IVUS-Guided versus Angiography-Guided PCI in Unprotected Left Main Coronary Disease

Clinical Snapshot

Key Findings

• P Value: P = 0.40 (not statistically significant)

• Effect Size: Hazard ratio 1.11 (no benefit for IVUS guidance)

• Primary Outcome: Composite of stroke, myocardial infarction, any revascularization, or death: 33.7% (IVUS) vs 30.9% (angiography)

• Nnt Or Sensitivity: No number needed to treat calculable as no significant benefit demonstrated

• Confidence Interval: 95% CI: 0.87 to 1.42

Clinical Application

IVUS guidance requires additional equipment, training, and procedural time. Results suggest angiographic guidance alone is adequate for most cases. Relevant to Australian interventional cardiology practice. IVUS available in major cardiac centers but adds cost without demonstrated benefit. Aligns with evidence-based approach favored by CSANZ guidelines. Patients with unprotected left main coronary artery disease suitable for percutaneous coronary intervention in tertiary cardiac centers

Abstract

BACKGROUND: Percutaneous coronary intervention (PCI) is increasingly used for revascularization of unprotected left main coronary artery disease. Whether intravascular ultrasonographic (IVUS) guidance during PCI results in better clinical outcomes than conventional angiographic guidance alone is uncertain. METHODS: In an international, multicenter, open-label trial, we randomly assigned patients with unprotected left main coronary artery disease in a 1:1 ratio to undergo either IVUS-guided PCI or angiography-guided PCI. The primary end point was a patient-oriented composite of any stroke, any myocardial infarction, any revascularization, or death from any cause at the longest follow-up. RESULTS: A total of 806 patients underwent randomization; 401 were assigned to undergo IVUS-guided PCI and 405 to undergo angiography-guided PCI. The mean (±SD) age of the patients was 71.4±10.7 years, 78.4% of the patients were men, and 34.7% had diabetes. At a median follow-up of 2.9 years, a primary end-point event had occurred in 135 patients (33.7%) in the IVUS-guided PCI group and in 125 patients (30.9%) in the angiography-guided PCI group (hazard ratio, 1.11; 95% confidence interval, 0.87 to 1.42; P = 0.40). The incidence of death, myocardial infarction, or revascularization appeared to be similar in the two groups. The percentages of patients with procedure-related and overall safety events also appeared to be similar in the two groups. CONCLUSIONS: Among patients with unprotected left main coronary artery disease, IVUS-guided PCI showed no additional benefit over angiography-guided PCI with respect to the incidence of stroke, myocardial infarction, any revascularization, or death from any cause at a median follow-up of 2.9 years. (Funded by Philips Image Guided Therapy Devices and Boston Scientific; OPTIMAL ClinicalTrials.gov number, NCT04111770.).

References

1. 1.Testa, L., De la Torre Hernandez, J. M., De Maria, G. L., Jones, D. A., Piñon-Esteban, P., Campo, G., Garcia Del Blanco, B., Pan, M., Garcia-Camarero, T., Sardella, G., O'Kane, P., Greenwood, J. P., Ribichini, F. L., Pescetelli, I., Ielasi, A., Lozano, I., Cockburn, J., Oreglia, J. A., Zaman, A. G., Bedogni, F., Lindeboom, W., Tijssen, J. G. P., Spitzer, E., & Banning, A. P. (2026). IVUS-Guided versus Angiography-Guided PCI in Unprotected Left Main Coronary Disease. *New England Journal of Medicine*. https://doi.org/10.1056/NEJMoa2600440