Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention: a reconstructed individual participant data meta-analysis of randomized controlled trials of intravascular ultrasound- and optical coherence tomography-guided strategies.

AIMS: Uncertainty persists regarding the comparative efficacy of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) vs. angiography-guided percutaneous coronary intervention (PCI). We synthesized randomized evidence using reconstructed individual participant data (IPD) and compared the two modalities indirectly. METHODS AND RESULTS: MEDLINE and CENTRAL were searched up to 31 March 2026. IPD were reconstructed from published Kaplan-Meier curves. Primary analyses used one-stage stratified Cox models; secondary analyses included random-effects and Bayesian hierarchical models. The primary outcome was major adverse cardiovascular events (MACE). Twenty-three randomized controlled trials enrolling 21 176 patients were included (16 IVUS, N = 15 209; 7 OCT, N = 5967). IVUS-guided PCI reduced MACE [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.67-0.83; P < 0.001], target-vessel revascularization (TVR; HR 0.70; 0.60-0.82), and stent thrombosis (ST; HR 0.54; 0.37-0.78). OCT-guided PCI reduced MACE (HR 0.75; 0.63-0.91; P = 0.003), cardiac death (HR 0.48; 0.27-0.83), myocardial infarction (HR 0.79; 0.63-0.99), ST (HR 0.40; 0.22-0.74), and TVR (HR 0.74; 0.57-0.97). Bayesian posterior probabilities of benefit exceeded 82% for all IVUS and 94% for all OCT endpoints. Indirect comparison detected no significant between-modality difference. Meta-regression of IVUS trials revealed heterogeneity by geographic region (P < 0.001) and attenuation of benefit over time (β = +0.034/year; P = 0.004); OCT analyses were non-significant. CONCLUSION: Both IVUS and OCT reduced MACE, revascularization, and ST compared with angiography-guided PCI. These findings support intravascular imaging as a routine adjunct to PCI in the populations studied.