Intravascular Imaging-Guided Drug-Eluting Stenting for Complex Coronary Lesions

Background Intravascular imaging (IVI) guidance improves percutaneous coronary intervention (PCI) outcomes, yet recent randomized controlled trials (RCTs) challenged these findings. Objectives This study aimed to evaluate the efficacy and safety of IVI-guided vs angiography-guided PCI in complex coronary lesions, incorporating recent large-scale trials with divergent findings. Methods The authors conducted a meta-analysis of RCTs evaluating IVI-guided vs angiography-guided PCI among patients with complex coronary lesions. The primary outcomes were major adverse cardiovascular events (MACE) and cardiac death. Pooled risk ratios (RRs) with 95% CIs were calculated using frequentist random-effects models and complementary Bayesian analyses. The analysis was complemented by several sensitivity and subgroup analyses. Results Eighteen RCTs enrolling 18,975 patients were included. IVI guidance was associated with significant reductions in MACE (RR: 0.67; 95% CI: 0.55-0.83), cardiac death (RR: 0.72; 95% CI: 0.53-0.97), myocardial infarction (RR: 0.87; 95% CI: 0.76-0.998), clinically driven target lesion revascularization (RR: 0.72; 95% CI: 0.51-0.999), and stent thrombosis (RR: 0.52; 95% CI: 0.35-0.78). A significant geographic interaction was identified for MACE, with benefit predominantly driven by Asian trial populations ( P interaction < 0.01). In subgroup analysis, patients achieving imaging-defined stent optimization were associated with lower event rates than those who did not (RR: 0.41; 95% CI: 0.26-0.62). Conclusions IVI guidance reduces the risk of adverse events for complex lesions. The benefit was in part driven by achieving imaging-defined stent optimization.