Received: 28 May 2021 Revised: 18 August 2021 Accepted: 29 September 2021

DOI: 10.1002/ccd.29976

ORIGINAL STUDIES

Outcomes of intravascular ultrasound versus optical coherence

tomography guided percutaneous coronary angiography:
A meta regression-based analysis

Yasar Sattar MD1 | Aminah Abdul Razzack MBBS2 | Ritika Kompella MD3 |
Noora Alhajri MD, MPH4 | Junaid Arshad MBBS5 | Waqas Ullah MD6 |
Mohamed Zghouzi MD7 | Tanveer Mir MD7 | David Power MD8 |
Waqas T. Qureshi MD, MS9 | Wael Aljaroudi MD10 | Islam Y. Elgendy MD11 |
Mamas A. Mamas BMBCh, MA, DPhil, FRCP12 | M. Chadi Alraies MD, MPH7

1
Cardiology, West Virginia University,
Morgantown, West Virginia, USA Abstract
2
Internal Medicine, Dr. N.T.R University of Background: Studies comparing clinical outcomes with intravascular ultrasound
Health Sciences, Vijayawada, India
(IVUS) versus optical coherence tomography (OCT) guidance for percutaneous coro-
3
Internal Medicine, University of Connecticut,
Farmington, Connecticut, USA nary intervention (PCI) in patients presenting with coronary artery disease, including
4
Public Health, Khalifa University College of stable angina or acute coronary syndrome, are limited.
Medicine and Health Science, Abu Dhabi, UAE
Methods: We performed a detailed search of electronic databases (PubMed, Embase,
5
Cardiology, Pakistan Institute of Medical
Sciences, Islamabad, Pakistan
and Cochrane) for randomized controlled trials and observational studies that com-
6
Cardiology, Thomas Jefferson University, pared cardiovascular outcomes of IVUS versus OCT. Data were aggregated for the
Philadelphia, Pennsylvania, USA primary outcome measure using the random-effects model as pooled risk ratio (RR).
7
Cardiology, Detroit Medical Center, Detroit,
The primary outcome of interest was major adverse cardiac events (MACE), cardiac
Michigan, USA
8
Internal Medicine, Icahn School of Medicine mortality, and all-cause mortality. Secondary outcomes included myocardial infarction
at Mount Sinai, New York, New York, USA (MI), stent thrombosis (ST), target lesion revascularization (TLR), and stroke.
9
Cardiology, University of Massachusetts,
Results: A total of seven studies met the inclusion criteria, comprising 5917 patients
Worcester, Massachusetts, USA
10
Cardiology, Augusta University, Augusta,
(OCT n = 2075; IVUS n = 3842). OCT-PCI versus IVUS-guided PCI comparison
Georgia, USA yielded no statistically significant results for all the outcomes; MACE (RR 0.78; 95%
11
Cardiology, Weill Cornell Medicine-Qatar, confidence interval [CI], 0.57–1.09; p = 0.14), cardiac mortality (RR 0.97; 95% CI,
Doha, Qatar
12 0.27–3.46; p = 0.96), all-cause mortality (RR 0.74; 95% CI, 0.39–1.39; p = 0.35), MI
Cardiology, Keele University School of
Medicine, Keele Cardiovascular Research (RR 1.27; 95% CI, 0.52–3.07; p = 0.60), ST (RR 0.70; 95% CI, 0.13–3.61; p = 0.67),
Group, Stoke-on-Trent, UK
TLR (RR 1.09; 95% CI, 0.53–2.25; p = 0.81), and stroke (RR 2.32; 95% CI, 0.42–
Correspondence 12.90; p = 0.34). Furthermore, there was no effect modification on meta-regression
M. Chadi Alraies, Detroit Medical Center,
including demographics, comorbidities, lesion location, lesion length, and stent type.
311 Mack Ave, Detroit, MI 48201, USA.
Email: alraies@hotmail.com Conclusions: In this meta-analysis, OCT-guided PCI was associated with no differ-
ence in clinical outcomes compared with IVUS-guided PCI.

KEYWORDS
intravascular ultrasound, optical coherence tomography, percutaneous coronary intervention

Yasar Sattar and Aminah Abdul Razzack contributed equally to this study.

Catheter Cardiovasc Interv. 2022;99:E1–E11. wileyonlinelibrary.com/journal/ccd © 2021 Wiley Periodicals LLC. E1


