IVUS-guided Percutaneous Coronary Intervention Research Articles

Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention for acute myocardial infarction with cardiogenic shock.

The benefits of intravascular ultrasonography (IVUS)-guided percutaneous coronary intervention (PCI) in the clinical context of cardiogenic shock (CS) complicating acute myocardial infarction are lacking. We aimed to investigate the impact of IVUS-guided PCI in patients with AMI and CS. From the pooled data based on a series of Korean AMI registries during 2011-2020, we identified 1418 consecutive patients who underwent PCI with second generation drug-eluting stent (DES) for AMI and CS. The primary endpoint was the 1-year rate of target lesion failure (TLF), defined as the composite of cardiac death, target vessel myocardial infarction, and ischemic-driven target lesion revascularization. In total, 294 (20.7%) and 1124 (79.3%) underwent IVUS-guided and angiography-guided PCI with second generation DES implantation, respectively. The 1-year TLF was not significantly different between groups after IPTW analysis (hazard ratio 0.93, 95% confidence interval 0.65-1.34, p = 0.70). Additionally, the adjusted landmark analysis for TLF at 30days and between 30days and 1year after PCI demonstrated no significant difference between the groups. In conclusion, in patients with AMI and CS who underwent PCI with second-generation DES, IVUS-guided PCI did not improve the 1-year TLF compared with angiography-guided PCI.Registration: URL: http://cris.nih.go.kr . KCT0000863 and KCT0008355.

Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Multivessel Disease and Diabetes

There is a scarcity of data on clinical outcomes after intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with multivessel disease and diabetes. OPTIVUS-Complex PCI study multivessel cohort was a prospective multicenter single-arm trial enrolling 1021 patients who underwent multivessel PCI including left anterior descending coronary artery using IVUS aiming to meet the prespecified OPTIVUS criteria for optimal stent expansion. We compared the clinical outcomes between those patients with and without diabetes. The primary endpoint was a composite of death, myocardial infarction, stroke, or any coronary revascularization. There were 560 patients (54.8%) with diabetes, and 461 patients (45.2%) without diabetes. Mean age was not different between the 2 groups (70.9±9.7 years versus 71.7±10.4 years, P=0.17). Patients with diabetes more often had chronic kidney disease and complex coronary artery disease as indicated by the greater total number of stents and longer total stent length. The rate of meeting OPTIVUS criteria was not different between the 2 groups (61.2% vs. 60.7%, P=0.83). The cumulative 1-year incidence of the primary endpoint was not different between the 2 groups (10.8% versus 9.8%, log-rank P=0.65). After adjusting confounders, the risk of diabetes relative to non-diabetes remained insignificant for the primary endpoint (HR, 0.97; 95%CI, 0.65-1.44; P=0.88).In conclusion, in patients who underwent multivessel IVUS-guided PCI, and were managed with contemporary clinical practice, patients with diabetes had similar 1-year outcomes compared with patients without diabetes.

Acute Kidney Injury After Percutaneous Coronary Intervention Guided by Intravascular Ultrasound.

Purpose We investigated the impact of intravascular ultrasound guidance on reducing the incidence of contrast-induced acute kidney injury (CI-AKI) in patients undergoing percutaneous coronary intervention (PCI). Methods Ninety-nine patients were enrolled in this prospective cohort who were not randomly assigned to angiography-guided percutaneous coronary intervention or intravascular ultrasound-guided percutaneous coronary intervention. The patients were hospitalized at the Vietnam National Heart Institute - Bach Mai Hospital between 2019 and 2020. Acute kidney injury incidence during hospitalization was the primary endpoint. Results A total of 99 patients were divided into two groups: the intravascular ultrasound-guided group (33 participants) and the angiography-guided group (66 participants). The mean ± SD contrast volume of each group was 95.2 ± 37.1 mL and 133.0 ± 36.0 mL for the ultrasound-guided and angiography-guided groups, with P < 0.0001. Intravascular imaging-guided percutaneous coronary intervention (IVUS-guided PCI) was associated with reduced acute kidney injury incidence during hospitalization: 0.0% vs. 12.12% and P = 0.049. Conclusions Intravascular ultrasound is a safe imaging tool that guides percutaneous coronary intervention and significantly reduces the rate of acute kidney injury compared to angiography alone. Patients who have a high chance of experiencing acute kidney injury benefit from using intravascular ultrasound.

