Abstract
Background:
Previous meta-analyses have extensively compared the outcomes of intravascular imaging-guided versus coronary angiography-guided percutaneous coronary intervention (PCI) in the treatment of coronary artery disease. However, conducting repeated meta-analyses within a short period may increase the probability of type I or type II errors. Therefore, we employed both traditional meta-analysis and trial sequential analysis (TSA) methods to compare the clinical outcomes of intravascular imaging-guided and coronary angiography-guided PCI.
Methods:
We searched PubMed, Cochrane Library, Embase, and Web of Science for literature comparing intravascular imaging-guided versus coronary angiography-guided PCI from inception to August 10, 2024. Four researchers, divided into 2 groups, independently extracted the data. The primary outcomes were major adverse cardiovascular events (MACEs) and target lesion failure (TLF). Secondary outcomes included stent thrombosis and all-cause mortality. TSA was used to analyze these outcomes.
Results:
A total of 23 randomized controlled trials with 17,766 participants were included. Compared to angiography, intravascular ultrasound has a significant advantage in reducing MACE (risk ratio [RR]: 0.66; 95% confidence interval [CI]: 0.55–0.80) and TLF (RR: 0.64; 95% CI: 0.54–0.75) during follow-up, supported by high certainty of evidence and confirmed by an 80% power TSA, demonstrating a true positive effect. However, no significant differences were observed in reducing stent thrombosis or all-cause mortality. Similarly, compared to angiography, optical coherence tomography shows a significant advantage in reducing MACE beyond 1 year (RR: 0.79; 95% CI: 0.64–0.99), but further exploration is needed, given that only 3 studies were included. In other aspects, including the reduction of stent thrombosis and all-cause mortality, no significant differences were found.
Conclusion:
Intravascular ultrasound showed truly superior efficacy in reducing MACE and TLF compared to angiography. However, additional studies are needed to further assess the effectiveness of optical coherence tomography.
Keywords: coronary angiography, intravascular imaging, intravascular ultrasound, percutaneous coronary intervention
Key point.
This study conducted a separate analysis of IVUS and OCT, incorporating trial sequential analysis to address the issue of repeated significance testing in multiple meta-analyses.
This meta-analysis conducted subgroup analyses based on the various patient characteristics, such as age, sex, diabetes mellitus, acute coronary syndrome, chronic kidney disease, multi-vessel disease, chronic total occlusion, left anterior descending artery lesion, bifurcation lesion, and degree of calcification.
For some outcomes analyzed, the number of included studies was limited, and the pooled outcomes had relatively wide confidence intervals.
1. Introduction
Coronary artery disease (CAD) is the leading cause of death globally and a major contributor to disability. In 2022, there were 315 million prevalent cases of CAD globally.[1] Coronary angiography-guided percutaneous coronary intervention (PCI) is the standard procedure for treating CAD. However, it has limitations in accurately assessing the severity of coronary artery stenosis and detecting nonobstructive atherosclerotic plaques.[2] The emergence of intravascular imaging technologies, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), has partially addressed these limitations.[3]
In the past decade, numerous randomized controlled trials (RCTs) have compared the effectiveness of intravascular imaging technologies with coronary angiography-guided PCI in the treatment of CAD.[3–6] Consequently, a large number of meta-analyses have emerged.[7–12] In 2023, a meta-analysis by Khan et al[7] that included 20 RCTs indicated that intravascular imaging-guided PCI, compared to angiography-guided PCI, significantly reduces the occurrence of cardiac death and cardiovascular events in patients. In 2024, Stone et al.[8] A network meta-analysis included 22 RCTs, which concluded that intravascular imaging guidance enhances the safety and efficacy of PCI. Subsequently, Giacoppo et al[9] performed a network meta-analysis including 24 RCTs, demonstrating that intravascular imaging-guided PCI is associated with a reduction in ischemia-driven target lesion revascularization, with IVUS showing the most pronounced difference. These meta-analysis results all indicate that intravascular imaging technologies have better outcomes compared to angiography. However, repeated meta-analyses conducted in a short period may be influenced by statistical heterogeneity and the inherent clinical heterogeneity of the trials, increasing the likelihood of type I or type II errors.[13] Trial sequential analysis (TSA) can reduce the risk of these random errors.[14,15] Additionally, a recent large RCT has been published, but was not included in those meta-analyses.[16]
Therefore, we plan to conduct a thorough evaluation of the existing evidence, utilizing both traditional meta-analysis and TSA methods to compare the clinical outcomes of intravascular imaging-guided and coronary angiography-guided PCI.
2. Methods
This meta-analysis of RCTs adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis checklist[17] and has been reported in line with assessing the methodological quality of systematic reviews.[18,19] The study protocol was prospectively registered on PROSPERO (Prospective Register of Systematic Reviews) (CRD42024546078).
2.1. Search strategy and selection criteria
On August 10, 2024, we conducted a comprehensive search in the databases PubMed, Cochrane Library, Embase, and Web of Science, without language restrictions, to compare literature on intravascular imaging-guided versus coronary angiography-guided PCI. The search details are provided in Table S1, Supplemental Digital Content, https://links.lww.com/MD/R262. After removing the duplicate literature, 4 researchers (XL, DZ, WQX, and ZY) were divided into 2 groups to screen the literature based on inclusion and exclusion criteria. When screening literature, start by reading the title and abstract to exclude unrelated articles, and then read the full text of the remaining ones to determine final inclusion. RCTs compared CAD patients undergoing PCI guided by intravascular imaging (including IVUS or OCT) versus coronary angiography, while also reporting cardiovascular outcomes, will be included in the study. Studies that failed to extract data will be excluded. If there was any disagreement about the included study, it would be discussed by senior researchers (CGW) to reach a consensus.
2.2. Data extraction
The 2 groups of researchers mentioned earlier independently extracted data from the included studies. If the outcome-related data cannot be directly obtained from the text, we will contact the corresponding author to request it. The extracted information includes: study characteristics, such as registration number, 1st author’s name, region, number of participants, demographic characteristics of participants, follow-up duration, etc; key elements of bias risk assessment, and outcomes of interest and measurement data.
