Economic Evaluations of Intravascular Imaging Guidance for Percutaneous Coronary Interventions: A Scoping Review

Abstract

Intravascular imaging (IVI), including intravascular ultrasound and optical coherence tomography, has been associated with improved outcomes when used with angiography-guided percutaneous coronary intervention (PCI). Adoption in the United States and Europe has been limited by factors such as operator familiarity with the technology, device cost, and additional procedure time, although use is increasing. In the context of value-based care and constrained health care budgets, understanding whether the long-term clinical benefits of IVI justify its higher upfront procedural costs is essential. To evaluate the economic implications of IVI, a scoping review was performed to synthesize literature on the upfront costs and longer-term cost-effectiveness, with the aim of identifying drivers of cost-effectiveness and highlighting patient populations for whom IVI may yield greater economic benefit. Twenty-five studies published between January 2006 and October 2024 were included, with costs converted to 2023 US dollars. Across studies assessing costs alone, IVI-guided PCI was consistently associated with increased provider costs, typically 10% to 30% higher than angiography-guided PCI. However, among studies evaluating both costs and clinical outcomes, IVI was most often found to be cost effective or economically dominant over longer time horizons. Subgroup analyses suggested IVI is particularly cost effective in patients at a higher risk of adverse events, including those with complex lesions, ST-elevation myocardial infarction, diabetes, reduced ejection fraction, or chronic kidney disease. Time horizon and the assumed duration of IVI benefit were key drivers of cost-effectiveness. Overall, these findings suggest IVI may deliver long-term economic value despite higher initial procedural costs.

Introduction

Clinical evidence demonstrates intravascular imaging (IVI), including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), significantly reduces the risk of adverse cardiac events when used alongside angiography during percutaneous coronary intervention (PCI).1, 2, 3 IVI provides better visualization of coronary and lesion anatomy than angiography alone, thereby allowing for more accurate vessel sizing, optimized stent expansion and strut apposition, and faster identification of PCI-related complications.⁴

In response to this growing body of evidence, clinical guidelines from the European Society of Cardiology and the American College of Cardiology/American Heart Association (ACC/AHA) have recently upgraded the use of IVI to a class 1A recommendation in anatomically complex PCI and acute coronary syndrome cases.^5,6 These updates reflect the vast array of data, which has consistently shown IVI-guided PCI is associated with a lower risk of cardiac death, target vessel-related myocardial infarction (MI), and clinically-driven target vessel revascularization.7, 8, 9 Further emphasizing its importance, 2023 interventional cardiology training guidelines from the ACC, AHA, and Society for Cardiovascular Angiography and Interventions now include minimum procedural volumes for IVI during fellowship.¹⁰

Despite a robust body of clinical evidence, the use of IVI remains relatively low in many regions. In the United States, utilization was estimated at ∼10% of PCI procedures in 2019, with similarly modest adoption reported across Europe.11, 12, 13, 14 However, adoption of IVI has increased over time and, with recent guideline updates, will likely continue to do so.¹⁵ IVI is associated with higher upfront procedural costs, and in some settings, facility reimbursement is inconsistent, leaving providers to absorb incremental expenses. As its use expands, it is critical to understand whether downstream reductions in adverse events and repeat revascularization offset the initial investment and translate into overall economic value.

The objective of this scoping review was to characterize the economic evidence surrounding IVI-guided PCI. Specifically, we synthesized data on upfront procedural costs and longer-term economic outcomes. Partial economic evaluations (cost-only analyses) were examined to quantify incremental procedural costs, whereas full economic evaluations (cost-effectiveness, cost-utility, and budget-impact analyses) were reviewed to assess whether higher upfront costs were justified by improved outcomes and quality-adjusted survival. We also identified key drivers of cost-effectiveness, including patient risk profile (eg, ST-elevation MI [STEMI] versus non-STEMI [NSTEMI]), time horizon, and assumptions regarding the duration of IVI-associated clinical benefit.

Methods

This scoping review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.¹⁶ A scoping review approach was selected to capture available economic evidence on IVI-guided PCI, including both peer-reviewed studies and conference abstracts that reported costs or cost-effectiveness, while excluding sources that did not present original economic data. Consistent with scoping review methodology, a formal quality appraisal of included studies was not conducted. Because this study did not involve human participants, neither institutional review board approval nor participant consent was obtained. A protocol was not published a priori.

