article · BMC Cardiovascular Disorders
Abstract Background Percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease is associated with increased anatomical complexity and adverse cardiovascular outcomes. Conventional angiography provides limited assessment of vessel structure and plaque characteristics, whereas intravascular imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) may improve procedural guidance. However, the clinical impact of imaging-guided PCI in this population remains uncertain. Methods We conducted a systematic review and meta-analysis of randomized controlled trials comparing intravascular imaging-guided versus angiography-guided PCI in patients with multivessel coronary artery disease regarding major adverse cardiovascular events (MACE). Major databases were searched through December 2025. Outcomes were pooled as risk ratios (RRs) with 95% confidence intervals (CIs) using random-effects models. Trial sequential analysis (TSA) and an exploratory network meta-analysis (NMA) were performed. Results Five randomized trials, including 3,023 patients, were analyzed. Imaging-guided PCI was associated with a significant reduction in MACE compared with angiography-guided PCI (RR 0.58, 95% CI 0.46 to 0.74; p < 0.0001; I 2 = 9.8%). In subgroup analyses by imaging modality, IVUS-guided PCI was associated with a reduction in MACE (RR 0.53, 95% CI 0.39 to 0.73; p < 0.0001; I 2 = 0%), as was OCT-guided PCI (RR 0.49, 95% CI 0.28 to 0.87; p = 0.014; I 2 = 24.3%). TSA provided supportive evidence for a beneficial effect of imaging-guided PCI. NMA suggested that both IVUS and OCT were associated with improved outcomes compared with angiography, with no significant difference between the two imaging modalities. Conclusion Intravascular imaging-guided PCI is associated with a reduction in MACE in patients with multivessel coronary artery disease. These findings support the clinical value of intravascular imaging in this population, with similar effects observed across imaging modalities.
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DOI: 10.1186/s12872-026-06135-7
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