Prognostic Impact of Intravascular Imaging–Guided Percutaneous Coronary Intervention in Chronic Total Occlusion
2023; Lippincott Williams & Wilkins; Volume: 148; Issue: 11 Linguagem: Inglês
10.1161/circulationaha.123.065876
ISSN1524-4539
AutoresDavid Hong, Sang-Min Kim, Sang Yeub Lee, Ki Hong Choi, Young Bin Song, Jong‐Young Lee, Seung Jae Lee, Kyeong Ho Yun, Jae Young Cho, Chan Joon Kim, Hyo–Suk Ahn, Chang‐Wook Nam, Hyuck–Jun Yoon, Yong Hwan Park, Wang Soo Lee, Jin‐Ok Jeong, Pil Sang Song, Joon‐Hyung Doh, Sang‐Ho Jo, Chang‐Hwan Yoon, Min Gyu Kang, Jin‐Sin Koh, Kwan Yong Lee, Young‐Hyo Lim, Yun‐Hyeong Cho, Jin‐Man Cho, Woo Jin Jang, Kook Jin Chun, Taek Kyu Park, Jeong Hoon Yang, Seung‐Hyuk Choi, Hyeon‐Cheol Gwon, Joo‐Yong Hahn, Joo Myung Lee,
Tópico(s)Peripheral Artery Disease Management
ResumoHomeCirculationVol. 148, No. 11Prognostic Impact of Intravascular Imaging–Guided Percutaneous Coronary Intervention in Chronic Total Occlusion Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPrognostic Impact of Intravascular Imaging–Guided Percutaneous Coronary Intervention in Chronic Total Occlusion David Hong, Sang Min Kim, Sang Yeub Lee, Ki Hong Choi, Young Bin Song, Jong-Young Lee, Seung-Jae Lee, Kyeong Ho Yun, Jae Young Cho, Chan Joon Kim, Hyo-Suk Ahn, Chang-Wook Nam, Hyuck-Jun Yoon, Yong Hwan Park, Wang Soo Lee, Jin-Ok Jeong, Pil Sang Song, Joon-Hyung Doh, Sang-Ho Jo, Chang-Hwan Yoon, Min Gyu Kang, Jin-Sin Koh, Kwan Yong Lee, Young-Hyo Lim, Yun-Hyeong Cho, Jin-Man Cho, Woo Jin Jang, Kook-Jin Chun, Taek Kyu Park, Jeong Hoon Yang, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Joo-Yong Hahn, Joo Myung Lee and The RENOVATE-COMPLEX-PCI Investigators David HongDavid Hong https://orcid.org/0000-0002-0623-0486 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Sang Min KimSang Min Kim https://orcid.org/0000-0002-1300-6079 Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (S.M.K.). , Sang Yeub LeeSang Yeub Lee Correspondence to: Sang Yeub Lee, MD, PhD, Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, 501 Iljik-dong, Gwangmyeong-si, Gyeonggi-do, 14353, Republic of Korea, Email E-mail Address: [email protected] https://orcid.org/0000-0003-1386-349X Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea (S.Y.L.). , Ki Hong ChoiKi Hong Choi https://orcid.org/0000-0001-7511-9581 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Young Bin SongYoung Bin Song https://orcid.org/0000-0003-3986-9152 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Jong-Young LeeJong-Young Lee Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.). , Seung-Jae LeeSeung-Jae Lee https://orcid.org/0000-0002-6553-9782 Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.). , Kyeong Ho YunKyeong Ho Yun https://orcid.org/0000-0003-4911-8854 Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.). , Jae Young ChoJae Young Cho https://orcid.org/0000-0001-7972-6223 Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.). , Chan Joon KimChan Joon Kim The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.). , Hyo-Suk AhnHyo-Suk Ahn https://orcid.org/0000-0001-9531-7286 The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.). , Chang-Wook NamChang-Wook Nam https://orcid.org/0000-0002-3370-5774 Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.). , Hyuck-Jun YoonHyuck-Jun Yoon https://orcid.org/0000-0002-0563-7014 Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.). , Yong Hwan ParkYong Hwan Park Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea (Y.H.P.). , Wang Soo LeeWang Soo Lee https://orcid.org/0000-0002-8264-0866 Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea (W.S.L.). , Jin-Ok JeongJin-Ok Jeong https://orcid.org/0000-0003-0763-4754 Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea (J.-O.J., P.S.S.). , Pil Sang SongPil Sang Song https://orcid.org/0000-0001-6427-3911 Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea (J.-O.J., P.S.S.). , Joon-Hyung DohJoon-Hyung Doh https://orcid.org/0000-0001-7966-9564 Inje University Ilsan Paik Hospital, Goyang, Korea (J.-H.D.). , Sang-Ho JoSang-Ho Jo https://orcid.org/0000-0002-2063-1542 Cardiovascular Center, Hallym University Sacred Heart Hospital, Anyang, Korea (S.