Use of intravascular ultrasound and long-term cardiac death or myocardial infarction in patients receiving current generation drug-eluting stents

Comparison of Long-Term Outcomes Between Intravascular Ultrasound-, Optical Coherence Tomography- and Angiography-Guided Stent Implantation: A Meta-Analysis

Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided percutaneous coronary interventions (PCI) are alternative techniques to angiography-guided (ANG-g) PCI in patients with coronary artery disease (CAD), especially for optimal stent deployment in coronary arteries. We conducted a network meta-analysis including studies comparing those three techniques. We searched databases for studies that compared IVUS, OCT, and ANG-g PCI in patients with CAD. Overall, 52 studies with 231,137 patients were included in this meta-analysis. ANG-g PCI had higher major adverse cardiovascular events (MACEs), all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) than IVUS-guided PCI. Of note, both OCT-guided and IVUS-guided PCI had similar outcomes. The frequency of MACEs, cardiac death, and MI were higher in ANG-g PCI than in OCT-guided PCI. The highest benefit was established with OCT for MACEs (P-score=.973), MI (P-score=.823), and cardiac death (P-score=.921) and with IVUS for all-cause death (P-score=.792), TLR (P -score=.865), and ST (P-score=.930). This network meta-analysis indicated that using OCT or IVUS for optimal stent implantation provides better outcomes in comparison with ANG-g in patients with CAD undergoing PCI.

Long-term outcomes of IVUS-guided and angiography-guided drug-eluting stent implantation for left main coronary artery disease: a retrospective consort study

BACKGROUND

In patients with unprotected left main coronary artery disease (ULMCAD), this study compared the long-term prognosis of drug-eluting stent insertion guided by intravascular ultrasonography (IVUS) vs. angiography.

PATIENTS AND METHODS

This retrospective consort investigation was performed in December 2021. This analysis included 199 patients who underwent IVUS-guided (IVUS group, n = 81) or angiography-guided (angiography group, n = 118) drug-eluting stent implantation at the Affiliated Hospital of Inner Mongolia Medical University between September 2013 and September 2018. Major adverse cardiac events (MACE) were defined as cardiovascular death, sudden cardiac death, myocardial infarction.

RESULTS

The IVUS group had considerably lower proportions of MACE within 1 year postoperatively (P = 0.002) and cardiac mortality within 3 years postoperatively (P = 0.018) compared to the angiography group. However, after adjusting for confounding variables, the hazard ratio for 3-year cardiac mortality was similar between the two groups (P = 0.28). In the IVUS group, there was considerably greater minimum lumen diameter (MLD) (P = 0.046), and reduced frequencies of target vessel restenosis (P < 0.050) and myocardial infarction (MI) (P = 0.024) compared to the angiography group. Cox regression analysis for 3-year cardiac mortality found that MSD was independently associated with low cardiac mortality (HR = 0.1, 95% CI: 0.01-14.92, P = 0.030).

CONCLUSION

IVUS-guided drug-eluting stent implantation may lead to better long-term prognosis in patients with ULMCAD, and MSD may be a predictor for lower cardiac mortality.

Drug-Coated Balloon Angioplasty in Patients Undergoing Complex Percutaneous Coronary Intervention

Background

There are limited clinical data on drug-coated balloon (DCB)-based percutaneous coronary intervention (PCI) compared with drug-eluting stent (DES)-only PCI in patients with complex coronary artery lesions.

Objectives

The goal of the current study was to investigate the efficacy of DCB in patients undergoing PCI for complex coronary artery lesions.

Methods

From an institutional registry of patients with de novo complex coronary artery lesions, 126 patients treated with DCB-based PCI were compared with 234 propensity score-matched patients treated with DES-only PCI. Complex coronary artery lesions were defined as the presence of at least 1 of the following: bifurcation, chronic total occlusion, unprotected left main disease, long lesion ≥38 mm, multivessel disease, lesion requiring ≥3 devices, or severe calcification. The primary endpoint was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization.

Results

Baseline characteristics were comparable between the 2 groups. DCB-based PCI showed a comparable risk of TVF vs DES-based PCI (7.6% vs 8.1%; HR: 0.81; 95% CI: 0.33-1.99; P = 0.638). The risks of cardiac death (5.0% vs 5.7%; HR: 0.78; 95% CI: 0.24-2.49), target vessel-related myocardial infarction (0.9% vs 1.3%; HR: 2.65; 95% CI: 0.26-27.06), and target vessel revascularization (3.5% vs 2.0%; HR: 1.30; 95% CI: 0.30-5.67) were also comparable between the 2 groups.

Conclusions

DCB-based PCI showed comparable risks of TVF vs those of DES-only PCI in patients with complex coronary artery lesions. DCB might be considered as a suitable alternative device to DES in patients undergoing complex PCI. (Long-term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI; NCT03870815).

