Three-dimensional versus two-dimensional quantitative coronary angiography for coronary lesion assessment: a systematic review and meta-analysis.

Accurate anatomical assessment of coronary lesions is fundamental to effective percutaneous coronary intervention (PCI). Conventional two-dimensional quantitative coronary angiography (2D-QCA) is limited by projection dependency, vessel overlap, and foreshortening, leading to imprecise estimation of lesion severity. Three-dimensional quantitative coronary angiography (3D-QCA), based on 3D reconstruction, provides more accurate vessel assessment than 2D analysis; however, its reported advantages remain inconsistent across studies. We conducted a systematic review and meta-analysis in accordance with PRISMA and Cochrane guidelines. PubMed, Embase, Scopus, and Cochrane Central were searched from inception to October 2025 for studies comparing 3D-QCA with 2D-QCA using validated software. Random-effects models pooled standardized mean differences (SMDs) with 95% confidence intervals (CIs). Risk of bias was assessed using ROB-2 and the Newcastle-Ottawa Scale. Sixteen studies were included. Compared with 2D-QCA, 3D-QCA reported significantly longer lesion length (SMD 0.29; 95% CI 0.04-0.53) and larger minimal luminal area (SMD 0.36; 95% CI 0.07-0.65). Diameter stenosis (SMD - 0.28; 95% CI - 0.48 to - 0.07) and percent stenosis (SMD - 0.57; 95% CI - 0.95 to - 0.20) were lower with 3D-QCA. No significant differences were observed for bifurcation angle, minimal luminal diameter, reference vessel diameter, or reference vessel area. Moderate-to-high heterogeneity was observed across outcomes. 3D-QCA provides more precise anatomical characterization of coronary lesions than conventional 2D-QCA, particularly for lesion length and area-based metrics, supporting its role in improving PCI planning, while further outcome-driven studies are needed.