Quantitative Coronary Angiography vs Intravascular Ultrasonography to Guide Drug-Eluting Stent Implantation

Although intravascular ultrasonography (IVUS) guidance promotes favorable outcomes after percutaneous coronary intervention (PCI), many catheterization laboratories worldwide lack access. To investigate whether systematic implementation of quantitative coronary angiography (QCA) to assist angiography-guided PCI could be an alternative strategy to IVUS guidance during stent implantation. This randomized, open-label, noninferiority clinical trial enrolled adults (aged ≥18 years) with chronic or acute coronary syndrome and angiographically confirmed native coronary artery stenosis requiring PCI. Patients were enrolled in 6 cardiac centers in Korea from February 23, 2017, to August 23, 2021, and follow-up occurred through August 25, 2022. All principal analyses were performed according to the intention-to-treat principle. After successful guidewire crossing of the first target lesion, patients were randomized in a 1:1 ratio to receive either QCA- or IVUS-guided PCI. The primary outcome was target lesion failure at 12 months, defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. The trial was designed assuming an event rate of 8%, with the upper limit of the 1-sided 97.5% CI of the absolute difference in 12-month target lesion failure (QCA-guided PCI minus IVUS-guided PCI) to be less than 3.5 percentage points for noninferiority. The trial included 1528 patients who underwent PCI with QCA guidance (763; mean [SD] age, 64.1 [9.9] years; 574 males [75.2%]) or IVUS guidance (765; mean [SD] age, 64.6 [9.5] years; 622 males [81.3%]). The post-PCI mean (SD) minimum lumen diameter was similar between the QCA- and IVUS-guided PCI groups (2.57 [0.55] vs 2.60 [0.58] mm, P = .26). Target lesion failure at 12 months occurred in 29 of 763 patients (3.81%) in the QCA-guided PCI group and 29 of 765 patients (3.80%) in the IVUS-guided PCI group (absolute risk difference, 0.01 percentage points [95% CI, -1.91 to 1.93 percentage points]; hazard ratio, 1.00 [95% CI, 0.60-1.68]; P = .99). There was no difference in the rates of stent edge dissection (1.2% vs 0.7%, P = .25), coronary perforation (0.2% vs 0.4%, P = .41), or stent thrombosis (0.53% vs 0.66%, P = .74) between the QCA- and IVUS-guided PCI groups. The risk of the primary end point was consistent regardless of subgroup, with no significant interaction. Findings of this randomized clinical trial indicate that QCA and IVUS guidance during PCI showed similar rates of target lesion failure at 12 months. However, due to the lower-than-expected rates of target lesion failure in this trial, the findings should be interpreted with caution. ClinicalTrials.gov Identifier: NCT02978456.

Intervención coronaria percutánea guiada por tomografía de coherencia óptica frente a guiada por ecografía intravascular en pacientes con infarto agudo de miocardio

Introduction and objectivesOptical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) yields clinical outcomes comparable to intravascular ultrasound (IVUS)-guided PCI in patients with stable ischemic heart disease. However, there is a scarcity of data comparing the clinical outcomes of OCT-guided and IVUS-guided PCI in the setting of acute myocardial infarction (AMI). We sought to compare the clinical outcomes of OCT-guided vs IVUS-guided PCI for patients with AMI in the era of second-generation drug-eluting stent (DES). MethodsWe identified 5260 consecutive patients who underwent PCI with a second-generation DES for AMI under IVUS or OCT guidance from pooled data derived from a series of Korean AMI registries between 2011 and 2020. The primary endpoint was the 1-year rate of target lesion failure, defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. ResultsA total of 535 (10.2%) and 4725 (89.8%) patients were treated under OCT and IVUS guidance, respectively. The 1-year target lesion failure rates were comparable between the OCT and IVUS groups before and after propensity score matching (hazard ratio, 0.92; 95%CI, 0.42-2.05, P=.84). The OCT utilization rate did not exceed 5% of total patients treated with second-generation DES implantation during the study period. The primary factors for the selection of OCT over IVUS were the absence of chronic kidney disease, non-left main vessel disease, single-vessel disease, stent diameter <3mm, and stent length ≤ 25mm. ConclusionsOCT-guided PCI in patients with AMI treated with a second-generation DES provided comparable clinical outcomes for 1-year target lesion failure compared with IVUS-guided PCI.