2.3. Quality assessment
The revised Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias. The criteria for evaluating RCTs include bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of outcomes, and bias in the selection of the reported result. The included literature was classified into 3 levels from low to high: low risk, which indicates a low risk of bias; unclear, which indicates uncertain risk of bias or insufficient information; and high risk, which indicates a high risk of bias. The same 4 researchers independently and blindly assessed the included studies. The grading of recommendations assessment, development, and evaluation (GRADE) was used to evaluate the quality of evidence.
2.4. Outcomes of interest
The primary outcome is major adverse cardiovascular events (MACEs) and target lesion failure (TLF). The MACE is defined as cardiac death, myocardial infarction, stent thrombosis, and ischemia-driven repeat revascularization.[20–23] TLF is defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. Other outcomes include stent thrombosis and all-cause mortality. Reported clinical outcomes include the latest follow-up results, 1-year outcomes, and outcomes beyond 1 year.
2.5. Statistical analysis
The combined effect size, forest plot creation, heterogeneity testing, sensitivity analysis, publication bias Egger test, and funnel plot creation were performed using Cochrane Collaboration software RevMan 5.4 and Stata 17. We used I2 to assess the statistical heterogeneity among the included studies, and significant statistical heterogeneity was recognized if I2 > 50% or P < .05. Based on the heterogeneity, either a fixed-effect or random-effect model was used for the included studies. The occurrence rates of outcomes were all dichotomous data, which were extracted in the form of an absolute number and a patient number. The Mantel-Haenszel method was used to pool the dichotomous variables and display the results as risk ratios (RRs) with their 95% confidence intervals (CIs). Then, we assessed publication bias and small study effects by using funnel plots and the Egger test.
Using TSA software version 0.9.5.10 beta, we performed a TSA analysis on the primary outcome MACE to verify the reliability of the meta-analysis results. The required information size on the relative calculated effect size for the intervention was calculated considering a type I error of 5% and a power of 90%. If the cumulative Z-curve does not exceed the required information size, further studies are needed.
3. Results
3.1. Study identification
The initial search yielded 6086 potential studies. Following the screening of titles and abstracts, 37 articles were selected for full-text assessment, of which 14 were excluded. Ultimately, 23 studies[2,3,5,6,16,22–39] met the criteria for inclusion in the meta-analysis. Figure 1 shows the flow chart of the literature search and study selection.
Figure 1.
Flow chart of literature retrieval. IVUS = intravascular ultrasound, OCT = optical coherence tomography.
3.2. Study characteristics and risk of bias
The 23 RCTs included a total of 17,766 participants: 6224 in the IVUS group, 2648 in the OCT group, and 8894 in the angiography group. One study[34] focused exclusively on patients with stable angina, 3 studies[25,33,37] included only patients with acute coronary syndrome, and 19 studies[2,3,5,6,16,22–24,26–32,35,36,38,39] included both patient groups. Among the IVUS studies, 10[3,16,26,29–31,34–36,38] out of 17[2,3,16,22,23,26–32,34–36,38,39] reported that IVUS was more effective than angiography. However, in the OCT studies, 7[6,22,25,27,33,34,37] out of 8[5,6,22,25,27,33,34,37] found that OCT was not more effective than angiography. The baseline characteristics of the included RCTs are presented in Table 1.
Table 1.
The characteristics of the included RCTs.
| Registration number | Study | Author name | Location | Number | Age | Stable angina proportion | ACS proportion | Follow-up | Conclusion |
|---|---|---|---|---|---|---|---|---|---|
| IVUS vs angiography | |||||||||
| NCT02471586 | ILUMIEN III: OPTIMIZE PCI, 2021 | Ali et al[22] | Eight countries | 136/142 | 66/67 | 35/35 | 36/36 | 30 d, 1-yr | No difference |
| Not available | Bendary et al[26] | Bendary et al[26] | Egypt | 90/91 | 63/61 | 57/53 | 40/45 | 1 yr | Effective |
| Not available | iSIGHT, 2021 | Chamié et al.[27] | Brazil | 50/49 | 60/59 | 35/35 | 36/36 | At least 1-yr | No difference |
| NCT00936169 | AVIO. 2013 | Chieffo et al[28] | Italy | 142/142 | 64/64 | 70/64 | 30/26 | 1 and 24 mo | No difference |
| NCT02215915 | ULTIMATE. 2021 | Gao et al[29] | China | 714/709 | 65/66 | 13/13 | 79/78 | 1, 2, and 3 yr | Effective |
| Not available | Hanboly et al[30] | Hanboly et al[30] | Egypt | 30/30 | 65/65 | 30/33 | 70/67 | 6 mo | Effective |
| NCT03866486 | IVUS-XPL et al, 2020 | Hong et al[31] | Korea | 589/594 | 63/63 | 51/51 | 49/49 | 1 and 5 yr | Effective |
| Not available | HOME DES IVUS, 2009 | Jakabcin et al[32] | Czech Republic | 105/105 | 59/60 | 38/40 | 62/60 | 18 mo | No difference |
| NCT01145079 | RESET, 2013 | Kim et al[23] | Korea | 269/274 | 63/64 | 53/52 | 47/48 | 1-yr | No difference |
| NCT01563952 | CTO-IVUS, 2015 | Kim et al[34] | Korea | 201/201 | 61/61 | 100/100 | 0/0 | 12 mo | Effective |
| NCT02978456 | GUIDE-DES, 2024 | Lee et al[2] | Korea | 765/763 | 65/64 | 70/71 | 30/29 | 12 mo | No difference |
| NCT03381872 | RENOVATE-COMPLEX_PCI, 2023 | Lee et al[3] | Korea | 1092/547 | 65/66 | 49/50 | 51/50 | 12 mo | Effective |
| NCT03971500 | IVUS-ACS, 2024 | Li et al[35] | China | 1753/1752 | 62/63 | 40/41 | 60/59 | 12 mo | Effective |
| Not available | Liu et al[36] | Liu et al[36] | China | 167/169 | 65/65 | 12/11 | 86/87 | 1-yr | Effective |
| Not available | Tan et al[38] | Tan et al[38] | China | 61/62 | 77/76 | 30/34 | 70/66 | 2 yr | Effective |
| ChiCTR 10000996 | AIR-CTO, 2015 | Tian et al[39] | China | 115/115 | 67/66 | 71/76 | 29/24 | 1, 12, 24 mo | No difference |
| NCT04255043 | The ULTIMATE III Trial, 2024 | Gao et al[16] | China | 130/130 | 68/67 | 15/11 | 85/89 | 1 and 6 mo | Effective |
| OCT vs angiography | |||||||||
| NCT02471586 | ILUMIEN III: OPTIMIZE PCI, 2021 | Ali et al[22] | Eight countries | 153/142 | 66/67 | 34/35 | 33/36 | 30 d, 1-yr | No difference |
| NCT03507777 | ILUMIEN IV: OPTIMIZE PCI, 2023 | Ali et al[6] | Eighteen countries | 1233/1254 | 66/66 | 27/29 | 63/61 | 2 yr | No difference |
| NCT02272283 | OCTACS, 2015 | Antonsen et al[25] | Denmark | 50/50 | 62/63 | 0/0 | 100/100 | 6 mo | No difference |
| Not available | iSIGHT, 2021 | Chamié et al[27] | Brazil | 51/49 | 60/59 | 34/35 | 33/36 | At least 1-yr | No difference |
| NCT03171311 | OCTOBER, 2023 | Holm et al[5] | European | 600/601 | 66/66 | 55/53 | 45/47 | 2 yr | Effective |
| NCT00888758 | ROBUST, 2018 | Kala et al[33] | Czech Republic | 105/96 | 57/59 | 0/0 | 100/100 | 9 mo | No difference |
| NCT01869842 | Kim et al[34] | Kim et al[34] | Korea | 50/51 | 59/62 | 61/62 | 39/38 | 1 yr | No difference |
| NCT01743274 | DOCTORS, 2016 | Meneveau et al[37] | France | 120/120 | 61/60 | 0/0 | 100/100 | 6 mo | No difference |
ACS = Acute coronary syndrome, OCT = optical coherence tomography, PCI = percutaneous coronary intervention, RCT = randomized controlled trial.
