Multimodal imaging in left main and bifurcation revascularization: contemporary evidence and comparative modalities
Inderbir Padda1, Harshan Atwal2, Inderjeet Bharaj3
1Department of Internal Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA. dr.padda91@gmail.com.
Insights
Advanced intravascular imaging like IVUS and OCT improves outcomes for complex left main (LM) and bifurcation coronary artery disease (CAD) interventions. Imaging guidance significantly reduces major adverse cardiac events compared to angiography alone.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Left main (LM) and bifurcation coronary artery disease (CAD) present complex anatomical challenges for revascularization.
- Conventional angiography has limitations in characterizing plaque and bifurcation anatomy, necessitating advanced imaging techniques.
Purpose of the Study:
- To review and compare the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), computed tomography coronary angiography (CTCA), and angiography in managing LM and bifurcation disease.
- To analyze anatomical challenges, lesion complexity, hemodynamic implications, and modality-specific advantages.
Main Methods:
- Comprehensive review of key randomized controlled trials (ULTIMATE, ILUMIEN, OCTOBER, RENOVATE-COMPLEX-PCI) and real-world data.
- Evaluation of IVUS, OCT, and CTCA for LM and bifurcation lesions, focusing on diagnostic accuracy and interventional guidance.
Main Results:
- IVUS is preferred for LM PCI, especially ostial/proximal lesions, due to tissue penetration and correlation with minimal lumen area (MLA).
- OCT provides high resolution, valuable for distal LM bifurcations and complex strategies.
- CTCA aids preprocedural planning for ostial/ambiguous lesions; hybrid imaging integrates anatomical and physiological data.
- Imaging-guided percutaneous coronary intervention (PCI) consistently shows improved stent expansion, reduced major adverse cardiac events (MACE), and lower target vessel failure (TVF) versus angiography alone.
Conclusions:
- While IVUS remains a gold standard, OCT and CTCA offer complementary roles in complex coronary interventions.
- Future advancements include AI-enhanced imaging, fusion technologies, and standardized algorithms to optimize outcomes and cost-effectiveness.
Abstract:
Left main (LM) and bifurcation coronary artery disease (CAD) are anatomically complex lesions which require detailed planning and precise execution for successful revascularization. Conventional angiography has limited ability to characterize plaque burden and complex bifurcation anatomy, prompting the use of adjunctive imaging. These limitations have driven the adoption of advanced intravascular imaging (IVI) modalities to enhance diagnostic accuracy and guide intervention. This review evaluates and compares the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), computed tomography coronary angiography (CTCA), and angiography in LM and bifurcation disease. A comprehensive analysis of anatomical challenges, lesion complexity, hemodynamic implications, and modality-specific advantages is provided. Key randomized controlled trials (ULTIMATE, ILUMIEN, OCTOBER, RENOVATE-COMPLEX-PCI) and real-world data are reviewed. IVUS remains the preferred modality for LM percutaneous coronary intervention (PCI), particularly for ostial and proximal lesions, due to its superior tissue penetration and correlation with physiologic indices such as minimal lumen area (MLA). OCT offers unmatched resolution and is valuable in distal LM bifurcations and complex bifurcation strategies. CTCA enhances preprocedural planning, especially for ostial and ambiguous lesions, while hybrid imaging techniques enable anatomical-physiological integration. Contemporary trials consistently demonstrate improved stent expansion, reduced major adverse cardiac events (MACE), and lower target vessel failure (TVF) with imaging-guided PCI versus angiography alone. While IVUS remains the gold standard, OCT and CTCA play complementary roles. Future directions include broader adoption of artificial intelligence (AI) enhanced imaging, fusion technologies, and standardized algorithms to improve outcomes, reduce variability, and promote cost-effectiveness in complex coronary interventions.
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