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1 | I N T RO DU CT I O N
Coronary angiography is the gold standard imaging modality for
immediate angiographic assessment of coronary lesions and
intraprocedural guidance during the percutaneous coronary interven-
tion (PCI). However, the inherent weakness of angiography to accu-
rately identify vessel and lumen geometry and its inability to
accurately detect the presence of early thrombus, stent morphological
characteristics, and 3-dimensional tomographical views of coronary
plaque and blood vessels has been well documented.1 These limita-
tions are overcome, in part, by intravascular ultrasound (IVUS) and
optical coherence tomography (OCT), which have been established as
both diagnostic and procedural guidance modalities for PCI optimiza-
tion over the past few decades.2–4 Each imaging technique has both
advantages and disadvantages. OCT is increasingly available in the
catheterization laboratory that can provide high axial resolution (10–
15 μm) to identify atherosclerotic plaque morphology, thrombus,
fibrous cap thickness, dissection, plaque prolapse, stent malposition,
and stent strut coverage.
In comparison, IVUS has greater penetration depth that allows
enhanced coronary vessel visualization, resulting in true vessel stent
sizing.5 Cumulative evidence has shown that IVUS and OCT optimize
procedural results and stent deployment alongside improving clinical
outcomes, particularly in anatomically challenging coronary artery dis-
ease (CAD) and prognostically significant lesions like unprotected left
main and multivessel CAD.6,7 As the evidence for OCT-guided PCI is
F I G U R E 1 PRISMA flow of the search strategy for systematic review and meta-analysis. PRISMA, preferred reporting items for systematic
reviews and meta-analyses
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SATTAR ET AL.
emerging, the 2018 ESC/European Association for Cardio-Thoracic
Surgery guidelines have elevated the recommendation level for
implementing OCT in PCI optimization from Class IIb to IIa.8 However,
the utilization rates of these imaging modalities in interventional prac-
tice in the United States remain low. Data from the National Inpatient
Sample Healthcare Utilization Project reported that OCT and IVUS
are being used in < 5% of total inpatient PCI procedures in the
United States.9 Evidence comparing these two different imaging
approaches during primary PCI is lacking.10 Therefore, we aim to com-
pare clinical outcomes between OCT and IVUS guided PCI.
2 | METHODS
2.1 | Search strategy and selection
A systematic search adhering to preferred reporting items for system-
atic reviews and meta-analyses guidelines was performed (Figure 1,
Section S1 of Data S1).11 Online bibliographic databases PubMed,
Embase, and Cochrane, were included. Online search was conducted
from inception to March 17, 2021 without any restriction variables,
including language, type of study, year, or author. Using boolean logic,
a combination of MeSH terms “intravascular ultrasound” “IVUS,”
“OCT,” “optical coherence tomography,” “coronary angiography,”
“percutaneous coronary angiography,” “intracoronary imaging” was
used to conduct a comprehensive search in the databases mentioned

SATTAR ET AL.
above (Section S1). A cross-reference check of previously published
meta-analysis on this topic was also performed.
2.2 | Inclusion criteria
Studies that included adult patients (age ≥18 years) undergoing PCI with
a metallic drug-eluting stent for elective purposes for angina (stable or
unstable), or emergent purposes for unstable angina, stent thrombosis
(ST) or non-ST-segment elevation myocardial infarction (MI) and com-
pared clinical outcomes with IVUS or OCT, were included. To decrease
the risk of bias inherent with including observational studies, propensity
score matching outcomes were included based on availability.
2.3 | Exclusion criteria
Patients with age <18, studies with insufficient data, systematic reviews,
meta-analyses, letters, editorials, case reports, conference abstracts, and
case series with less than 10 patients (n = 87,472) were also excluded.
2.4 | Data extraction and quality assessment
Information regarding the study design, demographic characteristics,
and various outcomes were extracted. No language restrictions were
made. All duplicates were removed using Endnote X9 by two indepen-
dent reviewers (Y.S. and J.A.). Titles and abstracts of all articles from the
initial search were independently screened by two authors (Y.S. and
J.A.). The senior author arbitrated any discrepancies concerning the
evaluation of the studies. Studies were also screened by searching ref-
erence lists of included studies (backward snowballing). For the quality
assessment of included studies in the systematic review and meta-anal-
ysis, the Cochrane Risk of Bias tool for randomized controlled trials
(RCTs) and the Newcastle-Ottawa (NOS) scale for observational studies
was employed to ascertain the quality of studies by two independent
reviewers (Y.S. and J.A.).12 Our study involved de-identified data and
was exempt from institutional board review approval.
2.5 | Definitions and endpoints
The primary outcome of interest was major adverse cardiac events
(MACE), cardiac mortality, and all-cause mortality. MACE was defined
as a composite of all-cause mortality, cardiac death, MI, ischemia-
driven target lesion revascularization (TLR), stroke, and ST. The stan-
dard variable definitions are given in Section S2.
2.6 | Statistical analysis
The statistical analysis was performed using the Cochran–Mantel
Haenszel (M–H) method under the random-effects model to calculate
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E3
the summary risk ratios (RR) for the primary and secondary outcomes.
The estimated effect size was reported as a point estimate and 95%
confidence interval (CI). The I2 statistic test was used for assessment
of in-between study heterogeneity, with values <25%, 25%–50%,
50%–75%, and >75%, corresponding to no, low, moderate, and high
degrees of heterogeneity, respectively.13 We used a CI of 95% and a
p-value < 0.05 to reflect statistically significant results in all our ana-
lyses. The studies reporting mean with standard deviation were ana-
lyzed using inverse standard mean difference by random effect model.
The publication bias was depicted graphically and numerically as a for-
est plot and Egger's regression test.14 Subgroup analysis was performed
based on elective presentation, type of studies, and duration of follow-
up. Meta-regression was performed to see any potential effect modi-
fiers using random effect models for study variance and Knapp–
Hartung modification.15–17 Univariate meta-regression was performed
on demographics (age and male sex), comorbidities (hypertension, dia-
betes mellitus, and hyperlipidemia), vessel involvement (right coronary
artery, left anterior descending, and left circumflex), type of stent, and
lesion length. Statistical analysis was performed using the Cochrane
review manager (RevMan) version 5.4 (The Cochrane Community,
London, UK) and STATA v. 16 (College State, TX).
3 | RE SU LT S
The search strategy is shown in Figure 1. The initial screening yielded
89,329 results. After the exclusion of duplicates, 87,760 results were
withheld for the screening of the title and abstract. Finally, after
screening 298 full-text articles, a total of seven studies with 5917 par-
ticipants were included (2075 patients in the OCT guidance group and
3842 patients in the IVUS guidance group).18–24 The quality of the
studies included was moderate. Among the seven studies included,
half were observational studies with matched cohorts, increasing the
potential risk of selection bias.22–24 The three observational studies all
had NOS score > 7.22–24 The remaining four were RCTs.18–21 Quality
assessment findings of the included studies are summarized in
Section S3, Figures S1 and S2.
4 | B A S E L I N E C H A R A C T E R I S TI C S
Baseline demographics, comorbidities, and characteristics of included
studies in the meta-analysis are summarized in Table 1. The follow-up
period ranged from in-hospital to a maximum of 4.8 years. The aver-
age age was 65.7 and 65.5 years in the OCT and IVUS groups, respec-
tively. 71% and 72.2% of patients were male in the OCT and IVUS
groups, respectively. The incidence of hypertension in each group was
62.2% and 55.9% for OCT and IVUS groups, respectively. Prior MI
was reported in 29.5% and 26.3% in the OCT and IVUS groups,
respectively. The incidences of diabetes mellitus in each group were
29.5% and 26.4% for OCT and IVUS arms, respectively. Out of 2075
patients in the OCT group, 731 (35.8%) and 124 (6%) underwent prior
PCI and coronary artery bypass graft (CABG), respectively.
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E4 SATTAR ET AL.

