Comparing coronary angiography, intravascular ultrasound, and optical coherence tomography for percutaneous coronary intervention: A network meta-analysis.

INTRODUCTION: Percutaneous coronary intervention (PCI) is widely used for coronary revascularization, with invasive coronary angiography (ICA) remaining the conventional method for guiding stent implantation. However, ICA provides only a two-dimensional luminal assessment and may underestimate vessel size, lesion morphology, stent under expansion, malapposition, and edge complications. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) provide detailed intravascular assessment and may improve PCI optimization. METHODS: This systematic review and network meta-analysis of randomized controlled trials compared ICA-guided, IVUS-guided, and OCT-guided PCI. PubMed, Embase, and Cochrane Library were searched, with an updated search to April 10, 2026. Binary outcomes were analyzed using random-effects frequentist and Bayesian network meta-analysis. ICA-guided PCI was the reference treatment. Treatment ranking was assessed using SUCRA, and inconsistency was evaluated using node-splitting. RESULTS: Thirty-three randomized trials including 25,315 participants were included. Compared with ICA-guided PCI, IVUS-guided PCI reduced target lesion revascularization, target vessel revascularization, major adverse cardiovascular events, and stent thrombosis. OCT-guided PCI reduced target lesion revascularization, all-cause death, cardiac death, target vessel myocardial infarction, and stent thrombosis compared with ICA. Myocardial infarction was directionally lower with both IVUS and OCT, although estimates were not statistically definitive. No clear difference was observed between IVUS and OCT for major clinical outcomes. Node-splitting analyses showed no significant inconsistency across treatment comparisons. CONCLUSION: Intravascular imaging-guided PCI was associated with improved outcomes compared with ICA-guided PCI. IVUS showed the most consistent benefit for repeat revascularization and major adverse cardiovascular events, whereas OCT ranked favorably for several safety outcomes. Current randomized evidence does not establish superiority of OCT over IVUS. IMPLICATIONS FOR PRACTICE: Intravascular imaging should be considered to optimize PCI, particularly in anatomically complex or high-risk coronary interventions.