Why carry out this study? |
The role of routine use of intravascular imaging in complex percutaneous coronary intervention (PCI) remains unclear. |
Our study aimed to compare the outcomes of intravascular imaging (specifically intravascular ultrasound) with conventional coronary angiography in complex percutaneous coronary intervention (PCI). |
What was learned from the study? |
Complex PCI guided by intravascular imaging reduced the risk of major adverse cardiac events, cardiac death, definite/probable stent thrombosis, and target vessel and target lesion revascularization compared with coronary angiography. |
Further efforts should be directed towards identifying the barriers behind the low use of intravascular imaging especially in complex coronary artery interventions. |
Introduction
Methods
Data Sources and Search Strategy
Selection Criteria
Data Extraction
Outcomes
Assessment of Quality of Included Studies
Statistical Analysis
Ethical Approval
Results
Included Studies
Study | Year of publication | No. of centers | Country | Group 1 (intravascular imaging-guided) | Group 2 (coronary-guided angiography) | Longest follow-up duration | Inclusion criteria | Primary outcome | Stent type |
---|---|---|---|---|---|---|---|---|---|
HOME DES IVUS | 2010 | Single-center | Czech Republic | 105 | 105 | 18 months | Complex coronary lesions or complex patient characteristics such as type B2 and C according to the American Heart Association, proximal left anterior descending artery, left main disease, reference vessel diameter < 2.5 mm, lesion length > 20 mm, in-stent restenosis, insulin-dependent diabetes mellitus, and acute coronary syndrome were included in this study | To assess the role of IVUS guidance during implantation of DES on long-term outcome in patients with high clinical and angiographic | CYPHER (sirolimus-eluting stents) and TAXUS (paclitaxel-eluting stents) |
Kim et al. [23] | 2013 | Multicenter | South Korea | 269 | 274 | 12 months | Age > 20 years and had a de novo lesion requiring a stent ≥ 28 mm in length in a vessel with a distal reference diameter ≥ 2.5 mm by visual angiographic estimation | MACE | Endeavor Sprint zotarolimus-eluting stents (E-ZES) or everolimus-eluting stent (EES) (Xience V, Abbott Vascular, Santa Clara, California) |
AVIO | 2013 | Multicenter | Italy | 142 | 142 | 24 months | Complex lesions defined as one of the following: long length (> 28 mm); CTO, i.e., a total occlusion of duration more than 3 months; lesions involving a bifurcation; small vessels (≤ 2.5 mm) and patients requiring 4 or more stents | Post-procedure in lesion minimal lumen diameter | DES |
AIR-CTO | 2015 | Multicenter | China | 115 | 115 | 2 years | Patients aged 18–80 years, who had at least one CTO lesion (defined as TIMI grade 0 and occlusion duration > 3 months) that had been successfully recanalized (defined as a wire-crossed CTO lesion and at the distal true lumen according to angiograms) | In-stent late lumen loss at 1-year follow-up | Either first- or second-generation DES |
Tan et al. [22] | 2015 | Single-center | China | 61 | 62 | 2 years | Unprotected left main coronary artery, defined as at least 50% stenosis by visual assessment in the LM vessel without bypass grafts to the left anterior descending artery or left circumflex artery | MACE | Sirolimus-eluting stents (Firebird-2, Microport, Shanghai, China) or sirolimus-eluting stents (Excel, Jiwei, Shandong, China) |
CTO-IVUS | 2015 | Multicenter | South Korea | 201 | 201 | 12 months | Patients with CTO who were aged 20–80 years and had typical symptomatic angina or positive test results for functional evaluation of ischemia | Cardiac death | Zotarolimus-eluting stents or Nobori biolimus-eluting stents |
