Relationship Between Intravascular Ultrasound Guidance and Clinical Outcomes After Drug-Eluting Stents: The ADAPT-DES Study

Study Questions:

What are the outcomes of intravascular (IVUS) guidance versus angiographic guidance of drug-eluting stent (DES) implantation?

Methods:

ADAPT-DES was a prospective, multicenter, nonrandomized “all-comers” study of 8,583 consecutive patients at 11 international centers designed to determine the frequency, timing, and correlates of stent thrombosis (ST) and adverse clinical events after DES. Propensity-adjusted multivariable analysis was performed to examine the relationship between IVUS guidance and 1-year outcomes.

Results:

IVUS was utilized in 3,349 (39%) patients, and larger diameter devices, longer stents, and/or higher inflation pressures were used in 74% of IVUS-guided cases. IVUS guidance compared to angiography guidance was associated with reduced 1-year rates of definite/probable ST (0.6% [18 events] vs. 1.0% [53 events]; adjusted hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.21-0.73; p = 0.003), myocardial infarction (MI) (2.5% vs. 3.7%; adjusted HR, 0.66; 95% CI, 0.49-0.88; p = 0.004), and composite adjudicated major adverse cardiac events (MACE: cardiac death, MI, or ST) (3.1% vs. 4.7%; adjusted HR, 0.70; 95% CI, 0.55-0.88; p = 0.002). The benefits of IVUS were especially evident in patients with acute coronary syndromes and complex lesions, although significant reductions in MACE were present in all patient subgroups including stable angina and single-vessel disease.

Conclusions:

The authors concluded that IVUS guidance was associated with a reduction in ST, MI, and MACE within 1 year following DES implantation.

Perspective:

This study reported that IVUS guidance was strongly associated with lower 1-year rates of definite/probable DES thrombosis, MI, and MACE, as well as ischemic target lesion revascularization and target vessel revascularization. Furthermore, the greatest absolute benefits of IVUS-guidance were present in patients with acute coronary syndromes and complex coronary anatomy, although significantly better event-free survival was observed in all patient groups. Given the nonrandomized nature of the study, lack of prespecified criteria of IVUS-guided optimization of stent deployment, and lack of adjudication of clinical endpoints, these study findings should be considered hypothesis generating. For now, angiography-guided percutaneous coronary intervention (PCI) remains the standard of care, which may be supplemented by intracoronary imaging in selected high-risk patients and lesion subsets as recommended in the current American College of Cardiology/American Heart Association PCI guidelines.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Interventions and ACS, Chronic Angina

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Angina, Stable, Coronary Restenosis, Drug-Eluting Stents, Disease-Free Survival, Sirolimus, Angioplasty, Balloon, Coronary, Stents, Percutaneous Coronary Intervention, omega-Chloroacetophenone, Cardiology, Coronary Thrombosis, Confidence Intervals, United States


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