Imaging-guided PCI improves outcomes in patients with multivessel disease a meta-analysis of randomized and observational trials comparing treatment of ACS

Objective: This meta-analysis sought to investigate if IVUS-guided PCI (IVUS-PCI) can improve outcomes compared to standard PCI and CABG in patients with multivessel CAD.

Background: Coronary artery disease (CAD) is traditionally revascularized by either percutaneous coronary intervention (PCI) or coronary artery bypass (CABG) with a historical benefit of CABG over PCI in multivessel CAD. Intravascular ultrasound-guided PCI (IVUS-PCI) may improve outcomes compared to angiography alone.

Methods: We undertook a systematic search using PubMed, MEDLINE, EMBASE, Web of Science, and Ovid from 2017 through 2022. We included randomized controlled trials and observational trials comparing PCI vs CABG for multivessel CAD evaluated by two independent reviewers. We extracted baseline data and major adverse cardiovascular events (MACE; death from any cause, MI, stroke, or repeat revascularization) at one year. Three trials were selected based on study arm criteria: FAME 3, BEST, and Syntax II.

Results: IVUS-PCI significantly reduced death from any cause (OR 0.45, CI 0.272-0.733, p = 0.001), repeat revascularization (OR 0.62, CI 0.41-0.95, p = 0.03), and showed a non-significant reduction in MACE (OR 0.74, CI 0.54-1.01, p = 0.054) when compared to CABG. IVUS-PCI significantly reduced MACE (OR 0.52, CI 0.38-0.72, p < 0.001) and showed a non-significant reduction in death (OR 0.66, CI 0.36-1.18, p = 0.16) and numerically reduced repeat revascularization (OR 0.66, CI95 0.431-1.02, p = 0.06) when compared to PCI without IVUS.

Conclusion: IVUS-PCI reduces cardiovascular outcomes in patients with multivessel disease compared to CABG and angiographically-guided PCI at one year. These results reinforce the importance of IVUS-PCI in complex CAD and provide evidence for improved PCI outcomes compared to CABG for multivessel CAD.