Intravascular Imaging for Percutaneous Coronary Intervention Guidance and Optimization: The Evidence for Improved Patient Outcomes

Figures

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  Figure 1. Kaplan-Meier estimates of occurrence of the primary end point for all patients and patients who underwent IVUS-guided stent implantation in IVUS-XPL. Cumulative incidence curves are for the primary end point of cardiac death, target lesion–related myocardial infarction, and target lesion revascularization. (A) Comparison of patients randomized to IVUS versus angiographic guidance. (B) Patients in the IVUS-guidance group, comparing those with versus those without stent optimization. HR, hazard ratio; IVUS, intravascular ultrasound; IVUS-XPL, Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions; PCI, percutaneous coronary intervention. Reprinted with permission from Hong SJ, Kim BK, Shin DH, et al. Effect of intravascular ultrasound-guided vs angiography-guided everolimus-eluting stent implantation: the IVUS-XPL randomized clinical trial. aThere were 30 patients in the angiography-guided PCI group who underwent IVUS-guided PCI but they are not included in this analysis. JAMA. 2015;314(20):2155-2163.

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  Figure 2. Kaplan-Meier estimates of occurrence of the primary end point for all patients and for patients who underwent IVUS-guided stent implantation in ULTIMATE. Cumulative incidence curves are for the primary end points of cardiac death, target vessel myocardial infarction, and clinically driven TLR. (A) Comparison of patients randomized to IVUS versus angiographic guidance. (B) Patients in the IVUS-guidance group, comparing those with versus those without stent optimization. HR, hazard ratio; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention; TLR, target vessel revascularization. Reprinted with permission from Zhang J, Gao X, Kan J, et al. Intravascular ultrasound versus angiography-guided drug-eluting stent implantation: the ULTIMATE trial. J Am Coll Cardiol. 2018;72(24):3126-3137.

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  Figure 3. Five-year data from IVUS-XPL. Cumulative incidence curves for the primary endpoint of cardiac death, target lesion–related myocardial infarction, and target lesion revascularization. (A) All patients. (B) Landmark analyses for all patients. (C) Patients in the IVUS-guided percutaneous coronary intervention group who underwent IVUS-guided stent implantation comparing those with versus those without stent optimization. (D) Landmark analyses for the patients in the IVUS-guided PCI group who underwent IVUS-guided stent implantation comparing those with versus those without stent optimization. HR, hazard ratio; IVUS, intravascular ultrasound; IVUS-XPL, Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions; PCI, percutaneous coronary intervention. Reprinted with permission from Hong SJ, Mintz GS, Ahn CM, et al. Effect of intravascular ultrasound-guided drug-eluting stent implantation: 5-year follow-up of the IVUS-XPL randomized trial. JACC Cardiovasc Interv. 2020;13(1):62-71.

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  Figure 4. Three-year data from ULTIMATE. (A) Landmark analyses for all patients. (B) Landmark analyses for patients in the IVUS guidance group comparing those with those versus without stent optimization. HR, hazard ratio; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention. Adapted from Gao XF, Ge Z, Kong XQ, et al. 3-year outcomes of the ULTIMATE trial comparing intravascular ultrasound versus angiography-guided drug-eluting stent implantation. JACC Cardiovasc Interv. 2021;14(3):247-257.

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  Figure 5. Pooled patient-level data from IVUS-XPL and ULTIMATE showing improved 3-year Cardiac survival after IVUS-guided drug-eluting stent implantation. (A) Cumulative incidence of cardiac death comparing patients randomized to IVUS versus angiographic guidance. (B) Cumulative incidence of the composite of cardiac death, MI, or ST death comparing patients randomized to IVUS versus angiographic guidance. (C) Cumulative incidence of cardiac death comparing patients in IVUS-guided percutaneous coronary intervention group who underwent IVUS-guided stent implantation comparing those with versus those without stent optimization. (D) Cumulative incidence of the composite of cardiac death, myocardial infarction, or stent thrombosis death comparing patients in IVUS-guided percutaneous coronary intervention group who underwent IVUS-guided stent implantation comparing those with versus those without stent optimization. HR, hazard ratio; IVUS, intravascular ultrasound; IVUS-XPL, Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions; MI, myocardial infarction; ST, stent thrombosis. Reprinted with permission from Hong SJ, Zhang JJ, Mintz GS, et al. Improved…