Search strategy and inclusion criteria

To identify relevant studies, a comprehensive search was conducted across multiple databases, including MEDLINE and Embase via Ovid (Wolters Kluwer), as well as manual searches of the International Health Technology Assessment Database (inahta.org) and the Centre for Reviews and Dissemination databases (https://www.crd.york.ac.uk/CRDWeb/). These sources were selected for their relevance to health economic literature, including submissions from national health agencies such as the UK’s National Institute for Health and Care Excellence. The search strategy used a combination of controlled vocabulary and free-text terms for IVI, PCI, and economic evaluations. Details regarding the search strategy are provided in Supplemental Table S1.

Studies were eligible for inclusion if they were published in English between January 1, 2006, and October 31, 2024, involved adult populations undergoing PCI in which the intervention was either IVUS or OCT imaging, and included angiography as a comparator. No geographic restrictions were applied. Eligible studies included both full economic evaluations, defined as an analysis that examines both costs and clinical outcomes, and partial economic evaluations, which assess costs alone.¹⁷ Partial economic evaluations were included to characterize upfront procedural costs associated with IVI use, whereas full economic evaluations were used to assess longer-term cost-effectiveness through the joint consideration of costs and clinical outcomes. Studies reporting only clinical outcomes without cost data, or those that provided insufficient economic metrics (eg, qualitative descriptions of cost without quantitative estimates) were excluded.

This review also included relevant conference abstracts and proceedings to capture emerging economic analyses that have not yet been published in a full peer-reviewed manuscript. If both a full-text publication and a conference abstract reported the same study, the full-text version was included. Letters, editorials, commentaries, case reports, preclinical studies, reviews, guidelines, systematic reviews, and animal or in vitro studies were excluded.

Study selection and data extraction procedures

Titles and abstracts were screened to identify potentially eligible studies, followed by full-text reviews to confirm inclusion. Two reviewers (S.K. and A.B.) independently conducted screening and full-text review, each assessing half of the studies. To assess interrater reliability, each reviewer double-screened 10% of the other’s work. Discrepancies were resolved through discussion and consensus.

Data extraction was performed independently by 2 reviewers (S.K. and A.B.) using a structured Microsoft Excel template. The template was pilot tested on 3 included studies and modified to improve clarity and comprehensiveness. For both cost analyses and full economic evaluations, extracted variables included study characteristics such as publication year, geographic setting, clinical population, and imaging modality (IVUS, OCT, or both). Methodological features were also collected, such as study design, data sources, and, for full economic evaluations, time horizon (the period over which costs and health outcomes are accrued), modeling assumptions, and assumptions regarding the duration of IVI benefit (the period over which the reduced risk of adverse events may persist). Economic outcomes extracted from cost analyses included costs (ie, estimated costs to the provider), or charges (ie, the amount submitted to the insurer, which does not always accurately reflect what the provider received in reimbursement) when costs were not reported. Outcomes from full economic evaluations included quality-adjusted life years (QALYs) or life years (LYs), incremental costs, and incremental cost-effectiveness ratios (ICERs) per QALYs or LYs gained. Covidence systematic review software (Veritas Health Innovation) was used to manage study screening, deduplication, and data abstraction, and EndNote (version 20) was used to import references to Covidence.

Synthesis of results

Cost-only analyses and full economic evaluations were synthesized separately, given their distinct objectives and outcome measures. Cost estimates from partial evaluations were standardized using the conversion approach. For studies that reported charges rather than costs, values were converted using the median cost-to-charge ratio from the National Inpatient Sample for the study’s final year of data collection (2023). Costs were then inflated to 2023 US dollars using conversion factors from the World Bank DataBank.¹⁸ If the cost year was not reported, it was assumed to be the last year of data collection. When not explicitly reported, absolute and percentage differences in costs between IVI-guided and angiography-guided PCI were calculated based on reported data.

ICERs from full economic evaluations were converted to 2023 US dollars by adjusting for cumulative local inflation rates and applying purchasing power parity exchange rates.¹⁹ ICERs were categorized according to commonly cited US willingness-to-pay thresholds: values <$50,000 per QALY gained were considered to reflect good economic value, whereas those >$120,000 per QALY gained were considered to reflect poor economic value.²⁰

A sensitivity analysis restricted to peer-reviewed manuscripts was conducted to assess the robustness of findings. Additionally, a comparison of economic value for ‘all-comer’ populations to other specific populations (eg, STEMI, NSTEMI, complex PCI) was also performed for full economic analyses.

ChatGPT and Microsoft Copilot were used to help with editing for clarity and conciseness. Authors reviewed and edited the content and take full responsibility for the content of the publication.

Results

Study selection

A total of 261 publications and conference abstracts were identified through the initial search. After removing duplicates, 200 were screened by title and abstract, of which 134 were excluded. Sixty-six full-text studies were reviewed for eligibility. A 10% random sample of included studies was reviewed in duplicate, with reviewers agreeing on 18 of 20, yielding an interrater reliability score of 90%. After full-text review, 41 studies were excluded: 13 were not economic studies, 9 did not include IVI as an intervention, 15 did not include angiography as a comparator, and 4 were abstracts of studies already included as full-text publications (Figure 1).

