Quantitative Coronary Angiography Guidance for Drug-Eluting Stent Implantation: A Narrative Review

Background: Percutaneous coronary intervention (PCI) using drug-eluting stents is an established strategy for the treatment of significant obstructive coronary artery disease. Evidence supports that intravascular imaging-guided PCI offers advantages over conventional angiography-guided PCI, though its use is limited, likely due to high costs. Angiography-guided PCI relies on visual estimation, leading to inter- and intra-observer variability and suboptimal outcomes. Quantitative coronary angiography (QCA) provides reliable information about vascular dimensions, overcoming these limitations. Poststenting postdilation with appropriately sized noncompliant balloons improves outcomes by increasing lumen area and reducing stent malapposition. Aims: We investigated the procedural details of each modality used to guide PCI and assessed the utility of QCA-guided PCI with routine postdilation when intravascular imaging is unavailable. Methods and Results: A systematic search was conducted from inception to May 31, 2024, identifying nine randomized controlled trials (with over 500 patients) that compared outcomes of PCI guided by intravascular imaging versus conventional angiography or QCA. The findings indicate that intravascular imaging guidance significantly improves clinical outcomes compared to angiography guidance. Notably, QCA-guided PCI with routine postdilation yielded outcomes comparable to those achieved with intravascular imaging-guided PCI. Conclusions: QCA-guided PCI with routine postdilation may be a viable alternative for improving PCI outcomes, especially in settings where intravascular imaging is unavailable.