Abstract 15493: Coronary Artery Revascularization Strategies for Angiographically Inconclusive Lesions: A Network Meta-Analysis of Randomized Controlled Trials

Background: There has been no head-to-head comparison among coronary artery revascularization strategies including different guiding modalities for percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG).

Aim: To compare the cardiovascular outcome of all available coronary artery revascularization strategies

Method: Systematic search of randomized controlled trials and study selection were performed in accordance with PRISMA guidelines. Coronary artery disease with angiographically inconclusive lesions was the domain of interest. Trials were excluded if they involved patients with left main disease, chronic total occlusion, or primary PCI for acute myocardial infarction (MI). The outcome of interest was a primary endpoint of all-cause death, non-fatal MI, or unplanned revascularization. Patient-level data was constructed from Kaplan-Meier (KM)-extracted data and combined across studies. A mixed-effect Weibull regression with accelerated failure time was used, and hazard ratios (HR) with 95% confidence intervals (CI) were then estimated.

Result: A network map of 7 interventions including 15 trials of 17286 patients and cumulative probability curves are shown in Figure 1A and 1B respectively. CABG is the most effective strategy with 42% risk reduction in primary endpoint compared to angiography-guided PCI (HR 0.58, 95% CI 0.50-0.67), followed by quantitative flow ratio (QFR)-guided PCI (HR 0.64, 95% CI 0.50-0.82), intravascular ultrasound (IVUS)-guided PCI (HR 0.70, 95% CI 0.53-0.93) and fractional flow reserve (FFR)-guided PCI (HR 0.79, 95% CI 0.66-0.96). PCI guided by instantaneous flow ratio (iFR) and optical coherence tomography (OCT) is also superior to angiography but not statistically significant as shown in Figure 1C.

Conclusion: CABG remains the most effective strategy in reducing the primary endpoint while QFR is superior to OCT, IVUS, FFR, iFR, and angiography in guiding PCI accordingly.