Seeing Is Saving: Navigating the Rocky Path With Intravascular Ultrasound

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Coronary artery calcification (CAC) remains a daily challenge for interventional cardiologists. 1) As the global population ages, the prevalence of severely calcified lesions are increasing, with CAC observed in approximately 40% of patients undergoing coronary angiography and in over 70% of lesions evaluated with intravascular imaging.2) These calcified lesions are associated with increased immediate complications including stent underexpansion, dissection and catastrophic long-term clinical outcomes such as stent thrombosis, repeat revascularization, and sudden cardiac death.To address moderate to severe calcified plaques, rotational atherectomy (RA) has served as a definitive tool for decades.Nevertheless, RA remains a high-risk procedure, associated with potential complications including vessel perforation, the no-reflow phenomenon, and periprocedural myocardial infarction.3) In this clinical setting, relying solely on 2 dimensional angiography is insufficient for evaluating complex disease morphology, plaque composition, plaque burden, or accurate stent sizing, highlighting the necessity for the clarity provided by intravascular imaging.Recent randomized controlled trials (RCTs) have demonstrated the significant benefits of imaging guided-percutaneous coronary intervention (PCI) compared to angiographic guidance alone, especially in complex lesions subsets.4)5) However, the efficacy of imaging guidance in moderately to severely calcified lesions remains poorly established, primarily attributable to small, underpowered subsets.In a comprehensive analysis of the multicenter ROCK registry, Jang et al. 6) showed that intravascular ultrasound (IVUS) guidance significantly reduces the 3-year risk of cardiac death or myocardial infarction compared to angiography alone (hazard ratio, 0.44; 95% confidence interval [CI], 0.23-0.87;p=0.02).These findings align with a recent network meta-analysis of RCTs evaluating the impact of imaging-guided PCI on major adverse cardiovascular events (MACE) in patients with various complex lesion subsets.7) This meta-analysis showed that both IVUS (relative risk [RR], 0.61; 95% CI, 0.38-0.98;p=0.04) and optical coherence tomography (OCT) guidance (RR, 0.66; 95% CI, 0.44-0.98;p=0.04) significantly reduce the risk of MACE compared to angiography in patients with moderately to severely calcified lesions, with no significant difference observed between 2 imaging modalities.

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