Table 2_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.