Intravascular Imaging–guided Percutaneous Coronary Intervention in Patients With and Without Diabetes: A Meta-analysis of Randomized Trials

Background Intravascular imaging improves percutaneous coronary intervention (PCI) outcomes, but its effect according to diabetes status remains insufficiently defined. Methods PubMed, Embase, and CENTRAL were systematically searched for randomized trials comparing intravascular imaging–guided vs angiography-guided PCI, or optical coherence tomography (OCT) vs intravascular ultrasound (IVUS), reporting outcomes by diabetes status. The primary outcome was target vessel failure (TVF) at ≥ 1 year. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated from event counts using a random-effects model. Results Eleven randomized controlled trials (n = 17,692) were included. Intravascular imaging–guided PCI reduces TVF compared with angiography guidance, with consistent effects in patients with diabetes (risk ratio [RR] 0.69, 95% confidence interval [CI] 0.53-0.90; P = 0.006) and without diabetes (RR 0.65, 95% CI 0.55-0.77; P < 0.001, P interaction = 0.72). Similar reductions were observed in complex PCI populations and with both IVUS and OCT guidance. In diabetes patients undergoing complex PCI, intravascular imaging likely reduces TVF (RR 0.74, 95% CI 0.53-1.04), whereas OCT guidance may reduce TVF (RR 0.70, 95% CI 0.42-1.16). In exploratory head-to-head analyses, OCT showed no difference in TVF risk compared with IVUS, with consistent findings across diabetes status. Meta-regression identified age and follow-up duration as potential effect modifiers in patients with diabetes. Conclusions Intravascular imaging–guided PCI reduces TVF compared with angiography guidance in both patients with and without diabetes. In some diabetic subgroups, intravascular imaging may reduce TVF, although estimates were imprecise. These findings support intravascular imaging to optimize PCI outcomes regardless of diabetes status. Copyright © 2026. Published by Elsevier Inc.