Impact of intravascular ultrasound for coronary bifurcations treated with last generations stents: insights from the BIFURCAT-ULTRA registry

Abstract Background Bifurcation lesions are associated with higher rates of major adverse cardiovascular events (MACE). Aim To investigate the impact of imaging-guided PCI in a real-world population with coronary bifurcation lesions. Methods From the ULTRA-BIFURCAT registry, we compared IVUS vs. angiographic guidance in a cohort of 3486 propensity matched patients. MACE a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization (TLR) and stent-thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease. Results PSM generated 1743 pairs. MACE occurred in 154 (9%) patients in the IVUS guided group and in 199 (11%) patients in the angio-guided group (p = 0.09). IVUS guidance was associated with lower MACE in the ULM population [HR 0.62, 95% CI 0.46–0.83], but had no impact in the non-ULM population [HR 1.12, 95% CI 0.83–1.51], p for interaction = 0.006. IVUS was associated with reduction in all-MI [HR 0.32, 95% CI 0.16–0.64] in the ULM population and with lower ST in the non-ULM population [HR 0.24, 95% CI 0.08–0.71]. Provisional stenting was associated with lower MACE in the ULM population [HR 0.67, 95% CI 0.45–0.98], whereas kissing balloon [HR 0.75, 95% CI 0.56–0.99] and ultra-thin stents [HR 0.44, 95% CI 0.29–0.67] were protective factors in the non-ULM population. Conclusions In a real-world scenario, IVUS guidance during DES implantation is associated with a lower rate of MACE in patients with ULM coronary bifurcation lesions. In non-ULM bifurcations, no difference was observed on MACE, while IVUS guidance was associated with a lower rate of ST.