IVUS-guided PCI confers better outcomes vs. angiography
Patients who underwent IVUS-guided PCI had more comorbidities but experienced less mortality, MI and repeat revascularization during the follow-up period than patients who underwent PCI without IVUS, researchers reported.
“The findings enforce the important role of IVUS in PCI. Mortality, MI and repeat revascularization were lower in the IVUS-guided PCI group,” Amgad Mentias, MD, MSc, associate professor of internal medicine at University of Iowa Carver College of Medicine, told Healio. “Intravascular imaging should be utilized more frequently by our interventional cardiologists and should be a fundamental element of interventional cardiology training in the U.S.”
For the study, published in JACC: Cardiovascular Interventions, investigators used the Medicare database to identify 1,877,177 U.S. patients who underwent PCI from 2009 to 2017. Researchers used propensity-score matching and inverse probability weighting to determine long-term outcomes of IVUS-guided PCI compared with non-IVUS-guided PCI.
Across the U.S., IVUS use in PCI increased from 3% of procedures in 2009 to 6.9% in 2017 (P < .01), but large variability was persistent (median, 5.7%; interquartile range, 3.1-10.7).
According to the study, patients who underwent IVUS-guided PCI had greater prevalence of comorbidities, including HF (28.6% vs. 25.8%), prior CAD (22.8% vs. 21.8%), prior stroke (5.1% vs. 4.2%), chronic kidney disease (21.1% vs. 19.3%), chronic lung disease (22.9% vs. 20.9%) and pulmonary hypertension (4.8% vs. 3.9%), compared with patients who did not receive IVUS (P < .001 for all).
Complex PCI was also more common in the IVUS group due to a higher number of stents placed, more vessels treated and more bifurcation and chronic total occlusion lesions. However, patients who underwent angiography-guided PCI were more likely to present with MI (56.2% vs. 48.8%; P < .001), according to the study.
“It is important to note that the use of IVUS in the current study was less common in patients with acute MI,” the researchers wrote. “Several plausible factors for this finding include reluctance of operators to perform intravascular imaging in the presence of intraluminal thrombus and increased risk of spasm. IVUS use in patients with MI can help identify the true culprit lesion and the severity of coronary remodeling and, hence, allow optimum choice of stent size.”
Outcomes in IVUS-guided PCI
Researchers found that in the propensity-matched cohort, IVUS-guided PCI conferred lower 1-year rates of mortality (11.5% vs. 12.3%), MI (4.9% vs. 5.2%) and repeat revascularization (6.1% vs. 6.7%), compared with angiography-guided PCI (P < .01 for all).
During a mean follow-up of 3.7 years, patients who underwent IVUS-guided PCI experienced lower risk for mortality (adjusted HR = 0.903; 95% CI, 0.885-0.922), MI (aHR = 0.899; 95% CI, 0.893-0.904) and repeat revascularization (aHR = 0.893; 95% CI, 0.887-0.898) compared with those who received angiography-guided PCI.
“It remains unknown whether the benefits of IVUS use in our study is linked to pre-stent imaging for PCI planning (ie, stent size and length, need for atherectomy, etc) vs. post-stent imaging for stent optimization (ie, stent expansion and apposition, ruling out complications such as edge dissection, etc), or both,” Mentias said in an interview. “It is also unclear if the favorable outcomes are entirely related to the use of IVUS or in some ways also reflect outcomes in the hands of experienced operators who utilize intravascular imaging for PCI optimization.
“The reluctance to routine use of IVUS in PCI in the U.S. is likely multifactorial, including high cost without adequate reimbursement, concern about being time-consuming and possibly lack of knowledge about its benefits or how to adequately interpret the data and act on it.” Mentias told Healio. “To help overcome these obstacles, regulators and payors should recognize the importance of IVUS in improving outcomes and start a national discussion about the appropriate reimbursement model, and the professional societies should continue to enforce the role of intravascular imaging in PCI in educational meetings and practice guidelines.”
IVUS ‘should become a mainstay’
“Collectively, the body of evidence investigating the role of IVUS in PCI guidance has matured and data consistently suggest that imaging-guided PCI should become a mainstay of complex PCI procedures,” Lorenz Räber, MD, PhD, and Yasushi Ueki, MD, interventional cardiologists at Bern University Hospital, Switzerland, wrote in a related editorial. “To close the gap between evidence and clinical practice, reimbursement for imaging catheters, easy-to-use semiautomated software applications, and standardized and widespread education are crucial.”