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Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drug-eluting stent implantation for patients with chronic total occlusion lesions: two-year results from a randomised AIR-CTO study

Selected in EuroIntervention by S. Brugaletta



Tian NL, Gami SK, Ye F, Zhang JJ, Liu ZZ, Lin S, Ge Z, Shan SJ, You W, Chen L, Zhang YJ, Mintz G, Chen SL


EuroIntervention. 2015 Apr 22;10(12):1409-17


2015 April


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My Comment

What is known

Percutaneous recanalisation of chronic total occlusion (CTO), defined as an occlusion duration of >3 months, in the coronary artery tree is the most challenging lesion subset in the interventional community. Recently, several novel approaches, including parallel wire, controlled antegrade and retrograde tracking procedures, have increased the rate of successful recanalisation. In overall PCI procedures, a meta-analysis has demonstrated that IVUS guidance is associated with significant reductions in death, major adverse cardiac events (MACE) and stent thrombosis (ST) compared to angiography guidance in an entire patient cohort who received PCI using drug-eluting stents (DES). Nevertheless, there are no data comparing IVUS vs. angiography guidance in CTO lesion. The present two-centre, randomised, prospective study was designed and aimed to investigate the difference in late lumen loss (LLL) between IVUS-guided and angiography-guided stenting CTO lesions. 

Major findings 

  • Patients with at least one CTO lesion recanalised successfully were randomly assigned to the IVUS-guided or the angiography-guided group. The use of IVUS for penetration of the true lumen and optimisation of stent expansion was only done in the IVUS-guided group.
  • A total of 230 patients with CTO lesions after successful recanalisation were enrolled and followed with office visits or telephone contact up to 24 months.
  • In-stent LLL in the IVUS-guided group was significantly lower compared to the angiography-guided group at one-year follow-up (0.28±0.48 mm vs. 0.46±0.68 mm, p=0.025), with a significant difference in restenosis of the “in-true-lumen” stent between the two groups (3.9% vs.13.7%, p=0.021).
  • The minimal lumen diameter and minimal stent cross-section area significantly and negatively correlated with LLL (all p<0.001).
  • The rates of adverse clinical events were comparable between the IVUS- and angiography-guided groups at two-year follow-up (21.7% vs. 25.2%, p=0.641). 

My comment

This represents to my opinion a very important study, which underlines the importance of IVUS use in CTO procedures in order to improve the long-term results. Unfortunately the study was not powered to demonstrate any difference in adverse clinical events, but the data on LLL and in-stent restenosis should encourage CTO operators to improve their skills on IVUS. Despite this study, IVUS use in CTO procedures is probably low especially in those operators who start their CTO program. For this reason, IVUS should be included from the beginning in such kind of program.

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