Figure 1.

Flow diagram of study selection. This diagram shows the number of studies identified, screened, and excluded through each stage of the scoping review process.

Characteristics of included studies

The final sample included 25 studies: 16 (64%) full-text publications and 9 (36%) conference abstracts. Of these, 18 (72%) were partial economic evaluations assessing costs alone, and 7 (28%) were full economic evaluations examining both costs and clinical outcomes. The geographic distribution of studies and the proportion of abstracts versus full-text publications across partial and full economic evaluations are summarized in the Central Illustration.

Central Illustration.

Intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) can be cost-effective, and often cost-saving, over time across several geographic regions. BIM, budget impact model; CEA, cost-effectiveness analysis; CUA, cost-utility analysis. Numbers indicate the number of studies identified in each country, and shading indicates the proportion of studies reported as abstracts.

All partial economic evaluations were conducted using US data spanning 2008 to 2020. Most (n = 14) leveraged the National Inpatient Sample database (Table 1^15,21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37). All studies analyzed the cost of a PCI encounter with or without the use of IVI, therefore capturing short-term costs to the provider from admission to discharge.

Table 1.

Study characteristics of partial economic evaluations (ie, cost-only analyses)

Reference, year	Intervention	Cost type	Data source	Years of data
Akuna et al,21 2021a	IVI	Charges	NIS	2016-2017
Amin et al,22 2015a	IVUS	Costs	SID	ND
Chothani et al,23 2015a	IVUS	Costs	NIS	2008-2011
Desai et al,24 2019	IVUS	Charges	NIS	2012-2014
Khalid et al,25 2020	IVUS	Costs	NIS	2016
Lazkani et al,26 2021	IVI	Costs	NRD	2016
Lemor et al,27 2020	IVI	Costs	NIS	2010-2014
Maknojia et al,28 2023	IVI	Costs	NIS	October 1, 2015-2018
Mantha et al,29 2019a	IVI	Costs	NRD	2011-2015
Megaly et al,30 2021	IVI	Costs	NIS	2016-2017
Movahed et al,31 2024	IVUS	Charges	NIS	2016-2020
Park et al,32 2023	IVI	Costs	NIS	2008-2019
Park et al,33 2023	IVI	Costs	NIS	2008-2020
Patel et al,34 2017a	IVUS	Costs	NIS	2008-2014
Shafi et al,15 2023	IVUS	Charges	NIS	2016-2019
Singh et al,35 2015	IVUS	Costs	NIS	2008-2011
Tariq et al,36 2018a	IVI	Costs	NRD	2010-2014
Titus et al,37 2023	IVUS	Charges	NIS	2016-2019

IVI, intravascular imaging; IVUS, intravascular ultrasound; ND, no data; NIS, National Inpatient Sample; NRD, Nationwide Readmission Database; SID, State Inpatient Database.

^aConference abstract.

Among partial evaluations, the patient populations varied. Seven of the 18 (39%) included an all-comer PCI population. Other patient populations studied included: acute coronary syndrome (n = 2), all MI patients (n = 1), STEMI (n = 4), NSTEMI (n = 3), unstable angina (n = 1), PCI with coronary atherectomy (n = 1), and patients with and without chronic total occlusion (n = 4). Nine studies evaluated IVUS as the sole imaging intervention, 7 assessed IVI generally, grouping IVUS and OCT together without distinguishing between modalities, and none assessed OCT alone. Two analyzed both IVUS and OCT and conducted separate analyses for each imaging modality. Comparator definitions also varied. Although all studies included angiography alone as the main comparator, 10 studies compared IVUS or OCT directly to angiography-guided PCI, and 8 compared IVUS to ‘non-IVUS.’ One study comparing IVI to angiography-guided PCI also included subanalyses that compared IVUS to non-IVUS and OCT to non-OCT. These variations in intervention and comparator definitions are detailed in Table 2.^15,21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37

Table 2.

