Intravascular Imaging–Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Reconstructed Individual Participant Data Meta-Analysis of Randomized Controlled Trials of IVUS- and OCT-Guided Strategies

Background and Aims Uncertainty persists regarding the comparative efficacy of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) versus angiography-guided percutaneous coronary intervention (PCI). We synthesized randomized evidence using reconstructed individual participant data (IPD) and compared the two modalities indirectly. Methods MEDLINE and CENTRAL were searched through March 31, 2026. IPD were reconstructed from published Kaplan–Meier curves. Primary analyses used one-stage stratified Cox models; secondary analyses included random-effects and Bayesian hierarchical models. The primary outcome was major adverse cardiovascular events (MACE). Results Twenty-three randomized controlled trials (RCTs) enrolling 21,176 patients were included (16 IVUS, n = 15,209; 7 OCT, n = 5,967). IVUS-guided PCI reduced MACE (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.67–0.83; P < .001), target vessel revascularization (TVR; HR 0.70; 0.60–0.82), and stent thrombosis (ST; HR 0.54; 0.37–0.78). OCT-guided PCI reduced MACE (HR 0.75; 0.63–0.91; P = .003), cardiac death (HR 0.48; 0.27–0.83), myocardial infarction (HR 0.79; 0.63–0.99), ST (HR 0.40; 0.22–0.74), and TVR (HR 0.74; 0.57–0.97). Bayesian posterior probabilities of benefit exceeded 82% for all IVUS and 94% for all OCT endpoints. Indirect comparison detected no significant between-modality difference. Metaregression of IVUS trials revealed heterogeneity by geographic region (P < .001) and attenuation of benefit over time (β=+0.034/year; P = .004); OCT analyses were nonsignificant. Conclusions Both IVUS and OCT reduced major adverse cardiovascular events, revascularization, and stent thrombosis compared with angiography-guided PCI. These findings support intravascular imaging as a routine adjunct to PCI in the populations studied.