Comparative effectiveness of OCT- vs. angiography-guided PCI: a meta-analysis with new evidence from RCTs

Background Optical coherence tomography (OCT), known for its high-resolution imaging, offers potential advantages in guiding stent implantation during PCI. This meta-analysis synthesises emerging evidence from randomised trials (RCTs) to evaluate the safety and efficacy of OCT-guided PCI versus angiography-guided PCI, aiming to determine its role in improving patient outcomes. Methods We conducted a systematic search of PubMed, Scopus, Embase, Cochrane, and Web of Science up to December 2024. RCTs comparing OCT-guided PCI with angiography-guided PCI in patients with coronary artery disease (CAD) were included. A random-effects meta-analysis was performed to calculate risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI). Statistical analysis was done using R Studio version 4.3.2. Results In our meta-analysis of 14 RCTs involving 6,909 patients (3,454 OCT-guided PCI and 3,455 angiography-guided PCI), OCT-guided PCI was associated with a significant reduction in cardiovascular mortality (RR 0.57, 95% CI 0.35–0.94, p = 0.03), though no significant difference was observed in all-cause mortality (RR 0.72, 95% CI 0.51–1.01, p = 0.056). Procedural efficacy outcomes showed that OCT-guided PCI resulted in a significantly larger minimum stent area (MD 0.33 mm², 95% CI 0.20–0.46, p < 0.01), but the minimum lumen diameter was similar between the two groups (MD 0.01 mm, 95% CI −0.08–0.11, p = 0.78). However, OCT guidance significantly increased contrast volume usage (MD 55.34 mL, 95% CI 34.60–76.08, p < 0.01). Regarding procedural outcomes, OCT guidance was associated with a significant reduction in stent thrombosis (RR 0.50, 95% CI 0.33–0.77, p < 0.01), while there was no significant difference in stent malapposition (RR 0.90, 95% CI 0.77–1.05, p = 0.19), coronary perforation (RR 1.08, 95% CI 0.39–3.00, p = 0.88), or contrast-induced nephropathy (RR 1.36, 95% CI 0.59–3.14, p = 0.47). Myocardial infarction outcomes showed no significant differences in all-cause MI (RR 0.82, 95% CI 0.66–1.01, p = 0.07), procedure-related MI (RR 1.07, 95% CI 0.83–1.40, p = 0.59), or target vessel-related MI (RR 0.62, 95% CI 0.34–1.13, p = 0.12). Revascularisation outcomes also showed no significant differences between OCT-guided and angiography-guided PCI in ischaemia-driven target lesion revascularisation (TLR) (RR 0.91, 95% CI 0.59–1.39, p = 0.66), ischaemia-driven target vessel revascularisation (TVR) (RR 0.71, 95% CI 0.41–1.23, p = 0.22), TLR (RR 0.66, 95% CI 0.37–1.18, p = 0.16), and TVR (RR 0.71, 95% CI 0.41–1.21, p = 0.21). Conclusions Our overview demonstrated that OCT-guided PCI may offer benefits in reducing cardiovascular mortality and stent thrombosis compared to angiography-guided PCI. Additionally, OCT enhances procedural efficacy by improving MSA. These promising results suggest that OCT-guided PCI could enhance patient outcomes, but further research is needed to fully establish its role in routine clinical practice.