Burhan M, Saeed H, Usama M, Tariq A, Shafiq S, Hurjkaliani S, Iqbal M, Shahid S, Khalid S, Tahirkheli NK. Optical coherence tomography-guided percutaneous coronary intervention compared to angiography-guided percutaneous coronary intervention for complex lesions. World J Cardiol 2025; 17(9): 110403 [DOI: 10.4330/wjc.v17.i9.110403]
Corresponding Author of This Article
Humza Saeed, Researcher, Department of Internal Medicine, Rawalpindi Medical University, New Teaching Block, Rawalpindi 87500, Punjab, Pakistan. hamzasaeed309@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Meta-Analysis
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Muhammad Burhan, Humza Saeed, Muhammad Usama, Aamnah Tariq, Saira Shafiq, Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi 87500, Punjab, Pakistan
Sonia Hurjkaliani, Department of Internal Medicine, Dow University of Health Sciences, Karachi 74200, Sindh, Pakistan
Minahil Iqbal, Department of Internal Medicine, Allama Iqbal Medical College, Lahore 54000, Punjab, Pakistan
Sufyan Shahid, Department of Internal Medicine, Khawaja Muhammad Safdar Medical College, Sialkot City 51300, Punjab, Pakistan
Salman Khalid, Naeem Khan Tahirkheli, Department of Cardiology, Oklahoma Heart Hospital, Oklahoma City, OK 73120, United States
Author contributions: Burhan M designed research, performed research, analyzed data, and wrote the paper; Saeed H performed research, analyzed data, and wrote the paper; Usama M performed research and analyzed data; Tariq A performed research and analyzed data; Shafiq S, Hurjkaliani S, Iqbal M, and Shahid S wrote the paper; Khalid S supervised research, validated findings, and wrote the paper; Tahirkheli N supervised research, validated findings, conceptualized the study, and wrote the paper; all of the authors read and approved the final version of the manuscript to be published.
Conflict-of-interest statement: The authors have no conflicts of interest statement to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Humza Saeed, Researcher, Department of Internal Medicine, Rawalpindi Medical University, New Teaching Block, Rawalpindi 87500, Punjab, Pakistan. hamzasaeed309@gmail.com
Received: June 7, 2025 Revised: June 12, 2025 Accepted: August 25, 2025 Published online: September 26, 2025 Processing time: 103 Days and 18.5 Hours
Abstract
BACKGROUND
Optical coherence tomography (OCT) offers detailed cross-sectional imaging during percutaneous coronary intervention (PCI), aiding in anatomically complex coronary lesions. Despite its advantages, evidence on the clinical effectiveness of OCT-guided PCI remains limited.
AIM
To compare clinical outcomes of OCT-guided vs angiography-guided PCI in patients with complex lesions.
METHODS
Major databases were systematically searched for randomized controlled trials (RCTs) comparing OCT-guided and angiography-guided PCI in complex lesions. Primary outcomes included major adverse cardiovascular events (MACE) and target vessel failure (TVF); secondary outcomes included mortality, myocardial infarction (MI), and other procedural outcomes. A random-effects model was used to pool risk ratio (RR), with 95%CI. Statistical analysis was conducted in R software (v4.4.1), with significance set at P < 0.05.
RESULTS
Five RCTs (5737 patients) showed OCT-guided PCI significantly reduced MACE (RR: 0.63, 95%CI: 0.52-0.77, P < 0.01), TVF (RR: 0.68, 95%CI: 0.56-0.83, P < 0.01), all-cause (RR: 0.58, 95%CI: 0.38-0.87, P < 0.01) and cardiac mortality (RR: 0.43, 95%CI: 0.24-0.76, P < 0.01), target-lesion revascularization (RR: 0.53, 95%CI: 0.33-0.84, P < 0.01), stent thrombosis (RR: 0.52, 95%CI: 0.31-0.86, P = 0.01), and target-vessel MI (RR: 0.64, 95%CI: 0.42-0.97, P = 0.04) vs angiography-guided PCI. Periprocedural MI, any revascularization, target-vessel revascularization, and contrast-associated kidney injury were similar between groups.