-H.J.). , Chang-Hwan YoonChang-Hwan Yoon https://orcid.org/0000-0001-6305-4442 Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea (C.-H.Y.). , Min Gyu KangMin Gyu Kang https://orcid.org/0000-0002-9672-1798 Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea (M.G.K., J.-S.K.). , Jin-Sin KohJin-Sin Koh https://orcid.org/0000-0003-2920-7411 Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea (M.G.K., J.-S.K.). , Kwan Yong LeeKwan Yong Lee The Catholic University of Korea, Incheon St Mary's Hospital, Seoul, Korea (K.Y.L.). , Young-Hyo LimYoung-Hyo Lim https://orcid.org/0000-0001-7203-7425 Hanyang University Seoul Hospital, College of Medicine, Hanyang University, Seoul, Korea (Y.-H.L.). , Yun-Hyeong ChoYun-Hyeong Cho https://orcid.org/0000-0001-7581-9545 Hanyang University Myongji Hospital, Goyang, Korea (Y.-H.C.). , Jin-Man ChoJin-Man Cho Kyung Hee University Hospital at Gangdong, Seoul, Korea (J.-M.C.). , Woo Jin JangWoo Jin Jang https://orcid.org/0000-0002-7421-308X Ewha Womans University College of Medicine, Seoul, Korea (W.J.J.). , Kook-Jin ChunKook-Jin Chun https://orcid.org/0000-0002-6463-9407 Pusan National University Yangsan Hospital, Yangsan, Korea (K.-J.C.). , Taek Kyu ParkTaek Kyu Park https://orcid.org/0000-0003-1440-3583 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Jeong Hoon YangJeong Hoon Yang https://orcid.org/0000-0001-8138-1367 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Seung-Hyuk ChoiSeung-Hyuk Choi https://orcid.org/0000-0002-0304-6317 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Hyeon-Cheol GwonHyeon-Cheol Gwon https://orcid.org/0000-0002-4902-5634 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Joo-Yong HahnJoo-Yong Hahn https://orcid.org/0000-0002-4412-377X Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). , Joo Myung LeeJoo Myung Lee Joo Myung Lee, MD, MPH, PhD, Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea, Email E-mail Address: [email protected] https://orcid.org/0000-0002-2178-4014 Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., Y.B.S., T.K.P., J.H.Y., S.-H.C., H.-C.G., J.-Y.H., J.M.L.). and The RENOVATE-COMPLEX-PCI Investigators Originally published11 Sep 2023https://doi.org/10.1161/CIRCULATIONAHA.123.065876Circulation. 2023;148:903–905In percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), intravascular imaging is used to evaluate lesion characteristics and determine stent optimization. RENOVATE-COMPLEX-PCI (Intravascular Imaging versus Angiography-Guided Percutaneous Coronary Intervention for Complex Coronary Artery Disease) showed that intravascular imaging–guided PCI for complex coronary artery lesions was superior to angiography-guided PCI in reducing the risk of target vessel failure (TVF).1 The prespecified substudy of RENOVATE-COMPLEX-PCI focused on patients undergoing CTO intervention and evaluated the prognostic impact of intravascular imaging–guided PCI over angiography-guided PCI in patients undergoing CTO intervention.CTO was defined as a major coronary artery obstruction with Thrombolysis in Myocardial Infarction flow grade 0 of at least 3 months duration on the basis of the patient's history.2,3 In patients assigned to intravascular imaging–guided PCI, the choice of intravascular imaging device between intravascular ultrasound and optical coherence tomography was left to operator discretion. Standard protocols for image acquisition and stent optimization were used during trial enrollment. Stent optimization was defined as sufficient stent expansion without major malapposition and edge dissection. If stent optimization was not achieved, additional stent dilatation or additional stent implantation was recommended in both groups. The primary outcome was TVF, defined as a composite of cardiac death, target vessel–related myocardial infarction, or clinically driven target vessel revascularization.1 Deidentified data will be provided upon reasonable request after discussion by the Executive Committee members. The trial protocol was approved by the institutional review boards and all patients provided informed consent before enrollment.From May 2018 to May 2021, a total of 1639 patients with complex coronary artery lesions were randomized to either intravascular imaging (n=1092) or angiography-guided