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  Figure 6. Freedom from adverse events in the IVUS-guided group versus the control (angiography-guided) group in a randomized controlled trial of left main coronary artery disease treated with drug-eluting stent implantation. (A) Freedom from MACE. (B) Freedom from CD. CD, cardiac death; IVUS, intravascular ultrasound; MACE, major adverse cardiac event. Adapted from Liu XM, Yang ZM, Liu XK, et al. Intravascular ultrasound-guided drug-eluting stent implantation for patients with unprotected left main coronary artery lesions: a single-center randomized trial. Anatol J Cardiol. 2019;21(2):83-90.

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  Figure 7. IVUS-CTO randomized controlled trial. Clinical impact of IVUS-guided CTO intervention. (A) Occurrence of MACE. (B) Composite of CD or MI. CD, cardiac death; CTO, chronic total occlusion; IVUS, intravascular ultrasound; MACE, major adverse cardiac event; MI, myocardial infarction. Reprinted with permission from Kim BK, Shin DH, Hong MK, et al. Clinical impact of intravascular ultrasound-guided chronic total occlusion intervention with zotarolimus-eluting versus Biolimus-eluting stent implantation: randomized study. Circ Cardiovasc Interv. 2015;8(7):e002592.

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  Figure 8. One-year angiographic and clinical results from the OPINION Trial: OCT versus IVUS in percutaneous coronary intervention. (A) Noninferiority test for target vessel failure (primary end point) and (B) target vessel failure-free survival curves through the 12-month follow-up. IVUS, intravascular ultrasound; OCT, optical coherence tomography; OFDI, optical frequency domain imaging; PCI, percutaneous coronary intervention. Reprinted with permission from Kubo T, Shinke T, Okamura T, et al. Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): one-year angiographic and clinical results. Eur Heart J. 2017;38(42):3139-3147.

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  Figure 9. Twenty-three meta-analyses comparing the clinical outcomes of IVUS-guided versus angiography-guided PCI. Risk reduction (95% CI) for the meta-analyses that reported on the comparison of IVUS- versus angiography-guided PCI for (A) all-cause mortality, (B) cardiovascular mortality, (C) MACE, (D) myocardial infarction, (E) stent thrombosis, (F) TVR, and (G) TLR. Point estimates in green indicate meta-analyses with randomized controlled trials only. Point estimates in blue represent meta-analyses of randomized controlled trials and observational studies. IVUS, intravascular ultrasound; MACE, major adverse cardiac event; PCI, percutaneous coronary intervention; TLR, target lesion revascularization; TVR, target vessel revascularization.

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  Figure 10. Meta-analysis of complex lesions or patients presenting with the acute coronary syndrome. Subanalysis of the meta-analysis by Zhang et al42 presenting the risk reductions (95% CI) of clinical outcomes for the comparison of IVUS- versus angiography-guided PCI in the subgroup of patients with acute coronary syndrome and complex lesions (red) versus unselected patients and lesions (gray). ACS, acute coronary syndrome; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention.

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  Figure 11. Meta-analyses comparing OCT-guided versus angiography-guided PCI. Risk reduction (95% CI) for the meta-analyses that reported on the comparison of OCT- versus angiography-guided PCI for (A) all-cause mortality, (B) cardiovascular mortality, (C) MACE, (D) myocardial infarction, (E) stent thrombosis, and (F) TLR. Point estimates in green indicate meta-analyses with randomized controlled trials only. Point estimates in blue represent meta-analyses of randomized controlled trials and observational studies. MACE, major adverse cardiac event; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; TLR, target lesion revascularization.

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  Figure 12. Meta-analyses evaluating the effects of IVUS guidance in the treatment of LMCA disease. Risk reduction (95% CI) for the meta-analyses that reported on the comparisons of IVUS- versus angiography-guided PCI in patients with left main coronary artery lesions for (A) all-cause mortality, (B) cardiovascular mortality, (C) myocardial infarction, (D) stent thrombosis, (E) TVR, and (F) TLR. All meta-analyses included randomized controlled trials and observational studies. IVUS, intravascular ultrasound; LMCA, left main coronary artery; PCI, percutaneous coronary intervention; TLR, target lesion revascularization; TVR, target vessel revascularization.