Abstract 4361778: Comparative efficacy of percutaneous coronary intervention guidance strategies: A network meta-analysis of 80 randomized clinical trials with reconstructed time-to-event analysis

Background: Recent randomized controlled trials (RCTs) of various strategies to guide percutaneous coronary intervention (PCI) have yielded mixed results. We aimed to compare the outcomes with various PCI guidance strategies, including coronary angiography (CA), optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), quantitative flow ratio (QFR), and instantaneous wave-free ratio (iFR). Method: We searched electronic databases until March 2025 to include RCTs that assessed the clinical outcomes with IVUS, FFR, QFR, iFR, and OCT compared to CA among patients undergoing PCI. The primary outcome was major adverse cardiac events (MACEs). Network meta-analysis was performed using a frequentist framework. The outcomes were reported as risk ratios (RR) with 95% confidence intervals (CIs) using a random-effect model. Results: Eighty studies, encompassing 45,146 patients, were included. Compared to CA, IVUS (RR 0.70, 95%CI 0.61-0.80), OCT (RR 0.74, 95%CI 0.58-0.93), and FFR (RR 0.82, 95%CI 0.70-0.95) were associated with a lower incidence of MACE. IVUS (RR 0.81, 95%CI 0.66-0.98), OCT (RR 0.75, 95%CI 0.56-0.99), and FFR (RR 0.75, 95%CI 0.59-0.94) were associated with a lower incidence of myocardial infarction. IVUS and OCT were also associated with a lower incidence of cardiovascular mortality (IVUS: RR 0.57, 95%CI 0.42-0.76; OCT: RR 0.51, 95%CI 0.29-0.88), stent thrombosis (IVUS: RR 0.60, 95% CI 0.41-0.88; OCT: RR 0.55, 95% CI 0.36-0.85) and ischemia-driven target lesion revascularization (IVUS: RR 0.62, 95% CI 0.42-0.90; OCT: RR 0.64, 95% CI 0.43-0.95) Conclusion: Intracoronary imaging and FFR guidance were associated with improved outcomes compared with CA. Intracoronary imaging was also associated with a lower incidence of cardiovascular mortality, stent thrombosis, and ischemia-driven TLR. These findings emphasize the importance of integrating intracoronary imaging and FFR to guide PCI decisions.