Meta-analysis and systematic review of intravascular ultrasound versus angiography-guided drug eluting stent implantation in left main coronary disease in 4592 patients

Abstract

Background: Although several meta-analyses have demonstrated the utility of intravascular ultrasound (IVUS) in guiding drug-eluting stent (DES) implantation compared to angiography-guidance, there has been a dearth of evidence in the left main coronary artery (LMCA) lesion subset.

Methods: We performed a meta-analysis to compare clinical outcomes of IVUS versus conventional angiography guidance during implantation of DES for patients with LMCA disease. Pubmed, Cochrane Library, Embase were searched.

Results: A total of 1002 publications were reviewed; and finally, seven clinical studies - one prospective randomized controlled trial and six observational studies with 4592 patients (1907 IVUS-guided and 2685 angiography-guided) - were included in the meta-analysis. IVUS guidance was associated with a significant reduction in major adverse cardiac events (relative ratio [RR] 95% CI 0.61; 95% confidence interval [CI] 0.53 to 0.70; P < 0.001), all-cause death (RR 0.55; 95% CI 0.42 to 0.71; P < 0.001), cardiac death (RR 0.45; 95% CI 0.32 to 0.62; P < 0.001), myocardial infarction (RR 0.66; 95% CI 0.55 to 0.80; P < 0.001), and stent thrombosis (RR 0.48; 95% CI 0.27 to 0.84; P = 0.01) compared with angiographic guidance. However, there was no significant difference regarding target lesion revascularization (RR 0.60; 95% CI 0.31 to 1.18; P = 0.099) and target vessel revascularization (RR 0.64; 95% CI 0.26 to 1.56; P = 0. 322).

Conclusions: Compared to angiographic guidance, IVUS-guided DES implantation was associated with better clinical outcomes for patients with LMCA lesions, especially hard endpoints of death, myocardial infarction, and stent thrombosis.

Keywords: Angiography; Drug eluting stent; Intravascular ultrasound; Left main disease; Meta-analysis.

Conflict of interest statement

Authors’ information

Yue Wang (first author) is a postgraduate student of grade 2016; Yue Wang (fifth author) is a postgraduate student of grade 2017.

Ethics approval and consent to participate

Not applicable

Competing interests

Dr. Mintz receives grant support and/or honoraria from Boston Scientific, Volcano, and ACIST. The other authors have no potential conflicts of interest.

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Figures

Fig. 1

Flow diagram of the process followed to identify the relevant studies that were included in the present meta-analysis

Fig. 2

Forest plot of RR for MACE (a), all cause death (b), cardiac death (c), MI (d), ST (e), TLR (f) and TVR (g) associated with IVUS guided vs angiography guided DES implantation to treat LMCA disease. Squares is the effect size of the individual studies; diamonds, the summarized effect size; horizontal lines, upper and lower border of 95% confidence interval. DES = drug eluting stent; LMCA = left main coronary artery; IVUS = intravascular ultrasound; MACE = major adverse cardiac event; MI = myocardial infarction; relative ratio = RR; ST = stent thrombosis; TLR = target lesion revascularization; TVR = target vessel revascularization

Fig. 3

Sensitivity analysis of MACE by omitting each individual study in turn. Cycle is relative ratio; horizontal lines, upper and lower border of 95% confidence interval. MACE = major adverse cardiac event

Fig. 4

Assessment of publication bias using the Egger’s linear regression analysis for MACE (a), all cause death (b), cardiac death (c), MI (d), ST (e), TLR (f). MACE = major adverse cardiac event; MI = myocardial infarction; ST = stent thrombosis. TLR = target lesion revascularization; TVR = target vessel revascularization