Comparative outcomes of fractional flow reserve and intravascular ultrasound guidance for percutaneous coronary intervention: a systematic review and meta-analysis

Abstract Introduction Advanced techniques beyond angiography increasingly guide percutaneous coronary intervention (PCI) [1]. Fractional flow reserve (FFR) and intravascular ultrasound (IVUS) are widely used for physiological and anatomical guidance, respectively [2]. Purpose This study compares clinical outcomes of FFR versus IVUS-guided PCI. Methods We conducted a systematic review and meta-analysis that identified studies comparing FFR- and IVUS-guided PCI. Primary outcomes included major adverse cardiovascular events (MACE), all-cause mortality, cardiac death, non-fatal myocardial infarction (MI), and target vessel revascularisation (TVR). A secondary outcome was the number of PCI procedures performed. Random effects modelling was used for all outcomes. Results Six studies comprising 5,040 patients (FFR: 2,517; IVUS: 2,523) were included. There were no significant differences between FFR- and IVUS-guided PCI in the incidence of MACE (RR = 1.13, 95% CI 0.89–1.44), all-cause mortality (RR = 0.82, 95% CI 0.41–1.64), cardiac death (RR = 1.05, 95% CI 0.60–1.85), non-fatal MI (RR = 1.35, 95% CI 0.72–2.52), or TVR (RR = 1.21, 95% CI 0.81–1.81). Subgroup analyses by study design (observational studies and randomised control trials) showed no significant effect modification for any outcome. There was no significant difference in the number of PCI procedures performed (RR = 0.78, 95% CI 0.59–1.02), although heterogeneity was high (I² = 95%). Conclusion FFR and IVUS both effective for guiding PCI, with similar outcomes in terms of MACE, mortality, MI, TVR, and PCI procedures performed. Modality selection should be tailored to lesion complexity, institutional expertise, and resource availability.