Contemporary evidence for intravascular imaging-guided percutaneous coronary intervention: a systematic review and meta-analysis of 21 812 patients from 18 randomized controlled trials

Background Coronary artery disease (CAD) remains a leading cause of global morbidity and mortality. This meta-analysis aimed to compare clinical outcomes of intravascular imaging-guided percutaneous coronary intervention (PCI) versus angiography – or fractional flow reserve (FFR)-guided PCI. Methods We systematically searched six databases through October 2024 for randomized controlled trials (RCTs) comparing intravascular ultrasound (IVUS)-guided or optical coherence tomography (OCT)-guided PCI versus angiography-guided or FFR-guided PCI. Primary outcomes included target-vessel failure (TVF), myocardial infarction (MI), mortality, stent thrombosis, repeat revascularization, and contrast-induced nephropathy. Risk ratios (RRs) were pooled using a random-effects model. Results Eighteen RCTs including 21 812 patients (11 215 imaging-guided; 10 597 angiography/FFR-guided) were analyzed. Imaging-guided PCI was associated with lower risks of TVF (RR: 0.66; 95% CI: 0.58–0.74), cardiac death (RR: 0.56; 95% CI: 0.44–0.71), all-cause mortality (RR: 0.77; 95% CI: 0.64–0.93), MI (RR: 0.84; 95% CI: 0.71–0.99), and definite stent thrombosis (RR: 0.41; 95% CI: 0.27–0.62). No significant differences were observed in repeat revascularization (RR: 0.99; 95% CI: 0.75–1.31) or contrast-induced nephropathy (RR: 1.08; 95% CI: 0.64–1.83). Although relative risk reductions were significant, absolute event rates were low, resulting in modest absolute risk reductions. Conclusion Intravascular imaging-guided PCI significantly improves key clinical outcomes, including mortality, MI, and stent thrombosis, compared with angiography-guided or FFR-guided PCI. These findings support broader implementation of IVUS and OCT in contemporary PCI, especially in patients with complex coronary disease.