CONCLUSION
OCT-guided PCI improves outcomes in complex lesions by reducing MACE, TVF, mortality, stent thrombosis, and target-vessel MI. These findings highlight the need for further large-scale RCTs to confirm its benefits.
Core Tip: This meta-analysis of five randomized controlled trials (RCTs) evaluates the clinical benefits of optical coherence tomography (OCT)-guided vs angiography-guided percutaneous coronary intervention (PCI) in patients with complex coronary lesions. OCT-guided PCI was associated with significantly reduced rates of major adverse cardiovascular events, target vessel failure, mortality, and stent thrombosis. These findings support OCT guidance as a superior imaging modality during PCI in complex cases and underscore the need for further large-scale RCTs to validate its routine use in clinical practice.
Citation: Burhan M, Saeed H, Usama M, Tariq A, Shafiq S, Hurjkaliani S, Iqbal M, Shahid S, Khalid S, Tahirkheli NK. Optical coherence tomography-guided percutaneous coronary intervention compared to angiography-guided percutaneous coronary intervention for complex lesions. World J Cardiol 2025; 17(9): 110403
Optical coherence tomography (OCT) is a catheter-based imaging modality that provides high-resolution cross-sectional images of the coronary arteries, allowing for precise visualization of vascular structures at the microscopic level[1]. It can be used to assess coronary lumen geometry, lesion morphology, plaque tissue characteristics, stent results[2], and post-percutaneous coronary intervention (PCI) findings including stent expansion, apposition and edge dissections[3]. Conventional angiography, on the other hand, provides only a two-dimensional view of coronary arteries. This limits its ability to fully assess atherosclerotic burden, characterize plaque, and define vessel diameter[4]. As a result, OCT-guided PCI offers greater sensitivity in detecting vulnerable plaque features, supporting better and more informed treatment decisions, and leading to better long-term outcomes with fewer major adverse cardiovascular events (MACE) and reduced cardiovascular deaths compared to angiography-guided PCI[5].
Although past meta-analyses have solidified the superiority of OCT-guided PCI as compared to angiography-guided PCI, scarce literature is present on the role of OCT-guided PCI in complex coronary artery lesions[6]. These lesions are prevalent in over 20% of patients with coronary artery disease (CAD) and are characterized by factors such as significant vessel tortuosity, calcifications, bifurcation involvement, and diffuse stenoses[7]. These lesions pose significant anatomical and functional challenges and are associated with higher risks of cardiac death, myocardial infarction (MI), and revascularization[8]. To our knowledge, no current meta-analysis has specifically focused on comparing OCT-guided PCI with angiography-guided PCI in this patient population. Therefore, we conducted this systematic review and meta-analysis to address this knowledge gap.
MATERIALS AND METHODS
This systematic review and meta-analysis was performed according to the Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines[9,10]. The protocol for this review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), No. CRD42025638554. Since this was a study-level meta-analysis that included publicly available, non-identifiable aggregated data from individual studies, formal ethical review board approval was not required.
Data sources and searches
An extensive search strategy was developed using MeSH terms and free text keywords: ‘optical coherence tomography’, ‘angiography’, ‘percutaneous coronary intervention’, ‘coronary revascularization’. A comprehensive search was then conducted across PubMed, EMBASE, and Cochrane Central databases from their inception till April 2025 without any language restriction. Detailed search strings for each database are provided in supplementary files (Supplementary Table 1). Furthermore, we conducted a manual review of the reference lists from all included articles to ensure that no relevant studies were missed during the initial search.
