IVUS Guidance for PCI and Long-Term Mortality

Study Questions:

Does intravascular ultrasound (IVUS) guidance for complex percutaneous coronary intervention (PCI) improve long-term outcomes compared to angiographic only guidance?

Methods:

This was a retrospective analysis from over 6,000 patients undergoing drug-eluting stent PCI of complex lesions from 2003-2015. Complex lesions were defined as bifurcation, chronic total occlusion, left main disease, long lesion, multivessel PCI, multiple stent implantation, in-stent restenosis, or heavily calcified lesions. Patients who received IVUS guidance were compared to those who did not receive IVUS guidance. Multiple sensitivity analyses, including multivariable adjustment, propensity score matching, and inverse-probability-weighted method, were performed to adjust for baseline differences.

Results:

Less than one third of the patients received IVUS guidance (28%). Among patients who received IVUS guidance, rates of cardiac death during 64 months of median follow-up were significantly lower compared with angiography-guided PCI (10.2% vs. 16.9%, hazard ratio, 0.573; 95% confidence interval, 0.460–0.714; p < 0.001). Patients receiving IVUS guidance also had lower rates of all-cause death, myocardial infarction, stent thrombosis, ischemia-driven target lesion revascularization, and major adverse cardiac events. Results were consistent after multiple sensitivity analyses.

Conclusions:

IVUS-guided PCI of complex lesions is associated with improved long-term outcomes including cardiac death compared to angiography-guided PCI.

Perspective:

Barring the limitations that come with nonrandomized, retrospective analyses, this study adds to the growing body of literature supporting the use of IVUS for coronary intervention. The strengths of the study include focus on ‘complex lesion set’ and long-term outcomes. The IVUS-guided group was more likely to have larger stent diameter, longer stent length, more frequent post-dilation, and higher maximal pressure inflation, which could translate into optimized PCI results. The benefit was most seen in the left main cohort where the importance of appropriate sizing and deployment are of greater clinical consequence. This along with other studies makes a strong case for IVUS-facilitated PCI, especially in the more complex lesions (left main, bifurcation).

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Angiography, Coronary Artery Disease, Dilatation, Drug-Eluting Stents, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Thrombosis, Ultrasonography


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