Intravascular imaging guidance in complex PCI: a meta-analysis of randomized trials across complex lesion subsets
In brief
Imaging-guided complex PCI cuts vessel failure 30%; 26 treated to prevent one
Across 15 randomized trials involving 11,557 patients, imaging-guided complex PCI reduced target-vessel failure by 30%, with 26 patients needing imaging guidance to prevent one event. Repeat procedures and stent thrombosis also fell, but all-cause mortality did not; benefits within specific lesion types remain uncertain because those analyses were exploratory.
- Journal
- International journal of cardiology (Q1)
- Published
- 8 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mattia Basile, Javier Gómez Herrero, Alejandro Lara García, José Maria de la Torre Hernández, Fernando Alfonso, Manuel Pan, et al.
- PMID
- 42849797
- DOI
- 10.1016/j.ijcard.2026.134971
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (paper of the day, 10 October 2026): IV imaging guidance reduces target vessel failure in complex PCI
Abstract
BACKGROUND: Recent randomized trials have reported conflicting results regarding the clinical benefit of intravascular imaging (IVI) in complex percutaneous coronary intervention (PCI). The aim of this research was to evaluate whether IVI guidance reduces target vessel failure (TVF) in complex PCI. METHODS: PubMed, Scopus, and the Cochrane Library were searched through June 2026 for randomized trials comparing IVI-guided with angiography-guided PCI in trial-defined complex PCI or extractable complex-lesion cohorts. Risk ratios (RRs) were pooled using random-effects models. Prespecified analyses evaluated left main, chronic total occlusion, bifurcation, and moderate-to-severely calcified lesions, with a sensitivity analysis excluding IVUS-CHIP. Secondary clinical outcomes and potential effect modification by imaging modality were evaluated in exploratory analyses. RESULTS: Fifteen trials, including 11,557 patients were analyzed. IVI reduced TVF (RR, 0.70; 95% confidence interval [CI], 0.56-0.86; number needed to treat, 26 [95% CI, 18-55]). Lesion-specific estimates consistently favored IVI but were not significant; all became significant after excluding IVUS-CHIP. IVI reduced target vessel revascularization (RR, 0.68; 95% CI, 0.53-0.87), target lesion revascularization (RR, 0.67; 95% CI, 0.52-0.85), and stent thrombosis (RR, 0.42; 95% CI, 0.24-0.73). All-cause mortality was not reduced, whereas IVI guidance showed a borderline association with 26% lower cardiovascular mortality (RR, 0.74; 95% CI, 0.54-1.00; p = 0.05). Effects were similar for intravascular ultrasound and optical coherence tomography (interaction p = 0.93). CONCLUSIONS: IVI guidance reduced TVF, repeat revascularization, and stent thrombosis in complex PCI, with consistent but exploratory effects across major lesion subsets and a borderline association with lower cardiovascular mortality.
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.