Long-term impact of intravascular ultrasound-guidance for percutaneous coronary intervention on unprotected left main. The IMPACTUS-LM, an observational, multicentric study

IntroductionThe potential benefit on long term outcomes of Percutaneous Coronary Intervention (PCI) on Unprotected Left Main (ULM) driven by IntraVascular UltraSound (IVUS) remains to be defined. MethodsIMPACTUS LM-PCI is an observational, multicenter study that enrolled consecutive patients with ULM disease undergoing coronary angioplasty in 13 European high-volume centers from January 2002 to December 2015. Major Adverse Cardiovascular Events (MACEs) a composite of cardiovascular (CV) death, target vessel revascularization (TVR) and myocardial infarction (MI) were the primary endpoints, while its single components along with all cause death the secondary ones. Results627 patients with ULM disease were enrolled, 213 patients (34%) underwent IVUS-guided PCI while 414 (66%) angioguided PCI. Patients in the two cohorts had similar prevalence of risk factors except for active smoking and clinical presentation. During a median follow-up of 7.5 years, 47 (22%) patients in the IVUS group and 211 (51%) in the angio-guided group underwent the primary endpoint (HR 0.42; 95% CI [0.31–0.58] p < 0.001). After multivariate adjustment, IVUS was significantly associated with a reduced incidence of the primary endpoint (adj HR 0.39; 95% CI [0.23–0.64], p < 0.001), mainly driven by a reduction of TVR (ad HR 0.30, 95% CI [0.15–0.62], p = 0.001) and of all-cause death (adj HR 0.47, 95% CI [0.28–0.82], p = 0.008). IVUS use, age, diabetes, side branch stenosis, DES and creatinine at admission were independent predictors of MACE. ConclusionsIn patients undergoing ULM PCI, the use of IVUS was associated with a reduced risk at long-term follow-up of MACE, all-cause death and subsequent revascularization.

OCT-guided versus IVUS-guided percutaneous coronary intervention in patients with acute myocardial infarction. Do we have a winner?

OCT-guided versus IVUS-guided percutaneous coronary intervention in patients with acute myocardial infarction. Do we have a winner?

Cost-effectiveness of intravascular ultrasound-guided percutaneous intervention in patients with acute coronary syndromes: A UK perspective.

Use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes over angiography alone. Despite this, the adoption of IVUS in clinical practice remains low. To examine the cost-effectiveness of IVUS-guided PCI compared to angiography alone in patients with acute coronary syndromes (ACS). A one-year decision tree and lifetime Markov model were constructed to compare the cost-effectiveness of IVUS-guided PCI to angiography alone for two hypothetical adult populations consisting of 1,000 individuals: ST-elevation myocardial infarction (STEMI) and unstable angina/ non-ST-elevation myocardial infarction (UA/NSTEMI) patients undergoing drug-eluting stent (DES) implantation. The UK healthcare system perspective was applied using 2019/20 costs. All-cause death, myocardial infarction (MI), repeat PCI, lifetime costs, life expectancy and quality-adjusted life-years (QALYs) were assessed. Over a lifetime horizon, IVUS-guided PCI was cost-effective compared to angiography alone in both populations, yielding an incremental cost-effectiveness ratio of £3,649 and £5,706 per-patient in STEMI and UA/NSTEMI patients, respectively. In the one-year time horizon, the model suggested that IVUS was associated with reductions in mortality, MI and repeat PCI by 51%, 33% and 52% in STEMI and by 50%, 29% and 57% in UA/NSTEMI patients, respectively. Sensitivity analyses demonstrated the robustness of the model with IVUS being 100% cost-effective at a willingness-to-pay (WTP) threshold of £20,000 per QALY-gained. From a UK healthcare perspective, an IVUS-guided PCI strategy was highly cost-effective over angiography alone amongst ACS patients undergoing DES implantation due to the medium- and long-term reduction in repeat PCI, death, and MI.