Using the Cochrane Collaboration’s Risk of Bias tool 2, 3 studies[34,36,38] were identified as having some concerns, while 20 studies were deemed to have a low risk of bias. The detailed distribution of bias is shown in Table S2, Supplemental Digital Content, https://links.lww.com/MD/R262.
3.3. IVUS versus angiography
For the outcome of MACE, IVUS was associated with a statistically significant lower risk compared to angiography during follow-up (RR: 0.66; 95% CI: 0.55–0.80; I2 = 49%). This significant reduction was consistent in both the <1-year and more than 1-year follow-up periods. However, during hospitalization, there was no statistically significant difference between IVUS and angiography (RR: 0.86; 95% CI: 0.42–1.73; I2 = 28%). TSA with 80% power also showed statistically significant differences with α-spending adjusted CIs for the overall follow-up (RR: 0.66; α-spending adjusted CI: 0.53–0.83), <1 year (RR: 0.65; α-spending adjusted CI: 0.50–0.84), and more than 1 year (RR: 0.62; α-spending adjusted CI: 0.50–0.78; Fig. 2).
Figure 2.
Forest plot of intravascular ultrasound versus coronary angiography. CI = confidence interval, MACE = major adverse cardiovascular event, RR = risk ratio.
Regarding TLF, IVUS showed a statistically significantly lower risk compared to angiography during follow-up (RR: 0.64; 95% CI: 0.54–0.75; I2 = 25%). This reduction was again consistent across both the <1-year and more than 1-year follow-up periods. However, no statistically significant difference was observed during hospitalization (RR: 0.58; 95% CI: 0.18–1.82; I2 = 38%). The TSA with 80% power confirmed statistically significant differences in the α-spending adjusted CIs for the overall follow-up (RR: 0.64; α-spending adjusted CI: 0.52–0.78), <1 year (RR: 0.62; α-spending adjusted CI: 0.50–0.77), and more than 1 year (RR: 0.64; α-spending adjusted CI: 0.50–0.81; Fig. 2).
For stent thrombosis, IVUS was also associated with a statistically significant lower risk compared to angiography during follow-up (RR: 0.54; 95% CI: 0.34–0.85; I2 = 0%), consistent across both the <1-year and more than 1-year follow-up periods. However, during hospitalization, there was no statistically significant difference between IVUS and angiography (RR: 0.28; 95% CI: 0.05–1.69; I2 = 0%). The TSA with 80% power indicated that only the α-spending adjusted CI for the overall follow-up (RR: 0.54; α-spending adjusted CI: 0.33–0.88) showed a statistically significant difference (Fig. 2).
For all-cause mortality, no statistically significant difference was observed between IVUS and angiography (Fig. 2). Other detailed results are shown in Figures S1–S16, Supplemental Digital Content, https://links.lww.com/MD/R262.
3.4. OCT versus angiography
For MACE, OCT was associated with a statistically significant lower risk compared to angiography during follow-up (RR: 0.79; 95% CI: 0.64–0.99; I2 = 20%). However, TSA with 80% power revealed that the α-spending adjusted CI showed no statistically significant difference (RR: 0.79; α-spending adjusted CI: 0.55–1.15; Fig. 3).
Figure 3.
Forest plot of optical coherence tomography versus coronary angiography. CI = confidence interval, MACE = major adverse cardiovascular event, RR = risk ratio.
For TLF, OCT also demonstrated a statistically significant lower risk compared to angiography during follow-up (RR: 0.78; 95% CI: 0.62–0.98; I2 = 11%). Yet, the TSA, with 80% power, indicated that the α-spending adjusted CI showed no statistically significant difference (RR: 0.78; α-spending adjusted CI: 0.59–1.05; Fig. 3).
For stent thrombosis, OCT had a statistically significantly lower risk compared to angiography during follow-up (RR: 0.58; 95% CI: 0.34–0.99; I2 = 0%). However, TSA with 80% power found that the α-spending adjusted CI showed no statistically significant difference (RR: 0.58; α-spending adjusted CI: 0.27–1.23; Fig. 3).
For all-cause mortality, there was no statistically significant difference between OCT and angiography (Fig. 3). Other detailed results are shown in Figures S17–S32, Supplemental Digital Content, https://links.lww.com/MD/R262.
3.5. Subgroup analysis
Based on various patient characteristics (including age, sex, diabetes mellitus, acute coronary syndrome, chronic kidney disease, multi-vessel disease, chronic total occlusion, left anterior descending artery lesion, bifurcation lesion, and degree of calcification), we conducted a subgroup analysis on MACE or TLF. The results showed no statistically significant differences between the subgroups (Table 2). Other detailed results are shown in Figures S33–S46, Supplemental Digital Content, https://links.lww.com/MD/R262.
