Intravascular Imaging-Guided Drug-Eluting Stenting for Complex Coronary Lesions: A Meta-Analysis of Randomized Controlled Trials
In brief
Imaging-guided stenting cut major events by one-third in complex lesions
In 18 randomized trials involving nearly 19,000 patients, imaging-guided stenting was linked to 33% fewer major cardiovascular events than angiography-guided stenting, along with fewer cardiac deaths and stent clots. The overall benefit was driven predominantly by Asian trial populations, so how consistently it applies across regions remains an open question.
- Journal
- JACC. Advances (Q1)
- Published
- 15 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mohammed A Elbahloul, Bahaa El Deen Wehbeh, Ahmed Samy Badran, Hadeel Aboueisha, Atef Akoum, Ayman Elbadawi, et al.
- PMID
- 42879937
- DOI
- 10.1016/j.jacadv.2026.103340
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (paper of the day, 18 October 2026): IVI‑guided drug‑eluting stenting meta‑analysis for complex lesions
Abstract
BACKGROUND: Intravascular imaging (IVI) guidance improves percutaneous coronary intervention (PCI) outcomes, yet recent randomized controlled trials (RCTs) challenged these findings. OBJECTIVES: This study aimed to evaluate the efficacy and safety of IVI-guided vs angiography-guided PCI in complex coronary lesions, incorporating recent large-scale trials with divergent findings. METHODS: The authors conducted a meta-analysis of RCTs evaluating IVI-guided vs angiography-guided PCI among patients with complex coronary lesions. The primary outcomes were major adverse cardiovascular events (MACE) and cardiac death. Pooled risk ratios (RRs) with 95% CIs were calculated using frequentist random-effects models and complementary Bayesian analyses. The analysis was complemented by several sensitivity and subgroup analyses. RESULTS: Eighteen RCTs enrolling 18,975 patients were included. IVI guidance was associated with significant reductions in MACE (RR: 0.67; 95% CI: 0.55-0.83), cardiac death (RR: 0.72; 95% CI: 0.53-0.97), myocardial infarction (RR: 0.87; 95% CI: 0.76-0.998), clinically driven target lesion revascularization (RR: 0.72; 95% CI: 0.51-0.999), and stent thrombosis (RR: 0.52; 95% CI: 0.35-0.78). A significant geographic interaction was identified for MACE, with benefit predominantly driven by Asian trial populations (Pinteraction < 0.01). In subgroup analysis, patients achieving imaging-defined stent optimization were associated with lower event rates than those who did not (RR: 0.41; 95% CI: 0.26-0.62). CONCLUSIONS: IVI guidance reduces the risk of adverse events for complex lesions. The benefit was in part driven by achieving imaging-defined stent optimization.
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.