Impact of post‐procedural minimal stent area on 2‐year clinical outcomes in the SYNTAX II trial

Abstract

Objectives To investigate the impact of minimal stent area (MSA) evaluated by post‐procedural intravascular ultrasound (IVUS) on clinical outcomes after contemporary PCI in patients with three‐vessel disease (TVD). Background The impact of post‐procedural MSA on clinical outcomes has not yet been extensively studied in patients with TVD. Methods The SYNTAX II study is a multicenter, all‐comers, open‐label, single arm study that investigated the impact of a state‐of‐the‐art PCI strategy on clinical outcomes in patients with TVD (454 patients with 1,559 lesions). The relationships between post‐procedural MSA and lesion‐level outcomes at 2 years were investigated. Clinical events adjudicated per patient by clinical event committee were assessed per lesion. Lesion‐oriented composite endpoint (LOCE) was defined as the composite of cardiac death, target‐vessel myocardial infarction, and ischemia‐driven target lesion revascularization. Results Eight hundred and nineteen lesions with post‐procedural MSA available in 367 patients were included in the analysis. The post‐procedural MSA per lesion was divided into terciles (smallest tercile: ≤5.0 mm2, intermediate tercile: 5.0–6.7 mm2, and largest tercile: >6.7 mm2). LOCE was observed in 16/288 (5.6%), 15/265 (5.7%), and 8/266 (3.0%) (P = 0.266). Target lesion revascularization (TLR) was observed in 16/288(5.6%), 12/265 (4.5%), and 4/266 (1.5%) (P = 0.042). The multivariate analysis demonstrated that smaller post‐procedural MSA, as well as creatinine clearance, history of previous stroke, chronic total occlusion, and lesion SYNTAX Score was an independent predictor of TLR. Conclusions In the SYNTAX II trial, larger post‐procedural MSA was independently associated with the lower rate of TLR at 2 years.

Intracoronary optical coherence tomography: state of the art and future directions

“…State of the art in OCT MSA, a consistent predictor of long-term PCI outcomes 3,[44][45][46][47][48][49][50] . OCT software provide automatic measurement of stent diameter and expansion and detection of underexpanded segments.…”

“…The OPINION trial and previous studies have shown that EEL-based stent sizing strategies result in the selection of larger diameter balloons and stents and more frequent post-dilation compared with lumen-based diameter measurements 100,101 . As lower MSA has consistently been shown to be a pre-eminent cause of late DES failure 3,[44][45][46][47][48][49][50] , the difference in stent sizing strategy in these previous studies may have been a disadvantage for OCT in comparison with IVUS. The ILUMIEN III trial 21 compared OCT-, IVUS-, and angiography-guided PCI using an EEL-based sizing strategy in the OCT arm.…”

Optimization of Percutaneous Coronary Intervention Using Optical Coherence Tomography

“…IVUS findings provide important information to physicians before and after coronary stenting. For example, the minimal stent area (MSA) among the IVUS parameters is known to be a predictor of a long-term major adverse cardiovascular event (MACE) 1)2). Until now, IVUS-guided PCI has been classified as Class IIa for a left main (LM) PCI or stent optimization in the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines 3)4).…”

Long‐term (beyond 5 years) clinical impact of Xience everolimus‐eluting stent implantation

“…Specifically, in our hospital, the optimal stenting endpoint (minimal stent area > 5.5 mm 2 ) is decided using IVUS imaging and is based on evidence from previous studies. 21,22 In three VLST cases of this study, the optimal stenting from the findings of the quantitative coronary angiography (QCA) and IVUS at the index PCI procedure was observed; however, in the other eight ST cases, malapposition and stent deformation were observed. All VLST cases had been prescribed with single antiplatelet therapy (aspirin 100 mg/day) at event occurrence, and two VLST cases had discontinued all antiplatelet therapy due to active bleeding.…”