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Intravascular Imaging–Guided PCI vs. Angiography-Guided PCI
Quick Takes
- Several large randomized clinical trials (RCTs) evaluating intravascular imaging (IVI)– vs. invasive coronary angiography (ICA)–guided PCI have shown inconsistent results. Authors of the current analysis performed a robust network analysis and systemic review of prior RCTs and compared both IVUS and OCT (combined as IVI) to ICA-guided PCI.
- Compared with ICA-guided PCI, IVI-guided PCI was associated with a significant reduction in ischemia-driven TLR with the most robust evidence supporting the role of IVUS (compared to OCT).
- There was no significant difference in rates of MI between IVI- and ICA-guided strategies.
- Although OCT-guided PCI was associated with reduced cardiac death and stent thrombosis compared with ICA-guided PCI, results were inconsistent across analyses.
Study Questions:
What are clinical outcomes in prior randomized clinical trials (RCTs) comparing invasive coronary angiography (ICA)–guided versus intravascular imaging (IVI)–guided percutaneous coronary intervention (PCI) (intravascular-guided ultrasound [IVUS] and optical coherence tomography [OCT])?
Methods:
Major electronic databases were searched to identify eligible trials evaluating ≥2 PCI guidance strategies among ICA, IVUS, and OCT. The two coprimary outcomes were target lesion revascularization (TLR) and myocardial infarction (MI). The secondary outcomes included ischemia-driven TLR, target vessel MI, death, cardiac death, target vessel revascularization, stent thrombosis, and major adverse cardiac events. Frequentist random-effects network meta-analyses were conducted. The results were replicated by Bayesian random-effects models. Pairwise meta-analyses of the direct components, multiple sensitivity analyses, and pairwise meta-analyses of IVI versus ICA were supplemented.
Results:
The results from 24 randomized trials (15,489 patients: IVUS vs. ICA, 46.4%, 7,189 patients; OCT vs. ICA, 32.1%, 4,976 patients; OCT vs. IVUS, 21.4%, 3,324 patients) were included in the network meta-analyses. IVUS was associated with reduced TLR compared with ICA (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.54–0.87), whereas no significant differences were observed between OCT and ICA (OR, 0.83; 95% CI, 0.63–1.09) and OCT and IVUS (OR, 1.21; 95% CI, 0.92–1.58). MI did not significantly differ between guidance strategies (IVUS vs. ICA: OR, 0.91; 95% CI, 0.70–1.19; OCT vs. ICA: OR, 0.87; 95% CI, 0.68–1.11; OCT vs. IVUS: OR, 0.96; 95% CI, 0.69–1.33). These results were consistent with the secondary outcomes of ischemia-driven TLR, target vessel MI, and target vessel revascularization, and sensitivity analyses generally did not reveal inconsistency.
OCT was associated with a significant reduction of stent thrombosis compared with ICA (OR, 0.49; 95% CI, 0.26–0.92), but only in the frequentist analysis. Similarly, the results in terms of survival between IVUS or OCT and ICA were uncertain across analyses. A total of 25 randomized trials (17,128 patients) were included in the pairwise meta-analyses of IVI versus ICA where IVI guidance was associated with reduced TLR, cardiac death, and stent thrombosis.
Conclusions:
IVI-guided PCI was associated with a reduction in ischemia-driven TLR compared with ICA-guided PCI, with the difference most evident for IVUS. In contrast, no significant differences in MI were observed between guidance strategies.
Perspective:
Several large RCTs evaluating IVI- vs. ICA-guided PCI have shown inconsistent results. The authors of the current analysis performed a robust network analysis and systemic review of prior RCTs and compared both IVUS and OCT (combined as IVI) to ICA-guided PCI. Compared with ICA-guided PCI, IVI-guided PCI was associated with a significant reduction in ischemia-driven TLR with the most robust evidence supporting the role of IVUS (compared to OCT). Use of IVI had no impact on rates of MI. Although OCT-guided PCI was associated with reduced cardiac death and stent thrombosis compared with ICA-guided PCI, results were inconsistent across analyses.
Findings leave unanswered questions about the role of IVI in clinical practice, especially as it pertains to more prognostically relevant clinical endpoints like cardiac death, stent thrombosis, and MI. IVUS use results in lower rates of ischemia-driven TLR; however, there remains uncertainty around OCT and its benefits in guiding PCI. Whether there is benefit of IVI in certain lesion and patient subsets remains to be determined.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Coronary Angiography, Tomography, Optical Coherence, Ultrasonography, Interventional
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