Results of partial economic evaluations (ie, cost-only analyses)

Study	Statistic, adjustmenta	Population	Imaging modality	Comparator	Imaging cost,b $	Comparator cost,b $	Difference,b $	Difference, %
Akuna et al,21 2021c	Means, A	ACS	IVI	Angio	54,315	47,407	6908	14.6
Amin et al,22 2015c	Means, A	All-comers	IVUS	Non-IVUS			2702
Chothani et al,23 2015c	Means, A	All-comers	IVUS	Angio	26,793	24,408	2384	9.8
Desai et al,24 2019	Means, U	With atherectomy	IVUS	Non-IVUS	59,953	52,054	7898	15.2
Khalid et al,25 2020	Means, A	STEMI	IVUS	Non-IVUS	38,423	31,156	7267	23.3
Lazkani et al,26 2021	Medians, A	All-comers	IVI	Angio	40,782	31,944	8837	27.7
	Medians, A	Non-left main STEMI	IVI	Angio	40,232	31,655	8577	27.1
	Medians, A	STEMI	IVI	Angio	40,820	31,772	9048	28.5
	Medians, A	NSTEMI	IVI	Angio	39,819	30,888	8931	28.9
	Medians, A	Unstable angina	IVI	Angio	33,016	26,457	6559	24.8
Lemor et al,27 2020	Medians, A	All-comers	IVI	Angio	26,631	23,532	3099	13.2
Maknojia et al,28 2023	Medians, U	SV CTO	IVI	Angio	33,281	26,031	7250	27.9
	Medians, U	SV CTO	IVUS	Non-IVUS	32,971	26,062	6909	26.5
	Medians, U	SV CTO	OCT	Non-OCT	41,458	26,423	15,036	56.9
	Medians, U	SV non-CTO	IVI	Angio	28,661	24,599	4063	16.5
	Medians, U	SV non-CTO	IVUS	Non-IVUS	28,557	24,618	3939	16.0
	Medians, U	SV non-CTO	OCT	Non-OCT	30,654	24,873	5781	23.2
Mantha et al,29 2019c	Means, A	CTO	IVI	Angio	36,595	31,345	5250	16.8
Megaly et al,30 2021	Medians, U	STEMI	IVI	Angio	31,348	25,502	5846	22.9
Movahed et al,31 2024	Means, U	All-comers, age 30+	IVUS	Non-IVUS	59,983	30,249	29,735	98.3
	Mean, A	SV CTO non-ACS	IVI	Angio			3050
Park et al,32 2023	Means, U	All MI	IVI	Angio	37,137	29,875	7262	24.3
	Means, A	All MI	IVI	Angio			5146
	Means, U	STEMI	IVI	Angio	38,259	31,049	7210	23.2
	Means, A	STEMI	IVI	Angio			5528
	Means, U	NSTEMI	IVI	Angio	36,345	28,839	7506	26.0
	Means, A	NSTEMI	IVI	Angio			4841
Park et al,33 2023	Means, U	CV CTO non-ACS	IVI	Angio	33,864	27,334	6530	23.9
Patel et al,34 2017c	Unclear, U	CTO	IVUS	Non-IVUS	34,656	29,864	4792	16.0
Shafi et al,15 2023	Means, U	ACS	IVUS	Non-IVUS	56,284	47,956	8327	17.4
Singh et al,35 2015	Means, A	All-comers	IVUS	Non-IVUS	26,688	23,310	3378	14.5
Tariq et al,36 2018c	Means, A	All-comers	IVUS	Angio	32,105	28,972	3133	10.8
	Unclear, A	All-comers	OCT	Angio	29,651	28,972	678	2.3
Titus et al,37 2023	Means, A	NSTEMI	IVUS	Non-IVUS	63,379	50,974	12,405	24.3

The table includes 34 estimates, all from a US provider prospective.

ACS, acute coronary syndrome; Angio, angiography; CTO, chronic total occlusion; IVI, intravascular imaging; IVUS, intravascular ultrasound; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NSTEMI, non-ST-elevated myocardial infarction; OCT, optical coherence tomography; STEMI, ST-elevated myocardial infarction; SV, single vessel.

^a“A” indicates statistic was adjusted for confounders and “U” indicates statistic was not adjusted for confounders.

^bAdjusted for inflation.

^cConference abstract.

The 7 full economic evaluations (Table 338, 39, 40, 41, 42, 43, 44) were conducted across 6 countries: Korea (n = 2), Italy (n = 1), Bulgaria (n = 1), China (n = 1), the UK (n = 1), and Australia (n = 1). Most used cost-utility analysis (CUA; n = 5), while 1 combined CUA and cost-effectiveness analysis (CEA), and another included CUA, CEA, and budget-impact modeling. Three evaluations adopted a payer perspective (Italy, Bulgaria, China), and 4 used a broader health system perspective (Korea [n = 2], UK, Australia). Among the 4 studies that specified the type of cost inputs, all used direct medical costs. The modeled patient populations included all-comer PCI patients (n = 4), those undergoing complex PCI (n = 1), and STEMI or non-STEMI patients (n = 2). Six studies evaluated IVUS alone, 1 study evaluated both IVUS and OCT, and none of the studies evaluated OCT alone. All of these studies compared IVI to angiography-guided PCI. Modeling assumptions about the duration of the IVI benefit varied. Some studies assumed the effect of IVI persisted over the lifetime of the patient, whereas other studies applied shorter durations (1-5 years) in either the base case or sensitivity analyses. These assumptions and patient populations are detailed in Tables 3 and 4.38, 39, 40, 41, 42, 43, 44

Table 3.