Absolute zero-contrast percutaneous coronary interventions: An intravascular ultrasound-guided case series and literature review

PurposeContrast media (CM)-associated adverse effects including mainly acute kidney injury and hypersensitivity reactions still remain a significant treatment burden to vulnerable patients requiring percutaneous coronary intervention (PCI). The complete omission of CM administration accompanied by intravascular ultrasound (IVUS) guidance may offer an appropriate revascularization treatment. MethodsWe hereby present a case series of four patients with challenging coronary lesions and relative/absolute contraindications to CM use [(hypersensitivity reaction owning to CM, history of contrast-induced acute kidney injury, solitary kidney, or advanced chronic kidney disease (CKD)] who underwent absolute zero-contrast IVUS-guided PCI following a predetermined protocol. ResultsThe initial diagnostic angiography was reviewed for landmark identification, and multiple guidewires created a metallic road map providing additional landmarks and protected side branches. IVUS imaging was performed to determine lesion length, reference segments and landing zones, assess stent expansion/apposition and identify major complications. All procedures were successfully completed without any CM administration, renal function deterioration, pericardial effusion, or stent edge dissection. ConclusionsWe demonstrated the feasibility of absolute zero-contrast IVUS-guided PCI in patients with complex coronary lesions susceptible to CM-associated adverse effects. Since the safety of this strategy is well-documented in patients with CKD and challenging lesions morphology even in acute settings, evidence-based validation of this approach is capable of changing the otherwise conservative treatment of vulnerable patients where even minimum doses of CM may have detrimental effects. Summary for the annotated table of contentsPatients with vulnerable renal function as well as former hypersensitivity reaction to contrast media encounter a significant treatment burden regarding coronary artery disease. Zero-contrast IVUS-guided strategy based on a predetermined protocol provides a feasible alternative approach in patients susceptible to contrast media-associated adverse effects even in the presence of complex coronary lesions.

Optical coherence tomography-guided versus intravascular ultrasound-guided percutaneous coronary intervention in patients with acute myocardial infarction

Introduction and objectivesOptical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) yields clinical outcomes comparable to intravascular ultrasound (IVUS)-guided PCI in patients with stable ischemic heart disease. However, there is a scarcity of data comparing the clinical outcomes of OCT-guided and IVUS-guided PCI in the setting of acute myocardial infarction (AMI). We sought to compare the clinical outcomes of OCT-guided vs IVUS-guided PCI for patients with AMI in the era of second-generation drug-eluting stent (DES). MethodsWe identified 5260 consecutive patients who underwent PCI with a second-generation DES for AMI under IVUS or OCT guidance from pooled data derived from a series of Korean AMI registries between 2011 and 2020. The primary endpoint was the 1-year rate of target lesion failure, defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. ResultsA total of 535 (10.2%) and 4725 (89.8%) patients were treated under OCT and IVUS guidance, respectively. The 1-year target lesion failure rates were comparable between the OCT and IVUS groups before and after propensity score matching (hazard ratio, 0.92; 95%CI, 0.42-2.05, P=.84). The OCT utilization rate did not exceed 5% of total patients treated with second-generation DES implantation during the study period. The primary factors for the selection of OCT over IVUS were the absence of chronic kidney disease, non-left main vessel disease, single-vessel disease, stent diameter <3mm, and stent length ≤ 25mm. ConclusionsOCT-guided PCI in patients with AMI treated with a second-generation DES provided comparable clinical outcomes for 1-year target lesion failure compared with IVUS-guided PCI.

Intravascular ultrasonography guided percuatneous coronary intervention with everolimus-eluting stents or bypass surgery for multivessel coronary artery disease: post-hoc analysis of the BEST study

