Optical Coherence Tomography–Guided versus Angiography-Guided PCI

The ILUMIEN IV trial randomized 2487 high-risk patients undergoing PCI those with medication-treated diabetes or complex coronary lesions to OCT-guided versus angiography-guided stent implantation. OCT guidance produced a significantly larger mean minimum stent area (5.72 ± 2.04 mm² vs. 5.36 ± 1.87 mm²; mean difference 0.36 mm²; P < 0.001). However, at 2 years, the composite clinical endpoint target-vessel failure (cardiac death, target-vessel myocardial infarction, or ischemia-driven revascularization) was similar between groups (7.4% vs. 8.2%; HR 0.90; P = 0.45). OCT use led to lower rates of major stent malapposition, edge dissection, tissue protrusion, and untreated focal disease. Notably, stent thrombosis was lower in the OCT group (0.5% vs. 1.4%; HR 0.36; P = 0.02). OCT was safe, with very few imaging-related complications. Despite procedural enhancements, OCT did not show a statistically significant reduction in major adverse events, prompting calls for longer-term and subgroup-specific studies. The findings reaffirm OCT's utility for stent optimization and thrombotic risk reduction but stop short of endorsing its routine use solely for improving clinical outcomes.

The ILUMIEN IV trial randomized 2487 high-risk patients undergoing PCI those with medication-treated diabetes or complex coronary lesions to OCT-guided versus angiography-guided stent implantation. OCT guidance produced a significantly larger mean minimum stent area (5.72 ± 2.04 mm² vs. 5.36 ± 1.87 mm²; mean difference 0.36 mm²; P < 0.001). However, at 2 years, the composite clinical endpoint target-vessel failure (cardiac death, target-vessel myocardial infarction, or ischemia-driven revascularization) was similar between groups (7.4% vs. 8.2%; HR 0.90; P = 0.45). OCT use led to lower rates of major stent malapposition, edge dissection, tissue protrusion, and untreated focal disease. Notably, stent thrombosis was lower in the OCT group (0.5% vs. 1.4%; HR 0.36; P = 0.02). OCT was safe, with very few imaging-related complications. Despite procedural enhancements, OCT did not show a statistically significant reduction in major adverse events, prompting calls for longer-term and subgroup-specific studies. The findings reaffirm OCT's utility for stent optimization and thrombotic risk reduction but stop short of endorsing its routine use solely for improving clinical outcomes.