Stent Optimization Cuts PCI Risk, OCTIVUS Trial Finds

Intravascular imaging is increasingly recognized as a cornerstone of modern percutaneous coronary intervention (PCI), yet the clinical significance of achieving formal stent optimization remains an area of active inquiry. A new analysis from the OCTIVUS trial, published by Kim et al., sheds light on the prognostic value of stent optimization as defined by European Association of Percutaneous Cardiovascular Interventions (EAPCI) criteria.

The study included 2,008 patients randomized to imaging-guided PCI with either optical coherence tomography (OCT; n=1,005) or intravascular ultrasound (IVUS; n=1,003). Operators followed EAPCI-defined optimization goals, including thresholds for stent expansion, plaque burden, malapposition, and dissection. Core laboratories adjudicated final imaging. Patients were stratified post hoc into optimized (n=1,022; 51.6%) and non-optimized (n=958; 48.3%) groups.

At a median follow-up of 2 years, the primary outcome of target vessel failure (TVF)—a composite of cardiac death, target vessel myocardial infarction, and ischemia-driven target vessel revascularization—was significantly lower in the optimized group (3.8%) compared to the non-optimized group (7.5%; HR: 0.52; 95% CI: 0.36–0.74; P<0.001). Kaplan-Meier estimates extended through 3 years demonstrated sustained benefit.

Among the individual EAPCI optimization criteria, failure to achieve adequate stent expansion was the most common reason for non-optimization, observed in nearly 80% of non-optimized cases. OCT was more sensitive than IVUS in detecting malapposition (17.4% vs 5.6%) and large dissections (14.6% vs 5.6%), reinforcing the value of high-resolution imaging in identifying subtle but potentially clinically relevant features. Notably, the benefit of optimization was consistent across imaging modalities, though outcomes trended more favorably with OCT.

Multivariate analysis identified prior myocardial infarction, left main coronary disease, higher SYNTAX score, and greater total stent length as predictors of failed optimization, highlighting the challenges of achieving optimal results in more complex lesions.

These findings underscore that, beyond simply using intravascular imaging, achieving guideline-directed optimization is associated with improved outcomes. As imaging-guided PCI continues to evolve, operator attention to defined criteria may further enhance procedural durability and patient benefit. The data also provides a foundation for refining optimization metrics and improving uptake in routine practice, where imaging use remains woefully underutilized.