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Current guidelines recommend intravascular imaging guidance for percutaneous coronary intervention (PCI). While both optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are endorsed, comparative data in STEMI remain limited. To compare clinical outcomes between OCT and IVUS guidance for primary PCI for ST-elevation myocardial infarction (STEMI). From a multicenter registry of 2,777 consecutive STEMI patients undergoing primary PCI within 24 hours from onset at 12 Japanese hospitals, we analyzed 2,291 patients who received OCT-guided (n = 244, 10.7%) or IVUS-guided (n = 2,047, 89.3%) PCI. The primary endpoint was target vessel-related major adverse cardiac events (TV-MACE): cardiovascular death, target vessel revascularization, and target vessel-related myocardial infarction. Propensity score matching was performed to adjust for baseline differences. During median follow-up of 722 days, TV-MACE rates tended to be lower in the OCT group in unmatched analysis (9.8% vs 14.5%; p = 0.051). After propensity matching (187 pairs), this difference disappeared (8.6% vs 10.2%; p = 0.723). Kaplan–Meier analysis showed no significant differences for TV-MACE (hazard ratio [HR] 0.82, 95% confidence interval [95% CI] 0.42 to 1.59, p = 0.552), cardiovascular death (HR 0.46, 95% CI 0.16 to 1.32, p = 0.150), or target vessel revascularization (HR 1.07, 95% CI 0.43 to 2.63, p = 0.891). OCT guidance was associated with more frequent procedures without stenting (12.8% vs 5.3%, p = 0.027) and fewer stents per patient (0.99 ± 0.52 vs 1.15 ± 0.56, p = 0.006). In conclusion, OCT-guided PCI demonstrated comparable outcomes to IVUS-guided PCI in STEMI patients, supporting the use of either imaging modality for primary PCI. Condensed abstract: This multicenter registry compared optical coherence tomography (OCT) versus intravascular ultrasound (IVUS) guidance for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). Clinical outcomes were compared between the patients undergoing OCT-guided PCI (n = 244) and those with IVUS-guided PCI (n = 2,047). After propensity score matching (187 pairs), target vessel-related major adverse cardiac events rates were similar between OCT and IVUS groups (8.6% vs 10.2%, p = 0.723) during median 722-day follow-up. No significant differences were observed in cardiovascular death or target vessel revascularization. OCT guidance was associated with more frequent procedures without stenting and fewer stents per patient. Both imaging modalities demonstrated comparable clinical outcomes.

Clinical data comparing intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) with angiography-guided PCI for chronic total occlusions (CTOs) are limited. This study aimed to compare clinical outcomes of IVI-guided versus angiography-guided PCI in patients with CTOs. A systematic review and meta-analysis were conducted to identify randomized controlled trials (RCTs) comparing IVI-guided with angiography-guided PCI in CTO populations. The primary endpoint was the incidence of major adverse cardiac events (MACE), a composite of death/cardiac death, myocardial infarction (MI), and target-vessel revascularization (TVR). Secondary outcomes included the individual components of MACE. A prespecified subgroup analysis was performed for intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Five RCTs, including 1,296 patients, were analyzed, with 713 (55%) undergoing IVI-guided PCI. Over 1 to 3 years, MACE was significantly lower in the IVI-guided PCI group (7.2% vs 13%; relative risk [RR] 0.55; 95% confidence interval [CI] 0.35 to 0.88; p = 0.012; I² = 31%). In the secondary analysis, TVR incidence was lower in the IVI group (3.1% vs 6.7%; RR 0.52; 95% CI 0.29 to 0.97; p = 0.038). No statistical differences were observed for MI or death/cardiac death. In the IVUS subgroup, MACE was also lower in the IVI-guided PCI group (8.4% vs 14.3%; RR 0.59; 95% CI 0.37 to 0.91; p = 0.019). A trial sequential analysis suggested a low likelihood of type I error. In conclusion, IVI-guided PCI is associated with improved clinical outcomes compared with angiography-guided PCI for the treatment of CTOs.

Intravascular near-infrared fluorescence (NIRF) imaging aims to improve the inspection of vascular pathology using fluorescent agents with specificity to vascular disease biomarkers. The method has been developed to operate in tandem with an anatomical modality, such as intravascular ultrasound (IVUS), and complements anatomical readings with pathophysiological contrast, enhancing the information obtained from the hybrid examination. However, attenuation of NIRF signals by blood challenges NIRF quantification. We propose a new method for attenuation correction in NIRF intravascular imaging based on a fluorophore-coated guidewire that is used as a reference for the fluorescence measurement and provides a real-time measurement of blood attenuation during the NIRF examination. We examine the performance of the method in a porcine coronary artery and phantoms using a 3.2F NIRF-IVUS catheter. We demonstrate marked improvement over uncorrected signals of up to 4.5-fold and errors of for target signals acquired at distances up to 1 mm from the catheter system employed. The method offers a potential means of improving the accuracy of intravascular NIRF imaging under conditions.

