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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e53 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1. In the evaluation of early or late stent thrombosis, several meta-analyses suggest that stents can be ranked from more safe to less safe as follows: durable-polymer DES ≥ biodegradable-polymer DES > BMS.1-4 A meta-analysis of individual-level data of 20 RCTs (N=26 616), in which 29% of patients had SIHD, 14% had unstable angina, 25% had NSTEMI, and 28% had STEMI,1 confirmed a significantly reduced risk of MI and stent thrombosis, as well as a trend toward a lower cardiac mortality rate, with a newer-generation DES compared with a BMS. Newer-generation DES were defined as any DES released after the original sirolimus-eluting or paclitaxel-eluting DES. For this reason, there are limited roles for the use of BMS except for unusual circumstances, such as a lack of DES availability or unique patient circumstances that warrant extremely short-duration DAPT (ie, <1 month). 10.3 Use of Intravascular Imaging Recommendations for Use of Intravascular Imaging Referenced studies that support the recommendations are summarized in Online Data Supplement 25. COR LOE Recommendations 2a B-R 1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events.1-10 2a B-R 2. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in ostial left main disease.11-13 2a C-LD 3. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.14-17 Synopsis Because of limitations in angiography, intracoronary imaging can be a useful tool to guide coronary stent implantation, particularly in cases involving the left main artery or complex lesions. IVUS enables full-thickness visibility of the vessel wall, enabling pre-PCI assessment of plaque burden, extent of calcification, lesion length, and external elastic lamina diameter for stent sizing and post-PCI assessment of minimum stent area, malapposition, underexpansion, tissue protrusion, edge disease, and edge dissection.18,19 OCT uses infrared light to generate high-resolution images of the vessel wall, with particular advantages in assessing calcium thickness, lipid, thrombus, fibroatheroma, and plaque rupture, as well as stent strut neointimal thickness and apposition, and edge dissections.20 However, OCT has more limited depth of imaging. It also requires blood clearance through the use of contrast injection, which diminishes its use in ostial left main disease. IVUS and OCT can assist with assessing the need for lesion preparation, stent sizing, minimizing geographic miss, verifying stent expansion, evaluating complications, and identifying causes of stent failure.20 Recommendation-Specific Supportive Text 1. In patients undergoing PCI, multiple meta-analyses2,3,21-23 have shown a reduction in MACE with IVUS-guided versus angiographic-guided PCI. The ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in “All-Comers” Coronary Lesions) trial, which was the largest trial of routine IVUS-guided PCI, demonstrated a lower rate of target-vessel failure (cardiac death, target-vessel infarction, and clinically driven target-vessel revascularization) with IVUS-guided PCI than with angiographic-guided PCI at 12 months.6 Additionally, at 3 years, there was a significantly lower rate of stent thrombosis and target-vessel revascularization with IVUS-guided PCI.10 Most of the RCTs focusing on the use of IVUS in complex lesions (left main, CTOs, and long lesions) were small and not powered to evaluate clinical endpoints. Some of these trials have reported lower MACE with IVUS-guided PCI in long lesions,4 CTOs,8 or left main stenting.5 A meta-analysis of RCTs of complex lesions also demonstrated lower rates of MACE, target-vessel revascularization, and target-lesion revascularization when IVUS guidance was used.1 2. The ILUMIEN (Optical Coherence Tomography Compared to Intravascular Ultrasound and Angiography to Guide Coronary Stent Implantation: a Multicenter Randomized Trial in Percutaneous Coronary Intervention) study showed noninferiority of OCT compared with IVUS with respect to the primary endpoint of post-PCI minimum stent area, with similarly low rates of procedural MACE.11 The OPINION (Optical Frequency Domain Imaging Versus Intravascular Ultrasound in Percutaneous Coronary Intervention) study showed noninferiority of OCT- compared with IVUS-guided PCI for the combined endpoint of cardiac death, target-vessel MI, and ischemia-driven target-lesion revascularization at 1 year.24 The DOCTORS (Does Optical Coherence Tomography Optimize Results of Stenting) trial demonstrated that, compared with angiography-guided PCI, OCT-guided PCI resulted in improved post-PCI FFR.12 Randomized and registry data have shown that an OCT minimum stent area of <4.5 to 5.0 mm2 is an independent predictor of MACE.25,26 The ILUMIEN IV (Optical Coherence Tomography [OCT] Guided Coronary Stent Implantation Compared to Angiography: a Multicenter Randomized Trial in PCI) trial is an ongoing trial designed to evaluate clinical Downloaded from http://ahajournals.org by on October 7, 2026