Intravascular Imaging Improves Clinical Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusions: A Meta-Analysis of Randomized Controlled Trials.

Summary

Across five RCTs (n=1,296), IVI-guided CTO PCI significantly reduced MACE (RR 0.55) and TVR (RR 0.52) over 1–3 years versus angiography guidance, with consistent benefit in the IVUS subgroup. MI and death/cardiac death did not differ significantly.

Key Findings

• IVI-guided CTO PCI reduced MACE vs angiography guidance (7.2% vs 13%; RR 0.55; p=0.012).
• Target-vessel revascularization was lower with IVI (3.1% vs 6.7%; RR 0.52; p=0.038).
• Benefits were consistent in the IVUS subgroup (MACE RR 0.59; p=0.019); MI and mortality were similar.

Clinical Implications

Routine IVI guidance in CTO PCI can be justified to reduce repeat revascularization and composite adverse events; programs should ensure access to IVUS/OCT and operator proficiency.

Limitations

• Modest total sample size and 1–3 year follow-up window
• Heterogeneity in imaging modality (IVUS vs OCT) and procedural techniques

Future Directions

Head-to-head IVUS vs OCT trials in CTO PCI; cost-effectiveness analyses and implementation studies across diverse health systems.