Cost-Effectiveness of Intravascular Imaging-Guided Complex PCI: Prespecified Analysis of RENOVATE-COMPLEX-PCI Trial

Intravascular Imaging as a Performance Measure for Percutaneous Coronary Intervention

BACKGROUND

Intravascular imaging (IVI) is widely recognized to improve outcomes after percutaneous coronary intervention (PCI). However, IVI is underutilized and is not yet established as a performance measure for quality PCI.

METHODS

We examined temporal trends of IVI use for all PCIs performed at Veterans Affairs hospitals in the United States from 2010 to 2022 using retrospective observational cohorts. IVI was defined as intravascular ultrasound or optical coherence tomography. A contemporary subset of PCIs from 2020 to 2022 was used to examine clinical characteristics associated with IVI use and test the reliability of IVI as a pass/fail performance measure. We then used a generalized linear mixed model to estimate the proportion of IVI use variability attributable to the hospital, physician, and patient level. Cox proportional hazard models were used to assess the association of IVI with clinical outcomes at 1 year.

RESULTS

IVI use increased from 12.3% in 2010 to 43.1% in 2022 in 136 071 PCIs included in the study. Among 22 918 PCIs in the contemporary cohort, IVI was more frequent with nonemergent presentations, chronic total occlusions, and left main lesions but usage variability was primarily attributable to hospital (54%) and physician (33%) levels. As a pass/fail performance measure, reliability was high (>0.96) at hospital and physician levels. However, IVI use was not associated with statistically significant differences in mortality or major adverse cardiovascular events in this cohort.

CONCLUSIONS

IVI use for PCI is increasing rapidly at Veterans Affairs hospitals in the United States but with marked variation at the hospital and physician levels. IVI meets established criteria for an effective performance measure and should be measured and reported by local and national organizations to encourage further uptake. Ongoing training and quality improvement may be required to maximize the benefit of IVI as it is more widely utilized.

Intravascular Imaging in the Diagnosis and Management of Patients With Suspected Intracoronary Pathologies: A CJC White Paper

Intravascular imaging has become an integral part of the diagnostic and management strategies for intracoronary pathologies. In this White Paper we summarize current evidence and its implications on the use of intravascular imaging in interventional cardiology practice. The areas addressed are planning and optimization of percutaneous coronary intervention, management of stent failure, and evaluation of ambiguous coronary lesions and myocardial infarction with nonobstructive coronary disease. The findings presented followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system in an expert consensus process that involved a diverse writing group vetted by a review group. Expert consensus was achieved around 9 statements. Use of intravascular imaging in guiding percutaneous revascularization is supported by high-quality evidence, particularly for lesions with increased risk of recurrent events or stent failure. Specific considerations for intravascular imaging guidance of intervention in left main lesions, chronic occlusion lesions, and in patients at high risk of contrast nephropathy are explored. Use of intravascular imaging to identify pathologies associated with stent failure and guide repeat intervention, resolve ambiguities in lesion assessment, and establish diagnoses in patients who present with myocardial infarction with nonobstructive coronary disease is supported by moderate- to low-quality evidence. Each topic is accompanied by clinical pointers to aid the practicing interventional cardiologist in implementation of the White Paper findings. The findings presented in this White Paper will help to guide the use of intravascular imaging toward situations in which the balance of efficacy, safety, and cost are most optimal.

Comparison between Imaging and Physiology in Guiding Coronary Revascularization: A Meta-Analysis

Background: Percutaneous coronary intervention (PCI) is a widely used revascularization strategy for coronary artery disease. The choice between imaging-guided and physiology-guided PCI has been a subject of debate. This meta-analysis aims to systematically compare outcomes between imaging and physiology-guided PCI and management of intermediate coronary lesions (ICLs). Methods: A comprehensive literature search was conducted across major databases for studies published up to December 2023 following PRISMA guidelines. Seven eligible studies comparing imaging-guided and physiology-guided PCI were selected for the final analysis. Relevant outcome measures included major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target vessel failure (TVF), and target lesion revascularization (TLR). Subgroup analysis was performed for ICLs. Results: A total of 5701 patients were included in the meta-analysis. After a mean follow-up of 2.1 years, imaging-guided PCI was associated with lower rates of TVR compared to physiology-guided PCI (OR 0.70, 95% CI 0.52-0.95, p = 0.02); concerning MACE, TVF, and TLR, no differences were found. When the analysis was restricted to studies considering ICLs management, there were no differences between the two techniques. Meta regression analysis did not show any impact of acute coronary syndromes (ACS) presentation on MACE and TVR. Conclusions: The findings suggest that imaging-guided PCI may reduce the need for future revascularization of the target vessel compared to the functional-guided approach, and this result was not influenced by ACS presentation. These results may have important implications for clinical practice, guiding interventional cardiologists in selecting the most appropriate guidance strategy.