Imaging-guided PCI was associated with lower major adverse cardiovascular event (MACE) risk compared with angiography-guided PCI, while overall mortality was comparable between PCI strategies and CABG in patients undergoing left main coronary artery (LMCA) revascularization.

The analysis published in the International Journal of Cardiology included 17 randomized controlled trials enrolling 7700 patients with LMCA disease. Studies evaluated outcomes after angiography-guided PCI, imaging-guided PCI, or CABG, with a median follow-up duration of 2 years. 

Co-primary endpoints were MACE, according to individual trial definitions, and all-cause death. Secondary outcomes included myocardial infarction (MI), stroke, target vessel revascularization (TVR), repeat revascularization, and stent thrombosis or graft occlusion.
Angiography-guided PCI was associated with a significantly higher risk of MACE compared with imaging-guided PCI (incidence rate ratio [IRR] 1.34, 95% CI 1.05-1.72) and CABG (IRR 1.49, 95% CI 1.10-2.03).

No significant differences in all-cause death were observed between imaging-guided PCI and CABG (IRR 1.00, 95% CI 0.81-1.24). Similarly, angiography-guided PCI and imaging-guided PCI showed comparable all-cause mortality (IRR 1.04, 95% CI 0.77-1.40).

Compared with PCI approaches, CABG was associated with lower risks of MI, TVR, and repeat revascularization. However, CABG showed a higher risk of stent thrombosis or graft occlusion. Angiography-guided PCI was associated with higher TVR risk compared with imaging-guided PCI, while stroke risk was lower with angiography-guided PCI than with CABG or imaging-guided PCI.

The findings showed comparable survival between PCI and CABG strategies in LMCA disease. Imaging-guided PCI was associated with lower MACE and reduced stent thrombosis or graft occlusion compared with angiography-guided PCI.