Intravascular Imaging-Guided Percutaneous Coronary Intervention for Calcified Coronary Lesions: A Network Meta-Analysis

BACKGROUND: The role of intravascular imaging guidance in percutaneous coronary intervention (PCI) of calcified coronary lesions remains incompletely defined. OBJECTIVES: The objective of the study was to compare intravascular ultrasound (IVUS) or optical coherence tomography (OCT) vs angiography-guided PCI in patients with calcified coronary lesions. METHODS: A systematic review and frequentist network meta-analysis was conducted. Randomized and observational studies comparing IVUS-, OCT-, and angiography-guided PCI in calcified lesions were included. The primary endpoint was major adverse cardiovascular events (MACE), defined as cardiac death, target vessel myocardial infarction, and target vessel revascularization (TVR). Secondary endpoints included target vessel failure, target lesion revascularization, TVR, minimum stent area (MSA), and stent thrombosis. RESULTS: Ten studies including 4,003 patients were included. IVUS- and OCT-guided PCI were associated with significantly lower MACE compared with angiography guidance (IVUS: relative risk [RR]: 0.56; 95% CI: 0.37-0.86; OCT: RR: 0.65; 95% CI: 0.52-0.82), with no statistically significant differences between imaging modalities. Results were consistent in randomized controlled trial-only sensitivity analyses. Stent thrombosis was also significantly lower with IVUS (RR: 0.15; 95% CI: 0.03-0.89) and OCT (RR: 0.12; 95% CI: 0.03-0.46). OCT-guided PCI was also associated with a larger MSA compared with angiography (MD +0.87 mm2; 95% CI: +0.03 to +1.70), whereas IVUS showed a nonsignificant trend in the same direction. No significant differences were observed for target vessel failure, target lesion revascularization, or TVR, although there was a trend in favor of imaging guidance for all outcomes. Heterogeneity was low except for MSA. CONCLUSIONS: In calcified coronary lesions, intravascular imaging is associated with lower MACE and stent thrombosis, compared with angiography guidance.