IVUS or OCT for Stent Guidance? What a New Meta-Analysis Shows About Coronary Mechanical Outcomes

A meta-analysis and trial sequential analysis published in the International Journal of Cardiology compared mechanical outcomes between intravascular ultrasound (IVUS)-guided and optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI), addressing a question that shapes day-to-day imaging strategy in complex coronary work.

Intravascular imaging has become standard for stent sizing and optimization in higher-risk PCI, but operators have lacked consensus on whether IVUS or OCT produces superior mechanical results. Individual randomized trials comparing the two modalities have returned inconsistent findings on stent expansion, residual stenosis, and procedural complications, leaving vessel-preparation strategy more dependent on operator preference than on pooled evidence.

The study, co-authored by Dr. Michael Megaly, pooled data from six randomized controlled trials totaling 2,696 patients (mean age 65.1 ± 10.2 years), of whom 1,396 (49.6%) underwent IVUS-guided PCI. Post-PCI minimum stent area was significantly larger with IVUS-guided PCI than with OCT-guided PCI (mean difference 0.64 mm²; 95% CI 0.17–1.10; p < 0.01), and post-PCI mean diameter stenosis was significantly lower with IVUS (mean difference -1.05%; 95% CI -1.90 to -0.21; p = 0.01). No significant differences emerged between the two modalities in acute lumen gain, stent expansion index, malapposition, tissue protrusion, or edge dissection. In subgroup analysis, the minimum stent area advantage for IVUS was more pronounced in studies that did not size vessels using external elastic membrane measurement. Notably, trial sequential analysis indicated that the cumulative evidence from these six RCTs has not yet reached the information size required to draw a definitive conclusion, meaning the observed differences, while statistically significant in the pooled analysis, warrant confirmation in adequately powered trials.

For operators managing complex, high-risk PCI, these findings reinforce that imaging modality selection is not interchangeable and should be matched to the specific vessel and sizing strategy being used. The larger minimum stent area achieved with IVUS carries downstream relevance for restenosis and stent thrombosis risk, both of which are amplified in the calcified, long, and bifurcation lesions characteristic of complex and CTO PCI.

At the same time, the absence of a definitive signal on softer mechanical endpoints, combined with an underpowered evidence base per trial sequential analysis, argues against treating either modality as categorically superior. The practical takeaway is that sizing methodology, not device brand, may be the more important variable driving mechanical outcomes, a distinction relevant to how vessel preparation and stent optimization protocols are built for high-risk coronary intervention.

Lingamsetty SS, Doma M, Kritya M, Thyagaturu H, Ubaid M, Jitta SR, Prajapati K, Ramadan A, Al-Shammari AS, Martignoni FV, Seto A, Shlofmitz E, Basir MB, Megaly MS, Goldsweig AM. Mechanical outcomes of coronary stenting guided by intravascular ultrasound versus optical coherence tomography: A systematic review and meta-analysis with trial sequential analysis of randomized trials. International Journal of Cardiology. 2025 May 13:133387.

Dr. Michael Megaly specializes in complex and high-risk coronary interventions, chronic total occlusion (CTO) PCI, surgical turn-downs, complex peripheral artery disease, and limb salvage at Integris Health Heart Hospital in Oklahoma City.