Eligibility criteria
Inclusion criteria: The inclusion criteria were defined using the Population, Intervention, Comparison, and Outcomes model, commonly employed in systematic reviews and meta-analyses. The population (P) consisted of patients with complex coronary lesions (Supplementary Tables 2 and 3)[11-15]. The intervention (I) was OCT-guided PCI, while the comparison (C) group consisted of angiography-guided PCI. Studies were included if they reported at least one of the specified outcomes of interest (O) and were randomized controlled trials (RCTs).
Outcomes: The study’s primary outcomes were MACE and target vessel failure (TVF). The definition of MACE and TVF in each study is provided in Supplementary Table 4. If any primary outcome composite was not mentioned in the study, it was calculated via summation of individual components according to the definition of that composite in the latest trial. Secondary outcomes included all-cause and cardiac mortality, target-vessel and periprocedural MI, and any revascularization along with target-vessel and target-lesion revascularization, stent thrombosis (definite or probable) and definite stent thrombosis, and contrast-associated acute kidney injury (AKI). The definition of each outcome in each study is mentioned in Supplementary Tables 4 and 5[11-15].
Exclusion criteria: Exclusion criteria were applied to non-RCTs, studies comparing techniques other than OCT or angiography-guided PCI, and studies involving patients undergoing PCI for conditions other than complex lesions. Studies with overlapping populations or those not reporting any of the specified outcomes of interest were also excluded.
Study selection
The studies found via search of databases were imported to EndNote version 21.3 (Clarivate) where the duplicates were removed. Two authors independently screened the studies in 2 phases: (1) Based on title; and (2) Abstract full-text screening. Any discrepancy was resolved by consultation with the third senior author.
Data extraction
Two independent authors used a pre-tested excel sheet and extracted the following information: (1) Study's name; (2) Year of publication; (3) Stent type; (4) Sample size; (5) Mean age; (6) Male (%); (7) Mean left ventricular ejection fraction; and (8) Comorbidities. Inclusion and exclusion criteria, definitions of complex lesions of each study were also extracted. Any disagreement was resolved with consultation with the third author.
Assessment of risk of bias
The Revised Cochrane Risk of Bias tool (RoB 2.0) was used to assess the quality of the included RCTs[16]. The trials were assessed based on 5 domains. (1) Assessing bias arising due to randomization process; (2) Deviation from intended treatment; (3) Reporting incomplete data; (4) Measurement of outcomes; and (5) Selective reporting of result. Each domain was judged as low, moderate, and high risk of bias by carefully assessing the article and protocol of the included trial. The risk of bias assessment was independently performed by two authors, with disagreements resolved through consensus.
Certainty of evidence
The quality of evidence for this meta-analysis was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach[17]. Initial level of confidence is based on study design i.e. RCTs for high level of confidence and observational studies for low level of confidence. Domains for downgrading the confidence include inconsistency, risk of bias, indirectness, imprecision and publication bias. Large effect size, dose-response gradient, plausible confounding are the domains which upgrade the confidence. Final confidence level is to be categorized as high, moderate, low, very low[17,18].
Statistical analysis
Random-effects model with the Mantel–Haenszel approach was used to perform the analysis. Primary outcomes were pooled using both risk ratio (RR) and hazard ratio (HR) along with their 95%CI, whereas secondary outcomes were pooled only by RR and 95%CI. Continuous outcomes were pooled using mean difference (MD) with their 95%CI. DerSimonian and Laird methods were used to estimate between-study variance (τ2) and 95%CI was calculated using the standard normal approximation. Cochran’s Q-statistic was used to check the heterogeneity between the studies, which was then quantified using Higgins I2 statistics[19]. Heterogeneity was categorized as low (< 25%), moderate (25%-75%), or high (> 75%). For outcomes reporting a moderate to high heterogeneity, we conducted a sensitivity analysis by leave-one-out approach, i.e. each study was omitted, and its effect on overall size and heterogeneity was noted. A sub-group analysis was performed for the outcome of MACE based on age, gender, clinical presentation, diabetic presentation, bifurcation, in-stent restenosis, calcification and multivessel PCI. As the studies were less than 10, no publication bias was assessed. For the similar reason, meta-regression could not be performed. Statistical significance was set at less than 0.05. All the analysis was done using R software v4.4.1 using the ‘meta’ package.
