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Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions

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Abstract

Stenting coronary artery bifurcation lesion is associated with suboptimal clinical results. Clinical improvement by intravascular ultrasound (IVUS) guided bifurcation stenting is controversial because small-side-branch (SB), low-risk patients and false bifurcations were included in previous studies that had no exact IVUS criteria for optimal stent expansion. We sought determine whether IVUS guidance is superior to angiography guidance for patients with true and complex bifurcation lesions. Between July 2006 and July 2012, 1465 patients with unstable angina and Medina 1,1,1 or 0,1,1 coronary bifurcation lesions were prospectively studied. 310 patients in the IVUS guidance (defined as stent symmetry index > 0.7, stent expansion index > 0.9, well apposition, and no Type B/C dissection) group were paired with 620 patients in the angiography group by propensity score-matching. The primary endpoint was the rate of composite major adverse cardiac events (MACE) (cardiac death, myocardial infarction (MI), or clinically-driven target vessel revascularization) at 1-year and at the end of study after indexed procedure. Use of IVUS guidance was mainly driven by stenting technique selection and identification of lesions’ specificities. IVUS criteria for optimal stent expansion were achieved in 82.9% of patients which contribute to IVUS group data assessment and the rest did not meet optimal criteria. MACE occurred in 10.0% of patients at 1-year follow-up and 15.2% at the 7-year follow-up in the IVUS group, significantly different from 15.0% (p = 0.036) and 22.4% (p = 0.01) in the angiography group, respectively. Compared to angiography guidance, IVUS guidance also resulted in a lower 7-year cardiac death rate (6.5 versus 1.3%, p = 0.002) and MI (8.4 versus 2.3%, P < 0.001). Any revascularization was also statistically lower in the IVUS group through whole study period, compared to the angiography group. Lower MACE rates were observed in IVUS guidance group in a 7-year follow-up compared with angiography guidance alone.

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Acknowledgements

We deeply acknowledge Dr. Bao-Xiang Duan (Chair) as the director of the independent committee. We thank Ms. Ling Lin (China, Clinical trial coordinator), Ms. Hai-Mei Xu (China), and Linda Liason (Indonesia) for their contributions to the completion of this study. We also appreciate the support through the whole study period of the Cooperative Innovational Center of Nanjing Medical University.

Disclosures

The authors certify that: (1) the paper is not under consideration elsewhere, (2) no part of the paper has been previously published, (3) all of the authors have read and approved the manuscript, and (4) none of the authors has any relevant disclosures.

Funding

The study was funded by a grant from the National Science Foundation of China (Funding No. NSFC 91639303).

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Author notes

  1. Liang Chen, Tian Xu and Xian-Jun Xue have contributed equally to the manuscript.

Authors and Affiliations

  1. Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China

    Liang Chen, Tian Xu, Xian-Jun Xue, Jun-Jie Zhang, Fei Ye, Nai-liang Tian & Shao-Liang Chen

  2. Department of Cardiology, Nanjing Heart Center, Nanjing, China

    Liang Chen, Tian Xu, Xian-Jun Xue, Jun-Jie Zhang, Fei Ye, Nai-liang Tian & Shao-Liang Chen

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  1. Liang Chen
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Correspondence to Shao-Liang Chen.

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This study was approved by the local ethics committee of our institution.

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Chen, L., Xu, T., Xue, XJ. et al. Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions. Int J Cardiovasc Imaging 34, 1685–1696 (2018). https://doi.org/10.1007/s10554-018-1393-2

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