Intravascular imaging-guided percutaneous coronary intervention versus angiography guidance: updated meta-analysis of randomised trials

Background Angiography-guided percutaneous coronary intervention (PCI) can miss stent underexpansion or malapposition that intravascular imaging may detect and correct during the index procedure, potentially reducing downstream ischaemic events and repeat revascularisation. Purpose To quantify the clinical impact of intravascular imaging guidance and assess whether effects are consistent across intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Methods Trial composite endpoints are not uniform; to keep the analysis anchored to what each study actually tested, we pooled each trial’s prespecified primary composite outcome (major adverse cardiovascular events, target vessel failure, or target lesion failure) rather than applying post-hoc endpoint harmonisation. Pubmed and ScienceDirect were searched through February 2025 for randomised controlled trials comparing IVUS- or OCT-guided versus angiography-guided PCI. Outcomes were extracted at the longest reported follow-up. Risk ratios were pooled using a Mantel–Haenszel random-effects model; heterogeneity was assessed with I2. We prespecified subgroup analyses by imaging modality (IVUS vs OCT). Secondary outcomes included target lesion revascularisation, myocardial infarction, stent thrombosis and all-cause death when reported. Results Ten trials (12,343 patients; 6,174 imaging-guided and 6,169 angiography-guided) were included. Imaging guidance reduced the trial-defined primary composite endpoint (risk ratio 0.60, 95% confidence interval 0.54–0.68; I2=0%). Effects were consistent across modalities: IVUS 0.56 (0.48–0.65) and OCT 0.67 (0.56–0.80). The clearest downstream signal was fewer repeat procedures: in IVUS trials reporting target lesion revascularisation, the pooled risk ratio was 0.52 (0.34–0.80). Estimates for myocardial infarction, stent thrombosis and all-cause death were imprecise with no clear between-group differences, reflecting low event rates and incomplete reporting across trials. Conclusion In contemporary randomised evidence, intravascular imaging guidance during PCI improves trial-defined composite clinical outcomes compared with angiography guidance, with benefit most consistently reflected in fewer repeat revascularisations. The trade-off is uncertainty on hard endpoints, supporting the need for adequately powered, longer-term randomised trials.