IVUS vs. Angiography in New-Generation Drug-Eluting Stents Preimplantation

Courtesy of Dr. Guillermo Migliaro.

The latest 2011 American College of Cardiology (ACC) guideline states that “coronary intravascular ultrasonography (IVUS) may be considered for guidance of coronary stent implantation, particularly in cases of left main coronary artery stenting (Class IIB, Level of Evidence: B).” This has been long debated with no clear winners. This analysis provides new information using current scaffolds.

The aim of this study was to evaluate the usefulness of IVUS in new-generation drug-eluting stent (DES) implantation in complex lesions. For that, a meta-analysis of individual patients from randomized trials was carried out. A total of 2345 patients included in 3 trials (RESET IVUS [2013], CTO-IVUS [2014], and IVUS-XPL [2015]) were analyzed; all of them presented long lesions or chronic total occlusions. The primary endpoint was a major adverse cardiac event (MACE, a composite of cardiovascular death, infarction, or stent thrombosis). An intention-to-treat analysis and per protocol analysis were performed.

At 1 year after the procedure, the MACE rate was higher in the group of patients who underwent angiography-guided implantation than in those who underwent IVUS-guided implantation (1.2% vs. 0.4%; hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.99; p = 0.040).

The infarction rate was lower in the IVUS-guided implantation group (0% vs. 0.4%; HR: 0.09; p = 0.026). In the per protocol analysis, the benefit of IVUS guidance regarding MACE was even stronger (HR: 0.32; 95% CI: 0.12 to 0.89; p = 0,021).

Conclusion

Authors conclude that in patients with long lesions or chronic total occlusions, IVUS-guided new-generation drug-eluting stent implantation reduces the rate of MACE at follow-up.

Editorial

Previous meta-analyses on this subject matter included different DES types, many including first-generation drug-eluting stents. Given the superior performance of new-generation drug-eluting stents when compared to older stents, a study with these characteristics was necessary for the clarification of IVUS usefulness in the implantation of these scaffolds. The fact that presented information applies only to long lesions or chronic total occlusions should be taken into account.

Another interesting characteristic of this study is that it only includes hard endpoints, as opposed to other studies such as IVUS-XPL, for example, which presented positive results mainly due to a reduction in target lesion revascularization (TLR). It should be noted that there were 3 cases of stent thrombosis in the IVUS group, none of which triggered an infarction. While the difference in hard endpoints is significant, the main difference observed is still related to TLR.

Courtesy of Dr. Guillermo Migliaro. Buenos Aires German Hospital, Argentina.

Original title: Effects of Intravascular Ultrasound–Guided Versus Angiography-Guided New-Generation Drug-Eluting Stent Implantation Meta-Analysis with Individual Patient–Level. Data From 2,345 Randomized Patients.

Reference: Shin DH et al. J Am Coll Cardiol Intv. 2016

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