Intravascular ultrasound (IVUS) to guide drug-eluting stent (DES) implantation has been evaluated in several studies. Two randomized studies, IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions), have shown fewer repeat revascularizations compared with angiography-guided stent implantation. However, there were no differences in terms of cardiovascular death, stent thrombosis, or AMI; this was linked to the low number of events in each study.
The aim of this study was to analyze patients from the IVUS-XPL and ULTIMATE studies to increase the statistical power that would allow researchers to detect whether IVUS-guided DES implantation has a long-term impact on patient survival (free from cardiovascular death). To do so, only lesions with a length ≥28mm were evaluated.
The primary endpoint (PEP) was cardiovascular death. The secondary endpoint (SEP) was a composite of cardiovascular death, AMI, stent thrombosis, and ischemia-driven revascularization.
The study enrolled 2577 randomized patients, 1289 to the IVUS-guided group, and 1288 to the angiography-guided group.
The mean age was 65 years, 70% of patients were male, and over half of them had hypertension. The most frequent clinical presentation was unstable angina. The most affected artery was the anterior descending artery.
The PEP was reached in 1% of the IVUS group vs. 2.2% of patients in the angiography group (hazard ratio [HR]: 0.43; 95% confidence interval [CI]: 0.22 to 0.84; p = 0.011). Furthermore, there were significant differences in favor of the IVUS group in the SEP (HR: 0.44; 95% CI: 0.25 to 0.80; p = 0.005) at the expense of a lower ischemia-driven revascularization rate (HR: 0.57; 95% CI: 0.40 to 0.82; p = 0.002).
At the 3-year follow-up, patients who met IVUS-measured stent optimization criteria had experienced fewer events (composite of cardiovascular death, AMI, stent thrombosis, and ischemia-driven revascularization) compared with those who did not meet optimization criteria.
Conclusion
Using IVUS to guide DES implantation compared with angiography alone resulted in improved cardiovascular survival and a decreased rate of major events (cardiovascular death, AMI, stent thrombosis) at the 3-year follow-up. In addition, patients who met the criteria for stent optimization compared with those who did not had significantly lower rates of cardiovascular death, AMI, stent thrombosis, and revascularization of the treated vessel at follow-up.
Dr. Andrés Rodríguez
Member of the editorial board in SOLACI.org .
Original Title: Improved 3-Year Cardiac Survival After IVUS–guided Long DES Implantation A Patient-Level Analysis From 2 Randomized Trials.
Reference: Sung-Jin Hong, MD, et al J Am Coll Cardiol Intv 2022;15:208–216.
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