Intravascular ultrasound imaging–guided versus coronary angiography–guided percutaneous coronary intervention: a systematic review and meta-analysis

When a cardiologist places a stent, the standard eyes-on guide is the angiogram — a two-dimensional shadow of the artery. This meta-analysis asks whether seeing from inside the vessel, with intravascular ultrasound, produces better outcomes.

Pooling 19 randomized and observational studies and more than 27,000 patients, the answer is yes — and on the endpoints that matter most. IVUS-guided stenting was associated with significantly lower cardiovascular death, heart attack, repeat revascularization of the treated lesion, and stent thrombosis than angiography alone. The mechanism is intuitive: ultrasound shows the operator the true vessel size and whether the stent is fully expanded, things the angiogram only implies.

The practical takeaway is a case for using IVUS routinely during stenting, not just in difficult lesions. The resistance is operational — added cost, added procedure time, and throughput-focused systems reluctant to absorb either.

We rate the evidence strong: a large meta-analysis combining randomized and adjusted observational data with no declared conflicts, carrying the usual caveat that mixing study types introduces some heterogeneity. Its clinical significance is high — millions of stent procedures are performed each year, and a guidance technique that lowers death and stent thrombosis could move the standard of care.