Key result
Imaging-guided PCI reduces target vessel failure ~37% vs. angiography guidance in complex procedures.
Why the study?
Data regarding intravascular imaging in complex PCI remain scarce, motivating this assessment of IVI-guided PCI according to procedural complexity.
Does intravascular imaging-guided PCI reduce target vessel failure compared to angiography-guided PCI across varying levels of procedural complexity in patients with complex coronary artery lesions?
RCT (n=1,639)
Open-label
2:1 ratio (post hoc analysis of RENOVATE-COMPLEX-PCI)
Yes
Does intravascular imaging-guided PCI reduce target vessel failure compared to angiography-guided PCI across varying levels of procedural complexity in patients with complex coronary artery lesions?
In patients undergoing complex PCI, intravascular imaging guidance significantly reduces target vessel failure compared to angiography guidance, with the clinical benefit becoming progressively more pronounced in moderate- and high-complexity procedures.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Imaging reduced target vessel failure across the spectrum, while its absolute benefit generally became larger as complexity accumulated. We argued then, as we do now, that imaging is a strategy of procedural precision whose benefit becomes easier to demonstrate and more efficient to harness as risk rises. It is not a therapy that abruptly starts working once a threshold is crossed.”
“Until then, the more coherent interpretation is that intracoronary imaging improves the precision of complex PCI and clinical outcomes across the spectrum of risk, while increasing lesion complexity makes the consequences of proceeding without imaging guidance more readily apparent.”
“The authors ask whether the benefit of intracoronary imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) varies according to percutaneous coronary intervention (PCI) procedural complexity. The results appear persuasive. Target vessel failure with imaging versus angiography was 4.5% versus 5.6% in the low-complexity group, 5.4% versus 13.1% in the moderate-complexity group, and 8.2% versus 12.4% in the high-complexity group, respectively, with an interaction p-value of 0.009.”
Supports intravascular imaging for moderate- and high-complexity PCI; extends RCT evidence by confirming complexity-dependent benefit.
Background: Data regarding intravascular imaging (IVI) in complex percutaneous coronary intervention (PCI) remain scarce. Aims: In this study, we sought to assess the effects of IVI-guided PCI according to procedural complexity. Methods: analysis of the RENOVATE-COMPLEX-PCI trial that compared IVI-guided PCI with angiography-guided PCI in patients with complex coronary artery lesions. The study population was stratified into three groups of low, moderate, and high risk, according to PCI procedural complexity, following the European Society of Cardiology criteria. The high-risk group included patients meeting at least one clinical risk criterion and at least one procedural risk criterion. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularisation. Results: At a median 2.1-year follow-up, TVF risk increased significantly in a stepwise manner from the low (reference) to moderate (adjusted hazard ratio [HR] 1.369, 95% confidence interval [CI]: 0.705-2.660; p=0.353) and high procedural complexity group (adjusted HR 1.619, 95% CI: 0.963-2.723; p=0.069). The benefit of IVI-guided PCI varied by procedural complexity, with significant risk reductions in the moderate-risk group (adjusted HR 0.374, 95% CI: 0.150-0.935; p=0.035) and the high-risk group (adjusted HR 0.633, 95% CI: 0.424-0.945; p=0.025) but not in the low-risk group (adjusted HR 0.735, 95% CI: 0.282-1.914; p=0.528). The interaction between the IVI effect and procedural complexity was statistically significant (pinteraction=0.009). Conclusions: In patients undergoing complex PCI, an IVI-guided procedure significantly reduced adverse cardiac events, with a greater magnitude of benefit observed in procedures of high complexity.
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Kim et al. (2026) conducted an RCT in Complex coronary artery lesions undergoing percutaneous coronary intervention (PCI) (n=1,639). Intravascular imaging (IVI)-guided PCI vs. Angiography-guided PCI was evaluated on Target vessel failure (composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularisation) in high procedural complexity group (Adjusted HR 0.633, 95% CI 0.424-0.945, p=0.025). Intravascular imaging-guided PCI reduced target vessel failure compared with angiography guidance in high-complexity (adjusted HR 0.633, p=0.025) and moderate-complexity procedures (p_int=0.009).
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