Procedural Characteristics of Intravascular Ultrasound–Guided Percutaneous Coronary Intervention and Their Clinical Implications

BACKGROUND: Despite the clinical benefits to intravascular ultrasound (IVUS) guidance for percutaneous coronary intervention (PCI), most patients with coronary artery disease undergo angiography‐guided PCI alone in the real‐world setting. We sought to investigate the procedural characteristics of IVUS‐guided PCI and their clinical outcomes, as compared with angiography‐guided PCI. METHODS AND RESULTS: This was a cohort study using patient‐level data from the IVUS‐XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All‐Comers Coronary Lesions) clinical trials. A total of 2848 patients with 3872 native coronary lesions were included and procedural characteristics assessed by quantitative coronary angiography (QCA) were compared between IVUS and angiography guidance. Stent‐to‐reference vessel diameter ratio (ie, QCA stent sizing) was greater (1.11±0.16 versus 1.07±0.14, P<0.001) and high‐pressure postdilation was more frequently performed (83.7% versus 75.4%, P<0.001) with IVUS guidance, whereas residual stent edge dissections were more frequent in lesions treated with IVUS guidance (4.6% versus 0.7%, P<0.001). Given the dissection risk, optimal QCA stent sizing for IVUS guidance was a stent‐to‐QCA reference vessel diameter ratio ≥1.1 to <1.3. Among 1424 patients (1969 lesions) treated with angiography guidance, QCA stent sizing <1.0 was observed in 651 (33.1%) lesions, while QCA stent sizing ≥1.1 to <1.3 was observed in only 526 (26.7%) lesions. Under angiography guidance, patients with both QCA stent sizing ≥1.1 to <1.3 and high‐pressure postdilation (235 of 1424, 16.5%) had a lower risk of 3‐year target lesion failure compared with others (hazard ratio, 0.532; 95% CI, 0.293–0.966 [P=0.038]). CONCLUSIONS: IVUS‐guided PCI resulted in larger QCA‐assessed stent sizing and more frequent postdilation with high‐pressure inflations. These procedures may further improve long‐term clinical outcomes in patients undergoing PCI without IVUS. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01308281 (IVUS‐XPL); NCT02215915 (ULTIMATE).