10.2 A Critical Appraisal of Intravascular Imaging: When Does It Really Matter?

These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.

Faculty Disclosures     Vendor Acknowledgments

2024 IAGS Summary Document

Statement of the problem or issue

The evidence base for intravascular imaging (IVI) in percutaneous coronary intervention (PCI) largely consists of trials in complex lesion subsets. There are robust randomized controlled trial and registry data supporting use of IVI to improve clinical outcomes, including cardiac death, target lesion myocardial infarction, and clinically- or ischemia-driven target lesion and vessel revascularization. These data exist for bifurcation lesions, long lesions, severely calcified lesions, left main lesions, ostial lesions, in-stent restenosis, and chronic total occlusions (CTO).^1,2 Thus, in these situations, it is easy to advocate both for routine use of IVI and an accompanying Guidelines upgrade to a 1A indication (from 2A currently). It may be more difficult to advocate for routine IVI in other, non-complex lesions, where the magnitude of benefit may be less. Nevertheless, more frequent, and even routine, use of IVI in PCI can be justified as a “Best Practice,” similar to radial access. Furthermore, routine use of IVI may improve individual and team technical competency, and also shorten procedure times, as IVI is incorporated into standard cardiac catheterization laboratory (CCL) workflow.³ In a comprehensive review of this subject, there were 3 broad areas outlined where IVI can be useful in routine PCI: (1) preintervention assessment; (2) lesion preparation and stent deployment; (3) assessment of postprocedure endpoints and complications.⁴ Details are summarized in Table 1.

Table 1. Intravascular imaging in PCI.

Gaps in current knowledge

The absolute benefit of routine use of IVI in all lesions is unclear. Similarly, the aggregate benefit of IVI as one component of a suite of CCL practices – including radial access, optimal antiplatelet therapy, ultrasound-guidance for vascular access, and physiologic lesion assessment – is also unknown.⁵ To the extent that IVI in PCI is looked upon as a “Best Practice,” the appropriate division of responsibilities to foster greater implementation remains unclear – but probably involves collaborative effort among individual operators, healthcare institutions, and national cardiovascular societies, as outlined in Table 2. Finally, the impact of integration of different invasive and noninvasive multimodality imaging techniques together to detect vulnerable plaque and influence follow-on PCI procedures, implement lifestyle interventions, adjust pharmacologic therapy, and guide lifelong disease prevention and surveillance is also unknown but likely worthwhile.⁶

Table 2. Recommendations for promoting intravascular imaging in PCI.

Possible solutions and future directions

We need to expand the evidence base for IVI from complex lesion subsets to a broader variety of lesions, and ultimately to routine use. It is hoped that as a “Best Practice,” routine use of IVI will lead to better and more complete and successful procedures that ultimately will reduce short-, medium-, and long-term costs by reducing target lesion and target vessel revascularization. Clinical outcomes data and cost issues should continue to be explored. Integrated multimodality imaging – combining multiple imaging technologies in a single device – may also soon be widely available. Industry partners should consider direct integration of IVI into future radiologic systems as part of a modern CCL “cockpit” (which may also include both invasive and noninvasive physiologic and histologic imaging data as standards). IVI data and endpoints should be considered for inclusion in all standard cardiac catheterization reports and NCDR data collection tools. Finally, artificial intelligence (AI) programs can be applied to aid image interpretation, lesion characterization, PCI guidance and endpoint assessment, and additionally can provide real-time and ongoing career-long operator and team education and training.

References

1.         Capodanno D, Spagnolo M. Optical coherence tomography or intravascular ultrasound for complex PCI: Different approaches, similar outcomes. J Am Coll Cardiol. 2024;83(3):414-416. doi: 10.1016/j.jacc.2023.10.044.

2.         Sreenivasan J, Reddy RK, Jamil Y, et al. Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention: A systematic review and meta-analysis of randomized trials. J Am Heart Assoc. 2024;13(2):e031111. Epub 2024 Jan 12. doi: 10.1161/JAHA.123.031111. 

3.         Sung JG, Sharkawi MA, Shah PB, Croce KJ, Bergmark BA. Integrating intracoronary imaging into PCI workflow and catheterization laboratory culture. Current Cardiovascular Imaging Reports. 2021;14:6.

4.         Truesdell AG, Alasnag MA, Kaul P, et al. Intravascular imaging during percutaneous coronary intervention: JACC State-of-the-Art Review. J Am Coll Cardiol. 2023;81(6):590-605. doi: 10.1016/j.jacc.2022.11.045

5.         Khuddus MA, Truesdell AG, Kirtane AJ. Leveraging the power of marginal gains to improve outcomes in interventional cardiology. JAMA Cardiol 2020;5(2):121-123. doi: 10.1001/jamacardio.2019.4278

6.         Li J, Montarello Nicholas J, Hoogendoorn A, et al. Multimodality intravascular imaging of high-risk coronary plaque. JACC: Cardiovascular Imaging 2022;15(1):145-159. Epub 2021 May 19. doi: 10.1016/j.jcmg.2021.03.028.