Intravascular ULTrasound Guided Versus Conventional Angiography Guided Strategy to Deploy Zotarolimus and Everolimus Eluting Third Generation Stents in the Long Coronary Artery Lesions: ULTRA-ZET Trial

Study Overview
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Brief Summary
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Although first generation DES reduced instent restenosis, still remained the unsolved problems such as stent thrombosis and restenosis in the era of DES. Second generation DES had been developed to improve the biocompatibility of stent coating focused on polymer compared to first generation DES, so that second generation stents showed better outcomes compared with first generation DES. On the other hands, in third generation DES, further refinement of DES involved more flexible stent platform. Promus ElementTM (Everolimus eluting stent, Boston Scientific, Nastick, MA) and Resolute Integrity® (Zotarolimus eluting stent, Medtronic Vascular, Santa Rosa, CA) are the third generation drug eluting stents which are designed to increase flexibility. In previous randomized controlled studies, both of these stents have shown at least non-inferior angiographic and clinical outcomes compared to second generation DES. However, there is lack of data about comparison of angiographic and clinical outcomes between Promus ElementTM and Resolute Integrity®. IVUS is one of the widely used intracoronary imaging devices to provide more reproducible and accurate information about coronary anatomy than angiography in current practice.8 Optimal stent expansion assessed by intravascular ultrasound (IVUS) has been reported as an important factor to prevent stent thrombosis or restenosis.9 Accordingly, there have been many studies to evaluate the procedural or clinical benefit of IVUS guided angioplasty. However, The clinical benefit of IVUS-guided angioplasty with stent implantation is still in a controversy. In the previous studies, IVUS-guided stent implantation showed positive or negative beneficial effect on clinical outcomes according to their study subjects. However, the stents used in the previous studies are less useful in current practice of cardiology and there is lack of data of 3rd generation DES, which have different stent profiles and outcomes with their predecessors. Thus we would perform a prospective randomized study in order to compare the efficacy of IVUS-guided angioplasty with conventional angioplasty-guided procedure in the long coronary lesion. Our main hypothesis is IVUS-guided 3rd generation DES implantation in the long coronary lesions would have better clinical outcomes compared with conventional angiography-guided strategy. We also intend to assess the clinical outcomes after Promus ElementTM and Resolute Integrity® implantation.

Conditions
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Coronary Artery Disease

Intervention / Treatment
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* Procedure: IVUS guided percutaneous coronary angioplasty with Resolute integrity stent insertion
* Device: Angiography guided percutaneous coronary angioplasty with Resolute integrity stent insertion
* Device: Angiography guided percutaneous coronary angioplasty with Promus element stent implantation
* Procedure: Angiography guided percutaneous coronary angioplasty with Promus element stent implantation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients ≥ 19 years old Coronary artery disease and lesions which are candidate for treatment with drug eluting stent according to current clinical practice guidelines PCI for lesion(s) which needs a stent of 26mm or more Reference diameter from 2.25 to 4.0mm Exclusion Criteria: Restenosis lesion Reference vessel diameter < 2.25 mm or > 4.0mm Primary PCI for STEMI Contraindication to anti-platelet agents Treated with any DES within 3 months at other vessel Severe hepatic dysfunction (3 times normal reference values) Pregnant women or women with potential childbearing Life expectancy < 1 year

Ages Eligible for Study
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Minimum Age: 19 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Resolute Integrity - IVUS<br>Resolute Integrity - IVUS arm | Procedure: IVUS guided percutaneous coronary angioplasty with Resolute integrity stent insertion<br>* Resolute integrity stent implantation (diameter from 2.5mm to 3.5mm, length 30, 34, 38mm) The size and number of stents and post-dilation will be determined on physician's discrete within the range allowed in this study protocol. All procedure will be performed according to current standard technique. IVUS will be used to assess the anatomic characteristics of lesion and determine appropriate stent size and length. Additional stent implantation or post dilation will be allowed according to attending physician's discrete based on IVUS results.<br>|
| Active Comparator: Resolute Integrity - Angio<br>Resolute Integrity - Angio arm | Device: Angiography guided percutaneous coronary angioplasty with Resolute integrity stent insertion<br>* Resolute integrity stent implantation (diameter from 2.5mm to 3.5mm, length 30, 34, 38mm) The size and number of stents and post-dilation will be determined on physician's discrete within the range allowed in this study protocol. All procedure will be performed according to current standard technique. Additional stent implantation or post dilation will be allowed according to attending physician's discrete. IVUS will be not used in this arm.<br>|
| Active Comparator: Promus - Angio<br>Promus - Angio arm | Device: Angiography guided percutaneous coronary angioplasty with Promus element stent implantation<br>* Promus element stent implantation (diameter from 2.5mm to 3.5mm, length 28, 32, 36mm) The size and number of stents and post-dilation will be determined on physician's discrete within the range allowed in this study protocol. All procedure will be performed according to current standard technique. Additional stent implantation or post dilation will be allowed according to attending physician's discrete. IVUS will be not used in this arm.<br>|
| Active Comparator: Promus - IVUS<br>Promus - IVUS arm | Procedure: Angiography guided percutaneous coronary angioplasty with Promus element stent implantation<br>* Promus element stent implantation (diameter from 2.5mm to 3.5mm, length 28, 32, 36mm) The size and number of stents and post-dilation will be determined on physician's discrete within the range allowed in this study protocol. All procedure will be performed according to current standard technique. IVUS will be used to assess the anatomic characteristics of lesion and determine appropriate stent size and length. Additional stent implantation or post dilation will be allowed according to attending physician's discrete based on IVUS results.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Efficacy of angiography or IVUS guided third generation stent implantation | MACEs including cardiovascular death, myocardial infarction, stent thrombosis, and target vessel revascularization | 1 year after implantation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Intravenous ultrasound,, third generation drug-eluting stent