Table 2.
Subgroup analysis of MACE or TLF was conducted according to age, sex, diabetes mellitus, acute coronary syndrome, chronic kidney disease, multi-vessel disease, chronic total occlusion, left anterior descending artery lesion, bifurcation lesion, and degree of calcification.
| Subgroup | Included studies | RR | Difference between subgroups |
|---|---|---|---|
| IVUS vs angiography | |||
| Age | |||
| <65 yr | 3 | 0.57 (0.44, 0.74) | P = .98 |
| ≥65 yr | 3 | 0.57 (0.44, 0.73) | |
| Sex | |||
| Male | 4 | 0.59 (0.49, 0.71) | P = .67 |
| Female | 4 | 0.54 (0.39, 0.76) | |
| Diabetes mellitus | |||
| Yes | 4 | 0.62 (0.42, 0.90) | P = .34 |
| No | 4 | 0.48 (0.32, 0.70) | |
| Acute coronary syndrome | |||
| Yes | 4 | 0.61 (0.51, 0.73) | P = .13 |
| No | 4 | 0.45 (0.32, 0.64) | |
| Chronic kidney disease | |||
| Yes | 3 | 0.53 (0.37, 0.77) | P = .55 |
| No | 3 | 0.61 (0.49, 0.74) | |
| Multi-vessel disease | |||
| Yes | 4 | 0.57 (0.44, 0.74) | P = .84 |
| No | 4 | 0.59 (0.47, 0.75) | |
| Chronic total occlusion | |||
| Yes | 2 | 0.44 (0.23, 0.84) | P = .22 |
| No | 2 | 0.68 (0.53, 0.89) | |
| LAD lesion | |||
| Yes | 2 | 0.49 (0.25, 0.97) | P = .89 |
| No | 2 | 0.53 (0.27, 1.05) | |
| Bifurcation lesions | |||
| Yes | 2 | 0.68 (0.36, 1.28) | P = .91 |
| No | 2 | 0.65 (0.49, 0.87) | |
| Moderate to severe calcification | |||
| Yes | 2 | 0.51 (0.33, 0.80) | P = .31 |
| No | 2 | 0.67 (0.51, 0.89) | |
| OCT vs angiography | |||
| Sex | |||
| Male | 2 | 0.81 (0.64, 1.02) | P = .93 |
| Female | 2 | 0.78 (0.35, 1.74) | |
| Acute coronary syndrome | |||
| Yes | 4 | 0.97 (0.72, 1.32) | P = .20 |
| No | 2 | 0.75 (0.56, 0.98) | |
| Diabetes mellitus | |||
| Yes | 2 | 0.85 (0.52, 1.38) | P = .72 |
| No | 2 | 0.77 (0.59, 1.00) | |
| Moderate to severe calcification | |||
| Yes | 2 | 0.71 (0.47, 1.08) | P = .62 |
| No | 2 | 0.82 (0.55, 1.23) | |
LAD = left anterior descending artery, MACE = major adverse cardiovascular event, OCT = optical coherence tomography, RR = risk ratio, TLF = target lesion failure.
3.6. Sensitivity analysis and publication bias
The leave-one-out method was used for the sensitivity analysis. For IVUS, the results for all outcomes across the entire follow-up period remained consistently comparable between groups. However, for OCT, during the at least follow-up period, the outcome of MACE showed no significant difference between the 2 groups after excluding the studies by Ali et al,[6] Antonsen et al,[25] Holm et al,[5] and Kim et al.[34] Similarly, after excluding the studies by Holm et al,[5] Kim et al,[34] and Lee et al,[3] there was no significant difference in the TLF outcome between the groups. This indicates that the results of these 2 analyses during at least the follow-up period are not robust (Table S3, Supplemental Digital Content, https://links.lww.com/MD/R262).
Publication bias assessed by the Egger test indicated potential bias (P < .05) for IVUS in MACE during hospitalization and within 1 year, TLF during hospitalization, stent thrombosis during follow-up and within 1 year, and all-cause mortality during hospitalization and within 1 year. For OCT, potential publication bias was found in MACE during follow-up, TLF during follow-up, and within 1 year, and all-cause mortality during follow-up (Figures S47–S77, Supplemental Digital Content, https://links.lww.com/MD/R262).
3.7. GRADE ratings and trails sequential analysis
GRADE ratings and TSA were assessed for the above outcomes. Among the 16 outcomes for IVUS, 2 were rated as having high certainty of evidence, while 1 of the 16 outcomes for OCT was rated similarly (Table 3).
Table 3.
GRADE system.