Abstract Background Previous studies suggested that intravascular ultrasonography (IVUS)-guided percutaneous coronary intervention (PCI) improved clinical outcomes compared with coronary angiography (CAG)-guided PCI in complex coronary artery disease. Objectives We compared long-term clinical outcomes of IVUS-guided PCI with everolimus-eluting stent and coronary-artery bypass grafting (CABG) in multivessel coronary disease (MVD). Methods Among 880 patients with MVD enrolled in the BEST Extended Follow-up study, 333 patients underwent IVUS-guided PCI and 131 patients underwent CAG-guided PCI, which were compared with 401patients underwent CABG. The primary endpoint was the composite of death from any cause, myocardial infarction, or target-vessel revascularization during a median follow-up of 11.8 years (interquartile range, 10.6 to 12.5 years). Results During an extended follow-up, primary endpoint occurred in 75 patients (22.8%) in the IVUS-guided PCI group, in 58 patients (44.38%) in the CAG-guided PCI group, and in 95 patients (24.0%) in the CABG group. Compared with the CABG group, the IVUS-guided PCI group had a similar rate of primary endpoint (adjusted hazard ratio [HR], 1.013; 95% confidence interval [CI], 0.747-1.374; P=0.93), whereas the CAG-guided PCI group had a significantly higher risk of clinical events (adjusted HR, 2.231; 95% CI, 1.582-3.145; P&amp;lt;0.001). Similarly, whereas the IVUS-guided PCI group had similar rate (adjusted HR, 0.845; 95% CI, 0.605-1.181; P=0.324), the CAG guided PCI group had the significantly higher rate of the safety composite of death, stroke and myocardial infarction (adjusted HR, 2.016; 95% CI, 1.405-2.895; P&amp;lt;0.001) compared with the CABG group. However, both IVUS- and CAG-guided PCI groups had significantly higher rate of any repeat revascularization than CABG group. Conclusions In patients with MVD, IVUS-guided PCI appeared to be an safe and effective alternative to CABG. This study advocated the routine use of intravascular imaging during PCI for MVD.KM curve of outcomesPrimary and secondary outcome

Discordance between quantitative coronary angiography and fractional flow reserve or intravascular ultrasound: a substudy of the FLAVOUR trial

Abstract Background Discrepancies between quantitative coronary angiography (QCA) and fractional flow reserve (FFR) or intravascular ultrasound (IVUS) are often observed in coronary lesions with intermediate stenosis. Objectives We investigated the impact of physiology- or intracoronary imaging-directed revascularization strategies on clinical outcomes in patients with discordant coronary lesions between QCA and FFR or IVUS. Methods This study was a post hoc analysis of the FLAVOUR study, an investigator-initiated, prospective, randomized, open-label, multinational trial performed at 18 sites in Korea and China. In the FLAVOUR study, 200 patients with ≥60% diameter stenosis (DS) deferred percutaneous coronary intervention (PCI) according to FFR &amp;gt; 0.8 (n=141) or a minimal lumen area &amp;gt; 3 mm2 or 3-4 mm2 with a plaque burden &amp;lt;70% on IVUS whereas 351 patients with &amp;lt;60% DS performed PCI according to positive FFR (n=118) or positive IVUS (n=233) results. The primary outcome was a patient-oriented composite outcome (POCO), a composite of death, myocardial infarction, or revascularization. Results The incidence of discordance was 28.1% in the FFR group and 32.4% in the IVUS group. At 24 months, among patients with ≥60% DS, the incidence of POCO was similar between FFR-guided and IVUS-guided deferral strategies (4.4% vs. 3.4%, p=0.757). Among patients with &amp;lt;60% DS, FFR-directed or IVUS-directed PCI did not differ in the POCO incidence (5.2% vs. 2.6%, p=0.207). However, FFR-guided PCI showed a higher incidence of periprocedural myocardial infarction than IVUS-guided PCI in &amp;lt;60% DS lesions (2.6% vs. 0.0%, p=0.014). Conclusions In patients with discordant intermediate stenosis between QCA and FFR or IVUS, physiology- and imaging-directed revascularization strategies are comparable concerning POCO at 24 months.

Abstract 17475: Intravascular Ultrasound versus Angiography in Percutaneous Coronary Interventions: A Meta-Analysis Unveiling Compelling Evidence of Ultrasound's Superiority

