Across 28 trials, imaging-guided PCI cut deaths, infarcts and stent thrombosis

Design

Meta-analysis of randomised trials with trial sequential and Bayesian analyses

Population

28 RCTs, 24,634 patients undergoing drug-eluting stent PCI

Primary outcome

Target lesion failure, cardiac and all-cause death, MI, stent thrombosis

Effect

TLF RR 0.72 (0.61–0.85); all-cause death RR 0.82 (0.70–0.96); stent thrombosis RR 0.55 (0.40–0.76)

An updated meta-analysis in JACC (10 September) pooled 28 randomised trials — 24,634 patients followed for a mean of 22 months — comparing intravascular ultrasound or OCT guidance with angiography guidance for drug-eluting stent PCI. It was prompted by recent trials that had shown no benefit.

Imaging guidance lowered target lesion failure (RR 0.72, 95% CI 0.61 to 0.85), cardiac death (RR 0.73, 0.58 to 0.91), myocardial infarction (RR 0.86, 0.75 to 0.97), stent thrombosis (RR 0.55, 0.40 to 0.76) and all-cause death (RR 0.82, 0.70 to 0.96). Heterogeneity was moderate for target lesion failure (I² = 61%) and near zero for death, infarction and stent thrombosis. Differences between trials were explained largely by region and lesion characteristics, including stent length and how much post-dilatation was done.

This strengthens the case already made in guidelines for complex and left main PCI, and suggests the neutral recent trials reflect who was enrolled and how the imaging was acted on, rather than a lack of effect. In India, cost and catheter availability limit routine use; the gains are most defensible in long lesions, left main and bifurcations, where the trials that drove the benefit were concentrated. Imaging only helps if its findings change the procedure — sizing, expansion, post-dilatation.

• Consider intravascular imaging for complex, long-lesion, left main and bifurcation PCI.
• Act on the images: optimise stent size, expansion and post-dilatation, or the benefit is lost.
• The mortality benefit came with low heterogeneity, which makes it more credible.
• Where cost limits access, prioritise imaging for the most complex lesions.

Why it matters

It answers the recent neutral trials: the benefit holds when pooled, including for death and stent thrombosis.

Don't overread it

Pooled trials enrolled different lesions and regions; the size of benefit in simple, short-lesion PCI is less certain.

The statistics, in plain English

A relative risk of 0.82 for all-cause death means about 18% fewer deaths with imaging guidance. I² describes how much trials disagree: 0% for death and stent thrombosis means consistent results; 61% for target lesion failure means trials varied, which the authors traced mainly to region and lesion type. A fragility index of 9 to 50 means that many events would need to flip before significance was lost.

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