Liu et al. [24] | 2019 | Single-center | China | 167 | 169 | 12 months | Adults, aged 18–75 years Unprotected left main coronary artery lesions and plan for DES implantation | MACE, defined as cardiac death, MI, or TVR | DES |
IVUS-XPL | 2020 | Multicenter | South Korea | 700 | 700 | 5 years | Patients with typical chest pain or evidence of myocardial ischemia were eligible for enrollment if implantation of an everolimus-eluting stent for a long coronary lesion (implanted stent ≥ 28 mm in length) was indicated on the basis of angiographic lesion length estimation | MACE, defined as cardiac death, target lesion-related MI, or ischemia-driven TLR at 5 years | Everolimus-eluting stent |
ULTIMATE | 2021 | Multicenter | China | 724 | 724 | 3 years | Patients with silent ischemia, stable or unstable angina, or MI with more than 24 h between onset of chest pain and admission and de novo coronary lesions requiring DES implantation | TVF at 3 years after the index procedure, including cardiac death, target vessel MI, and clinically driven TVR | Second-generation DES |
RENOVATE-COMPLEX-PCI | 2023 | Multicenter | South Korea | 1092 | 547 | 3 years | Patients 19 years of age or older who were undergoing PCI for complex coronary artery lesions, defined as true bifurcation lesions according to the Medina classification system with a side-branch diameter of at least 2.5 mm; a chronic total occlusion; unprotected left main coronary artery disease; long coronary artery lesions that would involve an expected stent length of at least 38 mm; multivessel PCI involving at least two major epicardial coronary arteries being treated at the same time; a lesion that would necessitate the use of multiple stents (at least three planned stents); a lesion involving in-stent restenosis; a severely calcified lesion; or ostial lesions of a major epicardial coronary artery | TVF, defined as the composite of death from cardiac causes, target vessel-related MI, or clinically driven TVR | Polymer-coated everolimus-eluting stents |
Studies | Groups | Age in years, mean (± SD) | Male % | Hypertension % | Diabetes mellitus % | Dyslipidemia % | Current smoking % | Previous PCI % | Previous MI % | Left ventricular ejection fraction % |
---|---|---|---|---|---|---|---|---|---|---|
HOME DES IVUS 2010 | Intravascular imaging-guided group | 59.4 ± 13 | 73 | 67 | 42 | 63 | 40 | 17 | 37 | – |
Coronary angiography-guided group | 60.2 ± 11 | 71 | 71 | 45 | 66 | 35 | 14 | 32 | – | |
Kim et al. [23] | Intravascular imaging-guided group | 62.8 ± 9.3 | 65.8 | 61.3 | 31.6 | 61.3 | 21.6 | – | 1.1 | 55.3 ± 23.9 |
Coronary angiography-guided group | 64.3 ± 8.7 | 54.7 | 65.8 | 29.9 | 61.7 | 17.2 | – | 2.9 | 54 ± 25 | |
AVIO 2013 | Intravascular imaging-guided group | 63.9 ± 10.1 | 82.4 | 70.4 | 23.9 | 70.4 | 34.5 | – | – | 55.3 ± 8.5 |
Coronary angiography-guided group | 63.6 ± 11.0 | 76.8 | 66.9 | 26.8 | 76.8 | 31 | – | – | 55.9 ± 8.6 | |
AIR-CTO 2015 | Intravascular imaging-guided group | 67 ± 10 | 88.7 | 74.8 | 29.6 | 21.9 | 39.1 | 20 | 20.9 | 55 ± 11 |
Coronary angiography-guided group | 66 ± 11 | 80 | 70.4 | 27 | 27.8 | 39.1 | 20.9 | 30.4 | 56 ± 12 | |
Tan et al. [22] | Intravascular imaging-guided group | 76.54 ± 4.95 | 62.3 | 41 | 34.4 | – | 44.3 | – | 16.4 | 55.32 ± 5.02 |
Coronary angiography-guided group | 75.85 ± 3.49 | 69.3 | 46.8 | 29.5 | – | 46.8 | – | 21 | 53.33 ± 7.14 | |
CTO-IVUS 2015 | Intravascular imaging-guided group | 61.0 ± 11.1 | 80.6 | 62.7 | 34.8 | – | 35.3 | 15.4 | 8 | 56.9 ± 13.1 |
