Intravascular Imaging Predictors Associated With Cardiovascular Events After Complex PCIs

Abstract

BACKGROUND: Intravascular imaging-guided percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes in patients with complex coronary artery lesions compared with angiography-guided PCI. However, the prognostic impact of suboptimal findings on intravascular imaging such as stent underexpansion, malapposition, or dissection is unclear in the era of contemporary drug-eluting stents.

METHODS: From RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) which compared imaging-guided PCI with angiography-guided PCI in patients with complex lesions, post-PCI intravascular imaging findings, including minimum stent area (MSA), relative stent underexpansion (MSA≤80% of the average reference lumen area), malapposition, or dissection, were assessed in nonleft main target lesions. The primary end point was target lesion failure (TLF), a composite of cardiac death, target lesion–related myocardial infarction, target lesion revascularization, or definite stent thrombosis.

RESULTS: A total of 897 nonleft main lesions from 714 patients undergoing imaging-guided PCI were included. During a median follow-up duration of 2.1 years, the optimal cutoff value of MSA to predict the occurrence of TLF was 5.5 mm2, and MSA<5.5 mm2 was associated with a significantly higher risk of TLF than MSA≥5.5 mm2 (2.2% versus 4.8%; adjusted hazard ratio, 3.09 [95% CI, 1.01–9.50]; P=0.048). Compared with the reference group (MSA≥5.5 mm2 and no suboptimal findings), the subgroup of patients with MSA≥5.5 mm2 and post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, or major dissection was associated with a numerically increased risk of TLF (0.0% versus 3.2%; P=0.057). Compared with the same reference group, the subgroup of patients with MSA<5.5 mm2 and suboptimal post-PCI intravascular imaging findings was associated with a significantly increased risk of TLF (0.0% versus 4.7%; P=0.017).

CONCLUSIONS: After intravascular imaging–guided PCI with contemporary drug-eluting stents for nonleft main complex lesions, inadequate absolute stent expansion was independently associated with a higher risk of TLF. Suboptimal post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, and major dissection seem to contribute to the risk of TLF.