUS and FFR and these types of measurements needs to change?
Dr. Pichard: Yes, definitely.

Q. In Japan IVUS is reimbursed by itself, as a stand-alone part of the procedure, correct?
Dr. Pichard: Right.

Q. In all of the DES clinical trials that were reported from Endeavor, Xience, all of them, the Japanese arms always seem to have better results. No matter which stent they were using, they seemed to have less restenosis. I asked Dr. Shigeru Saito, the principal investigator on many of these studies, about that and he said, it's because they use IVUS. Do you think that's a fair comment?
Dr. Pichard: That's a very fair statement. It's amazing how much I see among those that don't use IVUS. We have an open lab, so a lot of doctors call me to assess something. And I will use IVUS and I realize what an inadequate job has been done, although the angiography was acceptable. I’m all for understanding; there's nothing like knowing what you're doing. It's fascinating that, with all the trials that we've done, IVUS has not come out as a black-and-white winner. You would expect from what I say that all the trials would show much better outcome with IVUS. But it's been difficult to prove it. Part of it, I think, is because it's been so expensive. So physicians use it sparingly. So when they use it, they don't know how to use it well! There is an element of, like anything in life, if you use very rarely, you don't know how to use it best and you don't get all the benefits.

Q. So you need to use it regularly and you need to be trained on it more?
Dr. Pichard: If you're well-trained and use it regularly, then you get to understand what everything means. It's not just measuring diameter or length. You get to understand better plaque distribution, plaque thickness; you see that there is no calcium, but there is shadowing. That’s a very hard fact: all these little intricacies of a technology that is sophisticated.

OCT (Optical
                    Computed Tomography) Image
OCT (Optical Computed
Tomography) Image
    Q. What about OCT? Do you see that opening a new era? Or is that still in the future?
Dr. Pichard: OCT is fascinating, it gives us such good resolution, we understand so much better what's going on in that very thin segment of the vessel wall. We know exactly what's going on in the lumen. The clinical relevance will have to be proven. What this is doing is teaching us much better to understand what we do. Once we understand what we're doing, we may not need to image everyone, but it's a fascinating look into the vessel. In Spain I did a vein graft recently with the hypothesis that I always use a small stent in a large vein to minimize plaque prolapse and embolization. And on the angio it was a fantastic result, so it was on the IVUS. But on OCT I found a lot of plaque prolapse, which the IVUS did not show. So it makes you understand better each technique, each approach. With OCT, I hope they will be able to come up with a fiber that is not very expensive that people can use a lot and we'll all learn from it.

Q. What are you doing right now, things that might be new that we haven't heard about in the area of intravascular imaging?
Dr. Pichard: I think we are going to redefine the significance of a minimal lumen area by IVUS. We have that 4mm square break point that we've used for over 10 years and I think we are going to have to modify that and we are going to understand, thanks to FFR, according to lesion length and vessel diameter, what is the true ischemic minimum lumen area. So that 4mm square will no longer be what it has been in the past.

Q. It might be on a lesion by lesion basis?
Dr. Pichard: In a small vessel it might be 3mm, so 3.5mm is not significant; in a very small vessel, maybe 2.5mm square.

Q. What would you recommend to an interventional cardiologist who doesn't use the tools of FFR and IVUS? Is it something he or she really should do and how to learn?
Dr. Pichard: Definitely. I've seen two models - we have groups that come and spend 3-5 days with us and they see a lot of IVUS in one week at the hospital center. We give them talks on it and they get exposed to a lot of decision-making based on IVUS. That's one option. The other option is to take one of those two-day courses dedicated to it. There is a dedicated course on FFR in Nice that the European Society of Cardiology organizes -- and there are others. So they become familiar with the subject in depth, and then when they do it they feel confident, they know exactly how to do it and how to interpret it. Once they have these tools they can use them in their angioplasty practice to great benefit for the patients and themselves.

Doing IVUS removes all the stress from angioplasty, in my opinion. I do all direct stenting. I first do IVUS and once I have my measurement and the plaque characteristics, I know exactly what stent to put. If the plaque is very hard and is going to need Rotablator or a cutting balloon I do that first and then I do the stent. If the vessel is 3.5mm, I’ll downsize the stent to 3mm or 2.75mm and I bring it to high pressure, 18 or 20, and I now have plenty of room go out there, so I haven't had a perforation in many, many years, but I get beautiful expansion -- so all of this makes angioplasty free of stress and, in my opinion, fewer complications, safer.

