Table 3_Comparative effectiveness and outcomes of physiology- and imaging-guided PCI: an evidence synthesis and network meta-analysis of FFR, iFR, OCT, and IVUS.docx

BackgroundMultiple coronary guidance strategies including angiography, physiology-based assessment, and intracoronary imaging are used to optimize percutaneous coronary intervention, yet their comparative effectiveness across clinical outcomes remains uncertain.
MethodsA comprehensive network meta-analysis incorporated fifty randomized studies evaluating angiography, FFR, iFR, IVUS, and OCT. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization. Random effects models were applied and interventions were ranked using SUCRA.
ResultsA total of 50 studies involving 39,863 patients were included, of whom 29,571 were male and 10,031 were female. Across guidance modalities, 15,463 patients underwent angiography-guided PCI, 10,728 IVUS-guided, 6,001 FFR-guided, 3,512 iFR-guided, and 3,849 OCT-guided PCI. In the network meta-analysis, intravascular imaging strategies demonstrated favorable outcomes across evaluated endpoints. Compared with IVUS, angiography-guided PCI was associated with higher rates of major adverse cardiovascular events (RR 1.28, 95% CI 1.13–1.46), all-cause mortality (RR 1.30, 95% CI 0.98–1.63), myocardial infarction (RR 1.73, 95% CI 1.28–2.40), target lesion failure (RR 1.50, 95% CI 1.19–1.93), and stent thrombosis (RR 1.80, 95% CI 1.25–2.70). Physiology-guided PCI using iFR was associated with higher risk estimates for all-cause mortality (RR 1.72, 95% CI 1.06–2.79) and cardiac death (RR 2.21, 95% CI 1.24–4.24) compared with IVUS. OCT demonstrated outcomes comparable to IVUS, with no statistically significant differences in major adverse cardiovascular events (RR 1.00, 95% CI 0.80–1.28) or cardiac death (RR 0.86, 95% CI 0.47–1.59). Sensitivity analyses yielded similar estimates. Overall, probabilistic ranking analyses favored intravascular imaging strategies, although effect estimates among non-angiographic modalities overlapped.
ConclusionsAdvanced PCI guidance strategies using intravascular imaging or invasive physiological assessment are associated with improved clinical outcomes compared with angiography alone. However, no single non-angiographic modality demonstrates definitive superiority, supporting individualized selection of guidance strategies based on clinical and procedural context.
Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251238909, identifier CRD420251238909.

背景：目前临床中采用包括血管造影术（angiography）、基于生理学的评估（physiology-based assessment）以及冠状动脉内成像（intracoronary imaging）在内的多种冠状动脉介入引导策略，以优化经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI），但各类策略在临床结局中的相对疗效仍不明确。
方法：本研究开展一项全面的网络Meta分析，纳入50项针对血管造影术、血流储备分数（Fractional Flow Reserve, FFR、瞬时波值（Instantaneous Wave-free Ratio, iFR）、血管内超声（Intravascular Ultrasound, IVUS）以及光学相干断层成像（Optical Coherence Tomography, OCT）相关的随机对照研究。主要结局指标为主要不良心血管事件（major adverse cardiovascular events, MACE）；次要结局指标包括全因死亡率、心源性死亡、心肌梗死、支架内血栓形成、靶病变血运重建及靶血管血运重建。研究采用随机效应模型，并通过表面累积排序曲线下面积（Surface Under the Cumulative Ranking Curve, SUCRA）对各类干预措施进行排序。
结果：本研究共纳入50项研究，涉及39863例患者，其中男性29571例，女性10031例。按引导方式分组：血管造影引导PCI组15463例、IVUS引导PCI组10728例、FFR引导PCI组6001例、iFR引导PCI组3512例，以及OCT引导PCI组3849例。网络Meta分析结果显示，血管内成像引导策略在所有评估结局中均展现出更优的临床结局。与IVUS引导PCI相比，血管造影引导PCI的主要不良心血管事件发生率更高（相对危险度RR=1.28，95%置信区间CI：1.13~1.46），全因死亡率（RR=1.30，95%CI：0.98~1.63）、心肌梗死（RR=1.73，95%CI：1.28~2.40）、靶病变失败（RR=1.50，95%CI：1.19~1.93）及支架内血栓形成（RR=1.80，95%CI：1.25~2.70）的发生率亦显著升高。与IVUS引导PCI相比，采用iFR的生理学引导PCI与更高的全因死亡率（RR=1.72，95%CI：1.06~2.79）及心源性死亡（RR=2.21，95%CI：1.24~4.24）的风险估计值相关。OCT引导PCI的临床结局与IVUS引导PCI相当，主要不良心血管事件（RR=1.00，95%CI：0.80~1.28）及心源性死亡（RR=0.86，95%CI：0.47~1.59）的组间差异均无统计学意义。敏感性分析得到了相似的效应估计值。总体而言，概率排序分析结果倾向于血管内成像引导策略，尽管非血管造影类引导方式的效应估计值存在重叠。
结论：与单纯血管造影引导相比，采用血管内成像或有创生理学评估的高级PCI引导策略可改善临床结局。但目前尚无任何一种非血管造影类引导方式展现出明确的优越性，因此需结合临床及操作场景个体化选择引导策略。
系统评价注册：https://www.crd.york.ac.uk/PROSPERO/view/CRD420251238909，注册编号CRD420251238909。