Clinical and procedural outcomes of IVUS-guided versus angiography-guided PCI in unprotected left main coronary disease: An updated meta-analysis of randomized controlled trials.
Abstract
Background
The clinical benefit of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery disease (ULMCAD) remains uncertain. We performed an updated meta-analysis of randomized controlled trials (RCTs) comparing IVUS-guided versus angiography-guided PCI in ULMCAD.
Methods
We performed a meta-analysis of RCTs identified through PubMed, Cochrane CENTRAL, Scopus, and Web of Science from inception through May 2026. The primary outcome was major adverse cardiovascular events (MACE) at the longest follow-up period. Dichotomous outcomes were analyzed as risk ratios (RRs) and continuous outcomes as mean differences (MDs), both with 95% confidence intervals (CIs).
Results
Four RCTs comprising 1446 patients were included. MACE showed no statistically significant difference between groups (RR 0.57, 95% CI 0.30-1.09; P = 0.09). However, following exclusion of OPTIMAL Trial leave-one-out sensitivity analyses, IVUS-guided PCI was associated with a statistically significant reduction in the incidence of MACE. No significant differences were observed between IVUS-guided and angiography-guided PCI regarding cardiac mortality (RR 0.68, 95% CI 0.27-1.73; P = 0.41), myocardial infarction (RR 0.93, 95% CI 0.68-1.28; P = 0.66), target lesion revascularization (RR 0.67, 95% CI 0.36-1.22; P = 0.18), target vessel revascularization (RR 0.63, 95% CI 0.30-1.33; P = 0.22), or stent thrombosis (RR 0.78, 95% CI 0.22-2.70; P = 0.69).
Conclusions
In this meta-analysis of randomized trials, the primary random-effects analyses showed no statistically significant benefit of IVUS-guided PCI over angiography-guided PCI for MACE or any of the evaluated secondary clinical outcomes in patients with ULMCAD. Findings from leave-one-out sensitivity analyses were exploratory and did not alter the neutral overall conclusion. Further adequately powered contemporary randomized trials are needed to determine whether IVUS guidance benefits selected patient or lesion subgroups.