Detection of Blood Clots Using a Whole Stent as an Active Implantable Biosensor

Many cardiovascular problems stem from blockages that form within the vasculature and often treatment includes fitting a stent through percutaneous coronary intervention. This offers a minimally invasive therapy but re-occlusion through restenosis or thrombosis formation often occurs post-deployment. Research is ongoing into the creation of smart stents that can detect the occurrence of further problems. In this study, it is shown that selectively metalizing a non-conductive stent can create a set of electrodes that are capable of detecting a build-up of material around the stent. The associated increase in electrical impedance across the electrodes is measured, testing the stent with blood clot to mimic thrombosis. It is shown that the device is capable of sensing different amounts of occlusion. The stent can reproducibly sense the presence of clot showing a 16% +/-3% increase in impedance which is sufficient to reliably detect the clot when surrounded by explanted aorta (one sample t-test, p = 0.009, n = 9). It is demonstrated that this approach can be extended beyond the 3D printed prototypes by showing that it can be applied to a commercially available stent and it is believed that it can be further utilized by other types of medical implants.

Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond

The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.

Intravascular Imaging-Guided Percutaneous Coronary Intervention Before and After Standardized Optimization Protocols

BACKGROUND

Although benefits of intravascular imaging (IVI) in percutaneous coronary intervention (PCI) have been observed in previous studies, it is not known whether changes in contemporary practice, especially with application of standardized optimization protocols, have improved clinical outcomes.

OBJECTIVES

The authors sought to investigate whether clinical outcomes of IVI-guided PCI are different before and after the application of standardized optimization protocols in using IVI.

METHODS

2,972 patients from an institutional registry (2008-2015, before application of standardized optimization protocols, the past group) and 1,639 patients from a recently published trial (2018-2021 after application of standardized optimization protocols, the present group) were divided into 2 groups according to use of IVI. The primary outcome was 3-year target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization.

RESULTS

Significant reduction of TVF was observed in the IVI-guided PCI group compared with the angiography-guided PCI group (10.0% vs 6.7%; HR: 0.77; 95% CI: 0.61-0.97; P = 0.027), mainly driven by reduced cardiac death or myocardial infarction in both past and present IVI-guided PCI groups. When comparing past IVI and present IVI groups, TVF was significantly lower in the present IVI group (8.5% vs 5.1%; HR: 0.63; 95% CI: 0.42-0.94; P = 0.025), with the difference being driven by reduced target vessel revascularization in the present IVI group. Consistent results were observed in inverse-probability-weighting adjusted analysis.

CONCLUSIONS

IVI-guided PCI improved clinical outcomes more than angiography-guided PCI. In addition, application of standardized optimization protocols when using IVI further improved clinical outcomes after PCI. (Intravascular Imaging- Versus Angiography-Guided Percutaneous Coronary Intervention For Complex Coronary Artery Disease [RENOVATE-COMPLEX-PCI]; NCT03381872; and the institutional cardiovascular catheterization database of Samsung Medical Center: Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI; NCT03870815).

Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention Among Patients With Acute Coronary Syndrome

Intravascular ultrasound (IVUS) use in percutaneous coronary intervention (PCI) improves outcomes. However, data on outcomes of IVUS-guided PCI in patients presenting with acute coronary syndrome (ACS) is scarce. Therefore, we sought to study the utilization rate and outcomes of IVUS-guided PCI in patients with ACS. Using the National Readmission database, we identified all patients with ACS who underwent PCI from 2016 to 2019. We used a 1:1 propensity-matched analysis to compare the outcome of patients with ACS who underwent PCI with and without IVUS. In 1,263,997 patients with ACS, 563,521 (44.6%) underwent PCI without IVUS and 40,095 (3.17%) underwent IVUS-guided PCI. A Propensity scored matched comparison of PCI with and without IVUS showed IVUS-guided PCI was associated with a lower risk of in-hospital mortality (odds ratio 0.74, 95% confidence interval 0.64 to 0.85, p <0.01) compared with PCI without IVUS. The utilization of IVUS increased from 2.64% in 2016 to 4.10% in 2019, p <0.001. In conclusion, IVUS-guided PCI is associated with lower in-hospital mortality in patients with ACS, yet the current utilization of IVUS-guided PCI remains low across the United States.

Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Non-ST-Elevation Myocardial Infarction-Propensity Matched Regression Analysis

Intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) is indicated in complex interventions. There is a paucity of evidence for outcomes with large studies on using IVUS during PCI in non-ST-elevation myocardial infarction (NSTEMI). Our objective was to compare the in-hospital outcome of IVUS-guided with that of nonguided PCI among NSTEMI hospitalizations. The National Inpatient Sample (2016 to 2019) was queried to identify all hospitalizations with a principal diagnosis of NSTEMI. In our study, we compared outcomes of PCI with and without IVUS guidance using a multivariate logistic regression model after propensity score matching, with the primary outcome being in-hospital mortality. A total of 671,280 NSTEMI-related hospitalizations were identified, of whom 48,285 (7.2%) underwent IVUS-guided PCI compared with 622,995 (92.8%) who underwent non-IVUS PCI. After adjusted analysis on matched pairs, we found that IVUS-guided PCI had a lower risk of in-hospital mortality than that of non-IVUS PCI (adjusted odds ratio [aOR] 0.736, confidence interval (CI) 0.578 to 0.937, p = 0.013). However, there was a higher use of mechanical circulatory support in the IVUS-guided PCI (aOR 2.138, CI 1.84 to 2.47, p <0.001) than in non-IVUS PCI. The odds of cardiogenic shock (aOR 1.11, CI 0.93 to 1.32, p = 0.233) and procedural complications (aOR 0.794, CI 0.549 to 1.14, p = 0.22) were similar between the cohorts. Hence, we conclude that patients with NSTEMIs who underwent IVUS-guided PCI had less risk of in-hospital mortality and a greater requirement of mechanical circulatory support than did those who underwent non-IVUS PCI, with no difference in procedural complications. Large prospective trials are essential to validate these findings.

