Impact of Intravascular Ultrasound Versus Optical Coherence Tomography on Clinical Outcomes and Readmission After Percutaneous Intervention of Chronic Total Occlusion

Background
Intravascular imaging guidance utilizing optical coherence tomography (OCT) and intravascular ultrasound (IVUS) has improved stent selection and optimization during percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). However, the impact of these tools on cost of care, mortality, and readmissions in clinical practice remains unclear.

Methods
Patients with CTO undergoing PCI with IVUS or OCT from 2011-2015 in the National Readmission Database (NRD) were identified using the ICD 9 CM classification system. Maintained by the Healthcare Cost and Utilization Project, the NRD estimates over 37 million annual U.S. hospitalizations. Mortality, readmission, and cost were evaluated using generalized linear mixed models adjusting for demographics, hospital factors, and comorbid conditions.

Results
Of 714,995 patients admitted with CTO, 344,246 received PCI. IVUS and OCT were utilized in 20,471 and 491 patients, respectively. Patients in the highest income quartile were more likely to undergo imaging guidance (24.4% vs 19.5.%, P<0.001). Use of IVUS or OCT was associated with lower mortality (1.7% vs 3.2%, aOR: 0.55 P<0.001) as compared to angiography alone. Utilization of FFR was also independently associated with a reduced mortality (<1% vs 3.1%, aOR:0.34, P<0.001). The adjusted cost of care was higher among with imaging guidance ($28,466 vs $24,382, P<0.001). Mortality and cost were similar between IVUS and OCT. 30-day and 6-month readmissions were not significantly different with imaging guidance.

Conclusions
Utilization of imaging guidance reduced the odds of mortality among patients undergoing PCI for CTO by 45% after multivariable adjustment. However, the cost of care was 16% greater with OCT or IVUS than angiography alone. There were no significant differences in clinical outcomes or cost between imaging modalities. Thus, further research of the applications of imaging guidance to PCI for CTO is merited.