Physiology- or Imaging-Guided Strategies for Intermediate Coronary Stenosis
Authors: Yang Seokhun , Kang Jeehoon , Hwang Doyeon , Zhang Jinlong , Jiang Jun , Hu Xinyang , Hahn Joo-Yong , Nam Chang-Wook , Doh Joon-Hyung , Lee Bong-Ki , Kim Weon , Huang Jinyu , Jiang Fan , Zhou Hao , Chen Peng , Tang Lijiang , Jiang Wenbing , Chen Xiaomin , He Wenming , Ahn Sung Gyun , Yoon Myeong-Ho , Kim Ung , Lee Joo Myung , Ki You-Jeong , Shin Eun-Seok , Kim Hyo-Soo , Tahk Seung-Jea , Wang Jian’an , Koo Bon-Kwon 
Published: January 2024

ImportanceTreatment strategies for intermediate coronary lesions guided by fractional flow reserve (FFR) and intravascular ultrasonography (IVUS) have shown comparable outcomes. Identifying low-risk deferred vessels to ensure the safe deferral of percutaneous coronary intervention (PCI) and high-risk revascularized vessels that necessitate thorough follow-up can help determine optimal treatment strategies.ObjectivesTo investigate outcomes according to treatment types and FFR and IVUS parameters after FFR- or IVUS-guided treatment.Design, Setting, and ParticipantsThis cohort study included patients with intermediate coronary stenosis from the Fractional Flow Reserve and Intravascular Ultrasound-Guided Intervention Strategy for Clinical Outcomes in Patients With Intermediate Stenosis (FLAVOUR) trial, an investigator-initiated, prospective, open-label, multicenter randomized clinical trial that assigned patients into an IVUS-guided strategy (which recommended PCI for minimum lumen area [MLA] ≤3 mm2 or 3 mm2 to 4 mm2 with plaque burden [PB] ≥70%) or an FFR-guided strategy (which recommended PCI for FFR ≤0.80). Data were analyzed from November to December 2022.ExposuresFFR or IVUS parameters within the deferred and revascularized vessels.Main Outcomes and MeasuresThe primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, and revascularization at 2 years.ResultsA total of 1619 patients (mean [SD] age, 65.1 [9.6] years; 1137 [70.2%] male) with 1753 vessels were included in analysis. In 950 vessels for which revascularization was deferred, incidence of TVF was comparable between IVUS and FFR groups (3.8% vs 4.1%; P = .72). Vessels with FFR greater than 0.92 in the FFR group and MLA greater than 4.5 mm2 or PB of 58% or less in the IVUS group were identified as low-risk deferred vessels, with a decreased risk of TVF (hazard ratio [HR], 0.25 [95% CI, 0.09-0.71]; P = .009). In 803 revascularized vessels, the incidence of TVF was comparable between IVUS and FFR groups (3.6% vs 3.7%; P = .95), which was similar in the revascularized vessels undergoing PCI optimization (4.2% vs 2.5%; P = .31). Vessels with post-PCI FFR of 0.80 or less in the FFR group or minimum stent area of 6.0 mm2 or less or with PB at stent edge greater than 58% in the IVUS group had an increased risk for TVF (HR, 7.20 [95% CI, 3.20-16.21]; P &amp;lt; .001).Conclusions and RelevanceIn this cohort study of patients with intermediate coronary stenosis, FFR- and IVUS-guided strategies showed comparable outcomes in both deferred and revascularized vessels. Binary FFR and IVUS parameters could further define low-risk deferred vessels and high-risk revascularized vessels.