Comparison of procedural and clinical outcomes of angiography- vs. imaging-guided percutaneous coronary intervention with intravascular lithotripsy

Background Intravascular lithotripsy (IVL) is an innovative treatment for coronary artery calcification (CAC). However, the impact of intracoronary imaging (ICI)-guidance PCI, as compared to angiography-guided PCI, in combination with IVL, has not been specifically investigated. Purpose This study aimed to compare the procedural and clinical outcomes of ICI-guided PCI combined with IVL versus angiography-guided PCI with IVL in patients with CAC. Methods This retrospective study analyzed 509 patients from a multicenter registry (May 2019–September 2024). Angiography-guided PCI with IVL was defined as therapy under solely fluoroscopic guidance. ICI-guided IVL was defined as PCI treated with IVL with concomitant use of ICI for procedural guidance. The primary endpoint was procedural success, defined as a composite of Thrombolysis In Myocardial Infarction (TIMI) 3 flow, residual stenosis <30%, and absence of in-hospital events. Safety endpoints included procedural complications and major adverse cardiovascular events (MACE) up to two-year follow-up. Results A total of 537 lesions were treated with IVL: 252 (46.9%) with angiography-guided PCI and 285 (53.1%) with ICI-guided PCI. The ICI-guided group treated more complex lesions, including a higher prevalence of aorto-ostial lesions (20.2% vs. 30.9%; p=0.005), chronic total occlusions (CTOs) (2.8% vs. 12.3%; p=0.001), and long-segment disease (58.7% vs. 69.5%; p=0.009). Larger IVL balloon diameters were used more frequently (3.0–3.5 mm vs. 3.5–4.0 mm; p<0.001), along with pre-IVL rotational atherectomy (9.5% vs. 16.1%; p=0.02), post-dilatation (89.7% vs. 96.1%; p=0.006), and stent implantation (71.8% vs. 81.1%; p=0.01) in the ICI-guided group. Post-PCI quantitative coronary analysis showed significantly larger minimum lumen diameter (2.73 ± 0.60 mm vs. 3.07 ± 0.68 mm; p<0.001) in the ICI-guided group. Procedural success was comparable between groups (88.7% vs. 89.7%; p=0.71), with similar complication rates (4.6% vs. 8.1%; p=0.14). One-year follow-up data were available for 346 patients (68% of the cohort), and two-year follow-up data were available for 220 patients (43.2%). MACE rates were comparable between groups at one-year (angiography-guided: 8.2% vs. ICI-guided: 14.7%; p=0.28) and two-year follow-up (15.4% vs. 15.6%; p=0.46). Follow-up duration was significantly longer in the angiography-guided group (510.5 vs. 365 days; p<0.001). Kaplan-Meier survival analysis showed no significant differences in cumulative event-free survival at one- and two-year follow-up (p=0.18 and p=0.16, respectively). Conclusion In this real-world multicenter study, procedural success and complication rates were similar between angiography-guided and ICI-guided PCI with IVL. MACE rates at one- and two-year follow-up were also comparable. However, in the ICI-guided group more complex target lesions were treated, and different treatment strategies were performed.