Intravascular imaging–guided percutaneous coronary intervention (PCI) lowers the risk of death from cardiac causes by nearly 40% when compared to angiography-guided PCI in patients with complex coronary-artery lesions, according to a new study. Presenting at the American College of Cardiology (ACC) Scientific Sessions 2023 in New Orleans, Joo-Yong Hahn, MD, PhD, said the use of intravascular imaging–guided PCI was linked to a 37% lower incidence of target-vessel–related myocardial infarction or death from cardiac causes than angiography-guided PCI. “Our study shows that the use of intravascular imaging devices to visualize the interior of narrowed coronary arteries improves outcomes after stenting,” said Hahn, a professor of cardiology and medicine at Sungkyunkwan University School of Medicine in Seoul, South Korea, in a news release announcing the results. “The results of our trial may lead to an increase in the use of intravascular imaging—and, in turn, an improvement in clinical outcomes—among patients with complex coronary blockages who are undergoing stenting,” he added. Previous randomized, controlled trials have shown lower rates of major adverse clinical events after intravascular ultrasonography–guided PCI than after angiography-guided PCI. However, the findings are not considered definitive due to the limited sample size and the inclusion of highly selected coronary-lesion subsets. Official guidelines Guidelines from the ACC, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions recommend that intravascular ultrasonography or optical coherence tomography (OCT) be considered to optimize stent implantation. Hahn was the lead study author of the RENOVATE study, the results of which were also simultaneously published online in the New England Journal of Medicine. The research, funded by Abbott Vascular and Boston Scientific, the makers of the intravascular imaging devices used in the study, enrolled 1,639 patients (median age 66, 20.7% women). A total of 1,092 patients underwent randomization to undergo stenting guided by one of two types of intravascular imaging: intravascular ultrasound (IVUS), which uses sound waves to visualize the artery’s interior, and optical coherence tomography (OCT), which uses infrared light. A total of 547 patients were also assigned to undergo stenting guided by a standard angiography-guided stenting procedure. The study’s primary endpoint was a combination of death due to heart disease, a heart attack caused by a new blockage in the treated artery, or the need for a repeat stenting procedure in the treated artery. Main study results At baseline, the patients’ mean age was 65.6 ± 10.2 years, 79.3% were male, and the patients were nearly evenly split between presenting with an acute coronary syndrome (50.8%) or stable ischemic heart disease (49.2%). At a median follow-up of 2.1 years (interquartile range, 1.4 to 3.0), a primary endpoint event had occurred in 76 patients (cumulative incidence, 7.7%) in the intravascular imaging group. A primary endpoint event had also occurred in 60 patients (cumulative incidence, 12.3%) in the angiography group (hazard ratio [HR]: 0.64; 95% confidence interval [CI]: 0.45 to 0.89; P=0.008). Death from cardiac causes occurred in 16 patients (cumulative incidence, 1.7%) in the intravascular imaging group and in 17 patients (cumulative incidence, 3.8%) in the angiography group. Further results found that death occurred from target-vessel–related myocardial infarction in 38 (cumulative incidence, 3.7%) and 30 patients (cumulative incidence, 5.6%), respectively. A repeat stenting procedure, specifically a clinically driven target-vessel revascularization occurred in 32 (cumulative incidence, 3.4%) and 25 (cumulative incidence, 5.5%) patients respectively. There were no apparent between-group differences in the incidence of procedure-related safety events. Larger sample size and longer duration “The use of intravascular imaging–guided PCI in our trial appeared to be associated with a 37% lower incidence of target-vessel–related myocardial infarction or death from cardiac causes than angiography-guided PCI,” the study said. “This difference may be attributable to the larger sample size and longer duration of follow-up in our trial than in previous trials and to the fact that this trial exclusively enrolled patients with complex coronary-artery lesions. Our trial supports the use of intravascular imaging–guided PCI for complex coronary-artery lesions.” Hahn added in the news release that studies to evaluate the cost-effectiveness of intravascular imaging are warranted, as is research examining the effect of intravascular imaging-guided PCI on clinical outcomes in patients with complex coronary artery disease.