TABLE 1 Baseline raw data demographics, comorbidities, and study characteristics of studies included in the meta-analysis

Variable OPINION Kubo Musramatsu19 ILUMIEN III Ali20 Chamie21 Okura22 Jones23 Kim Yoon24

Sample (n) 412/405 54/55 158/146 51/50 152/1947 1149/10971 122/168

OCT/IVUS
Sample PS — — — — 1134/1125a 114/114a
matched (n)a
Patient Elective Elective Elective Elective ACS Elective and ACS Elective
presentation
Age 69/68 72/71 66/66 59.92/59.32 69/69 62.7/64.1 61.5/61.7
Male (%) 315(76.5)/322 41 (75.9)/44 109 (69)/107 (73) 31 (60.8)/36 (72.0) 117 (75)/1505 (77) 794 (69.1)/7819 84 (73.7)/89
(79.5) (80.0) (71.3) (78.1)
CAD risk factors
Hypertension 315/299 34/39 124/113 46/42 87/1304 649/5839 50/51
Dyslipidemia 316/321 43/36 115/107 36/30 70/1071 643/5334 56/56
Diabetes 169/165 27/24 52/55 17/20 46/565 288/2788 21/21
Mellitus
FHx of CAD 40/58 NA NA NA NA NA NA
Current 67/73 22/12 28/19 17/14 49/701 488/4868 75/70
smoker
Prior MI 70/61 19/16 35/29 9/10 17/195 470/3297 8/6
Prior PCI 140/140 24/26 11/8 NA 27/273 522/3791 7/11
Prior CABG 7/9 0/0 3/11 NA 1/39 113/1267 NA
Clinical presentation
Stable angina 363/352 NA 54/49 22/18 NA 662/5911 36/38
Unstable 48/53 NA 25/33 20/22 NA NA 31/27
Angina
Left NA 58/57 NA NA NA 30/30 57.0/56.2
ventricular
EF, %
Study characteristics
Year 2017 2020 2016 2021 2018 2018 2016
Study design RCT RCT RCT RCT Observational Observational PSM Observational
PSM
Center Multicenter Multicenter Multicenter Single-center Multicenter Multicenter Multicenter
Comparison OCT versus IVUS- OCT versus Angiography Angiography Angiography Angiography OCT versus IVUS-
Group guided PCI IVUS-guided versus OCT versus OCT versus OCT versus OCT guided PCI
PCI versus IVUS versus IVUS versus IVUS versus IVUS
Sample size 829 109 450 156 2788 123,764 290
IVUS MHz 40 MHz 40 MHz NA NA NA NA NA
IVUS ViewIT, Terumo ViewIT, NA NA NA NA AtlantiS (Boston
company Corp Terumo Corp Scientific) or
Eagle Eye
(Volcano
Therapeutics)
No. per 412/405 54/55 158/146 51/50 1521/947 1149/10971 122/168
Imaging
Guidance
Stent type DES DES DES DES DES DES DES
Primary Target vessel In-segment Efficacy-minimum Stent-expansion In-hospital Cardiac mortality MACE:
endpoint failure: minimum stent area post non inferiority mortality Composite of
composite of lumen area PCI safety- cardiac death,
cardiac death, procedural MI and TLR
target-vessel MACE
related MI, and (procedural
ischaemia-driven complications
target vessel requiring active
revascularization intervention)
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SATTAR ET AL. E5

TABLE 1 (Continued)

Variable OPINION Kubo Musramatsu19 ILUMIEN III Ali20 Chamie21 Okura22 Jones23 Kim Yoon24