PCI (n=547) groups in RENOVATE-COMPLEX-PCI. Among these patients, 319 (343 vessels) underwent CTO PCI, and were assigned to either intravascular imaging (n=220) or angiography-guided PCI (n=99) groups. Mean age of the study population was 63.7 years and 82.4% were men. Baseline characteristics did not differ between the intravascular imaging and angiography-guided PCI groups. The components of J-CTO score and the proportion of the study population satisfying them were as follows: blunt stump at entry, 55.5%; calcification within the CTO segment, 27.6%; bending >45°, 45.1%; occlusion length ≥20 mm, 71.2%; and re-attempted procedure, 7.8%. The J-CTO score did not differ between the 2 groups (2.0 [Q1 to Q3, 1.0 to 3.0] versus 2.0 [Q1 to Q3 1.0 to 3.0]; P=0.755). Among patients assigned to the intravascular imaging–guided PCI group, 80.4% underwent intravascular ultrasound and 19.6% underwent optical coherence tomography, and 34.5% (76/220) met the predefined stent optimization criteria. The incidence of overall procedure-related complications (5.0% [n=11] versus 5.1% [n=5]; P=0.999) did not differ between the 2 groups.During a follow-up of 2.1 years, the risk of TVF (5.0% versus 13.5%; hazard ratio [HR], 0.30; 95% CI, 0.13–0.71; P=0.006) and a composite of cardiac death or target vessel MI (5.0% versus 11.1%; HR, 0.36; 95% CI, 0.15–0.87; P=0.024) was significantly lower in the intravascular imaging–guided PCI group than in the angiography-guided PCI group. There was no significant difference in the risk of TVF between patients with CTO and non-CTO lesions (7.6% versus 9.6%; HR, 0.80; 95% CI, 0.51–1.26; P=0.331). When patients were classified according to the presence of CTO and intravascular imaging guidance, the risk of TVF was significantly different among the 4 groups, and the risk of TVF was the highest in patients with CTO treated by angiography-guided PCI and the lowest in patients with CTO treated by intravascular imaging–guided PCI (Figure [A]). TVF occurred in 1.3%, 6.8%, and 13.5% of patients in the intravascular imaging–guided PCI group who had optimized results, in those who failed to achieve optimized results, and in the angiography guided PCI group, respectively. Patients with (1.3% versus 13.5%; HR, 0.14; 95% CI, 0.02–0.56; P=0.003) and without (6.8% versus 13.5%; HR, 0.41; 95% CI, 0.17–0.99; P=0.049) stent optimization had significantly lower risk of TVF than the angiography-guided PCI group (Figure [B]).Download figureDownload PowerPointFigure. Primary end point according to presence of chronic total occlusion, treatment groups, and stent optimization. Cumulative incidence of the primary end point between (A) patients classified according to both the presence of chronic total occlusion (CTO) and intravascular imaging guidance and (B) patients classified according to treatment groups and stent optimization. CTO indicates chronic total occlusion; HR, hazard ratio; and PCI, percutaneous coronary intervention.Despite potential advantages of intravascular imaging in CTO intervention, previous trials presented conflicting results.4,5 In the current study, intravascular imaging–guided PCI showed significantly lower risk of TVF than angiography-guided PCI in patients with CTO. Although the risk of TVF between patients with CTO and non-CTO lesions did not differ, the absolute and relative risk reductions of TVF by using intravascular imaging were greater in patients with CTO (5.0% versus 13.5%) than in patients with non-CTO lesions (8.3% versus 12.0%). In addition, the risk of TVF gradually increased from patients with intravascular imaging–guided PCI and stent optimization, patients with intravascular imaging–guided PCI but no stent optimization, and patients with angiography-guided PCI. These results suggest the importance of not only using intravascular imaging but also achieving stent optimization in CTO lesions. The relatively low procedural optimization rates by intravascular imaging devices (34.5%) suggest that there is room for improvement. Therefore, meticulous step-by-step evaluation with intravascular imaging and subsequent adjunctive procedures should be encouraged in CTO intervention.Our study has limitations. First, this was a substudy of a