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Published on: September 14, 2009
Intravascular imaging-guided coronary drug-eluting stent implantation: an updated network meta-analysis
Gregg W Stone1, Evald H Christiansen2, Ziad A Ali3
1The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Insights
Intravascular imaging guidance for percutaneous coronary intervention (PCI) significantly reduces risks of death, myocardial infarction, and repeat revascularization compared to angiography alone. Optical coherence tomography (OCT) and intravascular ultrasound show similar benefits in drug-eluting stent procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Previous meta-analyses indicated reduced composite adverse events with intravascular imaging-guided PCI.
- Studies lacked power to confirm reduced all-cause death or myocardial infarction.
- Prior research predominantly used intravascular ultrasound, not newer optical coherence tomography (OCT).
Purpose of the Study:
- To assess the comparative effectiveness of intravascular imaging-guided PCI versus angiography-guided PCI.
- To evaluate outcomes in patients receiving drug-eluting stents.
- To include both intravascular ultrasound and OCT in the analysis.
Main Methods:
- Systematic review and updated meta-analysis of randomized controlled trials.
- Searched MEDLINE, Embase, and Cochrane databases up to August 30, 2023.
- Primary endpoint: target lesion failure (cardiac death, TV-MI, target lesion revascularisation).
- Network meta-analysis for direct and indirect treatment effects.
Main Results:
- 15,964 patients across 22 trials with a mean follow-up of 24.7 months.
- Intravascular imaging-guided PCI decreased target lesion failure (RR 0.71).
- Significant reductions observed in cardiac death (RR 0.55), TV-MI (RR 0.82), and revascularisation (RR 0.72).
- Reduced risks of stent thrombosis (RR 0.52), all MI (RR 0.83), and all-cause death (RR 0.75).
- OCT and intravascular ultrasound guidance showed similar outcomes.
Conclusions:
- Intravascular imaging guidance enhances safety and effectiveness of PCI with drug-eluting stents.
- Reduces risks of death, myocardial infarction, repeat revascularisation, and stent thrombosis compared to angiography.
- Both OCT and intravascular ultrasound are effective imaging modalities for guiding PCI.
Background:
Previous meta-analyses have shown reduced risks of composite adverse events with intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography guidance alone. However, these studies have been insufficiently powered to show whether all-cause death or all myocardial infarction are reduced with intravascular imaging guidance, and most previous intravascular imaging studies were done with intravascular ultrasound rather than optical coherence tomography (OCT), a newer imaging modality. We aimed to assess the comparative performance of intravascular imaging-guided PCI and angiography-guided PCI with drug-eluting stents.
Methods:
For this systematic review and updated meta-analysis, we searched the MEDLINE, Embase, and Cochrane databases from inception to Aug 30, 2023, for studies that randomly assigned patients undergoing PCI with drug-eluting stents either to intravascular ultrasound or OCT, or both, or to angiography alone to guide the intervention. The searches were done and study-level data were extracted independently by two investigators. The primary endpoint was target lesion failure, defined as the composite of cardiac death, target vessel-myocardial infarction (TV-MI), or target lesion revascularisation, assessed in patients randomly assigned to intravascular imaging guidance (intravascular ultrasound or OCT) versus angiography guidance. We did a standard frequentist meta-analysis to generate direct data, and a network meta-analysis to generate indirect data and overall treatment effects. Outcomes were expressed as relative risks (RRs) with 95% CIs at the longest reported follow-up duration. This study was registered with the international prospective register of systematic reviews (PROSPERO, number CRD42023455662).
Findings:
22 trials were identified in which 15 964 patients were randomised and followed for a weighted mean duration of 24·7 months (longest duration of follow-up in each study ranging from 6 to 60 months). Compared with angiography-guided PCI, intravascular imaging-guided PCI resulted in a decreased risk of target lesion failure (RR 0·71 [95% CI 0·63-0·80]; p<0·0001), driven by reductions in the risks of cardiac death (RR 0·55 [95% CI 0·41-0·75]; p=0·0001), TV-MI (RR 0·82 [95% CI 0·68-0·98]; p=0·030), and target lesion revascularisation (RR 0·72 [95% CI 0·60-0·86]; p=0·0002). Intravascular imaging guidance also reduced the risks of stent thrombosis (RR 0·52 [95% CI 0·34-0·81]; p=0·0036), all myocardial infarction (RR 0·83 [95% CI 0·71-0·99]; p=0·033), and all-cause death (RR 0·75 [95% CI 0·60-0·93]; p=0·0091). Outcomes were similar for OCT-guided and intravascular ultrasound-guided PCI.
Interpretation:
Compared with angiography guidance, intravascular imaging guidance of coronary stent implantation with OCT or intravascular ultrasound enhances both the safety and effectiveness of PCI, reducing the risks of death, myocardial infarction, repeat revascularisation, and stent thrombosis.
Funding:
Abbott.