| Outcome | RR with conventional 95%CI | Risk of bias① | Inconsistency② | Imprecision③ | Small study effects④ | Certainty of evidence | RR with α-spending adjusted CI | Reach RSA | Accuracy of conventional meta-analysis⑤ |
|---|---|---|---|---|---|---|---|---|---|
| IVUS vs angiography | |||||||||
| MACE | |||||||||
| During follow-up | 0.66 (0.55, 0.80) | Not downgraded | Not downgraded | Not downgraded | Not downgraded | High | 0.66 (0.53, 0.83) | Yes | True positive |
| 30 d/during hospitalization | 0.86 (0.42, 1.73) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.86 (0.05, 15.26) | No | False negative |
| <1 yr | 0.65 (0.50, 0.83) | Not downgraded | Downgraded | Downgraded | Downgraded | Very low | 0.65 (0.50, 0.84) | Yes | True positive |
| More than 1 yr | 0.62 (0.52, 0.75) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.62 (0.50, 0.78) | Yes | True positive |
| Target lesion failure | |||||||||
| During follow-up | 0.64 (0.54, 0.75) | Not downgraded | Not downgraded | Not downgraded | Not downgraded | High | 0.64 (0.52, 0.78) | Yes | True positive |
| 30 d/during hospitalization | 0.58 (0.18, 1.82) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.58 (0.01, 63.10) | No | False negative |
| <1 yr | 0.62 (0.50, 0.77) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.62 (0.50, 0.77) | Yes | True positive |
| More than 1 yr | 0.64 (0.53, 0.77) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.64 (0.50, 0.81) | Yes | True positive |
| Stent thrombosis | |||||||||
| During follow-up | 0.54 (0.34, 0.85) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.54 (0.33, 0.88) | Yes | True positive |
| 30 d/during hospitalization | 0.28 (0.05, 1.69) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.28 (0.01, 8.05) | No | False negative |
| <1 yr | 0.55 (0.33, 0.91) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.55 (0.30, 1.01) | Yes | True negative |
| More than 1 yr | 0.47 (0.22, 0.99) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.47 (0.19, 1.16) | No | False positive |
| All-cause mortality | |||||||||
| During follow-up | 0.83 (0.60, 1.14) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.83 (0.40, 1.72) | No | False negative |
| 30 d /during hospitalization | 0.28 (0.05, 1.71) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.28 (0.02, 4.28) | No | False negative |
| <1 yr | 0.68 (0.46, 1.00) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.68 (0.38, 1.22) | No | False positive |
| More than 1 yr | 0.97 (0.64, 1.49) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | NA | Yes | NA |
| OCT vs angiography | |||||||||
| MACE | |||||||||
| During follow-up | 0.79 (0.64, 0.99) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.79 (0.55, 1.15) | No | False positive |
| 30 d/during hospitalization | 3.87 (0.66, 22.66) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 3.87 (0.20, 76.44) | No | False negative |
| <1 yr | 0.92 (0.47, 1.82) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.92 (0.15, 5.50) | No | False negative |
| More than 1 yr | 0.81 (0.69, 0.94) | Not downgraded | Not downgraded | Not downgraded | Not downgraded | High* | 0.81 (0.69, 0.94) | No | True positive |
| Target lesion failure | |||||||||
| During follow-up | 0.78 (0.62, 0.98) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.78 (0.59, 1.05) | No | False positive |
| 30 d/during hospitalization | 2.55 (0.39, 16.64) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 2.55 (0.02, 278.66) | No | False negative |
| <1 yr | 0.78 (0.39, 1.54) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.78 (0.30, 1.99) | No | False negative |
| More than 1 yr | 0.82 (0.67, 1.01) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.82 (0.59, 1.15) | No | False negative |
| Stent thrombosis | |||||||||
| During follow-up | 0.58 (0.34, 0.99) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | 0.58 (0.27, 1.23) | No | False positive |
| 30 d/During hospitalization | 2.66 (0.11, 64.78) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | NA | NA | NA |
| <1 yr | 0.68 (0.11, 4.26) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | NA | No | False positive |
| More than 1 yr | 0.57 (0.33, 1.00) | Not downgraded | Downgraded | Downgraded | Downgraded | Very low | 0.57 (0.25, 1.30) | NA | NA |
| All-cause mortality | |||||||||
| During follow-up | 0.72 (0.50, 1.03) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | 0.72 (0.40, 1.30) | No | False negative |
| 30 d/during hospitalization | 2.75 (0.11, 66.59) | Not downgraded | Not downgraded | Downgraded | Downgraded | Low | NA | NA | NA |
| <1 yr | 1.39 (0.22, 8.77) | Not downgraded | Not downgraded | Downgraded | Not downgraded | Moderate | NA | No | False negative |
| More than 1 yr | 0.70 (0.48.1.01) | Not downgraded | Downgraded | Downgraded | Downgraded | Very low | 0.70 (0.39, 1.24) | NA | NA |
CI, confidence interval; NA, not available; IVUS, intravascular ultrasound; OCT, optical coherence tomography.①Downgraded by one level because >25% of participants in this comparison were from studies at high risk of bias.②Downgraded by one level because heterogeneity (I2) >50%.③Downgraded by one level because the limits of the 95% confidence interval were 20% different to the point estimates.④Downgraded by one level owing to small study bias.
*Included less than 5 studies.
In TSA, 8 of the 16 outcomes for IVUS showed true positives, and 1 showed a true negative. For OCT, only 1 of the 16 outcomes showed a true positive. When combining GRADE ratings and TSA, MACE, and TLF during follow-up for IVUS was associated with high certainty of evidence and true positives. For OCT, MACE beyond 1-year showed high certainty of evidence and a true positive (Figures S78–S107, Supplemental Digital Content, https://links.lww.com/MD/R262).
4. Discussion
Our meta-analysis found that compared to angiography, IVUS had a superior effect in reducing the incidence of MACE and TLF during follow-up. This conclusion is supported by high certainty of evidence and TSA, which included a sufficient number of studies, and the sensitivity analysis results showed robustness. IVUS may also have some advantage in reducing stent thrombosis, but the strength of evidence is insufficient and requires further investigation. In terms of reducing all-cause mortality, IVUS and angiography showed similar effects. For OCT, compared to angiography, although it showed some superiority in reducing the incidence of MACE and TLF, the certainty of evidence was low, and the sensitivity analysis results were not robust. The only outcome that showed high certainty of evidence and a true positive result in TSA was MACE in more than 1 year, but this was based on only 3 studies, so the interpretation of this result should be cautious. For other outcomes, such as stent thrombosis and all-cause mortality, OCT did not show significant differences compared to angiography.
In the past 2 years, a large number of meta-analyses have been published on the use of intravascular imaging techniques for PCI.[7–9,11,40–49] In 2024 alone, 7 related meta-analyses have already been released.[8,9,11,40–43] These meta-analyses all demonstrate that IVUS or OCT provides better outcomes than angiography. However, is the credibility and necessity of so many meta-analyses on this topic within such a short period of time justified?
The primary purpose of meta-analysis is to increase sample size to determine whether a specific intervention is effective.[50,51] Consequently, as new studies are published, meta-analysis results must also be updated. However, for a meta-analysis on a specific research topic, if the sample size is insufficient, frequent updates and repeated tests for differences can significantly increase the risk of type I errors, leading to a higher false-positive rate.[13] Moreover, when the number of trials and the sample size included in the meta-analysis are small, even if the results show significant differences, the bias introduced by the small sample size may exaggerate the treatment effect, rendering the evidence insufficient for clinical decision-making.
Additionally, due to the lack of hypothesis testing for sample size, current meta-analyses are unable to promptly stop trials for interventions that have been confirmed as effective (with sufficient sample size) or ineffective, leading to a waste of medical resources. Research has also shown that if repeated tests for differences are conducted and a P-value of <.05 is always taken as indicating “statistical significance,” the probability of committing a type I error further increases. To address this issue, it is necessary to repeatedly adjust the P-value and its corresponding CI level for each test, setting stricter thresholds each time, to ensure that the conclusions drawn have true statistical significance.