randomized controlled trial. Second, RENOVATE-COMPLEX-PCI was a not dedicated CTO trial. A dedicated CTO trial using intravascular imaging devices is needed to explain further how intravascular imaging devices in CTO intervention could result in improvement of prognosis.Intravascular imaging–guided PCI was associated with reduced risk of TVF in patients with CTO. Graded risk of TVF according to stent optimization by intravascular imaging supports the importance of intravascular imaging–guided PCI and achievement of stent optimization in CTO intervention.ARTICLE INFORMATIONSources of FundingThis trial is investigator-initiated with grant support from Abbott Vascular and Boston Scientific. Other than providing financial support, the sponsors were not involved with the protocol development or study process, including site selection, study management, data collection, or analysis of the result.Disclosures Dr Joo Myung Lee received institutional research grants from Abbott Vascular, Boston Scientific, Philips Volcano, Terumo Corporation, Zoll Medical, and Donga-ST. Dr Joo-Yong Hahn received institutional research grants from National Evidence-Based Healthcare Collaborating Agency; Ministry of Health & Welfare, Korea; Abbott Vascular; Biosensors; Boston Scientific; Daiichi Sankyo; Donga-ST; Hanmi Pharmaceutical; and Medtronic Inc. Dr Hyeon-Cheol Gwon received institutional research grants from Boston Scientific, Genoss, and Medtronic Inc. The other authors declare that there are no competing interests to declare.Footnotes*D. Hong and S.M. Kim contributed equally.†S.Y. Lee and J.M. Lee contributed equally.For Sources of Funding and Disclosures, see page 905.Circulation is available at www.ahajournals.org/journal/circRegistration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.Correspondence to: Sang Yeub Lee, MD, PhD, Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, 501 Iljik-dong, Gwangmyeong-si, Gyeonggi-do, 14353, Republic of Korea, Email louisahj@gmail.comJoo Myung Lee, MD, MPH, PhD, Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea, Email joomyung.lee@samsung.comREFERENCES1. Lee JM, Choi KH, Song YB, Lee J-Y, Lee S-J, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, et al. Intravascular imaging–guided or angiography-guided complex PCI.N Engl J Med. 2023; 388:1668–1679. doi: 10.1056/nejmoa2216607CrossrefMedlineGoogle Scholar2. Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, et al; EUROCTO trial investigators. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions.Eur Heart J. 2018; 39:2484–2493. doi: 10.1093/eurheartj/ehy220CrossrefMedlineGoogle Scholar3. Lee SW, Lee PH, Ahn JM, Park DW, Yun SC, Han S, Kang H, Kang SJ, Kim YH, Lee CW, et al. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion.Circulation. 2019; 139:1674–1683. doi: 10.1161/CIRCULATIONAHA.118.031313LinkGoogle Scholar4. Kim BK, Shin DH, Hong MK, Park HS, Rha SW, Mintz GS, Kim JS, Kim JS, Lee SJ, Kim HY, et al; CTO-IVUS Study Investigators. Clinical impact of intravascular ultrasound-guided chronic total occlusion intervention with zotarolimus-eluting versus biolimus-eluting stent implantation: randomized study.Circ Cardiovasc Interv. 2015; 8:e002592. doi: 10.1161/CIRCINTERVENTIONS.115.002592LinkGoogle Scholar5. Tian NL, Gami SK, Ye F, Zhang JJ, Liu ZZ, Lin S, Ge Z, Shan SJ, You W, Chen L, et al. Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drug-eluting stent implantation for patients with chronic total occlusion lesions: two-year results from a randomised AIR-CTO study.EuroIntervention. 2015; 10:1409–1417. doi: 10.4244/EIJV10I12A245CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nafee T, Shah A, Forsberg M, Zheng J and Ou J (2024) State-of-art review: intravascular imaging in percutaneous coronary interventions, Cardiology Plus, 10.1097/CP9.0000000000000069, 8:4, (227-246), Online publication date: 1-Oct-2023. September 12, 2023Vol 148, Issue 11 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.123.065876PMID: 37695832 Originally publishedSeptember 11, 2023 Keywordscoronary artery diseasepercutaneous coronary interventiontomography, optical coherencePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions
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