MACE Cardiac death, MI, Cardiac death, Cardiac death, MI, Cardiac death, MI, Cardiac death, Cardiac death, MI, Cardiac death, MI,
definition and TLR target lesion stent and TLR cardiac failure, stroke, and and TLR
MI, and TLR thrombosis, or ventricular reintervention
repeat tachycardia and PCI
revascularization or/ventricular
fibrillation and
bleeding during
hospitalization
Follow-up 8 months 3 years 30 day 1 year In-hospital 4.8 years 1 year
duration
Results Similar Similar Similar Similar stent IVUS is associated OCT versus Similar
angiographic angiographic angiographic expansion with better in- angiography- angiographic
and clinical and clinical and clinical outcomes hospital survival improved MACE and clinical
outcomes outcomes outcomes between OCT compared to rate and long- outcomes
and IVUS using both term survival
external elastic angiography and OCT versus
membrane sizing OCT IVUS-similar
strategy outcomes

Note: All the data is arranged in OCT/IVUS format.

Abbreviations: ACS, acute coronary syndrome; DES, drug-eluting stent; MI, myocardial infarction; PSM, propensity score matching; RCT, randomized control trial;
TLR, target lesion revascularization.
a
n sample size is PS matched for available outcomes.

5 | PROCEDURAL CHARACTERISTICS
The procedural characteristics, including access site, lesion character-
istics, and post-procedural complications, are summarized in Table 2.
The most frequently accessed route was radial in the OCT and IVUS
groups (50.5% and 29%), respectively. Left anterior descending lesions
constituted 55.1% of the target vessels in the OCT group and 49.1%
of the target vessels in the IVUS group. Right coronary lesions consti-
tuted 23.4% and 29.3% of the OCT and IVUS groups' target vessels,
respectively. The most common use of IVUS type was ViewIt (Terumo
Corporation, Tokyo, Japan), Atlantis (Boston Scientific Corporation,
Natick, MA), or Eagle Eye (Volcano Corporation, Rancho Cordova,
CA). The most common OCT used was made by FastView (Terumo
Corporation, Tokyo, Japan).
6 | C L I N I C A L O U T C O M E S A N D SU R V I V A L
Six out of seven studies reported data on MACE18,20–24 and MI.18–
21,23,24
Cardiac mortality was assessed in four out of seven stud-
ies. 18,19,21,24
Six out of seven studies assessed all-cause mortality dur-
ing short-term follow-up (in-hospital to 30 days) among the OCT and
IVUS groups. 18,19,21–24
TLR was reported in four studies, 18,20,21,24
ST
in three studies,18,20,24 and stroke was reported in only two stud-
18,23
ies. There were no statistically significant differences between
the two groups in terms of MACE (OCT = 51 [2.5%] vs. IVUS = 387
[10.2%]; RR 0.78; 95% CI, 0.57–1.09; p = 0.14), cardiac mortality
(OCT = 4 [0.6%] vs. IVUS = 4 [0.6%]; RR 0.97; 95% CI, 0.27–3.46;
p = 0.96), all-cause mortality (OCT = 14 [0.7%] vs. IVUS = 110
[2.97%]; RR 0.74; 95% CI, 0.39–1.39; p = 0.35), MI (OCT = 12 [0.6%]
vs. IVUS = 9 [0.4%]; RR 1.27; 95% CI, 0.52–3.07; p = 0.87), ST
(OCT = 2 [0.29%] vs. IVUS = 3 [0.45%]; RR 0.70; 95% CI, 0.13–3.61;
p = 0.67), TLR (OCT = 15 [2%] vs. IVUS = 13 [1.8%]; RR 1.09; 95%
CI, 0.53–2.25; p = 0.81), and stroke (OCT = 5 [0.3%] vs. IVUS = 2
[0.1%]; RR 2.32; 95% CI, 0.42–12.90; p = 0.34) with no heterogeneity
among the studies I2 = 0 (Figures 2 and 3). Furthermore, the standard
inverse variance model showed that OCT can have better acute lumi-
nal gain difference of 0.17 mm (95% CI 0.29 to 0.06; p = 0.002), but
no significant difference was noted for contrast volume (95% CI
0.80 to 1.42; p = 0.58) (Figure S3). The fixed effect model results of
RR are shown in the Figures S4 and S5.
Subgroup analysis of outcomes was performed based on short-
term follow-up (< 30 days) and long-term follow-up (≥ 1 year) among
different studies. Given limited data on ST and stroke, subgroup ana-
lyses for these outcomes were not reported. Estimated pooled out-
comes within each subgroup for the primary endpoint overall eligible
studies are presented in Figures S6–S9. At ≥ 1 year and 30 days follow-
ups, there was no significant difference in efficacy and safety of OCT-
guided PCI as compared to IVUS-guided PCI in terms of MACE
(RR 0.81; 95% CI 0.58–1.12; p = 0.78; I2 = 0); cardiac mortality (RR
0.97; 95% CI 0.27–3.46; p = 0.67) all-cause mortality (RR 0.75; 95% CI
0.40–1.40; p = 0.93; I2 = 0), MI (RR 1.26; 95% CI 0.52–3.04; p = 0.84;
I2 = 0), TLR (RR 1.09 95% CI 0.53–2.22; p = 0.89; I2 = 0), and stroke
(RR 2.31 95% CI 0.41–12.84, p = 0.45; I2 = 0) (Figures S6 and S7). Sub-
group analysis comparing RCT versus observational studies showed no
difference in the different outcomes assessed (Figures S8 and S9). Uni-
variate meta-regression results showed no effect modification based on
demographics, comorbidities, vessel, stent type, and lesion length.
(p > 0.05) (Table 3, Figures S10–S27).
To further explore potential bias due to the inclusion of observa-
tional studies, we pooled data from RCTs for the primary and second-
ary outcomes, which showed consistent results (Figure S28–S34).
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E6 SATTAR ET AL.

