IVUS, OCT, or Angiography as Guidance for PCI in Complex Coronary Artery Lesions: Network Meta-Analysis of Randomized Controlled Trials.

Background Intravascular imaging-guided percutaneous coronary intervention (PCI) reduces cardiovascular events compared with angiography-guided PCI alone. However, there is a paucity of data comparing these approaches in patients with complex coronary artery lesions and their respective subgroups.Objectives The aim of this study was to assess the impact of intravascular ultrasound (IVUS)-guided and optical coherence tomography (OCT)-guided PCI on reducing major adverse cardiovascular events (MACE) compared with angiography-guided PCI in different complex lesions subsets.Methods In this lesion-level network meta-analysis, the MEDLINE, Embase, and Cochrane databases were systematically searched to identify randomized controlled trials reporting outcomes following intravascular imaging-guided or angiography-guided PCI with drug-eluting stents (DES). OCT, IVUS, and angiography were separately compared as guidance for PCI. Using a frequentist random-effects model network meta-analysis, RRs with corresponding 95% CIs were calculated for each strategy. The primary endpoint was MACE, defined as a composite of cardiac death, myocardial infarction, or target vessel revascularization.Results Seventeen randomized controlled trials, encompassing 13,751 patients with complex coronary lesions undergoing PCI with DES were incorporated into the analysis. In the network comparison, both OCT (RR: 0.63; 95% CI: 0.55-0.72; P < 0.001) and IVUS (RR: 0.67; 95% CI: 0.56-0.79; P < 0.001) demonstrated superiority over angiography-guided PCI in preventing MACE in complex lesions. These results were consistent in the subgroups of patients with chronic total occlusions, left main coronary artery disease, bifurcation lesions, multivessel coronary artery disease, and moderately or severely calcified lesions. No significant difference in MACE was observed between OCT and IVUS (RR: 0.94; 95% CI: 0.78-1.14; P = 0.52).Conclusions In patients with complex coronary lesions undergoing PCI with DES, both OCT-guided PCI and IVUS-guided PCI are more effective at reducing MACE compared with angiography-guided PCI. These findings were consistent across various types of complex coronary lesions and suggest that intravascular imaging-guided PCI should be the preferred approach for this population.