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

Authors

• Ahmed Emara, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Ameer Awashra, Department of Medicine, An-Najah National University, Nablus, Palestine.
• Ahmed Mansour, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Ahmed Adel Azim, Faculty of Medicine, Assiut University, Assiut, Egypt.
• Heba Aboeldahab, Clinical Research Department, El-Gomhoria General Hospital, MOHP, Alexandria, Egypt.
• Belal Mohamed Hamed, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Abdalhakim Shubietah, Advocate Health - MidwestFollow
• Mahmoud Ismayl, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
• Fawzi Zghyer, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
• Giuseppe Andò, Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Papardo, Viale Ferdinando Stagno d'Alcontres, Messina, Italy. Electronic address: [email protected].

Recommended Citation

Emara A, Awashra A, Mansour A, et al. 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. Int J Cardiol. 2026;463:134755. doi:10.1016/j.ijcard.2026.134755

Affiliations

Advocate Illinois Masonic Medical Center

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 in 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.

Type

Article

PubMed ID

42648372