Intravascular Imaging Predictors Associated With Cardiovascular Events After Complex PCIs.

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 mm, and MSA<5.5 mm was associated with a significantly higher risk of TLF than MSA≥5.5 mm (2.2% versus 4.8%; adjusted hazard ratio, 3.09 [95% CI, 1.01-9.50]; =0.048). Compared with the reference group (MSA≥5.5 mm and no suboptimal findings), the subgroup of patients with MSA≥5.5 mm 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%; =0.057). Compared with the same reference group, the subgroup of patients with MSA<5.5 mm and suboptimal post-PCI intravascular imaging findings was associated with a significantly increased risk of TLF (0.0% versus 4.7%; =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.

Registration: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.