Randomized Comparison of Clinical Outcomes Between IVUS and Angiography-Guided DES Implantation for Long Coronary Artery Stenoses

This South Korean RCT asked whether intravascular ultrasound guidance improved outcomes for drug-eluting stent implantation in long coronary lesions — a setting where angiography’s two-dimensional silhouette is most limited.

In 543 patients, one-year major adverse cardiac events ran 4.5 percent with IVUS versus 7.3 percent with angiography guidance — a 38 percent relative reduction that fell short of statistical significance in intention-to-treat analysis. The per-protocol analysis (4.0% vs 8.1%) did reach significance, but this analysis is susceptible to selection bias.

The trial’s design limitation is that IVUS use was not fully prohibited in the angiography arm — operators could cross over — blurring the comparison. The ITT null result is the trial’s honest primary answer, even if the direction was consistently favorable.

This study preceded larger confirmatory trials, including RENOVATE-COMPLEX-PCI, that would eventually establish IVUS guidance’s benefit for complex lesions more definitively.

We rate the evidence moderate. An underpowered but directionally consistent RCT pointing toward IVUS benefit in long coronary lesions, before subsequent trials confirmed the signal at adequate scale.