Intravascular imaging associated with improved outcomes compared with angiography

ESC Congress 2023

Intravascular imaging-guided percuta­neous coronary intervention (PCI) is associated with a lower rate of target lesion failure compared with angiography-guided PCI, according to research presented at the ESC Congress 2023.

Numerous randomised trials have compared intravascular imaging-guided PCI with angiography-guided PCI. However, most of these prior trials have used intravascular ultrasound (IVUS). Optical coherence tomography (OCT) is a newer intravascular imaging modality that has enhanced resolution compared to IVUS. Two randomised trials of OCT-guided versus angiography-guided PCI were presented for the first time, the ILUMIEN IV trial in high-risk patients with complex lesions and the OCTOBER trial in bifurcation lesions.

The authors of the current study performed a real-time updated network meta-analysis, integrating data from the ILUMIEN IV and OCTOBER trials with prior studies, to examine the effects of intravascular imaging guidance versus angiography guidance. The analysis compared:
1. The overall effects of intravascular imaging (IVUS and OCT) in improving outcomes of the PCI procedure versus angiography;
2. IVUS versus angiography;
3. OCT versus angiography; and
4. IVUS versus OCT.

The analysis incorporated 20 randomised trials of intravascular imaging-guided PCI compared with angiography-guided PCI in 12,428 patients with chronic and acute coronary syndromes. Of those, 7,038 were randomly allocated to intravascular imaging guidance (including 3,120 patients randomised to IVUS guidance, 2,826 patients randomised to OCT guidance, and 1,092 patients randomised to IVUS or OCT guidance), and 5,390 patients were randomly allocated to angiography guidance. Patients were followed for between 6 months and 5 years. The primary endpoint was target lesion failure, defined as a “composite of cardiac death, target vessel myocardial infarction”, or target lesion revascu­larisation. Secondary endpoints included cardiac death, target vessel myocardial infarction, target lesion revascularisation, and stent thrombosis, as well as all-cause death, all myocardial infarction and target vessel revascularisation.

Primary outcome

Intravascular imaging (IVUS or OCT) guidance of PCI resulted in reductions in the primary composite outcome of target lesion failure by 31% compared with angiography guidance of PCI.

Secondary outcomes

Regarding secondary outcomes, intra­vascular imaging guidance of PCI resulted in reductions in cardiac death by 46%, target vessel myocardial infarction by 20%, target lesion revascularisation by 29%, and stent thrombosis by 52% compared with angiography guidance of PCI.

There were also statistically significant reductions in all-cause death, all myocardial infarction and target vessel revascularisation with intravascular imaging guidance of PCI.

The outcomes were similar for OCT-guided PCI and IVUS-guided PCI when compared individually against angiography and when compared
to each other.

Principal investigator Dr Gregg Stone of Icahn School of Medicine at Mount Sinai, New York, US said: “The results of this network meta-analysis emphasise the importance of physicians using intravascular imaging with either OCT or IVUS to optimise stent outcomes and improve the long-term prognosis of their patients.”