Objective: This meta-analysis aims to compare the effectiveness of intravascular ultrasound (IVUS) versus angiography alone in percutaneous coronary intervention (PCI) procedures. Methods: A comprehensive literature search was conducted to identify relevant studies comparing IVUS-guided PCI with angiography-guided PCI. The primary outcome measure was major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and target vessel revascularization. Secondary outcomes included all-cause mortality, stent thrombosis, and angiographic outcomes. Results: A total of 41 eligible studies involving 712635 patients were included in the meta-analysis. IVUS-guided PCI was associated with a significantly lower risk of MACE compared to angiography-guided PCI (pooled odds ratio [OR] 1.38, 95% confidence interval [CI] 1.24-1.53, p&lt;0.00001). The use of IVUS also resulted in a lower risk of all-cause mortality (pooled OR 1.61, 95% CI 1.41-1.83, p&lt;0.00001) and reduced rates of stent thrombosis (pooled OR 2.28, 95% CI 1.82-2.86, p&lt;0.00001) and TVR (pooled OR 1.31, 95% CI 1.21-1.42, p&lt;0.00001). Conclusion: This meta-analysis provides evidence supporting the use of IVUS-guided PCI over angiography-guided PCI. IVUS-guided procedures were associated with reduced MACE rates, improved procedural success, decreased stent thrombosis, and superior angiographic outcomes. The findings suggest that incorporating IVUS into PCI procedures may lead to improved clinical outcomes and more optimal stent deployment. However, further studies are warranted to explore potential subgroup differences and to evaluate the cost-effectiveness of IVUS-guided PCI.

Abstract 13725: Intravascular Ultrasound-Guided versus Angiography-Guided Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

Introduction: Intravascular ultrasound (IVUS) provides intra-procedural guidance in optimizing percutaneous coronary interventions (PCI) and has been shown to improve clinical outcomes in stent implantation. However, current data on the benefit of IVUS during PCI in STEMI patients is mixed. Research Question: Whether IVUS is associated with improved outcomes during PCI in STEMI patients is unclear. Aim: We performed a systematic review and meta-analysis assessing the utility of IVUS during PCI in the setting of STEMI. Methods: We performed a systematic search on PubMed and Embase for studies comparing IVUS versus angiography guided PCI in STEMI. Mantel-Haenszel random effects model was used to calculate risk ratios (RR) with 95% confidence intervals (CI) for outcomes of major cardiovascular adverse events (MACE), death, myocardial infarction (MI), target vessel revascularization (TVR) and stent thrombosis (ST). Analysis was performed using Review Manager version 5.4.1. Results: A total of 7 studies including 78,612 individuals presenting with STEMI were included for the meta-analysis. Follow-up ranged from 11 to 60 months. We found a significant association between IVUS-guided PCI with lower risk for MACE (RR 0.82, 95% CI 0.76-0.90) compared with angiography-guided PCI. We also found significant association between IVUS-guided PCI with lower risk for death, MI, and TVR but not ST (Figure 1). Conclusion: In our meta-analysis, IVUS-guided compared with angiography-guided PCI was associated with improved clinical outcomes in STEMI patients.

Enhancing Coronary Intervention Outcomes Using Intravascular Ultrasound: Analysis of Long-Term Benefits in a Japanese Multicenter Registry

BackgroundAlthough the use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes, its utilization remains inconsistent. We aimed to assess the association between IVUS-guided PCI and long-term outcomes in Japan, where a high proportion of patients undergo IVUS. MethodsWe analyzed 8721 consecutive patients in a multicenter PCI registry. The primary outcome was a composite of death, acute coronary syndrome, and heart failure requiring admission and coronary artery bypass grafting at 2 years after discharge. The secondary outcome was each component of the primary outcome. We used inverse probability-weighted analysis for adjustment. Subgroup analysis was conducted on patients with complex coronary anatomy (eg, those with bifurcation, chronic total occlusion, type C lesion, left main and those who underwent rotational atherectomy). ResultsOverall, 83.8% of patients underwent IVUS-guided PCI (mean age, 68.3 ± 11.3 years). After adjustments, the IVUS group had significantly lower rates of death and coronary bypass compared to no IVUS group (hazard ratio [HR], 0.73; 95% CI, 0.55-0.96; and HR, 0.62; 95% CI, 0.39-0.98) at 2-year follow-up, although the primary outcome showed only marginal differences (HR, 0.85; 95% CI, 0.71-1.01). In the subgroup analysis of complex coronary anatomy, the use of IVUS was significantly associated with a reduced risk of the primary outcome (HR, 0.72; 95% CI, 0.55-0.93) as well as death, coronary bypass, and heart failure. ConclusionsIVUS was frequently utilized in our registry and demonstrated potential benefit in reducing mortality and need for coronary bypass surgery, particularly in patients with complex coronary anatomy.