In 1997, Pogue and colleagues 1st proposed introducing sequential analysis into meta-analyses to address the problem of repeated tests for differences in updated meta-analyses, thereby reducing the occurrence of type I errors.[52] The advantage of TSA is that it can arrive at definitive conclusions earlier without increasing type I errors. More importantly, compared to traditional meta-analysis, TSA provides a stopping criterion for accepting the null hypothesis, addressing the limitation of traditional meta-analysis, where it cannot timely terminate ineffective trials when no true effect exists.[53,54] This approach saves medical resources and better aligns with ethical requirements.
Our study is the 1st to incorporate TSA into a meta-analysis comparing IVUS and OCT with angiography. Our findings indicate that for IVUS, TSA analysis generally confirms a statistically significant difference in most outcomes. Specifically, major endpoints such as MACE and TLF consistently show stable superiority. However, for OCT, TSA analysis reveals that results that were statistically significant in traditional meta-analysis, such as MACE during follow-up and TLF during follow-up, lose their statistical significance after TSA analysis and do not reach the corresponding required sample size. In summary, the superiority of IVUS over angiography is robust, but further research is needed to explore the effectiveness of OCT.
The strengths of our study lie in several key aspects. Firstly, we included all the latest RCTs and conducted a comprehensive analysis of the results based on different follow-up periods. Secondly, our study included only RCTs, which helps to strengthen the evidence. Thirdly, unlike many previous meta-analyses, we analyzed IVUS and OCT separately, allowing for a more precise evaluation of their respective effects. Most importantly, we introduced the TSA method to analyze this topic, providing a more accurate assessment of the true effect and determining whether the required sample size is sufficient.
However, our study also has some limitations. Firstly, although only RCTs were included, the trials varied in participant populations, outcome definitions, and follow-up durations, leading to potential confounding due to inter-trial heterogeneity and underscoring the need for standardized, multi-center studies in future research. Secondly, the criteria used for intravascular imaging guidance differed across trials. Thirdly, for some outcomes analyzed, the number of included studies was limited, and the pooled outcomes had relatively wide CIs. Finally, most included studies, especially those on IVUS, were conducted in Asia, potentially limiting generalizability. Future trials from more diverse regions are needed to validate global applicability across different populations and healthcare settings.
5. Conclusion
By combining traditional meta-analysis with TSA, result shows that IVUS demonstrates superior effectiveness in reducing MACE and TLF compared to angiography. Although traditional meta-analysis indicates that OCT is superior to angiography in reducing MACE and TLF, TSA suggests that this result might carry a risk of false positives. Therefore, further research is needed to validate the actual effectiveness of OCT.
Acknowledgments
We would like to give our sincere gratitude to the reviewers for their constructive comments.
Author contributions
Conceptualization: Xi Li, Kunli Chen, Chenggong Wang.
Methodology: Da Zhong, Wenqing Xie, Lingyu Kong.
Investigation: Da Zhong, Wenqing Xie.
Software: Zhen Yin, Hua Liu, Kunli Chen.
Resources: Da Zhong, Hua Liu, Kunli Chen.
Supervision: Zhen Yin, Zhan Liao, Jian Tian, Chenggong Wang.
Validation: Zhen Yin, Jian Tian.
Data curation: Zhan Liao.
Formal analysis: Lingyu Kong.
Writing – original draft: Xi Li, Chenggong Wang.
Writing – review & editing: Xi Li, Chenggong Wang.
Supplementary Material
Abbreviations:
- CAD
- coronary artery disease
- CI
- confidence interval
- GRADE
- grading of recommendations assessment, development, and evaluation
- IVUS
- intravascular ultrasound
- MACE
- major adverse cardiovascular event
- OCT
- optical coherence tomography
- PCI
- percutaneous coronary intervention
- RCT
- randomized controlled trial
- RR
- risk ratio
- TLF
- target lesion failure
- TSA
- trial sequential analysis
This work was supported by the National Natural Science Foundation of China (82472609), Natural Science Foundation of Hunan Province (2023JJ30941), Natural Science Foundation of Hunan Province (2022JJ30941), Horizontal Research Funding of Central South University (JXDY-ZD-20231101), and Hunan Provincial Research Project on Degree and Graduate Education Reform (2025JGYB039).
As the literature included in the meta-analysis had ethics approval, no additional ethics approval was required.
The authors have no conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article (and its supplementary information files).
Supplemental Digital Content is available for this article.
How to cite this article: Li X, Zhong D, Yin Z, Liu H, Xie W, Liao Z, Tian J, Kong L, Chen K, Wang C. Intravascular imaging-guided versus coronary angiography-guided percutaneous coronary intervention: Meta-analysis and trial sequential analysis of randomized controlled trials. Medicine 2026;105:7(e47193).
Contributor Information
Xi Li, Email: 1141404154@qq.com.
Da Zhong, Email: zhongda@csu.edu.cn.
Zhen Yin, Email: 2420166906@qq.com.
Hua Liu, Email: 2941153178@qq.com.
Wenqing Xie, Email: xiewenqing@csu.edu.cn.
Zhan Liao, Email: 443577685@qq.com.
Jian Tian, Email: jian_tian@csu.edu.cn.
Lingyu Kong, Email: kong_lingyu@csu.edu.cn.
Kunli Chen, Email: chenkunli@163.com.
