Quantitative coronary angiography acceptable alternative to IVUS to assist angiography-guided PCI: JAMA

The randomized clinical trial, including 1528 patients with coronary artery stenosis undergoing PCI, revealed similarly low rates of target lesion failure at 12 months in both QCA- and IVUS-guided percutaneous coronary intervention (PCI) groups. Guidance via quantitative coronary angiography resulted in a similar post-PCI minimum lumen diameter as IVUS guidance.

Coronary angiography is the most commonly used technique for guiding stent implantation. However, angiography-guided PCI relies on visual estimation, suffers from subjectivity, and often underestimates vessel size and stent expansion. IVUS can provide reliable quantitative and qualitative information regarding the lumen, vessel, plaque, and deployed stents.

Although intravascular ultrasonography guidance promotes favorable outcomes after PCI, many catheterization laboratories worldwide lack access. Therefore, Pil Hyung Lee, University of Ulsan College of Medicine, Seoul, Korea, and colleagues aimed to investigate whether systematic implementation of quantitative coronary angiography to assist angiography-guided PCI could be an alternative strategy to IVUS guidance during stent implantation.

For this purpose, the researchers conducted a randomized, open-label, noninferiority clinical trial enrolling adults with chronic or acute coronary syndrome and angiographically confirmed native coronary artery stenosis requiring PCI. Enrollment was done in 6 cardiac centers in Korea from 2017 to 2021, and follow-up occurred through 2022.

Following successful guidewire crossing of the first target lesion, patients were randomized in a ratio of 1:1 to receive either QCA- or IVUS-guided PCI. 1528 patients who underwent PCI with QCA guidance (763; mean age, 64.1 years; 5775.2% males) or IVUS guidance (765; mean age, 64.6 years; 81.3% males), were included in the trial.

The primary outcome was target lesion failure at 12 months, defined as a composite of target vessel myocardial infarction, cardiac death, or ischemia-driven target lesion revascularization. The trial was designed assuming an event rate of 8%.

The researchers reported the following findings:

• The post-PCI mean minimum lumen diameter was similar between the QCA- and IVUS-guided PCI groups (2.57 versus 2.60 mm).
• Target lesion failure at 12 months occurred in 3.81% of patients in the QCA-guided PCI group and 3.80% of patients in the IVUS-guided PCI group (absolute risk difference, 0.01 percentage points; hazard ratio, 1.00).
• There was no difference in the rates of stent edge dissection (1.2% versus 0.7%), stent thrombosis (0.53% versus 0.66%), or coronary perforation (0.2% versus 0.4%) between the QCA- and IVUS-guided PCI groups.
• The risk of the primary endpoint was consistent regardless of subgroup, with no significant interaction.

Findings of this randomized clinical trial suggest that QCA and IVUS guidance during PCI showed similar rates of target lesion failure at 12 months.

"However, due to the lower-than-expected rates of target lesion failure in this trial, the results should be interpreted cautiously," the researchers concluded.

Reference:

Lee PH, Hong SJ, Kim H, et al. Quantitative Coronary Angiography vs Intravascular Ultrasonography to Guide Drug-Eluting Stent Implantation: A Randomized Clinical Trial. JAMA Cardiol. Published online March 13, 2024. doi:10.1001/jamacardio.2024.0059