Guiding Intervention for Complex Coronary Lesions by Optical Coherence Tomography or Intravascular Ultrasound

BackgroundOptical coherence tomography (OCT) and intravascular ultrasound (IVUS) have shown comparable outcomes in guiding percutaneous coronary intervention (PCI). However, their comparative effectiveness in complex coronary artery lesions remains unclear. ObjectivesThis study compared the effectiveness and safety of OCT-guided vs IVUS-guided PCI for complex coronary artery lesions. MethodsThis was a prespecified, main subgroup analysis of complex coronary artery lesions in the OCTIVUS (Optical Coherence Tomography Versus Intravascular Ultrasound Guided Percutaneous Coronary Intervention) trial, which included unprotected left main disease, bifurcation disease, an aorto-ostial lesion, a chronic total occlusion, a severely calcified lesion, an in-stent restenotic lesion, a diffuse long lesion, or multivessel PCI. The primary endpoint was a composite of death from cardiac causes, target vessel–related myocardial infarction, or ischemia-driven target vessel revascularization. ResultsIn 2,008 randomized patients, 1,475 (73.5%) underwent imaging-guided PCI for complex coronary artery lesions; 719 (48.7%) received OCT-guided and 756 (51.3%) IVUS-guided PCI. At a median follow-up of 2.0 years, primary endpoint event had occurred in 47 patients (6.5%) in the OCT-guided group and in 56 patients (7.4%) in the IVUS-guided group (HR: 0.87; 95% CI: 0.59-1.29; P = 0.50). These findings were consistent in adjusted analyses. The incidence of contrast-induced nephropathy was similar between the 2 groups (1.9% vs 1.5%; P = 0.46). The incidence of major procedural complications was lower in the OCT-guided group than in the IVUS-guided group (1.7% vs 3.4%; P = 0.03). ConclusionsAmong patients with complex coronary artery lesions, OCT-guided PCI showed a similar risk of primary composite event of death from cardiac causes, target vessel–related myocardial infarction, or target vessel revascularization as compared with IVUS-guided PCI. (Optical Coherence Tomography Versus Intravascular Ultrasound Guided Percutaneous Coronary Intervention [OCTIVUS]; NCT03394079)

SYNTAX Score and 1-Year Outcomes in the OPTIVUS-Complex PCI Study Multivessel Cohort

The optimal revascularization strategy in patients with multivessel disease and intermediate SYNTAX score (SS) has not been fully elucidated. This study aimed to investigate the clinical outcomes of optimal intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) stratified by SS. This was a substudy of the OPTIVUS-Complex PCI study Multivessel Cohort, which aimed to meet the prespecified criteria for optimal stent expansion after IVUS-guided PCI. A total of 1,005 patients were divided into 3 groups according to SS: low, ≤22; intermediate, 23 to 32; and high, ≥33. The primary end points were major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of death, myocardial infarction, stroke, or coronary revascularization. The cumulative 1-year incidence of the primary end point was significantly higher in patients with high SS than in those with intermediate or low SS (25.0%, 10.9%, and 9.5%, respectively; p=0.003). This difference was mainly caused by the incidence of coronary revascularization. In the multivariable Cox proportional hazards models, the excess risk of patients with high versus low SS remained significant for the primary end point (hazard ratio 3.19, 95% confidence interval 1.65 to 6.16, p <0.001), whereas the excess risk of patients with intermediate versus low SS was no longer significant (hazard ratio 1.20, 95% confidence interval 0.72 to 2.01, p=0.46). After IVUS-guided multivessel PCI, patients with intermediate SS had a similar 1-year risk of MACCE to that of patients with low SS, whereas patients with high SS had a higher 1-year risk of MACCE than those with low SS.

Comparison of Long-Term Outcomes Between Intravascular Ultrasound-, Optical Coherence Tomography- and Angiography-Guided Stent Implantation: A Meta-Analysis.

Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided percutaneous coronary interventions (PCI) are alternative techniques to angiography-guided (ANG-g) PCI in patients with coronary artery disease (CAD), especially for optimal stent deployment in coronary arteries. We conducted a network meta-analysis including studies comparing those three techniques. We searched databases for studies that compared IVUS, OCT, and ANG-g PCI in patients with CAD. Overall, 52 studies with 231,137 patients were included in this meta-analysis. ANG-g PCI had higher major adverse cardiovascular events (MACEs), all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) than IVUS-guided PCI. Of note, both OCT-guided and IVUS-guided PCI had similar outcomes. The frequency of MACEs, cardiac death, and MI were higher in ANG-g PCI than in OCT-guided PCI. The highest benefit was established with OCT for MACEs (P-score=.973), MI (P-score=.823), and cardiac death (P-score=.921) and with IVUS for all-cause death (P-score=.792), TLR (P -score=.865), and ST (P-score=.930). This network meta-analysis indicated that using OCT or IVUS for optimal stent implantation provides better outcomes in comparison with ANG-g in patients with CAD undergoing PCI.

Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial.

Intravascular imaging-guided percutaneous coronary intervention (PCI) with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) showed superior clinical outcomes compared with angiography-guided PCI. However, the comparative effectiveness of OCT-guided and IVUS-guided PCI regarding clinical outcomes is unknown. In this prospective, multicenter, open-label, pragmatic trial, we randomly assigned 2008 patients with significant coronary artery lesions undergoing PCI in a 1:1 ratio to undergo either an OCT-guided or IVUS-guided PCI. The primary end point was a composite of death from cardiac causes, target vessel-related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year, which was powered for noninferiority of the OCT group compared with the IVUS group. Safety outcomes were also assessed. At 1 year, primary end point events occurred in 25 of 1005 patients (Kaplan-Meier estimate, 2.5%) in the OCT group and in 31 of 1003 patients (Kaplan-Meier estimate, 3.1%) in the IVUS group (absolute difference, -0.6 percentage points; upper boundary of one-sided 97.5% CI, 0.97 percentage points; P<0.001 for noninferiority). The incidence of contrast-induced nephropathy was similar (14 patients [1.4%] in the OCT group versus 15 patients [1.5%] in the IVUS group; P=0.85). The incidence of major procedural complications was lower in the OCT group than in the IVUS group (22 [2.2%] versus 37 [3.7%]; P=0.047), although imaging procedure-related complications were not observed. In patients with significant coronary artery lesions, OCT-guided PCI was noninferior to IVUS-guided PCI with respect to the incidence of a composite of death from cardiac causes, target vessel-related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year. The selected study population and lower-than-expected event rates should be considered in interpreting the trial. URL: https://www. gov; Unique number: NCT03394079.

Accuracy of IVUS-Based Machine Learning Segmentation Assessment of Coronary Artery Dimensions and Balloon Sizing

BackgroundAccurate intravascular ultrasound (IVUS) measurements are important in IVUS-guided percutaneous coronary intervention optimization by choosing the appropriate device size and confirming stent expansion. ObjectivesThe purpose of this study was to assess the accuracy of machine learning (ML) automatic segmentation of coronary artery vessel and lumen dimensions and balloon sizing. MethodsUsing expert analysis as the gold standard, ML segmentation of 60 MHz IVUS images was developed using 8,076 IVUS cross-sectional images from 234 patients, which were randomly split into training (83%) and validation (17%) data sets. The performance of ML segmentation was then evaluated using an independent test data set (437 images from 92 patients). The endpoints were the agreement rate between ML vs experts’ measurements for appropriate balloon size selection, and lumen and acute stent areas. Appropriate balloon size was determined by rounding down from the mean vessel diameter or rounding up from the mean lumen diameter to the next balloon size. The difference of lumen area ≥0.5 mm2 was considered as clinically significant. ResultsML model segmentation correlated well with experts’ segmentation for training data set with a correlation coefficient of 0.992 and 0.993 for lumen and vessel areas, respectively. The agreement rate in lumen and acute stent areas was 85.5% and 97.0%, respectively. The agreement rate for appropriate balloon size selection was 70.6% by vessel diameter only and 92.4% by adding lumen diameter. ConclusionsML model IVUS segmentation measurements were well-correlated with those of experts and selected an appropriate balloon size in more than 90% of images.