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ULTIMATE: IVUS guidance may mitigate poor PCI outcomes in chronic kidney disease
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LAS VEGAS — Among patients with chronic kidney disease from the ULTIMATE cohort, assignment to IVUS-guided drug-eluting stent implantation was linked to lower rates of target vessel failure compared with angiography-guided stent implantation, researchers reported at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.
As Cardiology Today’s Intervention previously reported, in the main results of ULTIMATE, IVUS guidance was associated with lower rates of 12-month TVF compared with angiography guidance in patients requiring PCI with DES.
For the present analysis, Jun-Jie Zhang, MD, PhD, vice director of the cardiovascular department at Nanjing First Hospital at Nanjing Medical University in China, and colleagues analyzed 1,443 patients from ULTIMATE for whom an estimated glomerular filtration rate (eGFR) was available (mean eGFR, 81.41 mL/min/1.73 m2).
Patients were stratified by whether they had chronic kidney disease (CKD), which was defined as eGFR less than 60 mL/min/1.73 m2 and identified in 24.2% of the cohort.
“The ULTIMATE trial has reported the clinical advantages of IVUS guidance for all-comer patients undergoing DES implantation,” Zhang said during a press conference. “However, it still remains controversial that routine-use IVUS guidance could be beneficial to patients with CKD.”
At 12 months, 7.2% of those with CKD had TVF compared with 3.2% of those without kidney disease (HR = 2.14; 95% CI, 1.18-3.89), according to the researchers.
The difference was driven by a higher rate of cardiac death in those with CKD (2.9% vs. 0.5%; HR = 6.06; 95% CI, 2.2-16.71), Zhang said.
Among those with CKD, 3.9% of those in the IVUS group and 10.7% of those in the angiography group had TVF (HR = 0.35; 95% CI, 0.15-0.84), the researchers found. Zheng noted this was driven by lower rates in the IVUS group of target vessel MI (0.6% vs. 3.6%; borderline P = .05) and target vessel revascularization (1.1% vs. 4.7%; P = .04).
“IVUS guidance was associated with use of larger stents and larger balloons,” Zheng said. “That may have helped reduce the [target vessel] MI and the in-stent restenosis.”
Among those without CKD, there was no difference by imaging type in TVR (IVUS, 2.6%; angiography, 3.8%; HR = 0.67; 95% CI, 0.34-1.32; P for interaction = .24), Zhang said.
Independent predictors of TVF at 12 months were age older than 75 years (adjusted HR = 1.83; 95% CI, 1.07-3.14), CKD (aHR = 2.66; 95% CI, 1.19-5.95) and stent length (aHR per 10 mm = 1.11; 95% CI, 1.01-1.23), whereas IVUS guidance was a predictor of 12-month freedom from TVF (aHR = 0.48; 95% CI, 0.28-0.82), Zhang said.
“The present prespecified subgroup analysis from the ULTIMATE trial demonstrated that CKD patients undergoing DES implantation were associated with a higher risk of TVF during 12 months of follow-up,” Zhang said during the press conference. “More importantly, the risk of TVF in CKD patients could be significantly decreased through IVUS guidance compared to angiography guidance.” – by Erik Swain
Reference:
Zhang J, et al. Featured Clinical Research II. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 19-22, 2019; Las Vegas.
Disclosure: Zhang reports no relevant financial disclosures.
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M. Chadi Alraies, MD
This study further emphasizes that we are not using IVUS enough. This might be driven by the demand to save cost and time in the cath lab. More importantly, there is a knowledge gap in regard to intracoronary imaging where the operators are not sure of the findings on IVUS. In relation to this study, operators may think that if they use IVUS on a patient with CKD, they will subject them to more contrast, which could be worse for their condition. But the data showed that even if IVUS is performed, the angiographic and clinical outcomes are better with IVUS with no adverse effect on GFR. IVUS use increased after the original ULTIMATE trial, and that should continue.
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