The following are key points to remember from an updated network meta-analysis on intravascular imaging-guided coronary drug-eluting stent (DES) implantation:

1. The current systematic review and meta-analysis aimed to assess the comparative performance of intravascular imaging-guided percutaneous coronary intervention (PCI) and angiography-guided PCI with DES.
2. Existing data on clinical benefits of intravascular imaging have been debated, especially for the outcomes of all-cause death and myocardial infarction (MI). Four recently published randomized controlled trials were included in the current meta-analysis to overcome the limitation of previous studies.
3. Included were studies (22 trials) that randomly assigned patients undergoing PCI with DES (n = 15,964) either to intravascular ultrasound or optical coherence tomography (OCT), or both, or to angiography alone to guide the intervention.
4. The primary endpoint was target lesion failure, defined as the composite of cardiac death, target vessel MI, or target lesion revascularization, assessed in patients randomly assigned to intravascular imaging guidance (intravascular ultrasound or OCT) versus angiography guidance.
5. Compared with angiography-guided PCI, intravascular imaging-guided PCI resulted in a decreased risk of target lesion failure (relative risk [RR], 0.71; 95% confidence interval [CI], 0.63–0.80; p < 0.0001).
6. The composite endpoint was driven by reductions in the risks of cardiac death (RR, 0.55; 95% CI, 0.41–0.75; p = 0.0001), target vessel MI (RR, 0.82; 95% CI, 0.68–0.98; p = 0.030), and target lesion revascularization (RR, 0.72; 95% CI, 0.60–0.86; p = 0.0002).
7. Intravascular imaging guidance also reduced the risks of stent thrombosis (RR, 0.52; 95% CI, 0.34–0.81; p = 0.0036), all MI (RR, 0.83; 95% CI, 0.71–0.99; p = 0.033), and all-cause death (RR, 0.75; 95% CI, 0.60–0.93; p = 0.0091).
8. The current study findings showed no significant difference in outcomes between OCT-guided or intravascular ultrasound–guided PCI. However, another recent meta-analysis did not find equivocal outcomes and benefits for OCT.
9. Limitations of all meta-analyses apply to the current study (the component of trial variation, lack of individual-level patient data, and temporal relationship on intervention and outcomes).
10. The current analysis is unable to identify clinical or anatomic subgroups that may benefit more from intravascular imaging than others.
11. Future research will need to: a) better understand specific reasons for limited application of intravascular imaging to facilitate coronary intervention in clinical practice despite the burgeoning evidence base supporting its benefits, and b) refine patient selection and intravascular imaging techniques to effectively guide PCI procedures.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Drug-Eluting Stents, Percutaneous Coronary Intervention, Ultrasonography, Interventional

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