Study characteristics of full economic evaluations (ie, assess costs and clinical outcomes)

Study	Location	Design	Perspective	Imaging	Time horizon	Model structure and data sources
Ahn et al,38 2020a	Korea	CUA	Health system	IVUS	5 y, lifetime	Markov model, COMPARE trial and literature
Alberti et al,39 2016	Italy	CUA	Payer	IVUS	Lifetime	Markov model, COMPARE trial (angiography arm) and Ahn et al38 meta-analysis (IVUS arm)
Dacheva et al,40 2023a	Bulgaria	CEA, CUA	Payer	IVUS	Lifetime	Model structure and data sources not described
Hong et al,41 2024	Korea	CUA	Health system	IVI	3 y, lifetime	Model 1: Decision tree model, 3 y, RENOVATE-COMPLEX PCI trial (both arms) Model 2: Markov model, lifetime, using same inputs as model 1 Model 3: Markov model, lifetime, meta-analysis of 20 trials (both arms)
Lao et al,42 2022a	China	BIM, CEA, CUA	Payer	IVUS	1 y, lifetime	Markov model, data sources not described
Sharp et al,43 2024	UK	CUA	Health system	IVUS	Lifetime	Model 1: Decision tree model, 1 y, EXAMINATION trial and real-world UK data (angiography arm) and ULTIMATE trial (IVUS arm) Model 2: Markov model, lifetime, using same inputs as model 1
Zhou et al,44 2021	Australia	CUA	Health system	IVUS	2 y, 5 y, lifetime	Model 1: Decision tree model, 2 y, Australian PCI registries or pooled analyses of literature (angiography arm) and meta-analysis of 10 trials (IVUS arm) Model 2: Markov model, 5 y and lifetime, using same inputs as model 1

BIM, budget-impact model; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; IVUS, intravascular ultrasound; OCT, optical coherence tomography; PCI, percutaneous coronary intervention.

^aConference abstract.

Table 4.

Results of full economic evaluations (ie, assess costs and clinical outcomes)

Study	Patient characteristics	Time horizon	IVI benefit	ICER, LYsa	ICER, QALYsa
Ahn et al,38 2020b	All-comers	5 y	ND	ND	43,693
	All-comers	Lifetime	ND	ND	(881)
Alberti et al,39 2016	All-comers (base case)	Lifetime	Indefinite	(6122)	(6748)
	Diabetes	Lifetime	Indefinite	(6216)	(6871)
	Renal insufficiency	Lifetime	Indefinite	(6209)	(6868)
	ACS	Lifetime	Indefinite	(6216)	(6870)
	Everolimus-eluting stents	Lifetime	Indefinite	(4086)	(4501)
	All-comers	Lifetime	1 y	ND	18,932
Dacheva et al,40 2023b	STEMI	Lifetime	ND	6624	12,282
	NSTEMI + UA	Lifetime	ND	12631	22,775
Hong et al,41 2024	Complex PCIc	3 y	Indefinite	ND	57,040
	Complex PCId	Lifetime	Indefinite	Dominant	Dominant
	Complex PCIe	Lifetime	Indefinite	Dominant	Dominant
	IVUSd	Lifetime	Indefinite	Dominant	Dominant
	OCTd	Lifetime	Indefinite	Dominant	Dominant
	Stable IHDd	Lifetime	Indefinite	Dominant	Dominant
	ACSd	Lifetime	Indefinite	Dominant	Dominant
	Age (<65 y)d	Lifetime	Indefinite	Dominant	Dominant
	Age (≥65 y)d	Lifetime	Indefinite	Dominant	Dominant
	Mend	Lifetime	Indefinite	Dominant	Dominant
	Womend	Lifetime	Indefinite	Dominant	Dominant
	Diabetes presentd	Lifetime	Indefinite	Dominant	Dominant
	Diabetes absentd	Lifetime	Indefinite	Dominant	Dominant
	CKD presentd	Lifetime	Indefinite	Dominant	Dominant
	CKD absentd	Lifetime	Indefinite	Dominant	Dominant
	LVEF <50%d	Lifetime	Indefinite	Dominant	Dominant
	LVEF ≥50%d	Lifetime	Indefinite	Dominant	Dominant
Lao et al,42 2022b	All-comers (base case)	Lifetime	Indefinite	ND	Dominant
	All-comers	Lifetime	1 y	ND	38,289
Sharp et al,43 2024	STEMI (base case)	Lifetime	1 y	ND	6535
	NSTEMI + UA (base case)	Lifetime	1 y	ND	10,219
	STEMI	1 y	1 y	ND	42,770
	NSTEMI + UA	1 y	1 y	ND	75,940
	STEMI	3 y	1 y	ND	16,858
	NSTEMI + UA	3 y	1 y	ND	30,976
Zhou et al,44 2021	All-comers (base case)	2 y	2 y	ND	120,745
	All-comers (base case)	5 y	2 y	ND	52,212
	All-comers (base case)	Lifetime	2 y	ND	14,226
	Complex lesions	Lifetime	2 y	ND	9200
	LM disease	Lifetime	2 y	ND	12,787
	All-comers	Lifetime	5 y	ND	5823
	All-comers	Lifetime	Indefinite	ND	Dominant
	All-comersf	Lifetime	1 y	ND	29,728

