Prognostic impact of intravascular imaging in percutaneous coronary intervention according to procedural complexity

Abstract Background/Introduction Few randomized controlled trials have shown reduction of adverse cardiac events with intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) compared with conventional angiography. However, data for IVI in complex PCI remains scarce. Purpose Current study investigated whether optimization of stent implantation in the IVI-guided PCI could improve the efficacy of PCI across various degrees of PCI procedural complexity. Methods This study was post-hoc analysis of the RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) trial. Study population was stratified according to PCI procedural complexity assessed by the ESC criteria into low-, moderate-, or high-procedural complexity group. The high-procedural complexity group consisted of patients meeting at least one of the clinical risk criteria [diabetes mellitus, chronic kidney disease, defined as glomerular filtration rate between 15 and 60 mL/min, prior myocardial infarction (MI), peripheral artery disease, age < 45 years, multivessel coronary artery disease] and at least one of the procedural risk criteria (≥3 stents implanted, ≥3 lesions treated, total stent length >60 mm, left main PCI, chronic total occlusion, bifurcation lesion treated with 2 stents). The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel-related MI, or clinically driven target vessel revascularization. Results At a median follow-up of 2.1 years (interquartile range 1.4 to 3.0 years), the risk of TVF significantly increased in a stepwise fashion from the low- (reference group) to the moderate- (adjusted hazard ratio [HR]: 3.530; 95% confidence interval [CI]: 1.226-10.163, p=0.019) and high-procedural complexity group (adjusted HR: 3.951; 95% CI: 1.576-9.908; p=0.003). The effect of IVI-guided PCI was heterogeneous per PCI procedural complexity, with a significant benefit in patients who underwent high-procedural complexity PCI (adjusted HR: 0.598; 95% CI: 0.370-0.966) compared with those who had low-procedural complexity PCI (adjusted HR: 1.969; 95% CI: 0.217-17.881). Importantly, the magnitude of the benefit with IVI-guided PCI was progressively greater per increase in procedural complexity (p for interaction=0.026). Conclusions In patients who underwent complex PCI, compared with a conventional angiography, IVI-guided PCI significantly reduced the risk of adverse cardiac events with a magnitude that was greater for higher procedural complexity.