TABLE 2 Showing procedural characteristics including access site, lesion characteristics, and post procedural complications

OPINION ILUMIEN III

Variable Kubo18 Musramatsu19 Ali20 Chamie21 Okura22 Jones23 Kim Yoon24
Arterial access
Radial NA 52/54 104/87 39/38 32/603.5 577/3016 NA
Brachial NA 6/4 NA NA NA NA NA
Femoral NA 4/6 54/59 NA NA NA NA
Coronary arteries
Right coronary artery (RCA) 102/117 18/22 35/36 20/19 NA 263/3225 26/31
Left anterior descending 223/197 31/25 80/68 19/22 NA 630/5312 81/70
(LAD)
Left circumflex (LCX) 84/87 13/17 43/42 12/10 NA 236/2595 7/13
Lesion characteristics
Thrombus 4/5 0/2 2/2 1/3 NA NA 21/24
Bifurcation 154/157 NA NA 8/6 NA NA NA
Moderate-heavy calcification 29/51 10/16 32/24 9/13 NA NA NA
Long lesion (>28 mm) 56/54 NA NA NA NA NA NA
ACC/AHA lesion type 329/319 26/30 NA NA NA NA A/B1: 31/33
B or C B2/C: 83/81
Multivessel disease, % NA 20/24 NA NA 30/46 234/2033 44/42
Bifurcation lesions, % 37.4/38.8 NA NA 15.7/11/7 NA NA NA
Chronic total occlusions, % NA NA NA NA NA NA NA
Reference vessel 2.62/2.59 2.69/2.75 2.78/2.87 2.82/2.85 2.82/2.85 NA 3.20/3.25
diameter, mm
Pre-Intervention MLD, mm 0.94/0.89 1.06/1.04 0.99/1.03 0.76/0.80 0.76/0/8 NA 0.59/0.53
Pre-Intervention diameter 64/65 58.5/59.0 64.1/63.7 73/71.49 73/71.49 NA 80.2/82.2
stenosis, %
Lesion length, mm 17.73/17.56 11.7/11.1 15.5/15.3 21.61/23.1 21.61/23.1 NA 21.2/21.6
Total stented length, mm 25.9/24.8 18.2/18.1 23.5/24.0 28.57/32.51 22/23 25.75/25.01 25.2/25
Post-dilation, n 316/304 42/41 NA 51/51 NA NA NA

Note: All the data is arranged in OCT/IVUS format.

Slow reflow occurred in three (0.2%) patients within the OCT-
arm out of 1149 patients and 22 (0.2%) out of 1125 patients receiving
IVUS-guided PCI.21 Perforation was documented in four (0.35%) and
21
63 (0.57%) patients in OCT and IVUS group, respectively. Finally,
there were no reported occurrences of thrombus or abrupt closure in
either imaging arms.
Our funnel plot was symmetrical on visual assessment, with an
equal number of studies on each side of the vertical axis. There was
no publication bias demonstrated. The limited scatter on the graph
was due to sampling variation (Figures S35 and S36). Egger's test for
the measure of publication bias was non-significant (two-tailed
p > 0.05).
7 | DISCUSSION
In this meta-analysis of seven studies, including 5917 patients, we
compared the clinical outcomes of OCT versus IVUS guidance across
the entire spectrum of patients with acute coronary syndrome under-
going PCI. The principal findings of the meta-analysis are as follows:
(1) OCT-guided PCI was associated with no statistically significant dif-
ference in clinical outcomes when compared with IVUS-guided PCI
(2) this effect was observed irrespective of any effect modifier,
follow-up duration (short vs. long term), and type of studies (RCT
vs. observational studies).
To our knowledge, this is the first comprehensive meta-analysis
that compared clinical outcomes of IVUS-guided PCI with OCT-guided
PCI, including the results of the recent MISTIC-1, ILUMIEN III: OPTI-
MIZE PCI and iSIGHT trials.19–21 Previous meta-analyses have
explored the impact of IVUS and OCT but were underpowered
because of the limited number of studies present.25,26 Extending the
role of intracoronary imaging, the current meta-analysis provides con-
vincing evidence that OCT and IVUS guided PCI have equivalent
clinical cardiovascular outcomes. These findings from the current
meta-analysis are in concordance with the recent results of MISTIC-1,
ILUMIEN III: OPTIMIZE PCI trials, and iSIGHT trials.19–21 The expert
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E7

F I G U R E 2 All primary outcome forest plot- random effect including (A) MACE (B) cardiac mortality and (C) all-cause mortality and elective
subgrouping for (D) MACE (E) cardiac mortality and (F) all-cause mortality. MACE, Major adverse cardiac events
SATTAR ET AL.

