Intravascular imaging during percutaneous coronary intervention: temporal trends and clinical outcomes in the USA

Abstract

Aims: Prior trials have demonstrated that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) results in less frequent target lesion revascularization and major adverse cardiovascular events (MACEs) compared with standard angiographic guidance. The uptake and associated outcomes of IVI-guided PCI in contemporary clinical practice in the USA remain unclear. Accordingly, temporal trends and comparative outcomes of IVI-guided PCI relative to PCI with angiographic guidance alone were examined in a broad, unselected population of Medicare beneficiaries.

Methods and results: Retrospective cohort study of Medicare beneficiary data from 1 January 2013, through 31 December 2019 to evaluate temporal trends and comparative outcomes of IVI-guided PCI as compared with PCI with angiography guidance alone in both the inpatient and outpatient settings. The primary outcomes were 1 year mortality and MACE, defined as the composite of death, myocardial infarction (MI), repeat PCI, or coronary artery bypass graft surgery. Secondary outcomes were MI or repeat PCI at 1 year. Multivariable Cox regression was used to estimate the adjusted association between IVI guidance and outcomes. Falsification endpoints (hospitalized pneumonia and hip fracture) were used to assess for potential unmeasured confounding. The study population included 1 189 470 patients undergoing PCI (38.0% female, 89.8% White, 65.1% with MI). Overall, IVI was used in 10.5% of the PCIs, increasing from 9.5% in 2013% to 15.4% in 2019. Operator IVI use was variable, with the median operator use of IVI 3.92% (interquartile range 0.36%-12.82%). IVI use during PCI was associated with lower adjusted rates of 1 year mortality [adjusted hazard ratio (aHR) 0.96, 95% confidence interval (CI) 0.94-0.98], MI (aHR 0.97, 95% CI 0.95-0.99), repeat PCI (aHR 0.74, 95% CI 0.73-0.75), and MACE (aHR 0.85, 95% CI 0.84-0.86). There was no association with the falsification endpoint of hospitalized pneumonia (aHR 1.02, 95% CI 0.99-1.04) or hip fracture (aHR 1.02, 95% CI 0.94-1.10).

Conclusion: Among Medicare beneficiaries undergoing PCI, use of IVI has increased over the previous decade but remains relatively infrequent. IVI-guided PCI was associated with lower risk-adjusted mortality, acute MI, repeat PCI, and MACE.

Keywords: Intravascular imaging; Intravascular ultrasound; Optical coherence tomography; Percutaneous coronary intervention.

Structured Graphical Abstract

Temporal trends and clinical outcomes associated with intravascular imaging during PCI in the United States. MACE, major adverse cardiovascular event; PCI, percutaneous coronary intervention.

Figure 1

Flow diagram of the study population. PCI, percutaneous coronary intervention.

Figure 2

Temporal trends in use of intravascular imaging for percutaneous coronary intervention.

Figure 3

Association of select patient, procedural and hospital characteristics with intravascular imaging use during PCI after multivariable adjustment. PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; CABG, coronary artery bypass graft; ESRD, end-stage renal disease; FFR, fractional flow reserve; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; VAD, ventricular assist device.

Figure 4

Cumulative distribution of operator use of intravascular imaging during percutaneous coronary intervention.

Figure 5

Kaplan–Meier curves of 1 year outcomes of IVI-guided PCI compared with non-IVI PCI. IVI, intravascular imaging; PCI, percutaneous coronary intervention; MACE, major adverse cardiovascular event.