Intravascular Imaging-Guided Versus Angiography-Guided PCI: Systematic Review and Meta-analysis of 24 Randomized Controlled Trials

Objective To evaluate comparative prognosis between intravascular imaging-guided PCI and angiography-guided PCI using a comprehensive meta-analysis including all previous randomized controlled trials. Design Systematic review and meta-analysis of randomized controlled trials. Data Sources Target trials were selected by a systematic electronic search strategy in the PubMed, EMBASE, and Cochrane databases from their inception to Sep, 2023. Study Selection Published randomized controlled trials which compared clinical outcomes between intravascular imaging-guided and angiography-guided PCI were included. Main Outcome and Measures Major adverse cardiac events (MACE), all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), and stent thrombosis. Review Methods Random-effects model was used to calculate pooled relative risk (RR) and 95% confidence interval (CI) between intravascular imaging-guided and angiography-guided PCI. Heterogeneity was assessed by I 2 values. Results Among a total of 14,037 patients (7,383 in intravascular imaging-guided PCI and 6,654 in angiography-guided PCI groups), intravascular imaging-guided PCI was associated with a lower risk of MACE than angiography-guided PCI (RR, 0.75; 95% CI, 0.67 to 0.84; P<0.001; I 2 , 18.9%), driven by lower risk of MI (RR, 0.83; 95% CI, 0.70 to 0.97; P=0.019; I 2 , 0.0%), TVR (RR, 0.70; 95% CI, 0.61 to 0.79; P<0.001; I 2 , 0.0%), and stent thrombosis (RR, 0.50; 95% CI, 0.32 to 0.78; P=0.002; I 2 , 0.0%). There was no difference in the risk of all-cause death (RR, 0.82; 95% CI, 0.67 to 1.01; P=0.068; I 2 , 0.0%), however, trials with 2 nd generation drug-eluting stent (DES) showed significant reduction of all-cause death following intravascular imaging-guided PCI (RR, 0.77; 95% CI, 0.61 to 0.95; P=0.018; I 2 , 0.0%). Conclusions Compared to angiography-guided PCI, intravascular imaging-guided PCI was associated with a reduced the risk of MACE, by lowering the risks of MI, TVR, and stent thrombosis. Pooled analysis of trials with 2 nd generation DES showed significantly lower risk of all-cause death following intravascular imaging-guided PCI than angiography-guided PCI. Systematic Review Registration PROSPERO, CRD42023402677 Summary Boxes What is already known on this topic Due to limited sample size, previous randomized controlled trials (RCTs) were not able to show significant differences in the risks of hard clinical events such as death, myocardial infarction (MI), or stent thrombosis between intravascular imaging-guided percutaneous coronary intervention (PCI) and angiography-guided PCI. Although previous meta-analyses showed that intravascular imaging-guided PCI resulted in a lower risk of death or MI than angiography-guided PCI, inclusion of both observational studies and RCTs caused heterogeneity and lowered the evidence level of the results. What this study adds The current meta-analysis exclusively included 24 RCTs and showed that intravascular imaging-guided PCI significantly reduced the risk of major adverse cardiac events (MACE), compared with angiography-guided PCI. It should be noted that intravascular imaging-guided PCI reduced not only the risk of target-vessel revascularization but also the risks of hard clinical events such as MI and stent thrombosis.