Intravascular imaging-guided PCI boosts outcomes, but utilization remains low
Eric Secemsky, MD, director of vascular intervention at Beth Israel Deaconess Medical Center in Boston, spoke to Cardiovascular Business at ACC.23 about a real-world study focused on the potential benefits of using intravascular imaging during percutaneous coronary intervention (PCI) procedures. The study included data from more than 1 million Medicare patients.
"We have really seen an evolution in how our coronary procedures are performed, where patients coming in for PCI are much more complex than when the field of interventional cardiology started. And we have demonstrated through randomized trials that the use of intravascular imaging, and the use of intravascular ultrasound (IVUS) in particular, can improve outcomes, particularly among these more complex subsets," Secemsky explained. "The trial data is showing us that use of intravascular imaging is the right thing to do, but the adoption has been really slow."
Secemsky noted that operators can be reimbursed for the use of intravascular imaging during PCI, but this has not greatly expanded its use. This is in part because many operators feel it is not needed and they can see what they need using angiography alone. Other factors include the increase in the cost of the procedure and the additional procedure time intravascular imaging requires.
The study looked at Medicare claims between 2013 and 2019. Secemski said the study was designed to see if usage increased over the last decade and what the usage impact was from large trials showing improved outcomes with intravascular imaging.
"We lookout at how clinical trials influenced adoption, and we did not see a significant correlation. We are generating this really high-quality data that should be changing practice. When we do large randomized trials, we expect people to pay attention and to listen, but we have not seen that happen in this field," Secemsky explained.
He added that guidelines are catching up and have strong recommendations for the use of intravascular imaging. This, he hopes, will push interventional cardiologists to use intravascular imaging more regularly.
Overall, the data show use of intravascular imaging is associated with a lower incidence of mortality, acute myocardial infarction (MI), repeat PCI, and major adverse cardiac events (MACE).
Usage of IVUS is slowly increasing
Overall, the study showed usage of IVIS and other modalities remains very limited. Secemsky said today the usage of intravascular imaging is still limited, below 15% of PCI cases in the U.S. While low, the study data showed usage grew by about 62% between 2013 and 2019. He said usage was in the single digits starting in 2013, but numbers increased over time.
The Medicare claims data show intravascular imaging is being used, but did not specify when modality, which can include IVUS, optical coherence tomography (OCT) or near-infrared spectroscopy (NIRS). However, Secemsky said it is known the majority of intravascular imaging use is for IVUS, which by far has the most market penetration in cath labs.
Use of intravascular imaging to improve patient care
At Beth Israel Deaconess, Secemsky said they look at what is best for patients, not at costs, so the interventional cardiologists there use IVUS in about 70% of PCI cases. He said some cases can be done without the need for angiography, but he feels this is the minority. This is because measurements using intravascular imaging are more accurate than eyeballing it on angiography, you can get a better 3D feel for the lesion looking at it in a cross section during a pullback, and you can see if you actually have good stent strut apposition against the vessel wall, or if more expansion is needed to get better long-term outcomes.
"There is enough reimbursement that you will not go broke using intravascular imaging," he said. "The hurdles are procedural time for set up and the flow of the cath lab procedure. But we have shown that if you are efficient and familiar with setting up the device, you may lessen the length of the procedure because you are now choosing devices that are being measured off an intravascular image, and that makes the procedures more efficient."
Secemsky said the biggest issue facing wider adoption intravascular imaging is the lack of training for residents and fellows on the use of IVUS or other modalities. Similar to issues facing wider adoption of radial access a decade ago, it was found adoption of radial was low because it was not part of most training programs. Once training for radial was included, adoption of the vascular access technique rose rapidly in the U.S. Secemsky said IVUS faces a similar barrier today than can be solved with earlier career training programs.
Another big issue, related to the lack of training, is the ability of operators to interpret IVUS or OCT imaging.
"If you are already practicing and are used to just looking at a coronary angiogram for your decision making, it is hard to learn a whole new technology and feel comfortable making decisions off it," Secemsky explained.
For this reason, he and colleges have made a lot of effort to emphasize the training in this area with up and coming interventionalists in fellowship programs and early career so the next generation of operators will not have that apprehension.
"There are always going to be cases where we elect not to use intravascular imaging, but that should always be considered a minority of cases, not a standard procedure," Secemsky stressed.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com