Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
JACC Cardiovasc Interv. 2019 Apr 8;12(7):607-620. doi: 10.1016/j.jcin.2019.01.227. Epub 2019 Mar 13.
This study sought to determine whether intravascular ultrasound (IVUS) guidance compared with angiographic guidance reduces long-term risk of cardiac death in patients undergoing complex percutaneous coronary intervention (PCI).
Although IVUS is a useful tool for accurate assessment of lesion profiles and optimal stent implantation, there are limited data on long-term clinical outcomes between IVUS-guided and angiography-guided PCI for patients with complex lesions.
From March 2003 through December 2015, a total of 6,005 patients undergoing PCI for complex lesions with drug-eluting stents were enrolled from a prospective institutional registry. All enrolled subjects had at least 1 complex lesion (defined as bifurcation, chronic total occlusion, left main disease, long lesion, multivessel PCI, multiple stent implantation, in-stent restenosis, or heavily calcified lesion). Patients were classified according to use of IVUS or not. Multiple sensitivity analyses, including multivariable adjustment, propensity-score matching, and inverse-probability-weighted method, were performed to adjust baseline differences.
Among the study population, IVUS was used in 1,674 patients (27.9%) during complex PCI. The IVUS-guided PCI group had a significantly larger mean stent diameter (3.2 ± 0.4 vs. 3.0 ± 0.4; p < 0.001), and more frequent use of post-dilatation (49.0% vs. 17.9%; p < 0.001) compared with the angiography-guided PCI group. IVUS-guided PCI was associated with a significantly lower risk of cardiac death during 64 months of median follow-up compared with angiography-guided PCI (10.2% vs. 16.9%; hazard ratio: 0.573; 95% confidence interval: 0.460 to 0.714; p < 0.001). Results were consistent after multivariable regression, propensity-score matching, and inverse-probability-weighted method. The risks of all-cause death, myocardial infarction, stent thrombosis, ischemia-driven target lesion revascularization, and major adverse cardiac events were also significantly lower in the IVUS-guided PCI group.
Among patients with complex coronary artery lesion, IVUS-guided PCI was associated with the lower long-term risk of cardiac death and adverse cardiac events compared with angiography-guided PCI. Use of IVUS should be actively considered for complex PCI.
本研究旨在确定血管内超声（IVUS）指导与血管造影指导相比，是否会降低接受复杂经皮冠状动脉介入治疗（PCI）患者的长期心脏死亡风险。
尽管 IVUS 是一种用于准确评估病变特征和优化支架植入的有用工具，但在复杂病变患者中，IVUS 指导和血管造影指导 PCI 的长期临床结局数据有限。
2003 年 3 月至 2015 年 12 月，一项前瞻性机构注册研究共纳入 6005 例接受药物洗脱支架治疗的复杂病变患者。所有入组患者至少有 1 处复杂病变（定义为分叉、慢性完全闭塞、左主干病变、长病变、多血管 PCI、多支架植入、支架内再狭窄或严重钙化病变）。根据是否使用 IVUS 将患者进行分类。进行了多项敏感性分析，包括多变量调整、倾向评分匹配和逆概率加权法，以调整基线差异。
在研究人群中，1674 例（27.9%）患者在复杂 PCI 中使用了 IVUS。IVUS 指导 PCI 组的平均支架直径明显较大（3.2 ± 0.4 对 3.0 ± 0.4；p < 0.001），并且后扩张的使用率明显较高（49.0%对 17.9%；p < 0.001）。与血管造影指导 PCI 组相比，IVUS 指导 PCI 在 64 个月的中位随访期间，心脏死亡风险显著降低（10.2%对 16.9%；风险比：0.573；95%置信区间：0.460 至 0.714；p < 0.001）。多变量回归、倾向评分匹配和逆概率加权法后结果一致。IVUS 指导 PCI 组的全因死亡、心肌梗死、支架血栓形成、缺血驱动的靶病变血运重建和主要不良心脏事件的风险也明显降低。
在复杂冠状动脉病变患者中，与血管造影指导 PCI 相比，IVUS 指导 PCI 与长期心脏死亡和不良心脏事件风险降低相关。对于复杂 PCI，应积极考虑使用 IVUS。
