INTRAVASCULAR ULTRASOUND-GUIDED VERSUS ANGIOGRAPHY-GUIDED PERCUTANEOUS CORONARY INTERVENTION IN COMPLEX LEFT MAIN CORONARY ARTERY DISEASE: A NARRATIVE REVIEW

Abstract

Background: Left main (LM) coronary artery disease threatens a large myocardial territory, and angiography alone assesses the LM imprecisely. Guidelines now endorse intravascular ultrasound (IVUS) guidance in complex PCI, but recent randomised data have questioned its benefit in LM disease.

Objective: To appraise evidence comparing IVUS-guided with angiography-guided percutaneous coronary intervention (PCI) in LM disease.

Methods: Narrative review of observational studies, randomised trials, meta-analyses and guidelines identified from PubMed and society sources up to 30 October 2026. Published values were tabulated; figures were produced in R without re-pooling.

Results: Fourteen key sources were tabulated (five randomised, four observational, five meta-analyses). Observational data consistently favoured IVUS; in MAIN-COMPARE, 3-year mortality in matched drug-eluting stent pairs was 4.7% versus 16.0%, and a meta-analysis of 11 studies (24,103 patients) reported a pooled hazard ratio of 0.59 for all-cause mortality. Randomised evidence was discordant: the RENOVATE-COMPLEX-PCI LM substudy (n=192) reported target vessel failure of 6.8% versus 25.1% (HR 0.31), whereas OPTIMAL (n=806) found no difference in its composite endpoint (33.7% versus 30.9%; HR 1.11, 95% CI 0.87–1.42) and numerically more stroke with IVUS. Meta-analyses restricted to randomised trials showed non-significant trends.

Conclusion: IVUS is a guideline-supported adjunct in LM PCI, but a clinical-outcome advantage over expert angiographic guidance has not been firmly established. Adequately powered, long-term trials with standardised optimisation criteria are needed.