References
- [1].Stark B, Johnson C, Roth GA. Global prevalence of coronary artery disease: an update from the global burden of disease study. J Am Coll Cardiol. 2024;83:2320. [Google Scholar]
- [2].Lee PH, Hong SJ, Kim HS, et al. Quantitative coronary angiography vs intravascular ultrasonography to guide drug-eluting stent implantation: a randomized clinical trial. JAMA Cardiol. 2024;9:428–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Lee JM, Choi KH, Song YB, et al. Intravascular imaging-guided or angiography-guided complex PCI. N Engl J Med. 2023;388:1668–79. [DOI] [PubMed] [Google Scholar]
- [4].Hong D, Lee J, Lee H, et al. Cost-effectiveness of intravascular imaging-guided complex PCI: prespecified analysis of RENOVATE-COMPLEX-PCI Trial. Circ Cardiovasc Qual Outcomes. 2024;17:e010230. [DOI] [PubMed] [Google Scholar]
- [5].Holm NR, Andreasen LD, Neghabat O, et al. OCT or angiography guidance for PCI in complex bifurcation lesions. N Engl J Med. 2023;389:1477–87. [DOI] [PubMed] [Google Scholar]
- [6].Ali ZA, Landmesser U, Maehara A, et al. Optical coherence tomography-guided versus angiography-guided PCI. N Engl J Med. 2023;389:1466–76. [DOI] [PubMed] [Google Scholar]
- [7].Khan SU, Agarwal S, Arshad HB, et al. Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis. BMJ. 2023;383:e077848. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Stone GW, Christiansen EH, Ali ZA, et al. Intravascular imaging-guided coronary drug-eluting stent implantation: an updated network meta-analysis. Lancet. 2024;403:824–37. [DOI] [PubMed] [Google Scholar]
- [9].Giacoppo D, Laudani C, Occhipinti G, et al. Coronary angiography, intravascular ultrasound, and optical coherence tomography for guiding of percutaneous coronary intervention: a systematic review and network meta-analysis. Circulation. 2024;149:1065–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Darmoch F, Alraies MC, Al-Khadra Y, Moussa Pacha H, Pinto DS, Osborn EA. Intravascular ultrasound imaging-guided versus coronary angiography-guided percutaneous coronary intervention: a systematic review and meta-analysis. J Am Heart Assoc. 2020;9:e013678. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Sreenivasan J, Reddy RK, Jamil Y, et al. Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention: a systematic review and meta-analysis of randomized trials. J Am Heart Assoc. 2024;13:e031111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Groenland FTW, Neleman T, Kakar H, et al. Intravascular ultrasound-guided versus coronary angiography-guided percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis. Int J Cardiol. 2022;353:35–42. [DOI] [PubMed] [Google Scholar]
- [13].Pereira TV, Ioannidis JP. Statistically significant meta-analyses of clinical trials have modest credibility and inflated effects. J Clin Epidemiol. 2011;64:1060–9. [DOI] [PubMed] [Google Scholar]
- [14].Wetterslev J, Thorlund K, Brok J, Gluud C. Estimating required information size by quantifying diversity in random-effects model meta-analyses. BMC Med Res Methodol. 2009;9:86. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Wetterslev JA-O, Jakobsen JC, Gluud C. Trial sequential analysis in systematic reviews with meta-analysis. BMC Med Res Methodol. 2017;17:39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Gao XF, Ge Z, Kong XQ, et al. Intravascular ultrasound vs angiography-guided drug-coated balloon angioplasty: the ULTIMATE III trial. JACC Cardiovasc Interv. 2024;17:1519–28. [DOI] [PubMed] [Google Scholar]
- [17].Moher D, Liberati A, Tetzlaff J, Altman DG; the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;151:264–9. [PMC free article] [PubMed] [Google Scholar]
- [18].Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;373:n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Kip KE, Hollabaugh K, Marroquin OC, Williams DO. The problem with composite end points in cardiovascular studies: the story of major adverse cardiac events and percutaneous coronary intervention. J Am Coll Cardiol. 2008;51:701–7. [DOI] [PubMed] [Google Scholar]
- [21].Park JY, Rha SW, Noh YK, et al. Real-world three-year clinical outcomes of biolimus-eluting stents versus other contemporary drug-eluting stents in patients with acute myocardial infarction patients: data from the Korea Acute Myocardial Infarction Registry (KAMIR). J Interv Cardiol. 2021;2021:6698582. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Ali ZA, Karimi Galougahi K, Maehara A, et al. Outcomes of optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation: one-year results from the ILUMIEN III: OPTIMIZE PCI trial. EuroIntervention. 2021;16:1085–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23].Kim JS, Kang TS, Mintz GS, et al. Randomized comparison of clinical outcomes between intravascular ultrasound and angiography-guided drug-eluting stent implantation for long coronary artery stenoses. JACC Cardiovasc Interv. 2013;6:369–76. [DOI] [PubMed] [Google Scholar]
- [24].Ali ZA, Maehara A, Généreux P, et al. Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial. Lancet. 2016;388:2618–28. [DOI] [PubMed] [Google Scholar]
- [25].Antonsen L, Thayssen P, Maehara A, et al. Optical coherence tomography guided percutaneous coronary intervention with Nobori stent implantation in patients with non-ST-segment-elevation myocardial infarction (OCTACS) trial: difference in strut coverage and dynamic malapposition patterns at 6 months. Circ Cardiovasc Interv. 2015;8:e002446. [DOI] [PubMed] [Google Scholar]
- [26].Bendary A, Elsaed A, Tabl MA, Ahmed ElRabat K, Zarif B. Intravascular ultrasound-guided percutaneous coronary intervention for patients with unprotected left main coronary artery lesions. Coron Artery Dis. 2024;35:171–8. [DOI] [PubMed] [Google Scholar]
- [27].Chamié D, Costa JR, Jr, Damiani LP, et al. Optical coherence tomography versus intravascular ultrasound and angiography to guide percutaneous coronary interventions: the iSIGHT randomized trial. Circ Cardiovasc Interv. 2021;14:e009452. [DOI] [PubMed] [Google Scholar]
- [28].Chieffo A, Latib A, Caussin C, et al. A prospective, randomized trial of intravascular-ultrasound guided compared to angiography guided stent implantation in complex coronary lesions: the AVIO trial. Am Heart J. 2013;165:65–72. [DOI] [PubMed] [Google Scholar]
- [29].Gao XF, Ge Z, Kong XQ, et al. 3-Year outcomes of the ULTIMATE trial comparing intravascular ultrasound versus angiography-guided drug-eluting stent implantation. JACC Cardiovasc Interv. 2021;14:247–57. [DOI] [PubMed] [Google Scholar]
