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Long-term outcomes of intravascular ultrasound-guided stenting in coronary bifurcation lesions
Sung-Hwan Kim1, Young-Hak Kim, Soo-Jin Kang
1Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Insights
Intravascular ultrasound (IVUS) guidance for coronary artery stenting in bifurcation lesions significantly reduced long-term mortality, especially in patients receiving drug-eluting stents (DESs). IVUS also lowered very late stent thrombosis in DES recipients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Coronary artery stenting at bifurcation lesions remains technically challenging.
- Long-term outcomes of intravascular ultrasound (IVUS) guidance in these complex cases are not well-established.
- Evaluating IVUS's impact on mortality, stent thrombosis, and target lesion revascularization is crucial.
Purpose of the Study:
- To assess the long-term (4-year) outcomes of IVUS-guided stenting versus conventional angiography in patients with coronary bifurcation lesions.
- To specifically evaluate the impact of IVUS guidance on all-cause mortality, stent thrombosis, and target lesion revascularization.
- To analyze outcomes stratified by stent type: bare metal stents (BMS) and drug-eluting stents (DESs).
Main Methods:
- Retrospective analysis of 758 patients with de novo non-left main coronary bifurcation lesions undergoing stenting (January 1998 - February 2006).
- Comparison of adverse outcomes (death, stent thrombosis, target lesion revascularization) within 4 years.
- Statistical adjustment using multivariate Cox proportional hazard models and propensity scoring.
Main Results:
- IVUS-guided stenting significantly reduced 4-year all-cause mortality in the overall population (HR 0.31) and in DES recipients (HR 0.24).
- No significant mortality benefit was observed in BMS recipients (HR 0.41).
- IVUS guidance did not significantly affect overall stent thrombosis (HR 0.48) or target lesion revascularization (HR 1.47), but reduced very late stent thrombosis in DES patients (0.4% vs 2.8%, p=0.03).
Conclusions:
- IVUS-guided stenting for bifurcation lesions significantly improves 4-year mortality in patients receiving DESs compared to angiography guidance.
- IVUS guidance is associated with a reduction in very late stent thrombosis specifically in patients treated with DESs.
- IVUS guidance offers a valuable adjunctive tool for optimizing stenting outcomes in complex coronary bifurcation lesions, particularly with DES implantation.
Abstract:
Stenting for bifurcation lesions is still challenging, and the effect of intravascular ultrasound (IVUS) guidance on long-term outcomes has not been evaluated. We assessed the long-term outcomes of IVUS-guided stenting in bifurcation lesions. We evaluated 758 patients with de novo nonleft main coronary bifurcation lesions who underwent stent implantation from January 1998 to February 2006. We compared the adverse outcomes (i.e., death, stent thrombosis, and target lesion revascularization) within 4 years, after adjustment using a multivariate Cox proportional hazard model and propensity scoring. IVUS-guided stenting significantly reduced the long-term all-cause mortality (hazard ratio [HR] 0.31, 95% confidence interval [CI] 0.13 to 0.74, p = 0.008) in the total population and in the patients receiving drug-eluting stents (DESs) (HR 0.24, 95% CI 0.06 to 0.86, p = 0.03), but not in the patients receiving bare metal stents (HR 0.41, 95% CI 0.13 to 1.26, p = 0.12). IVUS-guided stenting had no effect on the rate of stent thrombosis (HR 0.48, 95% CI 0.16 to 1.43, p = 0.19) or target lesion revascularization (HR 1.47, 95% CI 0.79 to 2.71, p = 0.21). In patients receiving DESs, however, IVUS guidance reduced the development of very late stent thrombosis (0.4% vs 2.8%, p = 0.03, log-rank test). In conclusion, in patients receiving DESs, IVUS-guided stenting for treatment of bifurcation lesions significantly reduced the 4-year mortality compared to conventional angiographically guided stenting. In addition, IVUS guidance reduced the development of very late stent thrombosis in patients receiving DESs.