Objective: To investigate in a prospective randomised study both long term clinical effects and cost effectiveness of percutaneous coronary interventions (PCI) with or without intravascular ultrasound (IVUS) guidance. Methods: 108 male patients with stable angina referred for PCI of a significant coronary lesion were randomly assigned to IVUS guided PCI or conventional PCI. Individual accumulated costs of the entire follow up period were calculated and compared in the randomisation groups. Effectiveness of treatment was measured by freedom from major adverse cardiac events. Results: Cost effectiveness of IVUS guided PCI that was noted at six months was maintained and even accentuated at long term follow up (median 2.5 years). The cumulated cost level was found to be lower for the IVUS guided group, with a cumulated cost of &163 672 in the IVUS guided group versus &313 706 in the coronary angiography group (p = 0.01). Throughout the study, mean cost per day was lower in the IVUS guided PCI group (&2.7 v &5.2; p = 0.01). In the IVUS group, 78% were free from major adverse cardiac events versus 59% in the coronary angiography group (p = 0.04) with an odds ratio of 2.5 in favour of IVUS guidance. Conclusion: IVUS guidance results in continued improvement of long term clinical outcome and cost effectiveness. The results of this study suggest that IVUS guidance may be used more liberally in PCI.I ntravascular ultrasound (IVUS) offers the unique opportunity of direct inspection of the coronary vessel wall, while angiography shows the lumen only. [1][2][3][4][5][6][7] In fact, IVUS imaging has shown that angiography underestimates the presence and extent of atherosclerosis. 6 8 9 Moreover, stent underexpansion can frequently be observed with IVUS despite a good angiographic result.10 11 The use of IVUS during percutaneous coronary intervention (PCI) may therefore help to optimise the results of PCI and particularly of stent implantation. In addition, IVUS provides the operator with more correct information on the real vessel size, which facilitates device selection. 12 The approach of IVUS guided PCI has previously been investigated, generally with a much shorter period of follow up, [13][14][15][16][17] but only a few cost effectiveness analyses on IVUS guidance have been published. [18][19][20][21] Most previous studies on IVUS guidance, however, have been performed in high volume centres for PCI.In the present study, we assessed the major adverse cardiac event (MACE) rate and cost effectiveness of IVUS guidance at five years after inclusion of the first patient in a relatively low volume centre for PCI. A hospital perspective was applied. Our cost effectiveness analysis addressed the cumulative costs related to the initial interventional procedure, hospitalisation, and outpatient treatment. The cost of documentary IVUS in the coronary angiography (CAG) guided group was not included. METHODS Study design and inclusion criteriaThe study was performed as a prospective randomised clinical trial. Male patients suffering f...

Following the encouraging results of trials testing the effect of primary percutaneous coronary intervention (PCI) more cases of left main arterial stenosis (LMS) as culprit lesions in acute myocardial infarction (AMI) are being handled. Not many cases of primary PCI on LMS have been published. We present 12 cases of primary PCI on LMS. Eighty-three percent of the patients presented with cardiogenic shock and only 42% were discharged alive. Due to the high rate of cardiogenic shock at presentation, PCI seems to be the treatment of choice, over coronary artery bypass grafting (CABG), although one might consider using PCI as a bridge over to CABG.

Objective-To assess the mechanism of restenosis after balloon angioplasty. Design-Prospective study. Patients-13 patients treated with balloon angioplasty. Interventions-111 coronary subsegments (2 mm each) were analysed after balloon angioplasty and at a six month follow up using three dimensional intravascular ultrasound (IVUS). Main outcome measures-Qualitative and quantitative IVUS analysis. Total vessel (external elastic membrane), plaque, and lumen volume were measured in each 2 mm subsegment. Delta values were calculated (follow up − postprocedure). Remodelling was defined as any (positive or negative) change in total vessel volume. Results-Positive remodelling was observed in 52 subsegments while negative remodelling occurred in 44. Remodelling, plaque type, and dissection were heterogeneously distributed along the coronary segments. Plaque composition was not associated with changes in IVUS indices, whereas dissected subsegments had a greater increase in total vessel volume than those without dissection (1.7 mm 3 v −0.33 mm 3 , p = 0.04). Change in total vessel volume was correlated with changes in lumen (p < 0.05, r = 0.56) and plaque volumes (p < 0.05, r = 0.64). The site with maximum lumen loss was not the same site as the minimum lumen area at follow up in the majority (n = 10) of the vessels. In the multivariate model, residual plaque burden had an influence on negative remodelling (p = 0.001, 95% confidence interval (CI) −0.391 to −0.108), whereas dissection had an eVect on total vessel increase (p = 0.002, 95% CI 1.168 to 4.969). Conclusions-The mechanism of lumen renarrowing after balloon angioplasty appears to be determined by unfavourable remodelling. However, diVerent patterns of remodelling may occur in individual injured coronary segments, which highlights the complexity and influence of local factors in the restenotic process. (Heart 2001;85:73-79)

In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was moderate to good.