RESULTS
Study selection
Our systematic search yielded a total of 997 articles. After removing the 278 duplicate articles, 718 articles remained for primary screening based on their title and abstract. A total of 130 articles were left for full-text assessment. Ultimately, our systematic review and meta-analysis included five studies (Figure 1)[11-15]. Post-hoc analyses and original trials were used to extract the data for ILUMIEN IV and RENOVATE-COMPLEX PCI[11,13,20,21].
Figure 1
Preferred Reporting Items for Systematic reviews and Meta-Analysis flow diagram for identification and selection of studies included in the meta-analysis.
Study characteristics
Our study constituted 5737 patients, with 2738 patients in the OCT-guided PCI group and 2999 patients in the angiography-guided PCI. The mean age of participants was 67 years, and 79.4% were male. All the included studies were multi-centred and were published between 2023 and 2025. Except for ILUMIEN IV and CALIPSO, all included trials were open label. Drug-eluting stent with Everolimus was used in each study. The baseline characteristics of each study are mentioned in Table 1[11-15]. Distribution of complex lesions across studies are present in Supplementary Table 6[11-15]. RoB 2.0 assessment that all five studies had a low overall risk of bias (Supplementary Figure 1)[11-15].
Table 1 Baseline characteristics of included studies, n (%).
MACE: OCT-guided PCI was significantly associated with a reduced risk of MACE (RR: 0.63, 95%CI: 0.52-0.77, P < 0.001, I2 = 0) compared to angiography-guided PCI (Figure 2A)[11-15]. Similarly, the hazard of MACE was significantly lower in the OCT-guided PCI group compared to the angiography-guided PCI group (HR: 0.66, 95%CI: 0.52-0.82, P < 0.001), with no observed heterogeneity (Figure 2B)[11,12,14]. Subgroup analysis was performed on the basis of age, gender, clinical presentation, diabetic status, bifurcation, in-stent restenosis, calcification, and multi-vessel PCI (Supplementary Figure 2). The GRADE assessment indicated a high level of certainty for the evidence supporting MACE reduction (Supplementary Table 7).
Figure 2 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of major adverse clinical events.
A: Meta-analysis using risk ratio as the effect measure; B: Meta-analysis using hazard ratio as the effect measure. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
TVF: Four studies reported TVF and pooled results showed that the risk (RR: 0.68, 95%CI: 0.56-0.83, P < 0.001, I2 = 18%) and hazard (HR: 0.67, 95%CI: 0.54-0.83, P < 0.001) were significantly reduced in the OCT-guided PCI group as compared to the angiography-guided PCI (Figure 3)[11-14]. According to the GRADE assessment, the certainty of evidence for TVF is rated as high (Supplementary Table 7).
Figure 3 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of target vessel failure.
A: Meta-analysis using risk ratio as the effect measure; B: Meta-analysis using hazard ratio as the effect measure. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
Secondary outcomes
Mortality outcomes: Mortality outcomes were reported in four studies without any heterogeneity (I2 = 0). A significantly lower incidence of all-cause mortality (RR: 0.58, 95%CI: 0.38-0.87, P = 0.009) and cardiac mortality (RR: 0.43, 95%CI: 0.24-0.76, P = 0.003) was observed in the OCT-guided PCI as compared to the angiography-guided PCI (Figure 4)[11-14]. According to the GRADE assessment, the certainty of evidence for all-cause mortality is rated as high (Supplementary Table 7).
Figure 4 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of all-cause mortality and cardiac mortality.
