When using the two-stent double-kissing (DK) crush technique for PCI to treat complex coronary artery bifurcation lesions, IVUS-guided PCI was associated with a greater reduction in target vessel failure compared to angiography-guided PCI, according to the DKCRUSH VIII trial presented during a Late-Breaking Clinical Trial session at ACC.26 in New Orleans and simultaneously published in JACC.

Shaoliang Chen Sr., MD, FACC, et al., conducted an open-label, superiority trial at 24 centers in China between 2018 and 2024, enrolled 555 patients, with 277 randomized to IVUS-guided PCI and 278 randomized to angiography-guided PCI. The median age of patients was 67 years and 78% were men. Complex bifurcation lesions were based on the DEFINITION criteria.

In the IVUS-guided and angiography-guided groups, respectively, 44.8% and 43.9% of patients had a bifurcation lesion involving the left main coronary artery. DK crush was used to treat 97% of all patients. The number of treated vessels and treated lesions was similar in the two groups. There were fewer procedural complications with IVUS guidance.

The primary endpoint was a composite of target vessel failure, defined as cardiac death, target vessel myocardial infarction (TVMI) or clinically driven target vessel revascularization (TVR) at one year.

Results showed that 17 patients in the IVUS-guided group and 41 in the angiography-guided group experienced a primary outcome event (6.0% vs. 14.7%, respectively; hazard ratio, 0.40; 95% CI, 0.23-0.71; p=0.002). The difference in endpoints was primarily driven by reductions in TVMI and TVR in the IVUS-guided group. Furthermore, the benefit favoring IVUS-guidance was consistent across the 12 prespecified subgroups.

In what the authors say is the first adequately powered trial to compare IVUS and angiography guidance in this setting, “the benefits of IVUS-guided PCI at one year were achieved largely through achievement of IVUS-defined optimization targets rather than IVUS use alone.” They note that these results apply only to the treatment of complex bifurcation lesions with the two-stent DK crush technique.

In a related editorial comment, Gaurav Arora, MD, and Gregg W. Stone, MD, FACC, note “Moving forward, the use of [intravascular imaging] guidance during coronary stenting should be as routine as is the use of cineangiography, a conclusion based on decades of evidence-based investigation. Thus, the question should no longer be ‘whether to use [intravascular imaging],’ but rather ‘which to use’ (IVUS or [optical coherence tomography]) and ‘how best to use.’”

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ACC Annual Scientific Session, ACC26, New Orleans, Angiography, Percutaneous Coronary Intervention