ACS, acute coronary syndrome; CKD, chronic kidney disease; ICER, incremental cost-effectiveness ratio; IHD, ischemic heart disease; IVI, intravascular imaging; IVUS, intravascular ultrasound; LM, left main coronary artery; LVEF, left ventricular ejection fraction; LY, life year; ND, no data; NSTEMI, non-ST-elevated myocardial infarction; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; QALY, quality-adjusted life year; STEMI, ST-elevated myocardial infarction; UA, unstable angina.

^aConverted to 2023 US dollars.

^bConference abstract.

^cWithin trial decision tree model with trial inputs.

^dMarkov model with trial inputs.

^eMarkov model with meta-analysis inputs.

^fWorst case scenario.

Upfront procedural costs from partial economic evaluations associated with IVI

Across the 18 partial economic studies, which included various imaging modalities and patient subgroups, there were 34 reported estimates comparing the upfront cost of encounters with IVI-guided PCI to non–IVI guided PCI from a US provider perspective. Nineteen of the estimates were adjusted for confounders that could be correlated with both the use of IVI and provider costs, 13 were not adjusted, and 2 were unclear.

Although all studies reported higher inflation-adjusted costs for IVI-guided PCI, the magnitude of the cost difference varied substantially across populations and study designs. Cost differences ranged from 2.3% ($678) (Tariq et al²⁵) to 98.3% ($29,735) (Movahed et al³¹). When the authors specified that the results were adjusted for confounders, the range fell within 2.3% ($678) (Tariq et al³⁶) to 28.9% ($8931) (Lazkani et al²⁶). Among the studies that adjusted for confounders, only 2 studies, Lazkani et al²⁶ and Park et al³², assessed how the cost of IVI-guided PCI varied across patient presentation, with both observing the highest cost differential in STEMI patients (Table 338, 39, 40, 41, 42, 43, 44).

ICERs and key drivers of cost-effectiveness

Seven full economic evaluations reported a total of 43 ICERs per QALY and 23 ICERs per LY, covering various patient populations and time horizons (defined as the period during which costs and health outcomes were accrued in the CEA model), ranging from 1 year to lifetime. Reported ICERs (Table 438, 39, 40, 41, 42, 43, 44; Supplemental Table S2) ranged from economic dominance (ie, IVI was more effective and cost-saving) to IVI not being cost effective at $120,745 per QALY (Zhou et al⁴⁴), with the substantial variation driven by model assumptions.

Time horizon and assumed duration of the IVI clinical benefit (defined as the length of time during which IVI-related risk reductions were applied in the model) were consistent drivers of cost-effectiveness across studies. In general, models with longer time horizons and models that assumed a lifetime benefit of IVI produced more favorable ICERs. Five studies (Alberti et al,³⁹ Hong et al,⁴¹ Lao et al,⁴² Zhou et al,⁴⁴ and Ahn et al³⁸) found IVI to be an economically dominant strategy over a lifetime horizon, under the assumption that the IVI benefit is indefinite (although Ahn et al did not specifically indicate the benefit duration, it is assumed). In studies that assumed a more limited benefit duration of IVI (1-5 years), ICERS ranged from $5,823 per QALY (Zhou et al,⁴⁴ 5-year effect duration) to $38,289 per QALY (Lao et al,⁴² 1-year effect duration). In each case, when modeled over a lifetime horizon, all estimated ICERs fell below the commonly accepted good economic value of $50,000 per QALY. Economic analyses that used shorter time horizons (1-5 years) generally produced ICERs that indicated IVI was cost effective but not economically dominant, reflecting the delayed clinical and economic impact of preventing major adverse cardiovascular events such as MI and revascularization. For example, Sharp et al⁴³ assumed the IVUS benefit lasted for 1 year and estimated an ICER of $16,858 per QALY at 3 years for STEMI patients, which fell to $6,535 per QALY over a lifetime horizon. The base case estimated by Ahn et al³⁸ used a 5-year time horizon and produced an ICER of $43,693 per QALY; when the model was extended to a lifetime horizon, IVI became economically dominant. The highest ICER described was calculated at $120,745 per QALY (Zhou et al⁴⁴), and this was derived from a 2-year model of all-comers and assumed a 2-year IVI benefit. Within the same model, ICERs dropped to $52,212 per QALY at 5 years and $14,226 per QALY over a lifetime horizon.