E8
F I G U R E 3 All secondary outcomes forest plot—random effect including (A) myocardial infarction (B) stent thrombosis (C) target lesion
revascularization (D) stroke
consensus of the European Association of Percutaneous Cardiovascu-
lar Interventions (EAPCI) in 2018 highly recommends the utilization of
OCT for stent failures.27 However, the neointimal healing score is
considered a major determinant of stent failure, such as restenosis.28
The findings of the MISTIC-1 trial demonstrated the non-inferiority of
OCT relative to IVUS-guided PCI in terms of arterial healing and in-
19
segment minimum lumen area at 8 months.
The ILLUMEN III trial demonstrated that OCT was comparable to
IVUS and led to fewer cases of major dissection and major stent mal-
position. Overall, however, procedural MACE was 3.8% without sig-
nificant differences between these two imaging groups.20 The
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SATTAR ET AL.
OPINION (optic frequency domain imaging vs. IVUS in PCI) trial fur-
ther demonstrated non-inferiority of OCT relative to IVUS-guided PCI
according to the primary endpoint of target vessel failure (composite
of cardiac mortality, MI, and target vessel revascularization), and rate
of restenosis (in-stent 1.6% vs.1.6%, p = 1.00; and in-segment: 6.2%
vs. 6.0%, p = 1.00).21
A previous randomized, blinded study including 70 patients dem-
onstrated that IVUS guidance was associated with greater stent expan-
sion (minimum stent area of 7.1 vs. 6.1 mm2, p = 0.04) and a smaller
stent-edge plaque burden (proximal edge 37.1 vs. 45.7%, p = 0.001;
distal edge 33.3 vs. 40.3%, p < 0.001) compared with OCT.29
 SATTAR ET AL.

TABLE 3 Meta-regression of potential effect modifiers for all study outcomes (p ≥ 0.05 shows that our study had no effect modifiers in our studied outcomes)

Cardiac mortality Mortality MACE MI TLR ST

Meta-regression variables Coefficient p Coefficient p Coefficient p Coefficient p Coefficient p Coefficient p

Demographic
Age 0.010 0.936 0.053 0.517 0.058 0.259 0.057 0.579 0.102 0.362 0.010 0.945
Male 0.091 0.607 0.078 0.463 0.007 0.273 0.028 0.821 0.123 0.461 0.109 0.597
Comorbidities
HTN 0.002 0.442 0.000 0.869 0.000 0.768 0.000 0.371 0.001 0.356 0.000 0.782
DM 0.004 0.477 0.000 0.875 0.000 0.789 0.000 0.363 0.002 0.346 0.001 0.762
HLD 0.002 0.419 0.000 0.878 0.000 0.801 0.000 0.364 0.001 0.349 0.000 0.752
Past cardiac history
Prior MI 0.007 0.623 0.000 0.923 0.000 0.858 0.000 0.403 0.007 0.362 0.001 0.899
Prior PCI 0.004 0.535 0.000 0.950 8.77 0.941 0.000 0.383 0.003 0.329 0.002 0.659
Prior CABG 0.006 0.923 0.000 0.902 0.000 0.611 0.015 0.901 0.024 0.866
Vessel involved
RCA occlusion 0.008 0.399 0.000 0.807 0.000 0.616 0.000 0.401 0.004 0.344 0.003 0.691
LAD occlusion 0.005 0.295 0.000 0.793 0.000 0.600 0.000 0.383 0.002 0.349 0.002 0.657
LCX occlusion 0.008 0.503 0.000 0.808 0.000 0.618 0.000 0.401 0.005 0.363 0.001 0.886
Stent/lesion characteristics
Stent type 0.751 0.564 0.103 0.794 0.267 0.220 0.373 0.433 0.569 0.431 0.522 0.564
Lesion length 0.860 0.642 0.123 0.925 0.123 0.498 0.033 0.853 0.137 0.518 0.060 0.802

Abbreviations: DM, diabetes mellitus; HLD, hyperlipidemia; HTN, hypertension; MACE, major adverse cardiac events; MI-myocardial infarction; PCI, percutaneous coronary intervention; TLR-target lesion
revascularization; ST, stent thrombosis.
E9