•A total of 151,998 percutaneous coronary interventions (PCIs) on single-vessel chronic total occlusions (CTOs) were analyzed from 2008 to 2020.•Number of intravascular ultrasound or optical coherence tomography in single-vessel CTO-PCIs substantially increased.•Only 9.2% of all single-vessel CTO-PCIs were guided by intravascular imaging.•Co-morbidities and complications also significantly increased over the years.•Inhospital mortality did not differ with the use of intravascular imaging. Intravascular imaging (IVI), including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), improves outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). We sought to quantify temporal trends in the uptake of IVI for CTO-PCI in the United States. We identified adults who underwent single-vessel PCI for CTO between 2008 and 2020. We quantified yearly trends in the number of IVUS-guided and OCT-guided single-vessel CTO-PCIs by Cochran-Armitage and linear regression tests. We also examined the rates of inhospital mortality and other prespecified inhospital outcomes in patients who underwent CTO-PCIs with and without IVI, using logistic regression. Our study included a total of 151,998 PCIs on single-vessel CTOs, with the absolute number of CTO-PCIs decreasing from 12,345 in 2008 to 8,525 in 2020 (p trend <0.001). IVUS use has increased dramatically from 6% in 2008 to 18% in 2020 for single-vessel CTO-PCIs (p trend <0.001). Rates of OCT use have increased as well, from 0% in 2008 to 7% in 2020 (p trend <0.001). There was no difference in inhospital mortality between patients who underwent CTO-PCI with and without IVI (p logistic = 0.60). In the largest national analysis of single-vessel CTO-PCI trends to date, we found that the use of IVUS has increased substantially accompanied by a similar but lesser increase in the use of OCT. There were no differences in rates of inhospital mortality between patients who underwent single-vessel CTO-PCIs with and without IVI.

•The current study exclusively evaluated the prognostic impact of intravascular imaging-guided percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients with high thrombus burden using nationwide, multicenter, prospective registries.•Intravascular imaging-guided PCI was associated with a lower risk of major adverse cardiovascular event and cardiac death without increased risk of stroke than angiography-guided PCI in AMI patients with high thrombus burden.•Intravascular imaging-guided PCI could be considered for optimal revascularization in AMI patients with high thrombus burden due to its potential survival benefit. Despite the established clinical efficacy following intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) than angiography-guided PCI, evidence regarding prognostic benefits of IVI-guided PCI in acute myocardial infarction (AMI) patients with high thrombus burden remains limited. Using the nationwide registries of KAMIR-NIH and KAMIR-V, we evaluated the prognostic impact of IVI-guided PCI in AMI patients with high thrombus burden. A total of 4,074 patients with AMI and TIMI thrombus grades 4 or 5 who underwent aspiration thrombectomy were selected, of whom 892 patients (21.9%) received IVI-guided PCI and 3,182 patients (78.1%) received angiography-guided PCI. Primary outcome was major adverse cardiovascular event (MACE, a composite of all-cause death, MI, repeat revascularization, and stent thrombosis). Major secondary efficacy outcome was cardiac death and safety outcome was stroke at 3 years. During the median 3 years of follow-up, the risk of MACE was significantly lower in the IVI-guided PCI group than in the angiography-guided PCI group (12.9% vs 16.3%; adjusted HR, 0.80; 95% CI, 0.65 to 0.98; p = 0.035), mainly driven by a lower risk of all-cause death (5.7% vs 10.0%; adjusted HR, 0.65; 95% CI, 0.48 to 0.89; p = 0.007). IVI-guided PCI also showed lower risk of cardiac death compared with angiography-guided PCI (3.8% vs 7.0%; adjusted HR, 0.65; 95% CI, 0.44 to 0.95; p = 0.025). There was no significant difference in the risk of stroke between the groups. In this hypothesis generating study, IVI-guided PCI was associated with a lower risk of MACE and cardiac death than angiography-guided PCI in AMI patients with high thrombus burden.

