Intravascular Ultrasound-Guided or Angiography-Guided Complex High-Risk PCI

Clinical Snapshot

Key Findings

• P Value: P = 0.08

• Effect Size: Hazard ratio 1.25 (favouring angiography-guided PCI)

• Primary Outcome: Target-vessel failure at median 19.0 months: 13.9% (IVUS) vs 11.1% (angiography)

• Nnt Or Sensitivity: Number needed to harm: approximately 36 patients (based on 2.8% absolute risk increase)

• Confidence Interval: 95% CI: 0.97 to 1.60

Clinical Application

Requires IVUS equipment, trained operators, and acceptance of 22.6-minute longer procedure times without demonstrated benefit Challenges current CSANZ and international guidelines recommending IVUS for complex lesions; may influence PBS funding decisions for IVUS catheters in complex PCI Patients requiring complex high-risk PCI in tertiary cardiac centres with IVUS capability

Abstract

BACKGROUND: Intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) has been associated with increased stent optimization and reduced adverse events among patients with complex coronary-artery lesions, but adoption of this strategy in Western countries remains low. Although practice guidelines recommend intracoronary imaging for anatomically complex lesions, evidence from current European practice is limited. METHODS: In this investigator-initiated, international, open-label, randomized, controlled trial, we assigned patients undergoing complex PCI to either IVUS-guided PCI, performed with the use of prespecified stent-optimization criteria, or angiography-guided PCI. The primary end point was target-vessel failure, defined as a composite of death from cardiac causes, target-vessel myocardial infarction, or clinically indicated target-vessel revascularization. RESULTS: Of the 2020 patients who underwent randomization, 1010 in the IVUS-guided PCI group and 1009 in the angiography-guided PCI group were included in the primary analysis. The mean age of the patients was 69 years, 79.4% were men, and 27.4% presented with an acute coronary syndrome. The mean procedure duration was 88.8 minutes with IVUS-guided PCI and 66.2 minutes with angiography-guided PCI. Dilation with balloon angioplasty after stent implantation was performed in 91.3% of the IVUS-guided PCI procedures and in 84.5% of the angiography-guided PCI procedures. At a median follow-up of 19.0 months (interquartile range, 15.2 to 23.4), target-vessel failure had occurred in 140 patients (13.9%) in the IVUS-guided PCI group and in 112 patients (11.1%) in the angiography-guided PCI group (hazard ratio, 1.25; 95% confidence interval, 0.97 to 1.60; P = 0.08). Procedural complications occurred in 11.3% of the IVUS-guided PCI procedures and in 10.2% of the angiography-guided PCI procedures. The frequency of adverse events appeared to be similar in the two groups. CONCLUSIONS: Among patients undergoing complex high-risk PCI, a strategy of routine IVUS-guided PCI performed with the use of prespecified stent-optimization criteria was not associated with a lower risk of target-vessel failure than angiography-guided PCI alone. (Funded by Boston Scientific; IVUS-CHIP ClinicalTrials.gov number, NCT04854070.).

References

1. 1.Diletti, R., Daemen, J., Faurie, B., Barbierato, M., Tchétché, D., Hovasse, T., Teeuwen, K., Cheng, J. M., Landt, M., Campo, G., Bennett, J., Alfonso, F., Mashayekhi, K., Moreno, R., Abdelwahed, Y. S., Heestermans, T., de la Torre Hernandez, J. M., Murphy, J. C., Amat-Santos, I., Dens, J., Franzé, A., Leistner, D. M., Ghattas, A., Spratt, J. C., Banning, A. P., Tijssen, J. G. P., Spitzer, E., & Van Mieghem, N. M. (2026). Intravascular ultrasound-guided or angiography-guided complex high-risk PCI. *New England Journal of Medicine*. https://doi.org/10.1056/NEJMoa2601521