Coronary angiography-guided group | 61.4 ± 10.1 | 80.6 | 63.7 | 33.8 | – | 34.3 | 15.9 | 8 | 56.7 ± 11.4 | |
Liu et al. [24] | Intravascular imaging-guided group | 65.3 ± 10.6 | 63.5 | 69.5 | 33.5 | 37.7 | 37.1 | 19.8 | 17.4 | 55.6 ± 11.7 |
Coronary angiography-guided group | 64.9 ± 11.2 | 63.9 | 72.2 | 30.8 | 37.9 | 35.5 | 16.6 | 14.2 | 58.4 ± 10.5 | |
IVUS-XPL 2020 | Intravascular imaging-guided group | 63.0 ± 9.0 | 69 | 65 | 32 | 68 | 22 | 11 | 5 | 63 ± 9.8 |
Coronary angiography-guided group | 64.0 ± 9.0 | 69 | 64 | 36 | 66 | 26 | 10 | 4 | 62.3 ± 10.2 | |
ULTIMATE 2021 | Intravascular imaging-guided group | 65.2 ± 10.9 | 73.9 | 70.7 | 30 | 53.7 | – | – | – | – |
Coronary angiography-guided group | 65.9 ± 9.8 | 73.2 | 72 | 31.2 | 55.2 | – | – | – | – | |
RENOVATE-COMPLEX-PCI 2023 | Intravascular imaging-guided group | 65.3 ± 10.3 | 79.6 | 62.5 | 36.1 | 51.3 | 19.4 | 24.5 | 6.9 | 58.4 ± 11.9 |
Coronary angiography-guided group | 66.0 ± 10.0 | 78.8 | 59 | 40.8 | 51.2 | 17.4 | 23.2 | 7.7 | 59.3 ± 11.0 |
Studies | Groups | Coronary artery lesion | Reference vessel diameter (mm) [mean ± SD] | Min luminal diameter (mm) [mean ± SD] | Diameter stenosis % [mean ± SD] | Lesion length (mm) [mean ± SD] | |||
---|---|---|---|---|---|---|---|---|---|
LAD % | LCX % | RCA % | Left main % | ||||||
HOME DES IVUS 2010 | Intravascular imaging-guided group | 56 | – | 29 | 3 | 3.17 ± 0.43 | 1.1 ± 0.40 | 82.3 ± 7.6 | 18.1 ± 7.3 |
Coronary angiography-guided group | 54 | – | 24 | 4 | 2.95 ± 0.34 | 0.97 ± 0.37 | 79.2 ± 9.3 | 17.6 ± 6.7 | |
Kim et al. [23] | Intravascular imaging-guided group | 62.1 | 15.2 | 22.7 | – | 2.82 (2.58–3.16)a | 0.95 (0.73–1.23)a | – | 29.6 (23.2–42.8)a |
Coronary angiography-guided group | 67.5 | 12.8 | 19.7 | – | 2.80 (2.56–3.15)a | 0.93 (0.70–1.22)a | – | 30.6 (24.2–40.9)a | |
AVIO 2013 | Intravascular imaging-guided group | 53.3 | – | – | – | 2.67 ± 0.46 | 0.76 ± 0.46 | 71.6 ± 15.8 | 27.4 ± 15.9 |
Coronary angiography-guided group | 48.6 | – | – | – | 2.62 ± 0.41 | 0.65 ± 0.45 | 75.5 ± 16.1 | 25.5 ± 15.0 | |
AIR-CTO 2015 | Intravascular imaging-guided group | 44.3 | 20.9 | 34.8 | 0 | Proximal: 2.95 ± 0.37 Distal: 2.26 ± 0.41 | – | – | 28.48 ± 17.76 |
Coronary angiography-guided group | 36.5 | 14.8 | 46.1 | 2.6 | Proximal: 2.89 ± 0.34 Distal: 2.25 ± 0.44 | – | – | 29.21 ± 19.11 | |
Tan et al. [22] | Intravascular imaging-guided group | – | – | – | 100 | – | – | – | – |
Coronary angiography-guided group | – | – | – | 100 | – | – | – | – | |
CTO-IVUS 2015 | Intravascular imaging-guided group | 41.8 | 14.4 | 43.8 | – | 2.69 ± 0.44 | – | – | 36.3 ± 17.1 |
Coronary angiography-guided group | 46.8 | 15.9 | 37.3 | – | 2.64 ± 0.55 | – | – | 35.5 ± 17.0 | |
Liu et al. [24] | Intravascular imaging-guided group | 55.7 | 44.3 | 62.3 | 100 | – | – | – | – |
Coronary angiography-guided group | 52.7 | 49.7 | 58 | 100 | – | – | – | – | |
IVUS-XPL 2020 | Intravascular imaging-guided group | 66 | 13 | 22 | – | 2.89 ± 0.46 | 0.83 ± 0.43 | 71.2 ± 14.4 | 34.9 ± 10.8 |
Coronary angiography-guided group | 60 | 16 | 25 | – | 2.84 ± 0.45 | 0.82 ± 0.43 | 71.4 ± 14.4 | 35.2 ± 10.5 | |
ULTIMATE 2021 | Intravascular imaging-guided group | – | – | – | – | – | – | – | – |
Coronary angiography-guided group | – | – | – | – | – | – | – | – | |
RENOVATE-COMPLEX-PCI 2023 | Intravascular imaging-guided group | 44.2 | 19.3 | 27.4 | 10.1 | Proximal: 3.2 ± 0.5 Distal: 2.7 ± 0.5 | 0.44 ± 0.37 | 85.4 ± 11.5 | 28.4 ± 15.9 |
Coronary angiography-guided group | 43.2 | 18.5 | 26.4 | 9 | Proximal: 3.1 ± 0.5 Distal: 2.7 ± 0.4 | 0.44 ± 0.36 | 85.2 ± 11.7 | 26.8 ± 14.8 |