Background
Although intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) is associated with a lower risk of major adverse cardiovascular events (MACE) in all comers, the benefits of IVUS in patients with complex and high-risk PCI is less clear.
Methods
We performed a systematic review and meta-analysis of studies that compared the long-term outcomes of IVUS-guided versus angiography-guided PCI in patients with chronic total occlusion (CTO), bifurcation lesions, left main coronary artery (LMCA) lesions and acute myocardial infarction (AMI)
Results
Data from twenty-six studies, with 37,625 patients (IVUS = 11,647 and angiography = 25,978), were analyzed. Overall, the use of IVUS was associated with a lower risk of MACE (OR 0.75, 95% CI [0.66, 0.86], P<0.01), all-cause mortality (OR 0.6, 95% CI [0.5, 0.73],
P<0.01), cardiac death (OR 0.44, 95% CI [0.32, 0.59],
P<0.01), MI (OR 0.72, 95% CI [0.58, 0.9],
P<0.01), TVR (OR 0.73, 95% CI [0.58, 0.92],
P<0.01), TLR (OR 0.7, 95% CI [0.53, 0.92],
P=0.01), composite of definitive and probable ST (OR 0.54, 95% CI [0.34, 0.85],
P<0.01) and definitive ST (OR 0.47, 95% CI [0.26, 0.85],
P=0.01). In LMCA PCI, IVUS was associated with a lower risk of MACE (OR 0.6, 95% CI [0.5, 0.73],
P<0.01), all-cause mortality (OR 0.51, 95% CI [0.39, 0.67],
P<0.01), cardiac death (OR 0.35, 95% CI [0.24, 0.51],
P<0.01), MI (OR 0.7, 95% CI [0.57, 0.86],
P<0.01) and TLR (OR 0.42, 95% CI [0.26, 0.67],
P<0.01). In CTO PCI, IVUS was associated with a lower risk of composite definitive and probable ST (OR 0.19, 95% CI [0.05, 0.67],
P=0.01). In bifurcation PCI, IVUS was associated with a lower risk of all-cause mortality (OR 0.58, 95% CI [0.39, 0.85],
P<0.01), cardiac death (OR 0.4, 95% CI [0.18, 0.93],
P=0.03) and TVR (OR 0.47, 95% CI [0.26, 0.85],
P=0.01). In AMI PCI, both strategies had similar outcomes.
Conclusions
In patients with complex and high-risk PCI, IVUS was associated with better long-term clinical outcomes compared with angiography. IVUS guided PCI showed the greatest benefit among patients with LMCA lesions. During bifurcation PCI, IVUS was associated with lower all-cause and cardiac mortality, while during CTO PCI, IVUS was associated with a lower risk of ST.