Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention for complex coronary lesions: A systematic review and meta-analysis
In brief
IVUS guidance cuts definite stent thrombosis risk by roughly two thirds
In a meta-analysis of 12 randomized trials (7089 patients, average 18-month follow-up), intravascular ultrasound-guided PCI did not lower cardiac death, overall death, or heart attack versus angiography alone, but it reduced definite stent thrombosis by about 70% and lowered repeat revascularization by one third. The revascularization benefit faded after statistical adjustment for possible publication bias, so IVUS may be best reserved for selected complex lesions.
- Journal
- Cardiovascular revascularization medicine : including molecular interventions (Q2)
- Published
- 31 July 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Zixiang Ye, Ximena S Paredes, Roberto Diletti, Luca Testa, Joost Daemen, Jose M de la Torre Hernandez, et al.
- PMID
- 42557127
- DOI
- 10.1016/j.carrev.2026.07.019
Why clinicians should know about it
- Picked for Anatomy (top studies of the week, 9 August 2026).
Abstract
BACKGROUND: Previous meta-analyses have suggested that intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk of adverse outcomes compared with angiography-guided PCI in patients with coronary artery disease. However, several large-scale randomized controlled trials published recently have provided new evidence, necessitating an updated evaluation. OBJECTIVES: This updated meta-analysis aimed to compare the clinical effects of IVUS-guided PCI versus angiography-guided PCI in patients with complex coronary artery lesions. METHODS: Randomized controlled trials (RCTs) comparing IVUS-guided PCI with angiography-guided PCI in patients with complex coronary anatomy were systematically searched in PubMed/MEDLINE, EMBASE, and the Cochrane Library. A random-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Sensitivity analyses and publication bias assessments were performed. The primary outcome was cardiac death. Secondary outcomes included all-cause death, myocardial infarction, stent thrombosis, any repeat revascularization, target lesion revascularization, and target vessel revascularization. RESULTS: A total of 12 RCTs comprising 7089 patients were included, with a weighted mean follow-up of 18.0 months (range 12-24 months). Compared with angiography-guided PCI, IVUS-guided PCI was not associated with significant reductions in cardiac death (RR 1.02, 95% CI 0.76-1.38, P = 0.870), all-cause death (RR 0.97, 95% CI 0.77-1.22, P = 0.800), or myocardial infarction (RR 0.90, 95% CI 0.71-1.15, P = 0.370). However, IVUS guidance significantly reduced definite stent thrombosis (RR 0.31, 95% CI 0.12-0.77, P = 0.010), any repeat revascularization (RR 0.67, 95% CI 0.51-0.88, P = 0.007), target lesion revascularization (RR 0.73, 95% CI 0.55-0.97, P = 0.031), and target vessel revascularization (RR 0.70, 95% CI 0.52-0.95, P = 0.039). These revascularization benefits were attenuated and no longer statistically significant after trim-and-fill adjustment for potential publication bias. CONCLUSIONS: In patients undergoing PCI for complex coronary artery lesions, IVUS-guided PCI did not reduce the incidence of cardiac death, all-cause death, or myocardial infarction compared with angiography-guided PCI. It was, however, associated with lower rates of definite stent thrombosis and repeat revascularization, although these benefits were sensitive to potential publication bias and largely driven by contemporary trials. These results support the selective use of IVUS-guidance for treatment of complex coronary lesions and call for further studies to optimize its use.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.