IVUS-Guided versus Angiography-Guided PCI in Unprotected Left Main Coronary Artery Disease: An Updated Systematic Review and Meta-Analysis

Abstract Background The role of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in unprotected left main coronary artery disease (CAD) remains unclear, despite evidence suggesting improved procedural optimization and clinical outcomes compared with angiography-guided PCI. Methods We systematically searched the PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) and non-randomized studies comparing IVUS-guided PCI with angiography-guided PCI in patients with unprotected left main CAD. Risk ratios (RR) with corresponding 95% confidence intervals (CI) were pooled for binary outcomes using a random-effects model. Additional subgroup analyses were performed separately for randomized controlled trials and observational studies. Results Twelve studies (five RCTs and seven observational studies) comprising 20,897 patients who underwent PCI for unprotected left main CAD were included, of whom 9,058 (43.4%) underwent intravascular imaging-guided PCI. IVUS-guided PCI was associated with lower all-cause mortality (RR 0.64; 95% CI 0.53–0.78; p < 0.001; I² = 45.5%), cardiac mortality (RR 0.53; 95% CI 0.34–0.82; p = 0.005; I² = 65.2%), myocardial infarction (RR 0.80; 95% CI 0.67–0.95; p = 0.012; I² = 0%), and target vessel revascularization (RR 0.53; 95% CI 0.33–0.85; p = 0.009; I² = 73.4%) than angiography-guided PCI. However, no statistically significant difference was observed in stent thrombosis. Subgroup analyses demonstrated that observational studies primarily drove the observed benefits, whereas pooled RCT data remained neutral. Conclusion In patients undergoing PCI for unprotected left main coronary artery disease, IVUS-guided PCI was associated with improved clinical outcomes compared with angiography-guided PCI, with similar stent thrombosis rates.