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IVUS-XPL: In long lesions, IVUS-guided PCI retains superior outcomes at 5 years
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SAN FRANCISCO — Among patients who underwent PCI for long lesions, IVUS-based guidance was associated with better outcomes than angiography-based guidance at 5 years, according to new data from the IVUS-XPL trial presented at TCT 2019.
As Healio previously reported, at 1 year, among patients who had PCI with an everolimus-eluting stent (Xience Prime, Abbott Vascular), those who had IVUS guidance had reduced risk for MACE (HR = 0.48; 95% CI, 0.28-0.83).
In the 5-year results, presented here by Myeong-Ki Hong, MD, PhD, professor of medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine in Seoul, South Korea, and published in JACC: Cardiovascular Interventions, MACE remained lower in the IVUS group compared with the angiography group (5.6% vs. 10.7%; HR = 0.5; 95% CI, 0.34-0.75). MACE was defined as cardiac death, target lesion-related MI or ischemia-driven target lesion revascularization.
As with the 1-year results, the 5-year results were mainly driven by differences in ischemia-driven TLR (4.8% vs. 8.4%; HR = 0.54; 95% CI, 0.33-0.89), Hong said during a presentation.
When the researchers performed a landmark analysis, they determined that between 1 year and 5 years, the rates of MACE were 2.8% in the IVUS group and 5.2% in the angiography group (HR = 0.53; 95% CI, 0.29-0.95).
Other 5-year analyses showed the treatment effect was similar across all subgroups.
“Sustained 5-year clinical benefits resulted from both within 1 year and from 1 to 5 years postimplantation, even in the current DES implantation era,” Hong said during the presentation.
The cohort included 1,400 patients (mean age, 64 years; 69% men; minimum estimated stent length, 28 mm), of whom 589 from the IVUS group and 594 from the angiography group completed 5-year follow-up. – by Erik Swain
References:
Hong M-K, et al. Late-Breaking Science 4. Presented at: TCT Scientific Symposium; Sept. 25-29, 2019; San Francisco.
Hong S-J, et al. JACC Cardiovasc Interv. 2019;doi:10.1016/j.jcin.2019.09.033.
Disclosures: Hong reports no relevant financial disclosures. Another author reports he consults for Boston Scientific, Philips/Volcano and Terumo.
Perspective
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Jay Giri, MD, MPH, FAHA
One interesting development that people have not talked much about was the 5-year data from IVUS-XPL. At 5 years in patients undergoing PCI, those assigned IVUS guidance had less MACE than those assigned angiography guidance. The researchers performed a landmark analysis and the curves continued to separate between 1 and 5 years.
This was fascinating for a key reason: Restenosis is most likely to occur between 3 months and 12 months. Then there is a long tail of later restenosis and thrombotic events. IVUS, and other kinds of intravascular imaging, seems to reduce these risks because patients end up receiving larger stents safely. If you start off with a larger luminal diameter, you are less likely to get restenosis. And now we know this is still true after 1 year. This strategy is paying pathophysiological dividends beyond the typical time point associated with neointimal hyperplasia and smooth muscle hypertrophy, the characteristic pathophysiologic findings from in-stent restenosis.
I was happy to see that vascular biology was relevant in a clinical study that should affect our clinical practice. It behooves us to be getting optimal results on these longer stents. But it’s hard to tell whether a study like this will move the needle. I have been moved by findings such as these and have been progressively using more IVUS, especially in cases that require long stents, over the last several years.
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