Intravascular Imaging-Guided Versus Coronary Angiography-Guided Complex PCI: A Meta-analysis of Randomized Controlled Trials

Introduction: Trials evaluating the role of intravascular imaging in percutaneous coronary intervention (PCI) for complex coronary artery disease have yielded mixed results. This study aimed to compare the outcomes of intravascular imaging specifically intravascular ultrasound (IVUS) with those from conventional coronary angiography in complex PCI. Methods: Comprehensive electronic search of MEDLINE, EMBASE, and Cochrane databases was performed until March 2023 for randomized clinical trials (RCTs) comparing intravascular imaging with coronary angiography in patients undergoing complex PCI. Complex PCI was defined per each study, and included PCI for American College of Cardiology/American Heart Association (ACC/AHA) type B2/C lesions, unprotected left main coronary artery disease, or multivessel stenting. The primary study outcome was major adverse clinical events (MACE). Results: The meta-analysis included 10 RCTs with a total of 6615 patients (3576 in the intravascular imaging group and 3039 in the coronary angiography group). The weighted mean-follow up was 28.9 months. Compared with coronary angiography, intravascular imaging reduced MACE (8% vs. 13.3%; relative risk [RR] 0.63; 95% confidence interval [CI] 0.54–0.73), cardiac death (RR 0.47; 95% CI 0.31–0.73), definite/probable stent thrombosis (RR 0.48; 95% CI 0.24–0.97), target vessel revascularization (RR 0.62; 95% CI 0.46–0.83), and target lesion revascularization (RR 0.61; 95% CI 0.47–0.79). There was no difference between both groups in all-cause death (RR 0.79; 95% CI 0.53–1.18) and myocardial infarction (RR 0.80; 95% CI 0.61–1.04). Conclusion: In patients undergoing complex PCI, intravascular imaging—specifically IVUS—reduced MACE by decreasing the incidence of cardiac death, stent thrombosis, and target vessel and target lesion revascularization.