Comparing Fractional Flow Reserve Versus Intravascular Ultrasound for Percutaneous Coronary Intervention Guidance: A Systematic Review and Meta-Analysis

Assessing lesion severity and optimizing percutaneous coronary intervention (PCI) are crucial for improving long-term outcomes in patients with coronary artery disease. Both strategies offer advantages over angiography alone; however, direct comparisons for revascularization decision-making are limited. This study evaluates and compares outcomes of FFR versus intravascular ultrasound (IVUS)-guided PCI strategies. We searched PubMed, Cochrane Central, and ScienceDirect from inception till April 2025. Data for various outcomes were extracted after computing the random-effect model and risk ratio (RR) with a 95% confidence interval (CI). The quality assessment of the included randomized controlled trials and observational studies was conducted using the Cochrane Risk of Bias 2 (ROB-2) and the Newcastle-Ottawa Scale, respectively. Publication bias was assessed visually through funnel plots and statistically through Egger's regression test. We included 5 studies comparing FFR and IVUS in 4714 patients undergoing PCI. The FFR and IVUS groups demonstrated comparable results across all endpoints including major adverse cardiovascular events (RR: 1.05; 95% CI: 0.84-1.30; P = 0.68), all-cause mortality (RR: 0.84; 95% CI: 0.50-1.39; P = 0.49), cardiac death (RR: 1.05; 95% CI: 0.59-1.87; P = 0.87), nonfatal myocardial infarction (RR: 1.31; 95% CI: 0.70-2.44; P = 0.40), and target vessel revascularization (RR: 1.20; 95% CI: 0.78-1.84; P = 0.40). The FFR (either hyperemic or angiography-driven) and IVUS groups showed comparable clinical outcomes in PCI for intermediate coronary lesions. However, FFR adds value with enhanced cost-efficiency and a physiology-driven approach that avoids unnecessary interventions. Selection should depend on patient factors, operator expertise, and institutional resources.