The Role of Vascular Imaging in Guiding Routine Percutaneous Coronary Interventions: A Meta-Analysis of Bare Metal Stent and Drug-Eluting Stent Trials

Background: The routine use of vascular imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in guiding percutaneous coronary interventions (PCI) is still controversial especially when using drug-eluting stents. A meta-analysis of trials using bare metal stents was previously published.

Methods: We conducted a meta-analysis of available published trials that compared imaging-guided PCI and angiography-guided PCI in patients undergoing routine PCI only. Trials that enrolled patients with acute coronary syndrome were excluded to decrease heterogeneity. We aimed to study both drug-eluting stents (DES) as well as bare metal stents (BMS). We identified seven randomized controlled trials on IVUS-guided bare metal stents. We also identified three randomized controlled trials on IVUS-guided drug-eluting stents. To improve the power of the drug-eluting stent data, we identified, and included, nine registries that compared IVUS-guided PCI to angiography-guided PCI in the drug-eluting stent era. Nonrandomized registries that included BMS only were excluded as there are multiple previous meta-analyses that studied these patients. Finally, we identified one registry that compared OCT-guided PCI to angiography-guided PCI using either a BMS or a DES. A total of 14,197 patients were studied overall. The meta-analysis was conducted using a random effect model.

Results: Imaging guidance was associated with a significantly larger postintervention minimal luminal diameter (SMD: 0.289. 95% CI: 0.213-0.365. P < 0.01). Imaging-guided stenting was associated with a significant decrease in the major adverse cardiac events (MACE) in the DES patients (odds ratio: 0.810. 95% CI: 0.719-0.912. P < 0.01) and combined DES and BMS patients (odds ratio: 0.782. 95% CI: 0.686-0.890. P < 0.01). Imaging guidance was associated with significantly lower events of death from all causes in DES patients (odds ratio: 0.654. 95% CI: 0.468-0.916. P < 0.01) and in the combined DES and BMS patients (odds ratio: 0.727. 95% CI: 0.540-0.980. P < 0.01). The risk of myocardial infarction (MI) was significantly lower with imaging guidance in both, DES patients (odds ratio: 0.551. 95% CI: 0.363-0.837. P < 0.01) and combined DES and BMS patients (odds ratio: 0.589. 95% CI: 0.425-0.816. P < 0.01). This may, in part, be explained by the significantly lower risk of stent thrombosis in imaging-guided DES patients (odds ratio: 0.651. 95% CI: 0.499-0.850. P < 0.01) and combined DES and BMS patients (odds ratio: 0.665. 95% CI: 0.513-0.862. P < 0.01). Patients who received a DES showed no difference between imaging guidance and angiography guidance in repeated target lesion revascularization, while the analysis of BMS alone and the DES and BMS combined showed significant superiority of the imaging-guided PCI group.

Conclusion: Imaging-guided PCI significantly lowered the risk of death, MI, stent thrombosis, and the combined MACE in DES-implanted patients and all stented patients (DES or BMS). However, imaging guidance had no significant effect on repeated target vessel or target lesion revascularization in patients who received DES, likely due to the effect of the drug in the stent.