September 1, 2026Journal of the American College of Cardiology
Intracoronary Imaging-Guided Percutaneous Coronary Intervention
Key result
Imaging-guided PCI cuts target lesion failure ~28% vs. angiography-guided PCI.
- RR 0.72
- 95% CI 0.61-0.85
- n=24,634
Why the study?
Recent societal guidelines recommend intracoronary imaging-guided PCI for complex or left main coronary artery disease, but recent trials have failed to show a benefit.
Key Points
- To re-evaluate the clinical efficacy of intracoronary imaging-guided percutaneous coronary intervention compared with angiography-guided intervention and determine sources of heterogeneity across randomized trials.
- Searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov through June 3, 2026, for randomized controlled trials comparing intracoronary imaging-guided vs angiography-guided percutaneous coronary intervention in the drug-eluting stent era.
- Identified 28 trials comprising 24,634 patients (mean age 64.8 years; 75.9% male) with a mean follow-up of 22 months.
- Conducted direct, mixed treatment, trial sequential, fragility, and Bayesian meta-analyses alongside meta-regression evaluating lesion and procedural characteristics.
- Intracoronary imaging guidance significantly reduced target lesion failure (RR: 0.72; 95% CI: 0.61-0.85; I²=61%), cardiac mortality (RR: 0.73; 95% CI: 0.58-0.91; I²=5%), and all-cause mortality (RR: 0.82; 95% CI: 0.70-0.96; I²=0%) compared to angiography guidance.
- Imaging-guided intervention lowered risks of myocardial infarction (RR: 0.86; 95% CI: 0.75-0.97; I²=0%), target vessel revascularization (RR: 0.69; 95% CI: 0.57-0.83; I²=41%), and stent thrombosis (RR: 0.55; 95% CI: 0.40-0.76; I²=0%).
- Trial sequential analysis confirmed evidence for at least a 20% reduction across all outcomes, with posterior probabilities of benefit exceeding 99%.
Study Design
Type
Meta-Analysis (n=24,634)
Multicenter
Yes
PICO
P
Population
24,634 patients (mean age 64.8 years, 75.9% male) from 28 RCTs undergoing PCI in the drug-eluting stent era, followed for a mean of 22 months.
I
Intervention / Comparator
Intracoronary imaging-guided percutaneous coronary intervention vs Angiography-guided PCI
O
Primary Outcome
Target lesion failure — RR 0.72 (0.61-0.85)
Main Result
Relative Risk: 0.72 (95% CI 0.61–0.85)
Limitations
- Geographic heterogeneity across trials for target vessel revascularization
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Firm evidence for at least 20% reductions in all major outcomes was present despite the inclusion of several recent trials with neutral results, suggesting that the totality of evidence continues to support intravascular imaging-guided intervention.”
Implication
Meta-analysis shows intracoronary imaging guidance lowers mortality and adverse events in patients undergoing percutaneous coronary intervention, highlighting procedural benefits.
Abstract
BACKGROUND Recent societal guidelines provide a Class I recommendation for intracoronary imaging (ICI)-guided percutaneous coronary intervention (PCI) for complex or left main coronary artery disease; however, recent trials have failed to show a benefit. OBJECTIVES The study aim was to re-evaluate the efficacy of ICI-guided PCI and to explore heterogeneity of results across trials. METHODS PubMed, Embase, Cochrane Central, and ClinicalTrials.gov databases were searched through June 3, 2026, for randomized controlled trials (RCTs) comparing outcomes with ICI-guided PCI vs angiography-guided PCI in the drug-eluting stent era. Direct comparison meta-analyses, mixed treatment comparison meta-analyses, trial sequential analyses, fragility analysis, and Bayesian meta-analyses were performed. Meta-regression analysis was performed to evaluate heterogeneity using the following variables: stent length (surrogate for lesion length), stent diameter, difference in postdilatation (percentage) between the groups, publication year, and geographic location. RESULTS A total of 28 RCTs met the inclusion criteria, comprising 24,634 patients (mean age 64.8 years; 75.9% male) with a mean follow-up of 22 months. ICI-guided PCI reduced target lesion failure (relative risk [RR]: 0.72; 95% CI: 0.61-0.85; I2 = 61%), cardiac mortality (RR: 0.73; 0.58-0.91; I2 = 5%), myocardial infarction (RR: 0.86; 0.75-0.97; I2 = 0%), target vessel revascularization (RR: 0.69; 95% CI: 0.57-0.83, I2 = 41%), stent thrombosis (RR: 0.55; 95% CI: 0.40-0.76; I2 = 0%), and all-cause mortality (RR: 0.82; 95% CI: 0.70-0.96; I2 = 0%) compared with angiography-guided PCI. Trial sequential analysis confirmed evidence for at least a 20% reduction in all outcomes with ICI-guided PCI. The fragility index was robust, ranging from 9 to 50. The posterior probability for benefit was >99% for all outcomes. Trial differences in geography and lesion characteristics explained most of the between-trial variance (residual tau = 0). CONCLUSIONS In this updated meta-analysis of RCTs, after accounting for modifier effects from recent studies, ICI-guided PCI was associated with significantly reduced cardiovascular events compared with angiography-guided PCI. Geographic heterogeneity across trials was present mainly for target vessel revascularization, explained in large part by differences in lesion characteristics and procedural technique.
Discussion
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Cite This Study
Bangalore et al. (2026) conducted a meta-analysis in Coronary artery disease (n=24,634). Intracoronary imaging-guided percutaneous coronary intervention vs. Angiography-guided PCI was evaluated on Target lesion failure (RR 0.72, 95% CI 0.61-0.85). Intracoronary imaging-guided PCI significantly reduced target lesion failure (RR 0.72; 95% CI 0.61-0.85) and other cardiovascular events compared with angiography-guided PCI.