IVUS‐Guided Versus Angiography‐Guided PCI for Unprotected Left Main Coronary Artery Disease: A Systematic Review, Meta‐Analysis, and GRADE Assessment of Randomized Trials

Abstract

BACKGROUND: Intravascular ultrasound (IVUS) has been increasingly used as an adjunctive tool for complex percutaneous interventions (PCIs); however, comparative randomized evidence with conventional angiography in unprotected left main coronary artery (ULMCA) disease remains scarce and fragmented. Therefore, this systematic review and meta-analysis aimed to assess and synthesize evidence regarding its use in ULMCA disease. METHODS: We performed a systematic literature search across PubMed, Scopus, Web of Science, and Cochrane until April 2026 to identify relevant RCTs comparing IVUS-guided PCI with conventional angiography-guided PCI in ULMCA disease. Risk of bias of studies was assessed using the Cochrane RoB-2 tool. A random-effects model meta-analysis was performed in R, with an exploratory univariate meta-regression of covariates. RESULTS: Four randomized trials involving 2278 patients with ULMCA disease were included. Compared with angiography-guided PCI, IVUS guidance was associated with numerically lower risks of all-cause death, cardiac death, target lesion revascularization, and target vessel revascularization, while myocardial infarction and stent thrombosis were similar between groups. CONCLUSION: In patients undergoing PCI for ULMCA disease, IVUS guidance was associated with numerically favorable but statistically nonsignificant reductions in mortality and repeat revascularization, without clear differences in myocardial infarction or stent thrombosis. Although randomized evidence is still lacking to determine clinical superiority, these results justify powered future trials to determine whether the effects of IVUS guidance vary according to prior myocardial infarction status and left ventricular ejection fraction.