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E10
Since post-stenting vessel dimensions are an important predictor of
clinical outcomes, one may argue for PCI optimization using OCT due
to the potential underestimation of proper stent/vessel size. Our anal-
ysis specifically conducted in a large sample of PCI patients with more
statistical power does not support this hypothesis. Despite technical
differences between IVUS and OCT and the potential benefits and lim-
itations for each technique, similar clinical outcomes were observed
for both imaging modalities. Therefore, the choice of imaging modality
between IVUS and OCT depends on the operator's experiences and
cost-effectiveness. Furthermore, OCT or IVUS PCI effects can be mod-
ified by effect modifiers which are excluded by performing regression
on all potential modifiers, strengthening our associations.30
OCT can have lower use of contrast and better luminal gain than
IVUS, but the cardiovascular outcomes are likely similar among both
groups. Currently, two large RCTs have been initiated to demonstrate
the superiority of OCT-guided PCI compared to angiography-guided
stenting in terms of MACE after 2 years of follow-up. The ILUMIEN
IV trial is a multicenter RCT that has completed recruiting 3656
patients.31 The OCTOBER trial is a European RCT that aims to include
1200 patients to demonstrate the superiority of OCT-guided stenting
in bifurcations lesions.32 The OCTIVUS study is another multicenter,
prospective, open-label RCT including 2000 patients that have been
initiated to test the hypothesis that OCT is non-inferior to IVUS-
guided PCI in terms of target vessel failure, which is a composite of
cardiac death, target vessel MI and ischemia driven TVR after a
follow-up of 1 year.33 The interim results of all three studies are
expected around the midterm of 2021.
8 | L I M I T A T I O NS
A few limitations of our study should be acknowledged. First, the defi-
nition of MACE varied among the included studies. Second, we could
not perform separate subgroup analysis for both elective and emergent
PCI given the data limitation. Therefore, our analysis included pooled
analysis of both elective and emergent PCI and a sub-analysis including
only elective PCI. Third, the inclusion of observational studies may have
potentially led to some bias in our pooled estimates due to residual con-
founding based on PS matching's unavailability in all studies. However,
the subgroup analysis comparing RCTs versus observational studies
showed no difference in the outcomes evaluated. Third, the compara-
tive efficacy between IVUS and OCT is limited to selected lesions and
may not be applicable to other complex lesions. Fourth, given the lack
of RCT, and large pooled sample, our study effect may have an underly-
ing bias due to sample size. Next, the power of funnel plot asymmetry
was low given the limited number of studies on this topic. Therefore, an
accurate assessment of publication bias was not possible.
9 | C O N CL U S I O N
In this meta-analysis comparing the use of IVUS and OCT for PCI,
there were no significant differences according to MACE outcomes,
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SATTAR ET AL.
cardiac mortality, all-cause mortality, MI, ST, TLR, and stroke. OCT is a
safe and feasible imaging modality for the guidance of PCI in CAD.
CONFLIC T OF INT ER E ST
Dr. Qureshi is on the Speaker Bureau of Penumbra Inc. Dr. Mamas
has received an unrestricted educational grant from Abbott.
DATA AVAILABILITY STAT EMEN T
Data were obtained from published articles on the topic. All data can
be obtained from the references mentioned in the supplementary file.
The consolidated extracted data is available on demand.
OR CID
Yasar Sattar https://orcid.org/0000-0002-1304-5748
Aminah Abdul Razzack https://orcid.org/0000-0001-7310-6824
Waqas Ullah https://orcid.org/0000-0002-4850-0309
Mohamed Zghouzi https://orcid.org/0000-0002-1521-332X
Islam Y. Elgendy https://orcid.org/0000-0001-9853-7591
M. Chadi Alraies https://orcid.org/0000-0002-7874-4566
RE FE RE NCE S
1. Lee CH, Hur S-H. Optimization of percutaneous coronary intervention
using optical coherence tomography. Korean Circ J. 2019;49(9):771.
2. Schiele F, Meneveau N, Vuillemenot A, et al. Impact of intravascular
ultrasound guidance in stent deployment on 6-month restenosis rate:
a multicenter, randomized study comparing two strategies—with and
without intravascular ultrasound guidance. J Am Coll Cardiol. 1998;
32(2):320-328.
3. Fitzgerald PJ, Oshima A, Hayase M, et al. Final results of the can rou-
tine ultrasound influence stent expansion (CRUISE) study. Circulation.
2000;102(5):523-530.
4. Gaster A, Skjoldborg US, Larsen J, et al. Continued improvement of
clinical outcome and cost effectiveness following intravascular ultra-
sound guided PCI: insights from a prospective, randomised study.
Heart. 2003;89(9):1043-1049.
5. Maehara A, Matsumura M, Ali ZA, Mintz GS, Stone GW. IVUS-guided
versus OCT-guided coronary stent implantation: a critical appraisal.
JACC Cardiovasc Imaging. 2017;10(12):1487-1503.
6. Elgendy IY, Gad M, Mintz GS. Meta-analysis of intravascular
ultrasound-guided drug-eluting stent implantation for left Main coro-
nary disease. Am J Cardiol. 2020;128:92-93.
7. Elgendy IY, Gad M, Jain A, Mahmoud AN, Mintz GS. Outcomes with
intravascular ultrasound-guided drug eluting stent implantation for
unprotected left Main coronary lesions: a meta-analysis. Am J Cardiol.
2019;124(10):1652-1653.
8. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guide-
lines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165.
9. Lee D, Wiernek S, Kaul P, Rossi J. Inpatient utilization of coronary optical
coherence tomography and intravascular ultrasound: findings from the
national inpatient sample. Catheter Cardiovasc Interv. 2018;91:S23-S225.
10. Elgendy IY, Ha LD, Elbadawi A, et al. Temporal trends in inpatient use
of intravascular imaging among patients undergoing percutaneous
coronary intervention in the United States. JACC Cardiovasc Interv.
2018;11(9):913-915.
11. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement.
PLoS Med. 2009;6(7):e1000097.
12. Wells GA, Shea B, Da O'C, et al. The Newcastle-Ottawa Scale (NOS)
for Assessing the Quality of Nonrandomised Studies in Meta-Ana-
lyses. Ottawa Hospital Research Institute; 2000.

