Intravascular Imaging vs. Angiography Guidance for PCI

Study Questions:

What are outcomes among patients undergoing intravascular imaging-guided (intravascular ultrasound [IVUS] or optical coherence tomography [OCT]) percutaneous coronary intervention (PCI) compared to coronary angiography–guided PCI?

Methods:

Approximately 1,200 randomized controlled trials or observational studies comparing two or more invasive imaging modalities for PCI and those that had mortality as an endpoint were screened. Thirty-one studies from 1998-2016 were included in the meta analysis. The primary endpoint was all-cause mortality. Secondary endpoints were major adverse cardiac events (MACE), cardiovascular (CV) death, myocardial infarction (MI), target lesion revascularization, and stent thrombosis.

Results:

This was a systematic review and Bayesian meta-analysis of 31 studies evaluating 17,882 patients. When compared with coronary angiography, IVUS-guided PCI was associated with lower odds of all-cause death (odds ratio [OR], 0.74; 95% credible interval [CrI], 0.58-0.98), MI (OR, 0.72; 95% CrI, 0.52-0.93), target lesion revascularization (OR, 0.74; 95% CrI, 0.58-0.90), and stent thrombosis (OR, 0.42; 95% CrI, 0.20-0.72). OCT or IVUS were associated with lower rates of MACE and CV death. There was no difference in efficacy between IVUS or OCT. All-cause mortality benefit associated with IVUS was not seen when the analysis was restricted to randomized controlled trials only; however, CV death remained significantly lower regardless of the type of study.

Conclusions:

Intravascular imaging-guided PCI is associated with lower rates of MACE including CV death compared to coronary angiography-guided PCI.

Perspective:

This meta-analysis adds to the growing literature supporting the advantage of intravascular imaging guidance to optimize PCI results. Although there are more data supporting the use of IVUS, OCT also appears to provide similar efficacy. Routine use of intravascular guidance for all PCI is not warranted; however, consideration for additional imaging beyond angiography alone should be given to more complex interventions (diffuse lesions, left main interventions, bifurcations, etc.). Cost and increased contrast exposure (OCT) are also aspects that should be considered when deciding when to use enhanced imaging to guide PCI.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Cardiac Imaging Techniques, Coronary Angiography, Myocardial Infarction, Myocardial Revascularization, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Stents, Thrombosis, Tomography, Optical Coherence, Ultrasonography


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