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Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention for complex coronary
Zixiang Ye1, Ximena S Paredes2, Roberto Diletti3
1Cardialysis, Rotterdam, the Netherlands; Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Insights
Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) did not lower cardiac death or myocardial infarction in complex coronary lesions. However, IVUS-guided PCI reduced stent thrombosis and repeat revascularization, though findings were sensitive to publication bias.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Previous meta-analyses suggested benefits of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) over angiography-guided PCI.
- Recent large-scale randomized controlled trials (RCTs) necessitate an updated evaluation of IVUS-guided PCI efficacy.
Purpose of the Study:
- To compare the clinical outcomes of IVUS-guided PCI versus angiography-guided PCI in patients with complex coronary artery lesions.
- To evaluate the impact of IVUS guidance on major adverse cardiac events and revascularization rates.
Main Methods:
- Systematic search of RCTs comparing IVUS-guided PCI and angiography-guided PCI in PubMed/MEDLINE, EMBASE, and Cochrane Library.
- Random-effects model used for meta-analysis, calculating risk ratios (RRs) and 95% confidence intervals (CIs).
- Primary outcome: cardiac death; Secondary outcomes: all-cause death, myocardial infarction, stent thrombosis, and repeat revascularization.
Main Results:
- 12 RCTs with 7089 patients were included; mean follow-up was 18 months.
- No significant reduction in cardiac death, all-cause death, or myocardial infarction with IVUS-guided PCI.
- IVUS guidance significantly reduced definite stent thrombosis and repeat revascularization, but benefits were sensitive to publication bias.
Conclusions:
- IVUS-guided PCI did not decrease cardiac death, all-cause death, or myocardial infarction in complex coronary lesions.
- IVUS guidance was associated with lower rates of definite stent thrombosis and repeat revascularization.
- Selective use of IVUS guidance for complex coronary lesions is supported, warranting further research for optimization.
Background:
Previous meta-analyses have suggested that intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk of adverse outcomes compared with angiography-guided PCI in patients with coronary artery disease. However, several large-scale randomized controlled trials published recently have provided new evidence, necessitating an updated evaluation.
Objectives:
This updated meta-analysis aimed to compare the clinical effects of IVUS-guided PCI versus angiography-guided PCI in patients with complex coronary artery lesions.
Methods:
Randomized controlled trials (RCTs) comparing IVUS-guided PCI with angiography-guided PCI in patients with complex coronary anatomy were systematically searched in PubMed/MEDLINE, EMBASE, and the Cochrane Library. A random-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Sensitivity analyses and publication bias assessments were performed. The primary outcome was cardiac death. Secondary outcomes included all-cause death, myocardial infarction, stent thrombosis, any repeat revascularization, target lesion revascularization, and target vessel revascularization.
Results:
A total of 12 RCTs comprising 7089 patients were included, with a weighted mean follow-up of 18.0 months (range 12-24 months). Compared with angiography-guided PCI, IVUS-guided PCI was not associated with significant reductions in cardiac death (RR 1.02, 95% CI 0.76-1.38, P = 0.870), all-cause death (RR 0.97, 95% CI 0.77-1.22, P = 0.800), or myocardial infarction (RR 0.90, 95% CI 0.71-1.15, P = 0.370). However, IVUS guidance significantly reduced definite stent thrombosis (RR 0.31, 95% CI 0.12-0.77, P = 0.010), any repeat revascularization (RR 0.67, 95% CI 0.51-0.88, P = 0.007), target lesion revascularization (RR 0.73, 95% CI 0.55-0.97, P = 0.031), and target vessel revascularization (RR 0.70, 95% CI 0.52-0.95, P = 0.039). These revascularization benefits were attenuated and no longer statistically significant after trim-and-fill adjustment for potential publication bias.
Conclusions:
In patients undergoing PCI for complex coronary artery lesions, IVUS-guided PCI did not reduce the incidence of cardiac death, all-cause death, or myocardial infarction compared with angiography-guided PCI. It was, however, associated with lower rates of definite stent thrombosis and repeat revascularization, although these benefits were sensitive to potential publication bias and largely driven by contemporary trials. These results support the selective use of IVUS-guidance for treatment of complex coronary lesions and call for further studies to optimize its use.
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