Intravascular ultrasound versus angiogram guided drug eluting stent implantation. A systematic review and updated meta-analysis with trial sequential analysis

Abstract

Background Further advances have been achieved in the field of intravenous ultrasound (IVUS) guided drug eluting stent (DES) implantation and hence there was a need to rejuvenate the evidence. Hence, we performed a cumulative meta-analysis with trial sequential analysis (TSA) of randomized controlled trials (RCTs) comparing IVUS versus angiogram guided DES implantation. Methodology We searched PubMed/Medline and Cochrane database for relevant articles using predefined inclusion and exclusion criteria. Outcomes of interest were cardiovascular mortality, myocardial infarction (MI), target lesion revascularisation (TLR), stent thrombosis (ST). We used Mantel-Haenszel method with random error model to calculate odds ratio (OR) with 95% confidence interval (CI). We also performed TSA to accommodate for possible type I error. Results A total of 11 RCTs with 5352 patients were included in the final analysis. Follow up duration of included studies varied from 12 to 24 months. IVUS use was associated with significantly reduced incidence of cardiovascular mortality [OR: 0.45, CI: 0.25–0.80, p value = 0.007, I 2 = 0%, χ 2 p -value = 0.98], TLR [OR: 0.56, CI: 0.41–0.77, p value = 0.0004, I 2 = 0%, χ 2 p -value = 0.95] and ST [OR: 0.47, CI: 0.24–0.94, p value = 0.03, I 2 = 0%, χ 2 p -value = 0.75]. IVUS use had no effect on incidence of MI on follow up. The cumulative z curve crosses the TSA boundary indicating sufficient evidence without type I error for reduced incidence of cardiovascular mortality and TLR with the use IVUS. Conclusion IVUS-guided DES implantation should be the standard of care as it significantly reduced cardiovascular mortality and TLR.

Intravascular Imaging–Guided Versus Angiography‐Guided Percutaneous Coronary Intervention: A Systematic Review and Meta‐Analysis of Randomized Trials

“…Our analysis differs from prior published meta‐analytic work in several ways. 10 , 11 , 12 , 13 , 14 , 15 , 17 , 40 First, it includes newly available trial data with the publication of 1 new large trial and longer‐term follow‐up from 2 other trials. Second, we were able to obtain additional previously unpublished data from the principal investigators of some trials for certain outcomes and subgroups, ensuring that this study is the most exhaustive and complete representation of the existing trial data in the field (Table S6 ).…”

“…The majority of RCTs comparing intravascular imaging‐guided PCI to angiography‐guided PCI have a relatively small sample size and are therefore underpowered to detect differences in clinically important but low‐frequency events such as death. Prior meta‐analyses have focused on either IVUS or OCT separately compared with angiography or have included observational studies with their attendant limitations when comparing therapeutic strategies 1 , 11 , 12 , 13 , 14 , 15 or not included the most recently published RCTs in their analyses. 16 , 17 , 18 There have been additional recent RCT data, with the publication of 1 large new trial and additional follow‐up from previously published trials.…”

When to use intravascular ultrasound or optical coherence tomography during percutaneous coronary intervention?

“…Meta-analyses of randomized trials and registry data have shown significant major adverse cardiovascular event (MACE) reductions with IVUS-guided PCI compared with conventional angiography-guided PCI (52)(53)(54)(55). The IVUS-XPL trial (56) was a randomized study comparing IVUS-guided PCI with conventional angiography in 1,400 patients with lesions ≥28 mm in length that were treated with XIENCE (Abbott Vascular, Santa Clara, California) stents.…”

“…This was mainly driven by lower rates of TLR. A recent meta-analysis of 5,532 patients from 11 clinical trials showed statistically significant reductions in cardiovascular mortality (OR: 0.45, 95% CI: 0.25-0.80), TLR (OR: 0.56, 95% CI: 0.41-0.77) and stent thrombosis (OR: 0.47, 95% CI: 0.24-0.94) with IVUS-guided PCI compared with conventional angiography (52). In another meta-analysis, IVUS was particularly beneficial in complex coronary lesions such as left main disease, bifurcations, ACS and chronic total occlusions (CTO) (57).…”

Long-term outcomes of IVUS-guided and angiography-guided drug-eluting stent implantation for left main coronary artery disease: a retrospective consort study

“…Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are advanced intracoronary imaging techniques used to provide detailed 3D morphological information of coronary plaques, vessels, and stents. Studies have demonstrated that SI guided by IVUS can result in improved outcomes compared to angiography-guided implantation [ 5 ]. IVUS enables high-resolution, cross-sectional images of the coronary artery, allowing for precise assessment of the vessel lumen, plaque burden, and stent placement [ 6 , 7 ].…”