Percutaneous coronary intervention (PCI) for complex coronary artery lesions is associated with increased procedural and long-term risk. The potential benefit of intravascular imaging guidance during PCI compared with conventional angiography-guided procedures remains under investigation. A prospective multicenter randomized trial published in the Journal of the American College of Cardiology assessed long-term outcomes of intravascular imaging–guided PCI in patients with complex Coronary Artery Disease.

Eligible patients with complex coronary artery lesions were enrolled at multiple centers in South Korea and randomized in a 2:1 ratio to undergo intravascular imaging–guided PCI or angiography-guided PCI. The trial used a prospective multicenter open-label superiority design.

The primary endpoint was a composite outcome of cardiac death, target vessel–related myocardial infarction, or clinically driven target vessel revascularization.

A total of 1,639 patients were randomized, including 1,092 assigned to imaging-guided PCI and 547 assigned to angiography-guided PCI. After a median follow-up of 5.3 years (interquartile range 4.4–6.2 years), the primary composite endpoint occurred in 10.5% of patients in the imaging-guided PCI group and 14.9% in the angiography-guided PCI group (hazard ratio [HR] 0.68; 95% CI 0.51–0.91; p=0.009). Cardiac death or target vessel–related MI occurred in 7.6% and 10.7% of patients, respectively. Clinically driven target vessel revascularization occurred in 4.4% versus 6.2%, and definite stent thrombosis occurred in 0.1% versus 0.7%. Procedure-related safety events were similar between the two groups.

Intravascular imaging guidance during PCI was associated with a lower long-term risk of cardiac death, target vessel–related myocardial infarction, or clinically driven target vessel revascularization compared with angiography guidance. Safety outcomes were comparable between the two procedural strategies.