SATTAR ET AL.
13. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-anal-
ysis. Stat Med. 2002;21(11):1539-1558.
14. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis
detected by a simple, graphical test. BMJ. 1997;315(7109):629-634.
15. Hartung J. An alternative method for meta-analysis. Biom J: J Math
Methods Biosci. 1999;41(8):901-916.
16. Hartung J, Knapp G. On tests of the overall treatment effect in meta-
analysis with normally distributed responses. Stat Med. 2001;20(12):
1771-1782.
17. Hartung J, Knapp G. A refined method for the meta-analysis of con-
trolled clinical trials with binary outcome. Stat Med. 2001;20(24):
3875-3889.
18. Kubo T, Shinke T, Okamura T, et al. Optical frequency domain imag-
ing vs. intravascular ultrasound in percutaneous coronary intervention
(OPINION trial): one-year angiographic and clinical results. Eur Heart
J. 2017;38(42):3139-3147.
19. Muramatsu T, Ozaki Y, Nanasato M, et al. Comparison between opti-
cal frequency domain imaging and intravascular ultrasound for percu-
taneous coronary intervention guidance in Biolimus A9-eluting stent
implantation: a randomized MISTIC-1 non-inferiority trial. Circ Cardi-
ovasc Interv. 2020;13(11):e009314.
20. Ali ZA, Maehara A, Généreux P, et al. Optical coherence tomography
compared with intravascular ultrasound and with angiography to
guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a
randomised controlled trial. Lancet. 2016;388(10060):2618-2628.
21. Chamié D, Costa JR Jr, Damiani LP, et al. Optical coherence tomogra-
phy versus intravascular ultrasound and angiography to guide percu-
taneous coronary interventions: the iSIGHT randomized trial. Circ
Cardiovasc Interv. 2021;14(3):e009452.
22. Okura H, Saito Y, Soeda T, et al. Frequency and prognostic impact of
intravascular imaging-guided urgent percutaneous coronary interven-
tion in patients with acute myocardial infarction: results from J-MIN-
UET. Heart Vessel. 2019;34(4):564-571.
23. Jones DA, Rathod KS, Koganti S, et al. Angiography alone versus angi-
ography plus optical coherence tomography to guide percutaneous
coronary intervention: outcomes from the pan-London PCI cohort.
JACC Cardiovasc Interv. 2018;11(14):1313-1321.
24. Kim IC, Yoon HJ, Shin ES, et al. Usefulness of frequency domain opti-
cal coherence tomography compared with intravascular ultrasound as
a guidance for percutaneous coronary intervention. J Interv Cardiol.
2016;29(2):216-224.
25. Kuku KO, Ekanem E, Azizi V, et al. Optical coherence tomography-
guided percutaneous coronary intervention compared with other
imaging guidance: a meta-analysis. Int J Cardiovasc Imaging. 2018;
34(4):503-513.
26. Buccheri S, Franchina G, Romano S, et al. Clinical outcomes following
intravascular imaging-guided versus coronary angiography-guided
1522726x, 2022, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccd.29976 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
E11
percutaneous coronary intervention with stent implantation: a sys-
tematic review and Bayesian network meta-analysis of 31 studies and
17,882 patients. JACC Cardiovasc Interv. 2017;10(24):2488-2498.
27. Räber L, Mintz GS, Koskinas KC, et al. Clinical use of intracoronary
imaging. Part 1: guidance and optimization of coronary interventions.
An expert consensus document of the European Association of Per-
cutaneous Cardiovascular Interventions. Eur Heart J. 2018;39(35):
3281-3300.
28. Joner M, Finn AV, Farb A, et al. Pathology of drug-eluting stents in
humans: delayed healing and late thrombotic risk. J Am Coll Cardiol.
2006;48(1):193-202.
29. Habara M, Nasu K, Terashima M, et al. Impact of frequency-domain
optical coherence tomography guidance for optimal coronary stent
implantation in comparison with intravascular ultrasound guidance.
Circ Cardiovasc Interv. 2012;5(2):193-201.
30. Elgendy IY, Mahmoud AN, Elgendy AY, Bavry AA. Does the baseline
coronary lesion length impact outcomes with IVUS-guided percutane-
ous coronary intervention? J Am Coll Cardiol. 2016;68(5):569-570.
31. Ali Z, Landmesser U, Karimi Galougahi K, et al. Optical coherence
tomography-guided coronary stent implantation compared to angiog-
raphy: a multicentre randomised trial in PCI - design and rationale of
ILUMIEN IV: OPTIMAL PCI. EuroIntervention. 2021;16(13):1092-
1099.
32. Holm NR, Andreasen LN, Walsh S, et al. Rational and design of the
European randomized optical coherence tomography optimized bifur-
cation event reduction trial (OCTOBER). Am Heart J. 2018;205:
97-109.
33. Kang DY, Ahn JM, Park H, et al. Comparison of optical coherence
tomography-guided versus intravascular ultrasound-guided percuta-
neous coronary intervention: rationale and design of a randomized,
controlled OCTIVUS trial. Am Heart J. 2020;228:72-80.
SUPPORTING INF ORMATION
Additional supporting information may be found in the online version
of the article at the publisher's website.
How to cite this article: Sattar Y, Abdul Razzack A,
Kompella R, Alhajri N, Arshad J, Ullah W, et al. Outcomes of
intravascular ultrasound versus optical coherence tomography
guided percutaneous coronary angiography: A meta
regression-based analysis. Catheter Cardiovasc Interv. 2022;
99:E1–11. https://doi.org/10.1002/ccd.29976