- [30].Hanboly NH, Baghdady YMK, Mostafa MM, Hashad AAF, Sadek YA. The clinical and angiographic impact of intravascular ultrasound guided stenting of unprotected left main and proximal left anterior descending coronary artery. A prospective randomized controlled study in Egypt. Cor et Vasa. 2023;65:468–76. [Google Scholar]
- [31].Hong SJ, Mintz GS, Ahn CM, et al. Effect of intravascular ultrasound-guided drug-eluting stent implantation: 5-year follow-up of the IVUS-XPL randomized trial. JACC Cardiovasc Interv. 2020;13:62–71. [DOI] [PubMed] [Google Scholar]
- [32].Jakabcin J, Spacek R, Bystron M, et al. Long-term health outcome and mortality evaluation after invasive coronary treatment using drug eluting stents with or without the IVUS guidance. Randomized control trial. HOME DES IVUS. Catheter Cardiovasc Interv. 2010;75:578–83. [DOI] [PubMed] [Google Scholar]
- [33].Kala P, Cervinka P, Jakl M, et al. OCT guidance during stent implantation in primary PCI: a randomized multicenter study with nine months of optical coherence tomography follow-up. Int J Cardiol. 2018;250:98–103. [DOI] [PubMed] [Google Scholar]
- [34].Kim JS, Shin DH, Kim BK, et al. Randomized comparison of stent strut coverage following angiography- or optical coherence tomography-guided percutaneous coronary intervention. Rev Esp Cardiol (Engl Ed). 2015;68:190–7. [DOI] [PubMed] [Google Scholar]
- [35].Li X, Ge Z, Kan J, et al. Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in acute coronary syndromes (IVUS-ACS): a two-stage, multicentre, randomised trial. Lancet. 2024;403:1855–65. [DOI] [PubMed] [Google Scholar]
- [36].Liu XM, Yang ZM, Liu XK, et al. Intravascular ultrasound-guided drug-eluting stent implantation for patients with unprotected left main coronary artery lesions: a single-center randomized trial. Anatol J Cardiol. 2019;21:83–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [37].Meneveau N, Souteyrand G, Motreff P, et al. Optical coherence tomography to optimize results of percutaneous coronary intervention in patients with non-ST-elevation acute coronary syndrome: results of the multicenter, randomized DOCTORS study (does optical coherence tomography optimize results of stenting). Circulation. 2016;134:906–17. [DOI] [PubMed] [Google Scholar]
- [38].Tan Q, Wang Q, Liu D, Zhang S, Zhang Y, Li Y. Intravascular ultrasound-guided unprotected left main coronary artery stenting in the elderly. Saudi Med J. 2015;36:549–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [39].Tian NL, Gami SK, Ye F, et al. Angiographic and clinical comparisons of intravascular ultrasound- versus angiography-guided drug-eluting stent implantation for patients with chronic total occlusion lesions: two-year results from a randomised AIR-CTO study. EuroIntervention. 2015;10:1409–17. [DOI] [PubMed] [Google Scholar]
- [40].Wang Y, Yang X, Wu Y, Li Y, Zhou Y. Optical coherence tomography (OCT) versus angiography-guided strategy for percutaneous coronary intervention: a meta-analysis of randomized trials. BMC Cardiovasc Disord. 2024;24:262. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [41].Ashraf DA, Ahmed U, Khan ZZ, et al. Long-term clinical outcomes of intravascular imaging-guided percutaneous coronary intervention versus angiography-guided percutaneous coronary intervention in complex coronary lesions: a systematic review and meta-analysis. Future Cardiol. 2024;20:137–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [42].Kalsi J, Suffredini JM, Koh S, et al. Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention for stent thrombosis elevation myocardial infarction: an updated systematic review and meta-analysis. Cardiology. 2024;149:196–204. [DOI] [PubMed] [Google Scholar]
- [43].Attar A, Hosseinpour A, Azami P, Kohansal E, Javaheri R. Clinical outcomes of optical coherence tomography versus conventional angiography guided percutaneous coronary intervention: a meta-analysis. Curr Probl Cardiol. 2024;49:102224. [DOI] [PubMed] [Google Scholar]
- [44].Yasmin F, Jawed K, Moeed A, Ali SH. Efficacy of intravascular imaging-guided drug-eluting stent implantation: a systematic review and meta-analysis of randomized clinical trials. BMC Cardiovasc Disord. 2022;49:102002. [DOI] [PubMed] [Google Scholar]
- [45].Macherey-Meyer SA-O, Meertens MM, Heyne S, et al. Optical coherence tomography-guided versus angiography-guided percutaneous coronary intervention in acute coronary syndrome: a meta-analysis. Clin Res Cardiol. 2024;113:967–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [46].Yan PF, Liu L, Yuan J, Xu CX, Song D, Yan H. The racial differences in the clinical outcomes of intravascular ultrasound-guided percutaneous coronary intervention: a systematic review and meta-analysis. Am J Cardiol. 2023;203:193–202. [DOI] [PubMed] [Google Scholar]
- [47].Park DY, An S, Jolly N, et al. Comparison of intravascular ultrasound, optical coherence tomography, and conventional angiography-guided percutaneous coronary interventions: a systematic review, network meta-analysis, and meta-regression. Cardiovasc Interv. 2023;102:440–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [48].Wulandari AP, Pintaningrum Y, Adheriyani R. Outcomes of optical coherence tomography guided percutaneous coronary intervention against angiography guided in patients with coronary artery disease: a systematic reviews and meta-analyses. Indian Heart J. 2023;75:108–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [49].Yuan XH, Hu X, Fang Y, et al. Efficacy of intravascular ultrasound versus coronary angiographic guided drug-eluting stent implantation in the treatment of left main coronary artery disease: a meta-analysis. Zhonghua Xin Xue Guan Bing Za Zhi. 2023;51:66–72. [DOI] [PubMed] [Google Scholar]
- [50].Brok J, Thorlund K, Gluud C, Wetterslev J. Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. J Clin Epidemiol. 2008;61:763–9. [DOI] [PubMed] [Google Scholar]
- [51].Trikalinos TA, Churchill R, Ferri M, et al. Effect sizes in cumulative meta-analyses of mental health randomized trials evolved over time. (0895-4356 (Print)). [DOI] [PubMed]
- [52].Pogue JM, Yusuf S. Cumulating evidence from randomized trials: Utilizing sequential monitoring boundaries for cumulative meta-analysis. Controlled Clin Trials 2002;18:580–93. [DOI] [PubMed] [Google Scholar]
- [53].DeMets DL, Lan KK. Interim analysis: the alpha spending function approach. Stat Med. 1994;13:1341–56. [DOI] [PubMed] [Google Scholar]
- [54].Higgins JP, Whitehead A, Simmonds M. Sequential methods for random-effects meta-analysis. Stat Med. 2011;30:903–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
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