A: All-cause mortality; B: Cardiac mortality. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
MI outcomes: The risk of any MI (RR: 0.79, 95%CI: 0.62-1.01, P = 0.3701, I2 = 6.4%) and periprocedural MI (RR: 0.80; 95%CI: 0.60-1.06, P = 0.579, I2 = 0%) was comparable between the two groups. Risk of Target-vessel MI (RR: 0.64; 95%CI: 0.42-0.97, P = 0.036, I2 = 47.2%) was significantly decreased in OCT-guided PCI compared to Angio-guided PCI (Figure 5)[11-15]. Leave-one out sensitivity analysis for target-vessel MI revealed that omitting OCCUPI (2024) reduced the heterogeneity to the lower range (I2 = 14.9%) (Supplementary Figure 3)[11-14]. MI is ranked as high level of evidence certainty according to GRADE assessment (Supplementary Table 7).
Figure 5 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of any myocardial infarction, periprocedural myocardial infarction, and target vessel myocardial infarction.
A: Any myocardial infarction; B: Periprocedural myocardial infarction; C: Target vessel myocardial infarction. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
Revascularization outcomes: Risk of any revascularization (RR: 0.76, 95%CI: 0.52-1.13, P = 0.174, I2 = 60.1%) and target vessel revascularization (TVR) (RR: 0.68, 95%CI: 0.45-1.03, P = 0.0664, I2 = 54.5%) were comparable between the two groups (Figure 6A and B)[11-14]. Leave-one out sensitivity analysis was performed and revealed that heterogeneity of both outcomes dropped to 0% by omitting OCCUPI (2024) (Supplementary Figure 4)[11-14]. A total of 3 studies reported target-lesion revascularization. The pooled results showed that it was significantly reduced in OCT-guided PCI as compared to angiography-guided PCI (RR: 0.53, 95%CI: 0.33-0.84, P = 0.0066, I2 = 21.5%) (Figure 6C)[12-14]. GRADE assessment of revascularization outcome indicated evidence certainty of this outcome to be moderate (Supplementary Table 7).
Figure 6 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of revascularization outcomes.
A: Any revascularization; B: Target vessel revascularization; C: Target lesion revascularization. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
Stent thrombosis: The risk of Stent thrombosis (RR: 0.52, 95%CI: 0.31-0.86, P = 0.011) and definite stent thrombosis (RR: 0.47; 95%CI: 0.27-0.85, P = 0.027) were significantly reduced in OCT-guided PCI as compared to the angiography-guided PCI group with no heterogeneity (I2 = 0%) (Figure 7)[11-14]. Stent thrombosis is ranked as high level of evidence certainty based on GRADE assessment (Supplementary Table 7).
Figure 7 Forest plots of studies comparing optical coherence tomography-guided percutaneous coronary intervention with angiography-guided percutaneous coronary intervention in terms of stent thrombosis and definite stent thrombosis.
A: Stent thrombosis; B: Definite stent thrombosis. HR: Hazard ratio; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; RR: Risk ratio.
Contrast-associated AKI: Contrast-associated AKI was reported by three studies and was comparable between the two groups (RR: 0.87, 95%CI: 0.24-3.16, P = 0.832, I2 = 47.4%) (Supplementary Figure 5)[11-13]. Omitting RENOVATE-COMPLEX PCI (2024) decreased the heterogeneity to 0% (Supplementary Figure 6)[11-13].
Procedural outcomes: Three studies reported procedural outcomes. Their pooled analysis showed that OCT-guided PCI was significantly associated with longer procedure duration (MD: 19.51, 95%CI: 7.48-31.53, P < 0.001, I2 = 97.2%), greater contrast volume (MD: 54.65, 95%CI: 12.16-97.15, P < 0.001, I2 = 97.7%), and total stent length (MD: 2.09, 95%CI: 0.44-3.75, P = 0.2006, I2 = 35.3%) (Supplementary Figure 7)[11,12,14,15]. The high heterogeneity in these outcomes did not change significantly upon leave-one out sensitivity analysis (Supplementary Figure 8)[11,12,14,15].
