Intravascular ultrasound versus angiogram guided drug eluting stent implantation. A systematic review and updated meta-analysis with trial sequential analysis

BACKGROUND: Further advances have been achieved in the field of intravenous ultrasound (IVUS) guided drug eluting stent (DES) implantation and hence there was a need to rejuvenate the evidence. Hence, we performed a cumulative meta-analysis with trial sequential analysis (TSA) of randomized controlled trials (RCTs) comparing IVUS versus angiogram guided DES implantation. METHODOLOGY: We searched PubMed/Medline and Cochrane database for relevant articles using predefined inclusion and exclusion criteria. Outcomes of interest were cardiovascular mortality, myocardial infarction (MI), target lesion revascularisation (TLR), stent thrombosis (ST). We used Mantel-Haenszel method with random error model to calculate odds ratio (OR) with 95% confidence interval (CI). We also performed TSA to accommodate for possible type I error. RESULTS: A total of 11 RCTs with 5352 patients were included in the final analysis. Follow up duration of included studies varied from 12 to 24 months. IVUS use was associated with significantly reduced incidence of cardiovascular mortality [OR: 0.45, CI: 0.25–0.80, p value = 0.007, I(2) = 0%, χ(2)p-value = 0.98], TLR [OR: 0.56, CI: 0.41–0.77, p value = 0.0004, I(2) = 0%, χ(2)p-value = 0.95] and ST [OR: 0.47, CI: 0.24–0.94, p value = 0.03, I(2) = 0%, χ(2)p-value = 0.75]. IVUS use had no effect on incidence of MI on follow up. The cumulative z curve crosses the TSA boundary indicating sufficient evidence without type I error for reduced incidence of cardiovascular mortality and TLR with the use IVUS. CONCLUSION: IVUS-guided DES implantation should be the standard of care as it significantly reduced cardiovascular mortality and TLR.