Revascularization strategies for left main coronary lesions: a meta-analysis of ultrasound-guided and angiography-directed PCI outcomes

Abstract Background Unprotected left main coronary artery (ULMCA) disease represents the most prognostically significant manifestation of coronary artery disease, carrying substantial risks of cardiovascular mortality and morbidity. While coronary artery bypass grafting (CABG) has traditionally been the gold standard, percutaneous coronary intervention (PCI) with drug-eluting stents has emerged as a viable alternative for select patients, as demonstrated in contemporary clinical trials. However, conventional angiographic guidance presents inherent limitations in complex lesion assessment. Methods We conducted a systematic evidence synthesis comparing intravascular ultrasound (IVUS)-guided versus angiography-guided PCI for ULMCA disease, incorporating randomized controlled trials and propensity score-matched observational studies. Following PRISMA guidelines, we comprehensively searched multiple databases through March 2024. Study quality was assessed using Cochrane ROB 2.0 and ROBINS-I tools. Primary and secondary outcomes were analyzed using random-effects models in R software. Results Our analysis included 12 studies (3 RCTs, 9 PSM studies) encompassing 15,370 patients. IVUS guidance demonstrated superior outcomes across multiple endpoints: significant reductions in major adverse cardiovascular events (RR 0.60, 95% CI 0.49-0.74), all-cause mortality (RR 0.65, 0.59-0.72), cardiac mortality (RR 0.44, 0.30-0.63), myocardial infarction (RR 0.70, 0.57-0.85), stent thrombosis (RR 0.38, 0.21-0.70), and revascularization endpoints (TLR RR 0.55, 0.33-0.91; TVR RR 0.64, 0.46-0.91). Heterogeneity was generally low (I²