Original title: Intravascular Ultrasound-Guided Implantation of Drug-Eluting Stents to Improve Outcome. A Meta-Analysis. Reference: Jae-Sik Jang et al. J Am Coll Cardiol Intv 2014, epub ahead of print.

Several previous studies and meta-analysis showed that implantation of conventional stents (BMS) intravascular ultrasound (IVUS) guided may decrease restenosis and clinical events. This information was not yet clear to drug-eluting stents.

This meta- analysis included 15 studies (3 randomized and 12 observational) with 24849 patients, 11793 received IVUS-guided angioplasty and 13056 guided by angiography. IVUS-guided angioplasty showed a significantly lower rate of death from any cause (OR 0.64, CI 95% 0.51 to 0.81, P < 0.001), acute myocardial infarction (OR 0.57, CI 95% 0.42 to 0.78, P < 0.001) and target vessel revascularization (OR 0.81, CI 95% CI 0.68 to 0.95, P = 0.01). IVUS -guided angioplasty was also associated with significantly less definite or probable thrombosis (OR 0.59, CI 95% 0.42 to 0.82, P = 0.002). Overall, IVUS decreased by 21% the risk of combined events and 36% the risk of death compared with angioplasty guided by angiography alone. In the stratified analysis, according to study design a lower incidence of events in non- randomized studies was observed (OR 0.81; CI 95% 0.68 to 0.96, p = 0.02) compared with randomized studies. In fact the latter only showed a trend in favor of IVUS versus angiography (OR 0.69, CI 95% 0.46 to 1.04, P = 0.07). 

Conclusion

This meta-analysis showed that angioplasty with drug-eluting stents guided by IVUS reduces clinical events compared with angiographic guidance only. Additional trials with adequate statistical power to identify patients or lesions with different risk profiles that may especially benefit from this technique are need it. 

Editorial comment

The advantage of IVUS in this work seems to be related to a lower incidence of heart attack or death rather than decreased angiographic restenosis and repeat revascularization rate. The mechanism is related to the ability of IVUS to identify factors associated with peri-procedural complications such as dissection or hematoma at the edges, sub-expansion or incomplete stent apposition.

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