Impact of Intravascular Ultrasound-Guided Drug-Eluting Stent Implantation on Patients With Chronic Kidney Disease: Subgroup Analysis From ULTIMATE Trial
JJ Zhang, XF Gao, the ULTIMATE Investigators.

KEYWORDS
IVUS guidance vs angiography guidance; TVF; CKD

BACKGROUND - Patients with chronic kidney disease (CKD) present more frequently with complex and extensive lesions, and intravascular ultrasound (IVUS)–guided drug-eluting stent (DES) implantation is associated with improved clinical outcomes in complex lesions. However, it still remains controversial that routine IVUS guidance could be beneficial to CKD patients.

METHODS - This study aimed to investigate the impact of IVUS- or angiography-guided DES implantation on patients with CKD based on the database from the ULTIMATE trial.

RESULTS - Estimated glomerular filtration rate (eGFR) was available in 1,443 patients, with mean eGFR 81.41 ± 28.92 ml/min/1.73 m², of whom 723 were in the IVUS guidance group and 720 in the angiography guidance group. Finally, CKD was present in 349 (24.2%) patients. At 12 months, the target vessel failure (TVF) in the CKD group was 7.2%, significantly higher than 3.2% in the no CKD group (hazard ratio [HR]: 2.30; 95% CI: 1.38 to 3.84; p = 0.001), mainly driven by increased risk of cardiac death (2.9% vs. 0.5%; p < 0.001) in CKD patients. Moreover, there were 25 TVFs in CKD patients, with 7 (3.9%) in the IVUS group and 18 (10.7%) in the angiography group (HR: 0.35; 95% CI: 0.15 to 0.84; p = 0.01) (Figure), while 35 TVFs occurred in patients without CKD, with 14 (2.6%) in the IVUS group and 21 (3.8%) in the angiography group (HR: 0.67; 95% CI: 0.34 to 1.32; p = 0.25; p for interaction = 0.24). The reduced risk of TVF in the IVUS group for CKD patients was mainly driven by the lower risk of TVMI (0.6% vs. 3.6%; borderline p = 0.05) and TVR (1.1% vs. 4.7; p = 0.04).

CONCLUSION - The present study demonstrated that CKD patients undergoing DES implantation had a higher risk of TVF during 12 months of follow-up. More importantly, the risk of TVF in CKD patients could be significantly decreased through IVUS guidance compared with angiography guidance.