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Meta-analysis: IVUS-Guided Stent Placement Improves Outcomes vs Angiography

By L.A. McKeown

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The use of intravascular ultrasound (IVUS) to guide stent placement in percutaneous coronary intervention (PCI) leads to better clinical outcomes than use of angiography guidance, according to a meta-analysis published online February 12, 2014, ahead of print in JACC: Cardiovascular Interventions.

Jae-Sik Jang, MD, PhD, of the University of Inje College of Medicine (Busan, South Korea), and colleagues looked at 3 randomized trials and 12 observational studies published between 2005 and 2013 totaling 24,849 patients (n = 11,793 IVUS-guided and n = 13,056 angiography-guided).

Follow up ranged from 12 to 48 months. Three of the 15 studies had routine angiographic follow-up data available at 6 or 12 months, and 2 studies reported rates of restenosis. Four recent studies included zotarolimus-eluting stents or everolimus-eluting stents, while the remainder used sirolimus-eluting stents and paclitaxel-eluting stents; 3 studies did not report the type of DES used.

Significant Reductions with IVUS

Compared with angiography, IVUS-guided PCI was associated with a reduction in the risk of MACE, all-cause mortality, MI, TVR, and stent thrombosis (table 1).

Table 1. IVUS- vs Angiography-Guided PCI

 

OR (95% CI)

P Value

MACE

0.79 (0.69-0.91)

0.001

All-Cause Mortality

0.64 (0.51-0.81)

< 0.001

MI

0.57 (0.42-0.78)

< 0.001

TVR

0.81 (0.68-0.95)

0.01

Stent Thrombosis

0.59 (0.42-0.82)

0.002

 

In sensitivity analyses for MACE according to coronary anatomy, exclusion of studies with predominantly bifurcation lesions failed to offset the benefit of IVUS guidance over angiography (OR 0.78; 95% CI 0.65-0.94; P = 0.009), as did exclusion of left main coronary disease (OR 0.80; 95% CI 0.69-0.92; P = 0.002).

Mean post-intervention minimal lumen diameter (MLD) ranged from 2.50 to 3.00 mm in the IVUS-guided group and from 2.40 to 2.87 mm in the angiography-guided group. The pooled weighted mean difference of post-intervention MLD was 0.12 mm (P < 0.001).

A separate analysis of 9 propensity score-matched studies (n = 13,545) maintained results of the main analysis in terms of clinical outcomes. However, it did not demonstrate differences in the risk of TVR (HR 0.93; 95% CI 0.79-1.09; P = 0.34) or TLR (HR 0.85; 95% CI 0.64-1.13; P = 0.26).

Periprocedural Assessment Key

The study authors conclude that the advantage of IVUS-guided DES implantation appears related to lower incidence of MI or risk of death rather than a decreased rate of angiographic restenosis or repeat revascularization. Specifically, they suggest that the benefit of IVUS in the DES era might be “the capability to identify factors associated with periprocedural complications, such as side branch occlusion, stent edge dissections and hematoma, stent underexpansion, and incomplete stent apposition.”

Dr. Jang and colleagues add that their finding of a reduction in stent thrombosis corresponds with several other studies suggesting that IVUS allows for assessment of the types of suboptimal results known to be associated with the occurrence of stent thrombosis.

“These data should provide further support for IVUS use in the modern DES era, but adequately powered trials that measure patient-oriented outcomes in participants with different risk profiles and lesion subsets are needed,” they write.

Technical Superiority Suggested

In an e-mail with TCTMD, Bimmer E. Claessen, MD, of the Academic Medical Center (Amsterdam, the Netherlands), observed that “the randomized trial meta-analysis is underpowered, and the observational study meta-analysis is hampered by inherent limitations such as selection bias. Also, it is not clear if IVUS was used before and after stent implantation, or just at 1 of those time points.”

He agreed with the study authors that definitive evidence for the potential benefit of routine IVUS-guided PCI should come from an adequately powered randomized clinical trial. Nevertheless, he said the meta-analysis along with the inclusion of the sensitivity analysis strongly suggests that IVUS-guided PCI leads to improved technical results (ie, adequate stent sizing, adequate stent expansion, and complete lesion coverage), which in turn result in lower rates of stent thrombosis and restenosis.

 

Source:

Jang J-S, Song Y-J, Kang W, et al. Intravascular ultrasound-guided implantation of drug-eluting stents to improve outcome: a meta-analysis. J Am Coll Cardiol Intv. 2014;Epub ahead of print.

Disclosures

  • Drs. Jang and Claessen report no relevant conflicts of interest.

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