Mintz Gary S
Cardiovascular Research Foundation, New York, New York, USA.
Coron Artery Dis. 2017 Jun;28(4):346-352. doi: 10.1097/MCA.0000000000000483.
There have been nine published randomized trials and 30 registry studies comparing intravascular ultrasound (IVUS)-guided drug-eluting stent implantation versus conventional angiographic guidance. These trials and registries have been evaluated and summarized in (i) eight meta-analyses that included from nine to 18 registries and from one to seven randomized trials and (ii) four meta-analyses that included from three to eight randomized trials. Although with one exception no two meta-analyses have included the same trials or studies, in each meta-analysis, IVUS guidance was associated with a reduction in major adverse cardiac events as well as secondary hard endpoints of death (primarily cardiovascular mortality), myocardial infarction, and stent thrombosis, especially in randomized trial meta-analyses. This was explained in three meta-analyses comparing the acute results of IVUS versus angiographic guidance showing that (i) postdilation was used more frequently, and stent sizes, final angiographic minimum lumen diameters, and IVUS minimum stent areas were larger with IVUS guidance to minimize stent underexpansion and (ii) more stents were implanted and stents were longer with IVUS guidance to minimize geographic miss and treat edge dissections. IVUS-guided stent implantation can be used to minimize contrast during stent implantation, a strategy that is especially useful in patients with underlying renal insufficiency. Finally, an economic analysis showed that IVUS guidance was a dominant and cost-effective strategy, especially in patients with comorbid conditions who were at a higher risk of cardiac events and especially when the benefits of IVUS continued beyond 1 year.
已有 9 项发表的随机试验和 30 项注册研究比较了血管内超声（IVUS）引导下药物洗脱支架植入术与传统血管造影引导术。这些试验和注册研究已在以下研究中得到评估和总结：（i）8 项荟萃分析，纳入了 9 至 18 项注册研究和 1 至 7 项随机试验；（ii）4 项荟萃分析，纳入了 3 至 8 项随机试验。尽管除一项研究外，没有两项荟萃分析纳入相同的试验或研究，但在每项荟萃分析中，IVUS 引导均与主要不良心脏事件以及死亡（主要是心血管死亡率）、心肌梗死和支架血栓形成等次要硬终点的减少相关，尤其是在随机试验荟萃分析中。三项比较 IVUS 与血管造影引导急性结果的荟萃分析对此进行了解释，结果表明：（i）后扩张更频繁应用，且在 IVUS 引导下支架尺寸、最终血管造影最小管腔直径和 IVUS 最小支架面积更大，以尽量减少支架扩张不足；（ii）在 IVUS 引导下植入的支架更多且支架更长，以尽量减少病变遗漏并处理边缘夹层。IVUS 引导下的支架植入可用于在支架植入期间尽量减少造影剂用量，这一策略对有潜在肾功能不全的患者尤其有用。最后，一项经济学分析表明，IVUS 引导是一种占优且具有成本效益的策略，尤其是在合并症患者中，这些患者发生心脏事件的风险更高，特别是当 IVUS 的益处持续超过 1 年时。
