Resource utilization and clinical outcomes of coronary stenting: a comparison of intravascular ultrasound and angiographical guided stent implantation.

BACKGROUND: Intravascular ultrasound (IVUS) guided stent implantation studies have demonstrated that inadequate stent implantation can occur despite achieving an optimal angiographic result. Furthermore, IVUS-guided stent implantation has been shown to improve lesional acute gain. However, it is unknown whether the use of IVUS guidance during stent implantation is associated with improved acute and long-term clinical outcomes. Moreover, the additional procedural cost and time incurred with the use of IVUS-directed stent implantation has not been evaluated. Thus the purpose of this study was to determine whether IVUS-guided stent implantation is associated with improved clinical outcomes compared with angiographically guided stent implantation and to evaluate the difference in resource utilization between these respective stent deployment strategies.

METHODS: Data were collected on 278 consecutive patients in whom 455 stents were deployed in native coronary arteries. High-pressure (> or = 12 atm) balloon inflations were performed until an optimal angiographic result was obtained. In the angiographically guided group, no IVUS imaging was performed. In the IVUS-guided group, IVUS imaging and additional interventions were performed attempting to achieve full apposition, absence of edge tear, and acute gain (lesion lumen area: distal reference lumen area) > or = 0.8 in subsequent IVUS imaging. Total procedure time, fluoroscopy time, contrast media volume, number of balloons, stents, guidewires, guide catheters, and procedural cost were calculated. In hospital abrupt closure rate and 6-month major adverse cardiovascular events (cardiac death, myocardial infarction, target vessel revascularization) rate were obtained.

RESULTS: A total of 178 patients underwent IVUS-guided stent placement and 100 patients underwent angiographically guided stent implantation. There was no significant difference in procedure time (107 +/- 49 vs 100 +/- 50 minutes, P = .22), fluoroscopy time (33 +/- 24 vs 30 +/- 18 minutes, P = .36), contrast volume (411 +/- 157 vs 386 +/- 181 mL, P = .23), guide catheters (1.3 +/- 0.8 vs 1.3 +/- 0.6, P = .69), guidewires (1.6 +/- 1.2 vs 1.6 +/- 1.0, P = .99), balloons (2.4 +/- 1.0 vs 2.3 +/- 1.3, P = .58), and stents (1.7 +/- 0.9 vs 1.6 +/- 0.9, P = .42). Intraprocedural cost was significantly higher in the IVUS-guided group, $4142 +/- 1547 verus $3635 +/- 1949 (P = .03), which was primarily related to the cost of the IVUS catheter. However, the in-hospital acute vessel closure rate was significantly lower in the IVUS-guided group, 0.6% versus 4% (P = .04). There was a trend toward lower target vessel revascularization rate in the IVUS-guided group (11% vs 19%, P = .08). By multivariate analysis IVUS use was demonstrated to be an independent negative predictor of cardiac death, myocardial infarction, repeat revascularization, and abrupt stent closure with a relative risk of 0.49 (95% confidence interval of 0.25 to 0.98), and P = .04.

CONCLUSIONS: The use of IVUS guidance during stent implantation does not significantly increase procedure time, fluoroscopy exposure, contrast volume, or device utilization. Furthermore, despite the increase in procedural cost, IVUS-guided stent implantation is associated with a significant decrease in the in-hospital abrupt closure rate and a trend toward a lower 6-month target vessel revascularization.