Impact of Intracoronary Imaging‐Guided Percutaneous Coronary Intervention on Procedural Outcomes Among Complex Patient Groups

Abstract

Background Intracoronary imaging (ICI) has been shown to improve survival after percutaneous coronary intervention (PCI). Whether this prognostic benefit is sustained across different indications remains unclear. Methods and Results All PCI procedures performed in England and Wales between April, 2014 and March 31, 2020, were retrospectively analyzed. The association between ICI use and in‐hospital major acute cardiovascular and cerebrovascular events; composite of all‐cause mortality, stroke, and reinfarction and mortality was examined using multivariable logistic regression analysis for different imaging‐recommended indications as set by European Association for Percutaneous Cardiovascular Interventions consensus. Of 555 398 PCI procedures, 10.8% (n=59 752) were ICI‐guided. ICI use doubled between 2014 (7.8%) and 2020 (17.5%) and was highest in left main PCI (41.2%) and lowest in acute coronary syndrome (9%). Only specific European Association for Percutaneous Cardiovascular Interventions imaging‐recommended indications were associated with reduced major acute cardiovascular and cerebrovascular events and mortality, including left main PCI (odds ratio [OR], 0.45 [95% CI, 0.39–0.52] and 0.41 [95% CI, 0.35–0.48], respectively), acute coronary syndrome (OR, 0.76 [95% CI, 0.70–0.82] and 0.70 [95% CI, 0.63–0.77]), and stent length >60 mm (OR, 0.75 [95% CI, 0.59–0.94] and 0.72 [95% CI, 0.54–0.95]). Stent thrombosis and renal failure were associated with lower mortality (OR, 0.69 [95% CI, 0.52–0.91]) and major acute cardiovascular and cerebrovascular events (OR, 0.77 [95% CI, 0.60–0.99]), respectively. Conclusions ICI use has more than doubled over a 7‐year period at a national level but remains low, with <1 in 5 procedures performed under ICI guidance. In‐hospital survival was better with ICI‐guided than angiography‐guided PCI, albeit only for specific indications.

Intravascular Imaging–Guided Versus Angiography‐Guided Percutaneous Coronary Intervention: A Systematic Review and Meta‐Analysis of Randomized Trials

“…Our analysis differs from prior published meta‐analytic work in several ways. 10 , 11 , 12 , 13 , 14 , 15 , 17 , 40 First, it includes newly available trial data with the publication of 1 new large trial and longer‐term follow‐up from 2 other trials. Second, we were able to obtain additional previously unpublished data from the principal investigators of some trials for certain outcomes and subgroups, ensuring that this study is the most exhaustive and complete representation of the existing trial data in the field (Table S6 ).…”

“…Despite this, adoption of intravascular imaging to guide PCI remains low. 8 , 9 , 10 This may in part reflect skepticism regarding the benefit of intravascular imaging on harder clinical end points such as death, and in part be a reflection of the modest endorsement from guidelines. 11 Other potential reasons for low adoption of intravascular imaging include lack of education and training for operators; perceived additional procedural time; additional procedural costs; and, depending on the specific health care systems, lack of linkage to reimbursement and perceived low reimbursement.…”

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock

“…In a study by Smilowitz and colleagues the rate of ICI between 2013 and 2014 was 6.6% in their national analysis of all US PCI procedures, while our previous work showed only 17.5% of all PCI procedures in England and Wales in 2020 were ICI-guided. 20,21 Several reasons may explain the low rates of ICI use, especially in this patient group, including reluctance to prolong procedure time in unstable patients, catheterization laboratory time constraints and lack of staffing and device resources.…”

Intracoronary optical coherence tomography—An introduction

“…Consensus statements have outlined the indications for use 2,16 and real-world data confirms an advantage in left main bifurcation treatment, acute coronary syndrome (as detailed in this supplement (ref ACS paper) and diffuse disease. 17 Previous physician surveys have highlighted the financial cost, a lack of education and prolongation of the procedure as the commonest barriers to adoption. 18 A standardized approach to OCT use and the ongoing development of artificial intelligence guided image interpretation could transform the approach for less experienced PCI operators who are willing to learn.…”

“…Despite the obvious benefits of enhanced visualization provided by OCT and the clinical benefits demonstrated in the most recent meta‐analysis presented in this supplement (Ref Meta‐analysis manuscript within supplement), real‐world adoption of the technology remains limited. Consensus statements have outlined the indications for use 2,16 and real‐world data confirms an advantage in left main bifurcation treatment, acute coronary syndrome (as detailed in this supplement (ref ACS paper) and diffuse disease 17 . Previous physician surveys have highlighted the financial cost, a lack of education and prolongation of the procedure as the commonest barriers to adoption 18 .…”