Cost-effectiveness by patient subgroup

Several studies identified specific patient subgroups in whom IVI-guided PCI was more cost effective. Dacheva et al⁴⁰ and Sharp et al⁴³ reported lower ICERs for STEMI patients compared with those with NSTEMI and unstable angina. In Sharp’s model, the ICER at a lifetime horizon was $6535 per QALY for STEMI patients versus $10,219 per QALY for NSTEMI and unstable angina patients, whereas in Dacheva’s model, those values were $12,282 and $22,775, respectively. Hong et al,⁴¹ whose analysis was based on the RENOVATE-COMPLEX-PCI trial population, reported more favorable lifetime cost savings in higher-risk patients among a complex PCI population (economically dominant over a lifetime horizon). These included individuals with lower ejection fraction, diabetes, chronic kidney disease, or advanced age. Only 2 studies, Alberti et al³⁹ and Zhou et al,⁴⁴ examined both all-comer and higher-risk populations. Alberti et al³⁹ reported slight improved savings among patients with diabetes, renal insufficiency, and acute coronary syndromes compared to all-comers, but the authors demonstrated economic dominance of IVI over angiography for all patient groups studied. Zhou et al⁴⁴ found IVUS was more cost effective over a patient’s lifetime for those with complex lesions (ICER = $9200 per QALY gained) than for all-comers (ICER = $14,226 per QALY gained). These findings consistently demonstrate that IVI is more cost effective in higher-risk populations in whom the downstream clinical and economic impact of adverse event reduction are amplified.

Sensitivity analysis of peer-reviewed publications

A sensitivity analysis of partial economic evaluations, which excluded conference abstracts, was performed and found consistent results with the original analysis. In this sensitivity analysis, 12 peer-reviewed publications reported 27 estimates. Among adjusted analyses, cost differences ranged from 13.2% ($3099) (Lemor et al²⁷) to 28.9% ($8931) (Lazkani et al²⁶).

A sensitivity analysis of full economic evaluations, including only peer-reviewed publications, also found consistent results with the original analysis. Four full economic evaluations reported a total of 37 ICERs per QALY and 21 ICERs per LY, covering various patient populations and time horizons ranging from one year to lifetime.^39,41,43,44 These studies were conducted from health care perspectives from Italy, South Korea, and Australia.

Unlike the abstracts, each peer-reviewed full economic evaluation included multiple models varying assumptions. Three studies (Hong et al,⁴¹ Zhou et al,⁴⁴ and Sharp et al⁴³) varied the time horizon and modeled both short-term cost-effectiveness (1-5 years) and lifetime. Two studies (Zhou et al⁴⁴ and Alberti et al³⁹) explored different durations of the IVI benefit, both short-term (1-5 years) and indefinite. All 4 examined various patient populations. In each case, when modeled over a lifetime horizon, all estimated ICERs fell below the commonly accepted $50,000 per QALY threshold.

Discussion

This scoping review found that IVI guidance in PCI was generally associated with favorable long-term economic outcomes across several countries, particularly when evaluated over a patient’s lifetime. In light of updated ACC/AHA and European Society of Cardiology guidelines that recommend IVUS and OCT in anatomically complex cases, this evidence underscores the long-term economic rationale for expanded adoption of IVI-guided PCI.

This review identified substantial variability in provider costs associated with IVI in the United States. Across the 18 partial economic evaluations that assessed costs only, IVI-guided PCI was associated with increased provider costs ranging from 2.3% to 98.3% higher than angiography-guided PCI, with most estimates falling between 10% and 30%. This variability may reflect the more frequent use of IVI in higher risk or more complex cases, as recommended by clinical guidelines.⁶ When restricting analyses to cost estimates adjusted for patient complexity, the incremental costs narrowed to 2.3% to 28.9%. Because administrative claims data cannot fully account for patient complexity, increases in encounter costs attributed to IVI use may still be inflated.¹⁵ Although these partial economic evaluations do not address cost-effectiveness, they provide important context regarding the upfront procedural costs associated with IVI use during PCI. In the United States, where most hospitals are reimbursed based on diagnosis-related groups, facilities do not receive increased payment for the use of IVI,⁴⁵ and therefore, the initial investment is borne entirely by the facility.

