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DAPT Duration

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IVUS指导PCI，决与未决

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当时间步入2020跑道，IVUS指导PCI可带来的预后获益研究仍需探源溯流。现已明确的是IVUS指导PCI可对长病变、全患者群、慢性完全性闭塞病变和高危患者群的预后带来净获益。IVUS-XPL5年随访结果的发布还未能回答以下几个核心问题：

1. 尚缺乏统一的指南性理想IVUS指导PCI标准，而不同的标准制定对于临床预后的影响尚待进一步随机对照研究的证实；比如支架膨胀指数的拟定及对术中并发症的质控；

2. 尚缺乏随机对照研究证实IVUS指导PCI是否对心源性死亡及靶病变相关心梗具预防作用；

3. 尚缺乏有症状的复杂分叉病变经IVUS指导双支架术式临床获益的随机对照研究；

4. 尚需证明IVUS指导PCI通过改善支架膨胀或促进内皮恢复是否可缩短DES置入患者术后的双抗疗程的专项随机对照研究。



IVUS-XPL研究定义最小支架面积应大于远端参考管腔面积，即膨胀指数>1.0, 而ULTIMATE研究发现为达到理想膨胀指数的激进性后扩策略与严重边缘夹层、慢血流和/或穿孔发生率增加相关。

ULTIMATE研究提出的理想化IVUS指导PCI达标的标准：①术后支架段最小管腔面积(MLA)>5.0 mm2，或>90%的远端参考血管的管腔面积；②支架边缘5 mm内斑块负荷<50%；③无深达中层且长度超过3 mm的边缘夹层，三条标准需同时满足。研究主要终点为术后1年时靶血管失败率（TVF），包括心源性死亡、靶血管心肌梗死（TV-MI）和临床驱动的靶血管血运重建（TVR）。


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