Q. Could you talk a little bit about what spot stenting is, and specifically the ways that it involves having to be able image things in a different way?
Dr. Pichard: It's a very exciting hypothesis, and it’s based on the new knowledge regarding coronary disease. The new knowledge is that, based on COURAGE and FAME plus a number of IVUS studies, we can achieve plaque stabilization, even plaque regression, with optimal medical therapy, including high dose statins, Plavix, etc. The older work of the RAVEL era is no longer needed; it’s over. When RAVEL came out we were told you need top put a drug-eluting stent from normal to normal, because if you leave plaque on the edge there will be a lot of restenosis or thrombosis.

And I reviewed that very carefully; the data published on edge restenosis goes from zero to 5% at the worst, most of them are about 2% incidence of edge restenosis. And the edge restenosis is determined by the amount of plaque that you leave. If you leave more than 50% plaque burden at the edge, then there is more likelihood of restenosis. It's not much, but those are the ones that get it. So based on the two concepts then, I thought maybe there is no need to cover the entire plaque; we can just cover the tight segments of a long lesion.

In addition to the new understanding of the evolution of intermediate plaque, is the fact that we know now that the longer the stent, the more metal we put in, the more polymer we put in, the more drugs -- the more problems for that artery, all kinds of problems: more thrombosis, more restenosis. The physiology of the vessel, we understand, is altered and, of course, if some day that patient needs other interventions, like bypass surgery or more percutaneous interventions, that vessel is already sacrificed, it's already “metalized.”

Two or three years ago I started using the concept of spot stenting: attend to really tight lesions and leave the rest alone. And I do this guided by intravascular ultrasound, to make sure that what I leave alone is truly an intermediate lesion and not something severe that I just don't see on angiography. And the results have been outstanding. There is no increase in restenosis or thrombosis.

Q. There was a randomized study published about the spot stenting technique?
Dr. Pichard: It was over 150 patients and was published in the American Journal of Cardiology. That's the only randomized study. In addition to that, I have experience at the hospital where we've been doing this for three years, with mostly my cases, and the outcome is very good. We’re looking at the database and there is no hint of increased events doing it this way. For many, many patients, most of my patients get the least amount of metal that is necessary and we see no sign of increased events. So I'm excited about that. I think it's a good strategy that goes along with modern thinking that optimal medical therapy is very effective. Of course to do it optimally, ideally you need either FFR or IVUS or maybe even OCT. I have not done this with OCT. But knowing what OCT shows, it would also be very helpful to this type of work.

What I look at with IVUS is to make sure that at the edge there is no more than 50% plaque. If there is dissection I never put an additional stent, unless there is an occlusive dissection. What I routinely do for edge dissection, I put the same balloon from the stent, a low pressure, 4 or 5 atmospheres and leave it there for two minutes. Invariably it fills in nicely and again, it's not associated with later events. There are a few publications, some of them from our group showing that edge dissection is not associated with events unless it is an occlusive dissection. With IVUS this becomes a very simple and safe way to do it, because you know exactly what's going on. You know if the plaque is left at the edge, if it’s an area of remodeling, you know if you’ve got rupture, you know if there's thrombus, and you can act accordingly.

Q. IVUS or possibly FFR or OCT are very important. You couldn't really do this without some kind of new imaging technique?
Dr. Pichard: You could, but it's much superior to do it with an imaging technique. The new knowledge has shown that angiography is not an accurate way to access lesions. There is a recent paper in Circulation with intermediate left main stenosis and FFR showing the same constant, that 20-30% of what looks severe on angio, was not judged significant. So there are both extremes: some severe angiographic lesions on the left main were not severe by FFR and some minimal lesions on angiography are actually severe on FFR.

So from FFR and IVUS we have learned that angiography misdiagnosed about 1/4 to 1/3 of lesions, re-enforcing the concept that good angioplasty should be guided by some form of imaging. You can always get a beautiful print to give the family. But that's not what I'm after. I'm after 5 and 10-year excellent outcomes. And that's why I'm trying to put less metal, less polymer in the artery so that the physiology is not so affected, so there are less complications in the long term. So the vessel is left open for future interventions if at all needed.

This interview was conducted in November 2009 by Burt Cohen of Angioplasty.Org.