Intravascular Imaging Use in Percutaneous Coronary Interventions of Chronic Total Occlusions

Abstract

Background. Intravascular ultrasound (IVUS) can assist percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). Methods. We analyzed 8,983 CTO PCIs performed in 8,771 patients between 2012 and 2022 at 39 centers. Results. Overall, IVUS was used in 44.5% of the cases, for crossing in 11.5% and for stent optimization in 33.1%. IVUS for stent optimization was used more often for complex lesions with higher prevalence of calcification (51.2% vs 34.3%, P<.001); was associated with lower air kerma radiation dose (1.78 [1.00, 3.09] vs 2.30 (1.35, 3.91) min, P<.001) and contrast volume (190 [138, 258] vs 220 [160, 300] ml, P<.001). Among cases with successful guidewire crossing, those that used IVUS for stent optimization had higher technical (99.3% vs 96.3%, P<.001) and procedural (96.1% vs 94.6%, P=.002) success rates and similar major adverse complication event rates (2.04% vs 1.62%, P=.176). The use of IVUS for stent optimization significantly increased over time. Conclusion. In a contemporary, multicenter registry, IVUS was used in 44.5% and its use for stent optimization significantly increased over time. Cases where IVUS was used for stent optimization had higher technical and procedural success and similar risk of complications compared with cases where IVUS was not used for stent optimization.

J INVASIVE CARDIOL 2023;35(5):E265-E268. ePub 2023 April 14.

Key words: chronic total occlusions, intravascular imaging, intravascular ultrasound, percutaneous coronary intervention

Introduction

Intravascular ultrasound (IVUS) can be used in chronic total occlusions (CTO) percutaneous coronary intervention (PCI) to facilitate crossing (by resolving proximal cap ambiguity, clarifying guidewire position in antegrade and retrograde crossing attempts, etc.) and for stent optimization.^1,2

Materials and Methods

We analyzed the association between IVUS utilization and procedural outcomes in 8983 CTO PCIs performed in 8771 patients enrolled in the PROGRESS-CTO Registry, (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention- Clinicaltrials.gov Identifier: NCT02061436) between 2012 and January 2022 at 39 centers. Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Minneapolis Heart Institute Foundation.^3,4 The study was approved by the institutional review board of each site.

Results

Overall, IVUS was used in 44.5% of the cases: in 11.5% for crossing, in 33.1%, for stent optimization, and in 6.0% for both crossing and stent optimization. Mean patient age was 64.4±10 years and 81% were men. Patients in whom IVUS was used for stent optimization were more likely to have diabetes mellitus (45% vs. 42%, P=.002) and prior coronary artery bypass graft surgery (31% vs. 26%, P<.001) compared with patients in whom IVUS was not used. IVUS was used more often for stent optimization in complex lesions with higher prevalence of calcification (51.2% vs. 34.3%, P<.001), in-stent restenosis (19% vs. 15%, P<.001), higher J-CTO scores (Japan CTO scores- 2.50 ± 1.20 vs. 2.14 ± 1.29, P<.001) and PROGRESS CTO scores (1.20 ± 0.99 vs. 1.07 ± 0.99, P<.001), and larger number of stents (2.4 ± 1.1 vs. 2.3 ± 1.1, P<.001). IVUS for stent optimization was associated with longer procedure time (138 [95, 195] vs. 102 [66, 151] min, P<.001) but lower air kerma radiation dose (1.78 [1.00, 3.09] vs. 2.30 (1.35, 3.91) Gray, P<.001) and contrast volume (190 [138, 258] vs. 220 [160, 300] mL, P<.001 Figure 1). Among cases with successful guidewire crossing, those that used IVUS for stent optimization had higher technical (99% vs. 96%, P<.001) and procedural (96% vs. 95%, P=.002) success and similar major adverse complication event rates (2.04% vs. 1.62%, P=.176). The use of IVUS for stent optimization increased over time (Figure 1).

Discussion

Several randomized trials have demonstrated that IVUS-guided is superior to angiography-guided drug-eluting stent (DES) implantation,⁵ however results on CTO PCI are limited. A recently published meta-analysis on two observational and two randomized studies including 1,975 patients reported that IVUS-guided CTO PCI is associated with lower risk of stent thrombosis.⁶ Use of intravascular imaging to optimize stent deployment in CTO PCI is one of the key guiding principles in a global expert consensus document.¹ CTO-PCIs can be complex procedures with long duration and high contrast and radiation dose, that could benefit from IVUS guidance.⁷ In spite of the increasing evidence, IVUS is still underutilized in everyday practice with wide variability even among experienced centers,² likely due to the cost of the device and the time added to the procedure.

Study limitations. Our study has limitations. First, it is an observational, retrospective study. Second, there was no clinical event adjudication by a clinical events committee. Third, all procedures were performed at high-volume, experienced PCI centers, limiting the generalizability of our findings to centers with limited CTO PCI experience.

Conclusion

In a contemporary, multicenter registry, IVUS was used 44.5% and its use for stent optimization significantly increased over time. Cases where IVUS was used for stent optimization had higher technical and procedural success and similar risk of complications compared with cases where IVUS was not used for stent optimization.

Acknowledgments. Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation (MHIF), Minneapolis, Minnesota. REDCap is a secure, web-based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.

Affiliations and Disclosures

From the ¹Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota; ²Henry Ford Hospital, Detroit, Michigan; ³St Francis Hospital & Heart Center, Roslyn, New York; and ⁴Columbia University, New York, New York.

Funding: The authors are grateful for the generosity of our many philanthropy partners, including our anonymous donors, Drs Mary Ann and Donald A. Sens, Ms. Dianne and Dr Cline Hickok, Ms Charlotte and Mr Jerry Golinvaux Family Fund, the Roehl Family Foundation, and the Joseph Durda Foundation, Ms Wilma and Mr Dale Johnson, for making this work possible at the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD).

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Ali: Institutional research/grant support from Abbott Vascular, Boston Scientific, Philips Volcano, Cardiovascular Systems, Inc., Medtronic, Acist Medical, Opsens, and personal consulting honoraria from Amgen, Astra Zeneca and Boston Scientific, and equity in Shockwave Medical. Dr. Kirtane: Consulting from IMDS; Travel Expenses/Meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. Dr. Alaswad: consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 27, 2023.

Address for correspondence:  Khaldoon Alaswad, MD, FACC, FSCAI, Henry Ford Hospital, Detroit, MI, Email: kalaswad@gmail.com

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