TCT.14: IVUS-guided PCI beats out angiography for CTOs

WASHINGTON, D.C.—For improved outcomes in patients with chronic total occlusion (CTO), intravascular ultrasound (IVUS)-guided PCI appears to win out over conventional angiography, according to results presented Sept. 14 at the Transcatheter Cardiovascular Therapeutics (TCT) conference.

Yang-Soo Jang, MD, PhD, of the Severance Cardiovascular Hospital and Yonsei University Health System in Seoul, Korea, presented the findings at the late-breaking clinical trials press conference. The randomized trial compared IVUS to conventional angiography when placing zotarolimus-eluting stents or biolimus-eluting stents into CTO patients.

During the 12-month follow-up, patients were found to have fewer combined incidents of MI, target vessel revascularization (TVR) and cardiac death. Irrespective of stent placed, IVUS-CTO patients experienced about a third as many combined MI, TVR and cardiac deaths as those who had stents placed via angiography (2.6 percent vs 7.1 percent).

At 12 months, angiography-guided CTO stenting had a TVR rate of 5.2 percent while IVUS-guided stents had 2.6 percent.

When asked about the use of this technology in practice, David G. Rizik, MD, a discussant and director of the Heart & Vascular Division at Scottsdale Healthcare in Arizona, said that IVUS "is grossly underused" in catheterization laboratories in the U.S. despite its potential cost savings. "Reclosure and repeat revascularization is an expensive proposition as compared to, I believe, the cost of using an IVUS.”

He stated that adoption in the U.S. was about 11 percent. “As we have more studies like this, the data will be practice changing,” Rizik said.

While the scope of this study did not include cost effectiveness, moderator Ori Ben-Yehuda, MD, stated, “It would be interesting to collect utilization of resources and really see the cost-effectiveness analysis even of this study, if [there are] data on resource utilization. The usual standard is to compare it to American costs. I’m not sure that’s fair worldwide, but I think it would be very interesting for this study.” Ben-Yehuda is the executive director of the Cardiovascular Research Foundation's Clinical Trials Center in New York City.

Jang said the cost savings of this procedure is in the lives it saves and the complications it avoids. “But economically? I think that really depends on the country.”

Some clinicians may be reticent to try this procedure because they fear it takes too much time and that reimbursement may be difficult to obtain; however, Jang said he was confident about the benefit.

Ben-Yehuda said, “One of the things that I think this (study) highlights is how the more complex the patient, how much more important imaging is in guiding our procedures.”