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 I2 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; I2, 18.9%), driven by lower risk of MI (RR, 0.83; 95% CI, 0.70 to 0.97; P=0.019; I2, 0.0%), TVR (RR, 0.70; 95% CI, 0.61 to 0.79; P<0.001; I2, 0.0%), and stent thrombosis (RR, 0.50; 95% CI, 0.32 to 0.78; P=0.002; I2, 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; I2, 0.0%), however, trials with 2nd 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; I2, 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 2nd generation DES showed significantly lower risk of all-cause death following intravascular imaging-guided PCI than angiography-guided PCI. Systematic Review Registration PROSPERO, CRD42023402677 ### Competing Interest Statement Dr. Joo Myung Lee received an Institutional Research Grant from Abbott Vascular, Boston Scientific, Philips Volcano, Terumo Corporation, Zoll Medical, and Donga-ST. Prof. Joo-Yong Hahn received an Institutional Research Grant from National Evidence-based Healthcare Collaborating Agency, Ministry of Health & Welfare, Korea, Abbott Vascular, Biosensors, Boston Scientific, Daiichi Sankyo, Donga-ST, Hanmi Pharmaceutical, and Medtronic Inc. Prof. Hyeon-Cheol Gwon received an Institutional Research Grant from Boston Scientific, Genoss, and Medtronic Inc. All other authors declare that there are no competing interests to declare. ### Clinical Protocols ### Funding Statement None ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The current study-level meta-analysis used the published trials data. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Original data used in the current meta-analysis including the analytic codes will be shared upon reasonable request. Any relevant inquiry should be emailed to Dr. Joo Myung Lee (Email: drone80{at}hanmail.net). The lead author (JML) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained. * CI : confidence interval DES : drug-eluting stent IVUS : intravascular ultrasound MACE : major adverse cardiac events MI : myocardial infarction OCT : optical coherence tomography OR : odds ratio PCI : percutaneous coronary intervention RCT : randomized controlled trial TVR : target vessel revascularization