Abstract Background and introduction Percutaneous coronary intervention (PCI) guided by intravascular imaging improves outcomes compared with angiography guidance alone, but has not been directly compared with coronary artery bypass graft surgery (CABG) in patients with unprotected left main disease (ULMD). It is unclear whether intravascular imaging guidance during PCI can improve clinical outcomes sufficiently such that outcomes are similar compared with CABG in patients with ULMD. Purpose We performed a network meta-analysis (NMA) to compare the different revascularization strategies (angiography-guided PCI, imaging-guided PCI, and CABG) in patients with ULMD. Methods Randomized controlled trials (RTCs) comparing angiography-guided PCI, imaging-guided PCI or CABG for patients with ULMD were included. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction or repeat revascularization. The present NMA was prospectively registered in PROSPERO (ID CRD42025636884). Results The NMA consisted of 11 RCTs (n=5926 patients), including 3 RCTs (n=1011) comparing angiography-guided PCI vs. CABG, 3 RCTs (n=3689) comparing imaging-guided PCI vs CABG, and 5 RCTs (n=1226) comparing angiography-guided PCI vs. imaging-guided PCI in ULMD. At median 2-year follow-up, the hazard ratio (HR) for MACE after imaging-guided PCI compared with angiography-guided PCI was 0.76 (95% confidence interval (CI): 0.53, 1.01). CABG was associated with reduced MACE compared with angiography-guided PCI (HR: 0.63, 95% CI: 0.45, 0.85), but not compared with imaging-guided PCI (HR: 0.83, 95% CI: 0.64, 1.13). There were no significant differences in all-cause death or myocardial infarction between the three treatment groups. CABG was associated with a reduced risk of revascularization, but more so compared with angiography-guided PCI (HR: 0.47, 95% CI: 0.35, 0.63) than with imaging-guided PCI (HR: 0.71, 95% CI: 0.57, 0.88). The risk of revascularization was reduced with imaging-guided PCI compared with angiography-guided PCI (HR: 0.66, 95% CI: 0.47, 0.91). Conclusions In this NMA of revascularization modalities in patients with ULMD, CABG was superior to angiography-guided PCI whereas imaging-guided PCI had similar rates of 2-year MACE compared with CABG. The benefit of CABG in reducing the need for repeat revascularization during follow-up was reduced but not eliminated by imaging-guided PCI. Imaging-guided PCI should be mandatory in patients with ULMD to optimize revascularization outcomes.For image description, please refer to the figure legend and surrounding text.
Bruno et al. (Sun,) studied this question.