DISCUSSION
Our systematic review and meta-analysis included five RCTs with 5737 patients, comparing OCT-guided PCI vs angiography-guided PCI in complex lesions. According to our findings, OCT-guided PCI was associated with a significantly decreased risk of MACE, TVF, all-cause mortality, and cardiac mortality. In addition, OCT guidance was linked with a significant reduction in target-lesion revascularization, stent thrombosis, and target-vessel MI when compared to angiography-guided PCI. However, the incidence of periprocedural MI, any revascularization, target-vessel revascularization, and contrast-associated acute renal damage was similar in both groups. These data show the therapeutic benefits of OCT-guided PCI in lowering adverse cardiovascular events while retaining comparable safety outcomes.
Our study builds on the findings of the previous studies and broader meta-analyses on all kinds of lesions, which compared imaging-guided PCI with angiography-guided PCI[2,22-25]. However, to our knowledge, no prior meta-analysis has specifically focused on OCT-guided PCI in complex lesions, providing an in-depth evaluation of its clinical benefits and its potential to optimise outcomes in high-risk patients. Aligning with our findings, a Bayesian network meta-analysis of 31 studies reported a significant reduction with intravascular imaging guidance where OCT-guided PCI was associated with a lower incidence of MI compared to angiography guidance[2]. Additionally, it also reported a significantly lower risk of stent thrombosis with intravascular ultrasound (IVUS), consistent with our findings in the OCT-guided PCI group. However, discrepancies were observed in the findings related to all-cause mortality. While the Bayesian meta-analysis found a significant reduction in all-cause mortality with IVUS guidance, this effect was neutralized in their analysis restricted to RCTs. In contrast, our meta-analysis suggests a trend toward lower mortality with OCT guidance, though statistical significance was not reached. Similarly, Attar et al[6] in their meta-analysis reported that TVR was comparable between OCT-guided PCI and angiography-guided PCI in all lesions, which is contrary to our meta-analysis where TVR is significantly decreased in OCT-guided PCI group. This finding highlights the inefficacy of conventional angiography-guided PCI in a complex lesion population leading to significant difference in TVR rates among the two groups.
While our meta-analysis found a significant reduction in MI with OCT guidance, a previous network meta-analysis did not find a statistically significant difference in MI between OCT-guided and IVUS-guided PCI, possibly due to variations in patient populations and lesion complexity[4]. Similarly, another study found that patients who underwent OCT-guided PCI had better in-hospital outcomes and fewer MACE than those treated with traditional angiography[26]. Building on this, another study reported that OCT-guided PCI showed a significantly lower percentage of uncovered struts at six months compared with angiography guidance alone in patients with non-ST-segment elevation MI[27].
We observed that OCT-guided PCI significantly lowered TVF rates, a finding corroborated by a previous meta-analysis, validating the safety of imaging-guided PCI (OCT/intravascular)[28]. Our study found that OCT-guided PCI was associated with greater contrast volume, longer procedure durations, and increased total stent length. Longer stent lengths and improved post-dilatation parameters with OCT guidance contribute to more complete lesion coverage and potentially lower MACE rates, underscoring the procedural advantages of OCT guidance despite the increased resource utilization[29,30]. Additionally, the use of longer stents at high pressure may contribute to prolonged event-free survival by ensuring greater minimum stent area, a benefit previously demonstrated in IVUS-guided PCI trials[31,32]. Importantly, OCT enables precise visualization of stent expansion and apposition, which facilitates immediate correction of malapposed or under-expanded segments through post-dilatation. Such stent optimization strategies, supported by insights from intravascular imaging studies, are believed to enhance stent apposition and expansion, thereby reducing thrombus formation and potentially lowering the risk of stent thrombosis[33-35]. While we found that higher contrast volume was associated with the OCT-guided PCI group, but still no significant difference was present between the two groups in incidence of contrast associated AKI. This finding was consistent with a study showing that incidence of decline in kidney function was comparable between OCT-guided PCI and IVUS-guided PCI[36], further validating the safety of OCT-guided PCI.
