Intravascular vs. Angiographic Guidance for Treatment of Coronary Bifurcation Lesions

A randomized trial demonstrates that intravascular imaging with optical coherence tomography leads to improved clinical outcomes.

Treatment of lesions at coronary branch points (bifurcation lesions) with percutaneous coronary intervention (PCI) is associated with increased rates of acute and longer-term complications compared with lesions without branch involvement. Several studies demonstrate that use of intravascular imaging guidance, predominantly with intravascular ultrasound (IVUS), leads to improved PCI outcomes compared with angiographic guidance alone across many lesion types. Now, a new study investigates whether these benefits extend to treatment of coronary bifurcation lesions and the use of optical coherence tomography (OCT) guidance.

In the industry-funded, multicenter OCTOBER trial (NCT03171311), 1201 adults (mean age, 66 years; 21% women; 19% left main disease) undergoing PCI for a bifurcation lesion were randomized to OCT guidance or angiographic guidance alone. All bifurcation lesions were complex (i.e., involving both the main vessel and side branch with a branch stenosis ≥50%). The primary endpoint was the composite of cardiovascular death, target lesion–related myocardial infarction, and ischemia-driven target-lesion revascularization (TLR).

At a median follow-up of 2 years, the primary endpoint incidence was significantly lower with OCT guidance compared with angiographic guidance (10.1% vs. 14.1%), driven mainly by reductions in cardiac death (1.4% vs. 2.6%) and ischemia-driven TLR (2.8% vs. 4.6%). OCT guidance led to significant increases in median procedure duration (by 33 minutes) and median contrast volume (by 100 mL).

Comment

These findings extend previously demonstrated benefits of intravascular imaging during PCI to include treatment of coronary bifurcation lesions (including distal left main disease) and use of OCT as well as IVUS. I suspect that the consistency of these findings with multiple previous randomized trials will lead to a Class IA recommendation for use of some form of intravascular imaging guidance during PCI for complex coronary lesions in the near future, with the choice of imaging modality determined mainly by local availability and operator experience.

Reviewing Author

David J. Cohen, MD, MSc

Disclosures

Consultant/Advisory BoardMedtronic; Edwards Lifesciences; Abbott Vascular; Boston Scientific; St. Francis Hospital

Speaker’s BureauBoston Scientific; ZOLL Medical

Grant/Research SupportEdwards Lifesciences; Abbott Vascular; Boston Scientific; Corvia Medical; National Heart, Lung, and Blood Institute; Phillips, Inc.; St. Paul’s Hospital; V-Wave, Inc; ZOLL Medical; CathWorks, ANCORA

Editorial BoardsJACC; American Heart Journal; EuroIntervention; JSCAI; Structural Heart Journal

Leadership Positions in Professional SocietiesSociety of Thoracic Surgeons/American College of Cardiology TVT Registry (Co-Chair, Risk Model Development Committee); Cardiovascular Research Foundation (Co-Director, TCT Annual Meeting; Co-Director, New York Valves Annual Meeting)