Intravascular Imaging-Guided or Angiography-Guided Complex PCI (RENOVATE-COMPLEX-PCI)

The RENOVATE-COMPLEX-PCI trial randomized 1,639 patients with complex coronary artery lesions — the situations where angiography’s two-dimensional view is most limited — to intravascular imaging-guided (IVUS or OCT) versus angiography-guided stent implantation.

Intravascular imaging guidance reduced the composite of cardiac death, target-vessel MI, or ischemia-driven revascularization from 12.3 percent to 7.7 percent over three years — a 36 percent relative risk reduction (HR 0.64, p=0.008). The benefit was consistent across lesion subtypes and across both imaging modalities (IVUS and OCT), suggesting the advantage comes from improved anatomical visualization rather than from either specific technology.

The trial resolves a long-standing debate. Prior evidence for IVUS guidance was predominantly observational or from underpowered RCTs; RENOVATE provides the strongest randomized evidence to date that intracoronary imaging in complex lesions translates directly to fewer adverse clinical events. Complex lesion PCI — long left main, true bifurcations, heavily calcified segments, ostial disease — is precisely where the additional information from imaging is most actionable.

We rate the evidence strong. A well-designed contemporary RCT definitively establishing intravascular imaging guidance as superior to angiography alone for complex percutaneous coronary intervention.