Although multiple randomized clinical trials (RCTs) have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography-guided PCI, its benefits specifically in calcified coronary lesions is unclear due to the small number of patients included in individual trials. We performed a meta-analysis of RCTs to investigate benefits of IVI-guided PCI compared with angiography-guided PCI in heavily calcified coronary lesions. The primary endpoint was major adverse cardiac events (MACE), a composite of cardiac death, target-vessel or target-lesion myocardial infarction, and target-vessel or target lesion revascularization. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated by using a random-effects meta-analysis based on the restricted maximum likelihood method. A search PubMed, EMBASE, and Cochrane Library from their inception to January 2024 identified 4 trials that randomized 1319 patients with angiographically moderate or severe or severe coronary calcification to IVI-guided (n = 702) vs. angiography-guided PCI (n = 617). IVI-guided PCI resulted in a significantly lower odds of MACE (OR 0.57, 95% CI 0.40–0.80) compared with angiography-guided PCI at a weighted median follow-up duration of 27.3 months. There was no evidence of heterogeneity among the studies (I2 = 0.0%), and included trials were judged to be low risk of bias. Compared with angiography-guided PCI, IVI-guided PCI was associated with a significantly lower MACE in angiographically heavily calcified coronary lesions.

Significance: Intravascular imaging is key to investigations into atherosclerotic plaque pathobiology and cardiovascular diagnostics overall. The development of multimodal imaging devices compatible with intracoronary applications has the potential to address limitations of currently available single-modality systems. Aim: We designed and characterized a robust, high performance multimodal imaging system that combines optical coherence tomography (OCT) and multispectral fluorescence lifetime imaging (FLIm) for intraluminal simultaneous assessment of structural and biochemical properties of coronary arteries. Approach: Several shortcomings of existing FLIm-OCT catheter systems are addressed by adopting key features, namely (1) a custom fiber optic rotary joint based on an air bearing, (2) a broadband catheter using a freeform reflective optics, and (3) integrated solid-state FLIm detectors. Improvements are quantified using a combination of experimental characterization and simulations. Results: Excellent UV and IR coupling efficiencies and stability (IR: 75.7  %    ±  0.4  %  , UV: 45.7  %    ±  0.35  %  ) are achieved; high FLIm optical performance is obtained (UV beam FWHM: 50  μm) contemporaneously with excellent OCT beam quality (IR beam FWHM: 17  μm). High-quality FLIm OCT image of a human coronary artery specimen was acquired. Conclusion: The ability of this intravascular imaging system to provide comprehensive structural and biochemical properties will be valuable to further our understanding of plaque pathophysiology and improve cardiovascular diagnostics.

Evidence regarding the comparative efficacy of the different methods to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available methods guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses who were considered for PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (interquartile range: 32.6%, 100%) acute coronary syndrome participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared with coronary angiography (CA) (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82, high certainty), fractional flow reserve (FFR) (RR 0.73, 95% CI 0.58 to 0.92, moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95% CI 0.49 to 0.82, moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93, 95% CI 0.82 to 1.06, moderate certainty) and iFR (RR 1.07, 95% CI 0.90 to 1.28, moderate certainty) likely did not decrease the risk of MACE compared with CA. Intravascular imaging may not be associated with a significant decrease in MACE compared with CA (RR 0.85, 95% CI 0.62 to 1.17, low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared with CA, FFR, and iFR in a mixed stable coronary disease and acute coronary syndrome population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.

Intravascular imaging (IVI) has emerged as a pivotal tool in percutaneous coronary intervention (PCI), offering superior visualization of coronary anatomy compared with conventional angiography. This literature review synthesizes the latest evidence from randomized trials and meta-analyses published since 2022, assessing the comparative efficacy of IVI modalities—including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)—in complex coronary lesions. Multiple landmark trials, such as RENOVATE-COMPLEX PCI, ILUMIEN IV, OCTOBER, and OCTIVUS, demonstrated that IVI-guided PCI significantly improves procedural outcomes, stent optimization, and clinical endpoints such as target-vessel failure, myocardial infarction, and stent thrombosis. OCT was shown to be particularly beneficial in bifurcation and left main interventions, while IVUS consistently improved outcomes in long lesions and complex anatomies. Despite some trials not meeting their primary clinical endpoints, substudy findings and pooled analyses support a shift toward routine IVI use in anatomically complex cases. Consequently, updated guidelines now recommend IVI as a Class I indication in select patient populations. These findings underscore the need for broader clinical adoption and training in IVI techniques to enhance PCI outcomes.

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.