The Supreme Biodegradable Polymer DES in Acute and Chronic Coronary Syndromes: A PIONEER III Substudy

Background

The PIONEER III trial demonstrated noninferiority of 12-month target lesion failure (TLF) with the Supreme DES (Sinomed), a thin-strut cobalt-chromium, biodegradable polymer, sirolimus-eluting stent, compared with a durable polymer, everolimus-eluting (XIENCE/PROMUS) stent (DP-EES). The relative safety and effectiveness of the Supreme DES in patients with acute coronary syndromes (ACS) and those with chronic coronary syndromes (CCS) is not known.

Methods

PIONEER III was a prospective, multicenter, international, 2:1 randomized trial stratified by clinical presentation. The primary end point was TLF at 12 months (a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization).

Results

A total of 1628 patients were enrolled, including 41% of patients with ACS (unstable angina and non-ST-elevation myocardial infarction) randomized to Supreme DES (n = 441) versus DP-EES (n = 232) and 59% of patients with CCS randomized to Supreme DES (n = 645) versus DP-EES (n = 310). Patients with ACS were younger, fewer presented with less diabetes, hypertension, and previous revascularization, but more were current smokers. The primary end point of TLF (6.4% vs 4.4%; P = .1), major adverse cardiac events (8.5% vs 6.5%; P = .16), and stent thrombosis (0.4% vs 0.9%; P = .25) at 12 months were similar in the ACS and CCS groups. There was no difference in TLF at 12 months between Supreme DES and DP-EES among patients with ACS (6.6% vs 6.0%; P = .89) and those with CCS (4.5% vs 4.3%; P = .83); interaction P = .51 for TLF by clinical presentation.

Conclusions

Compared with the DP-EES, the Supreme DES seemed safe and effective with a similar TLF at 12 months in both patients with ACS and those with CCS.

CADNet: an advanced architecture for automatic detection of coronary artery calcification and shadow border in intravascular ultrasound (IVUS) images

Intravascular Ultrasound (IVUS) is a medical imaging modality widely used for the detection and treatment of coronary heart disease. The detection of vascular structures is extremely important for accurate treatment procedures. Manual detection of lumen and calcification is very time-consuming and requires technical experience. Ultrasound imaging suffers from the generation of artifacts which obstructs the clear delineation among structures. Considering, the need, to provide special attention to crucial areas, convolutional block attention modules (CBAM) is integrated into an encoder-decoder-based U-Net architecture along with Atrous Spatial Pyramid Pooling (ASPP) to detect vessel components: lumen, calcification and shadow borders. The attention modules prove effective in dealing with areas of special attention by assigning additional weights to crucial channels and preserving spatial features. The IVUS data of 12 patients undergoing the treatment is taken for this study. The novelty of the model design is such that it is able to detect the lumen area in the presence/absence of calcification and bifurcation artifacts too. Also, the model efficiently detects the calcification area even in case of severely complex lesions with shadows behind them. The main contribution of the work is that IVUS images of varying degrees of calcification till 360° are also considered in this work, which is usually neglected in previous studies. The experimental results of 1097 IVUS images of 12 patients resulted in meanIoU (0.7894 ± 0.011), Dice Coefficient (0.8763 ± 0.070), precision (0.8768 ± 0.069) and recall (0.8774 ± 0.071) of the proposed model CADNet which show the model's effectiveness relative to other state-of-the art methods.

A State-Of-The-Art Review on Coronary Artery Border Segmentation Algorithms for Intravascular Ultrasound (IVUS) Images

Intravascular Ultrasound images (IVUS) is a useful guide for medical practitioners to identify the vascular status of coronary arteries in human beings. IVUS is a unique intracoronary imaging modality that is used as an adjunct to angioplasty to view vessel structures using a catheter with high resolutions. Segmentation of IVUS images has always remained a challenging task due to various impediments, for example, similar tissue components, vessel structures, and artifacts imposed during the acquisition process. Many researchers have applied various techniques to develop standard methods of image interpretation, however, the ultimate goal is still elusive to most researchers. This challenge was presented at the MICCAI- Computing and Visualization for (Intra)Vascular Imaging (CVII) workshop in 2011. This paper presents a major review of recently reported work in the field, with a detailed analysis of various segmentation techniques applied in IVUS, and highlights the directions for future research. The findings recommend a reference database with a larger number of samples acquired at varied transducer frequencies with special consideration towards complex lesions, suitable validation metrics, and ground-truth definition as a standard against which to compare new and current algorithms.

Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond

The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.