TCT.18: Ultrasound-guided DES implantation yields better outcomes than angiography-guided surgery

Intravascular ultrasound (IVUS)-guided stent implantation offers improved clinical outcomes for heart patients over a traditional angiography-guided approach, researchers from China reported at this week’s Transcatheter Cardiovascular Therapeutics (TCT) meeting in San Diego, California.

“Percutaneous implantation of a drug-eluting stent (DES) has dramatically reduced the incidence of in-stent restenosis and the requirement of revascularization when compared with bare-metal stents,” study leader Junjie Zhang, MD, wrote in the Journal of the American College of Cardiology, where his team’s results were published Sept. 24. “However, stent thrombosis and target vessel revascularization (TVR) after implantation of a first-generation DES still remain to be major concerns, especially in patients who are at high-risk and have complex lesions.”

IVUS, on the other hand, collects detailed anatomical information about a patient’s reference vessel dimensions and lesion characteristics, including the severity of diameter stenosis, lesion length and vulnerable plaque. Zhang et al. said that while coronary angiography is the current industry standard for guided PCI procedures, those same details are “poorly detected” by angiography.

Enter the ULTIMATE trial,  which recruited 1,448 all-comer DES patients from eight centers in China between 2014 and 2017. Participants were randomized 1:1 to DES implantation with IVUS guidance or angiography guidance.

The authors said just over half of the pool presented with multi-vessel disease, and the population’s average lesion length was 34.5 millimeters. Sixty-seven percent of lesions were classified as either Type B2 or Type C.

A year after PCI, 4.2 percent of all patients experienced the primary endpoint of target vessel failure (TVF), defined as a composite of cardiac death, target vessel MI and clinically driven target vessel revascularization, Zhang et al. reported. TVF was more common in the angiography group, affecting 5.4 percent of those patients and 2.9 percent of the IVUS cohort.

Patients who underwent PCI with IVUS were more likely to have longer procedures, according to the data. On a per-lesion basis, those implantations used slightly larger stent diameters and longer stents.

“This study for the first time reports the benefit of IVUS guidance over angiography guidance from all-comers of a large population who underwent implantation of a DES,” Zhang and colleagues wrote, though they noted there was still more work to do. “While IVUS guidance was associated with improved clinical outcome and there was a realization of the presence of different optimal criteria for IVUS guidance, the lingering question remains: how to achieve optimal IVUS-guided PCI?”