Across evaluations, assumptions about time horizon and the persistence of IVI’s clinical benefit were the primary drivers of cost-effectiveness. In studies that modeled multiple time horizons, longer durations consistently yielded more favorable ICERs, both within and across studies. Similarly, models that assumed the clinical benefit of IVI persisted indefinitely were more likely to report economic dominance, while those with conservative assumptions of 1 to 5 years of clinical benefit still found IVI to be cost effective in most cases. These patterns highlight the importance of aligning model assumptions with long-term clinical data. For example, sustained reductions in adverse events have been demonstrated in 3-year follow-up data from the ULTIMATE trial,⁴⁶ and other analyses of real-world data have suggested that the clinical benefits of IVI may persist for several years beyond the index procedure.^47,48 However, additional evidence on the long-term impact of IVI is needed to better inform cost-effectiveness analyses. In particular, assumptions regarding the duration of the IVI benefit can materially influence model results and should reflect the potential for longer-term clinical benefit to avoid underestimating the value of IVI.

Subgroup analyses suggested IVI-guided PCI may be particularly cost effective in higher-risk populations for whom the burden of adverse events is greater. More favorable ICERs were reported for patients with STEMI compared to those with NSTEMI and unstable angina, as well as for individuals with complex lesions, diabetes, reduced ejection fraction, or chronic kidney disease. The enhanced economic value in these groups was likely driven by higher baseline rates of adverse cardiac events such as MI and repeat revascularization,49, 50, 51 which are events IVI have been shown to reduce. Notably, 2 studies also identified greater cost savings in patients with renal insufficiency, likely reflecting the added value of IVUS in minimizing contrast use and preserving kidney function.⁵²

Limitations

This review has several methodological limitations. First, by including conference abstracts in the search, we captured all evidence on the cost and cost-effectiveness of IVI; however, abstracts do not provide the level of detail as a full manuscript, nor are they peer-reviewed. As such, a sensitivity analysis was conducted without them, but evidence derived from the abstracts should be considered hypothesis-generating. Moreover, by including only studies in English, the results may be biased to evidence from English-speaking regions. To enable comparisons across studies, charges were converted to costs; these conversions can introduce bias or error, especially when assumptions were made about the year the data were reported. Furthermore, the partial economic evaluations rarely listed the confounders used to adjust the cost analyses, making it impossible to assess the comprehensiveness or appropriateness of the studies’ ability to control for confounders. Additionally, the full economic studies did not always fully report the drivers of cost-effectiveness in their models, limiting the ability to identify those drivers Finally, cost components, such as capital, disposables, and staff time, may differ by study, further complicating comparisons across studies.

Future research

This scoping review also identified several gaps in the literature. First, all cost analyses were US focused, but none of the cost-effectiveness analyses were from a US perspective. Additionally, most cost-effectiveness analyses were based on data from randomized trials rather than real-world populations, which may limit generalizability to routine clinical practice. Furthermore, the partial economic evaluations often lacked a consistent comparison group; some compared IVUS or OCT to angiography-guided PCI, while others compared imaging modalities to mixed or undefined comparator groups (eg, “non-IVUS” or “non-OCT”), complicating cross-study comparisons. Moreover, the majority of the available economic evidence identified in this review was derived from studies evaluating IVUS, with relatively limited data specific to OCT. As a result, generalizing findings across all IVI modalities should be done with caution. As IVUS and OCT continue to evolve, clinical outcomes may become more pronounced. Future studies should therefore prioritize modality-specific economic evaluations to better characterize the distinct costs and benefits associated with IVUS and OCT separately.

Conclusion

IVI was frequently cost effective and, in several cases, cost-saving, particularly when modeled over a lifetime horizon or applied in high-risk populations such as those with complex lesions, STEMI, diabetes, or chronic kidney disease. At the same time, evidence from cost-only analyses highlight the upfront procedural costs associated with IVI. Depending on the reimbursement system, the upfront costs could be borne by the health care payer, which also stands to gain from the downstream reduction in adverse events. However, in systems where IVI is not incrementally reimbursed, costs are borne by the provider, creating a mismatch in financial incentives. Additional cost-effectiveness analyses are needed using US data, including real-world data, to better reflect current practice, resource utilization, and pricing structures. Such analyses will be essential for informing value-based reimbursement and ensuring that guideline-endorsed technologies like IVUS and OCT are accessible to patients who are most likely to see clinical benefit: those with STEMI, diabetes, or chronic kidney disease.