■多项随机临床试验的结果比较了血管内超声(IVUS)和光学相干断层扫描(OCT)引导的经皮冠状动脉介入治疗(PCI)和侵入性冠状动脉造影(ICA)引导的PCI以及比较两种血管内成像(IVI)技术的关键试验的结果,结果喜忧参半。
■搜索了主要的电子数据库,以确定评估ICA中至少2种PCI指导策略的合格试验,IVUS,和OCT。2个共同主要结果是靶病变血运重建和心肌梗死。次要结局包括缺血驱动的靶病变血运重建,靶血管心肌梗死,死亡,心脏死亡,靶血管血运重建,支架内血栓形成,和主要不良心脏事件。进行了频繁随机效应网络荟萃分析。结果由贝叶斯随机效应模型复制。直接成分的成对荟萃分析,多重敏感性分析,并补充了IVI与ICA的成对荟萃分析。
■来自24项随机试验的结果(15489例患者:IVUS与ICA,46.4%,7189名患者;OCT与ICA,32.1%,4976例患者;OCT与IVUS,21.4%,3324例患者)被纳入网络荟萃分析。与ICA相比,IVUS与靶病变血运重建减少相关(比值比[OR],0.69[95%CI,0.54-0.87]),而OCT和ICA之间没有观察到显著差异(OR,0.83[95%CI,0.63-1.09])和OCT和IVUS(OR,1.21[95%CI,0.92-1.58])。指导策略之间的心肌梗塞没有显着差异(IVUS与ICA:OR,0.91[95%CI,0.70-1.19];OCT与ICA:或,0.87[95%CI,0.68-1.11];OCT与IVUS:或,0.96[95%CI,0.69-1.33])。这些结果与缺血驱动的靶病变血运重建的次要结果一致。靶血管心肌梗死,和目标血管血运重建,敏感性分析通常没有发现不一致。与ICA相比,OCT与支架内血栓形成显著减少相关(OR,0.49[95%CI,0.26-0.92]),但仅在频率分析中。同样,在所有分析中,IVUS或OCT与ICA之间的生存率结果不确定.共有25项随机试验(17128例患者)纳入IVI与ICA的成对荟萃分析,其中IVI指导与减少靶病变血运重建相关。心脏死亡,和支架血栓形成。
■与ICA引导的PCI相比,IVI引导的PCI与缺血驱动的靶病变血运重建减少相关,差异在IVUS中最为明显。相比之下,两种指导策略在心肌梗死方面无显著差异.
Results from multiple randomized clinical trials comparing outcomes after intravascular ultrasound (IVUS)- and optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) with invasive coronary angiography (ICA)-guided PCI as well as a pivotal trial comparing the 2 intravascular imaging (IVI) techniques have provided mixed results.
Major electronic databases were searched to identify eligible trials evaluating at least 2 PCI guidance strategies among ICA, IVUS, and OCT. The 2 coprimary outcomes were target lesion revascularization and myocardial infarction. The secondary outcomes included ischemia-driven target lesion revascularization, target vessel myocardial infarction, death, cardiac death, target vessel revascularization, stent thrombosis, and major adverse cardiac events. Frequentist random-effects network meta-analyses were conducted. The results were replicated by Bayesian random-effects models. Pairwise meta-analyses of the direct components, multiple sensitivity analyses, and pairwise meta-analyses IVI versus ICA were supplemented.
The results from 24 randomized trials (15 489 patients: IVUS versus ICA, 46.4%, 7189 patients; OCT versus ICA, 32.1%, 4976 patients; OCT versus IVUS, 21.4%, 3324 patients) were included in the network meta-analyses. IVUS was associated with reduced target lesion revascularization compared with ICA (odds ratio [OR], 0.69 [95% CI, 0.54-0.87]), whereas no significant differences were observed between OCT and ICA (OR, 0.83 [95% CI, 0.63-1.09]) and OCT and IVUS (OR, 1.21 [95% CI, 0.88-1.66]). Myocardial infarction did not significantly differ between guidance strategies (IVUS versus ICA: OR, 0.91 [95% CI, 0.70-1.19]; OCT versus ICA: OR, 0.87 [95% CI, 0.68-1.11]; OCT versus IVUS: OR, 0.96 [95% CI, 0.69-1.33]). These results were consistent with the secondary outcomes of ischemia-driven target lesion revascularization, target vessel myocardial infarction, and target vessel revascularization, and sensitivity analyses generally did not reveal inconsistency. OCT was associated with a significant reduction of stent thrombosis compared with ICA (OR, 0.49 [95% CI, 0.26-0.92]) but only in the frequentist analysis. Similarly, the results in terms of survival between IVUS or OCT and ICA were uncertain across analyses. A total of 25 randomized trials (17 128 patients) were included in the pairwise meta-analyses IVI versus ICA where IVI guidance was associated with reduced target lesion revascularization, cardiac death, and stent thrombosis.
IVI-guided PCI was associated with a reduction in ischemia-driven target lesion revascularization compared with ICA-guided PCI, with the difference most evident for IVUS. In contrast, no significant differences in myocardial infarction were observed between guidance strategies.