Intracoronary Imaging-Guided Percutaneous Coronary Intervention: An Updated Meta-Analysis of Randomized Trials

Recent societal guidelines provide a Class I recommendation for intracoronary imaging (ICI)-guided percutaneous coronary intervention (PCI) for complex or left main coronary artery disease; however, recent trials have failed to show a benefit.

The study aim was to re-evaluate the efficacy of ICI-guided PCI and to explore heterogeneity of results across trials.

PubMed, Embase, Cochrane Central, and ClinicalTrials.gov databases were searched through June 3, 2026, for randomized controlled trials (RCTs) comparing outcomes with ICI-guided PCI vs angiography-guided PCI in the drug-eluting stent era. Direct comparison meta-analyses, mixed treatment comparison meta-analyses, trial sequential analyses, fragility analysis, and Bayesian meta-analyses were performed. Meta-regression analysis was performed to evaluate heterogeneity using the following variables: stent length (surrogate for lesion length), stent diameter, difference in postdilatation (percentage) between the groups, publication year, and geographic location.

A total of 28 RCTs met the inclusion criteria, comprising 24,634 patients (mean age 64.8 years; 75.9% male) with a mean follow-up of 22 months. ICI-guided PCI reduced target lesion failure (relative risk [RR]: 0.72; 95% CI: 0.61-0.85; I² = 61%), cardiac mortality (RR: 0.73; 0.58-0.91; I² = 5%), myocardial infarction (RR: 0.86; 0.75-0.97; I² = 0%), target vessel revascularization (RR: 0.69; 95% CI: 0.57-0.83, I² = 41%), stent thrombosis (RR: 0.55; 95% CI: 0.40-0.76; I² = 0%), and all-cause mortality (RR: 0.82; 95% CI: 0.70-0.96; I² = 0%) compared with angiography-guided PCI. Trial sequential analysis confirmed evidence for at least a 20% reduction in all outcomes with ICI-guided PCI. The fragility index was robust, ranging from 9 to 50. The posterior probability for benefit was >99% for all outcomes. Trial differences in geography and lesion characteristics explained most of the between-trial variance (residual tau = 0).

In this updated meta-analysis of RCTs, after accounting for modifier effects from recent studies, ICI-guided PCI was associated with significantly reduced cardiovascular events compared with angiography-guided PCI. Geographic heterogeneity across trials was present mainly for target vessel revascularization, explained in large part by differences in lesion characteristics and procedural technique.