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Improving PCI Outcomes Using Postprocedural Physiology and Intravascular Imaging. JACC Cardiovasc Interv 2021; 14:2415-2430. [PMID: 34794649 DOI: 10.1016/j.jcin.2021.08.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/07/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022]
Abstract
Although clinical outcomes after percutaneous coronary intervention (PCI) are improving, the long-term risk for target vessel failure remains concerning. Although the application of intravascular imaging and physiological indexes significantly improves outcomes, their routine use in practice remains limited. Nevertheless, merely using these modalities is not enough, and to truly improve patient outcomes, optimal intravascular dimensions with minimal vascular injury should be targeted. When assessing post-PCI results using either type of physiological or imaging technology, a broad spectrum of stent- and vessel-related anomalies can be expected. As not all of these issues warrant treatment, a profound knowledge of what to expect and how to recognize and when to treat these intraluminal problems is needed. Additionally, promising new modalities such as angiography-derived coronary physiology and hybrid imaging catheters are becoming available. The authors provide an overview of the currently available tools and techniques to define suboptimal PCI and when to apply these technologies to improve outcomes.
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Fujimura T, Matsumura M, Witzenbichler B, Metzger DC, Rinaldi MJ, Duffy PL, Weisz G, Stuckey TD, Ali ZA, Zhou Z, Mintz GS, Stone GW, Maehara A. Stent Expansion Indexes to Predict Clinical Outcomes: An IVUS Substudy From ADAPT-DES. JACC Cardiovasc Interv 2021; 14:1639-1650. [PMID: 34353595 DOI: 10.1016/j.jcin.2021.05.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate various stent expansion indexes to determine the best predictor of clinical outcomes. BACKGROUND Numerous intravascular ultrasound (IVUS) studies have shown minimum stent area (MSA) to be the most powerful predictor of future events. METHODS ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a prospective, multicenter registry of 8,582 patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents. Native coronary artery lesions treated with IVUS-guided PCI with final analyzable IVUS were included. Ten stent expansion indexes (MSA, MSA/vessel area at MSA site, conventional stent expansion [MSA/average of proximal and distal reference luminal area], minimum stent expansion using Huo-Kassab or linear model accounting for vessel tapering, stent asymmetry [minimum/maximum stent diameter within the entire stent], stent eccentricity [smallest minimum/maximum stent diameter at a single slice within the stent], IVUS-XPL [Impact of intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions] criteria, ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in "All-Comers" Coronary Lesions] criteria, and ILUMIEN IV criteria) were evaluated for their associations with lesion-specific 2-year clinically driven target lesion revascularization (TLR) or definite stent thrombosis. RESULTS Overall, 2,140 lesions in 1,831 patients were included; final MSA measured 6.2 ± 2.4 mm2. Among the 10 stent expansion indexes, only MSA/vessel area at the MSA site was independently associated with 2-year clinically driven TLR or definite stent thrombosis (hazard ratio: 0.77; 95% confidence interval: 0.59-0.99; P = 0.04) after adjusting for morphologic and procedural parameters. CONCLUSIONS In this IVUS-guided PCI cohort with excellent final MSA overall, stent/vessel area at the MSA site, an index of relative stent expansion, was superior to absolute MSA and other expansion indexes in predicting 2-year clinically driven TLR or definite stent thrombosis.
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Affiliation(s)
- Tatsuhiro Fujimura
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Mitsuaki Matsumura
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Michael J Rinaldi
- Sanger Heart & Vascular Institute/Atrium Health, Charlotte, North Carolina, USA
| | - Peter L Duffy
- Appalachian Regional Healthcare System, Boone, North Carolina, USA
| | - Giora Weisz
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Thomas D Stuckey
- LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, North Carolina, USA
| | - Ziad A Ali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA; St. Francis Hospital, Roslyn, New York, USA. https://twitter.com/ziadalinyc
| | - Zhipeng Zhou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Gary S Mintz
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/GreggWStone
| | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA.
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