The observed heterogeneity across outcomes in our meta-analysis can be explained by several factors, such as variations in study design, patient characteristics, lesion complexity, operator expertise, and procedural protocols. For procedural outcomes, the high variability in procedure duration (I² = 97.2%) may be caused by the additional imaging and post-processing requirements of OCT-guided PCI, as well as variations in operator familiarity and the complexity of cases chosen for OCT use[37]. Similarly, contrast volume (I² = 97.7%) displayed high heterogeneity, likely influenced by variations in imaging protocols, the number of pullbacks, and strategies to minimize contrast use in patients with impaired renal function[38]. Moreover, the variability in total stent length may be due to the use of OCT in more complex cases requiring extensive stenting. The moderate-to-high heterogeneity observed for TVR (I² = 54.5%) may be attributed to differences in lesion complexity types across studies and variability in operator experience, both of which can impact the need for repeat revascularization.
In contrast, MACE showed no heterogeneity, suggesting a consistent benefit of OCT across studies, possibly due to standardized outcome definitions and rigorous trial methodologies[39]. TVF exhibited moderate heterogeneity, potentially due to variations in lesion complexity, post-PCI medical therapy, and follow-up duration. While periprocedural MI showed uniformity across studies, target-vessel MI displayed moderate heterogeneity, likely influenced by procedural techniques, stent optimization, and differences in follow-up[40]. Any revascularization and target-vessel revascularization had high heterogeneity which was resolved by removing OCCUPI study potentially due to its relatively low follow-up duration[41]. Target-lesion revascularization, on the other hand, demonstrated less heterogeneity, indicating more consistent results across studies. Contrast-associated acute kidney injury displayed moderate heterogeneity, which could be explained by variations in baseline renal function, hydration regimens, and contrast volume thresholds[42].
The Society for Cardiovascular Angiography and Interventions (SCAI) expert consensus statement on calcified coronary lesion recommends use of intravascular imaging to determine the use of calcium modification techniques and prepare the vessel for optimal stent deployment in calcified CAD[43]. 2025 American College of Cardiology/American Heart Association/American College of Emergency Physicians/National Association of EMS Physicians/SCAI Guidelines have upgraded use of intracoronary imaging to class 1a in left main artery or in complex lesions considering the latest trials and two large network meta-analyses[44]. While those network meta-analyses were majorly IVUS-based, our study focused solely on OCT-guided PCI strengthens the findings and shows superiority over angiography-guided PCI[4,45].
Our study provides a comprehensive and up-to-date comparison of OCT-guided vs angiography-guided PCI by including a broader range of RCTs, ensuring a thorough assessment of clinical outcomes and emerging trends. Our study, however, is not without any limitations. The small number of included studies can decrease the statistical power of our findings and limit us from assessing the publication bias and meta-regression. We acknowledge that publication bias assessment, especially egger’s test, was not feasible due to the inclusion of fewer than 10 studies, which is a recognized threshold for reliable evaluation. Moreover, due to a lack of individual patient data, we could not check the association of our findings with patient comorbid and types of complex lesions.
CONCLUSION
In conclusion, we found that OCT-guided PCI is associated with decreased MACE, target-vessel failure, mortality, target-vessel MI, target-lesion revascularization, and stent thrombosis. These findings might solidify the superiority of OCT-guided PCI in patients with complex lesions. However, interpretation of the findings should be made with caution due to the limited number of studies and inherent limitations. Given the increased procedure duration and resource utilization associated with OCT, it is important to weigh these clinical benefits against overall healthcare costs and resource implications. More focused RCTs are warranted comparing the safety and efficacy of OCT-guided PCI in patients with complex lesions.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Cardiac and cardiovascular systems
Country of origin: Pakistan
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade C
Creativity or Innovation: Grade B
Scientific Significance: Grade C
P-Reviewer: Qiao JM, Associate Chief Nurse, China S-Editor: Luo ML L-Editor: A P-Editor: Wang WB
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