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<p>Left main (LM) and bifurcation coronary artery disease (CAD) are anatomically complex lesions which require detailed planning and precise execution for successful revascularization. Conventional angiography has limited ability to characterize plaque burden and complex bifurcation anatomy, prompting the use of adjunctive imaging. These limitations have driven the adoption of advanced intravascular imaging (IVI) modalities to enhance diagnostic accuracy and guide intervention. This review evaluates and compares the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), computed tomography coronary angiography (CTCA), and angiography in LM and bifurcation disease. A comprehensive analysis of anatomical challenges, lesion complexity, hemodynamic implications, and modality-specific advantages is provided. Key randomized controlled trials (ULTIMATE, ILUMIEN, OCTOBER, RENOVATE-COMPLEX-PCI) and real-world data are reviewed. IVUS remains the preferred modality for LM percutaneous coronary intervention (PCI), particularly for ostial and proximal lesions, due to its superior tissue penetration and correlation with physiologic indices such as minimal lumen area (MLA). OCT offers unmatched resolution and is valuable in distal LM bifurcations and complex bifurcation strategies. CTCA enhances preprocedural planning, especially for ostial and ambiguous lesions, while hybrid imaging techniques enable anatomical-physiological integration. Contemporary trials consistently demonstrate improved stent expansion, reduced major adverse cardiac events (MACE), and lower target vessel failure (TVF) with imaging-guided PCI versus angiography alone. While IVUS remains the gold standard, OCT and CTCA play complementary roles. Future directions include broader adoption of artificial intelligence (AI) enhanced imaging, fusion technologies, and standardized algorithms to improve outcomes, reduce variability, and promote cost-effectiveness in complex coronary interventions.</p> Graphical abstract <p> The graphical abstract summarizes the role of multimodality imaging in left main and bifurcation PCI, highlighting the limitations of angiography and the complementary roles of IVUS, OCT, and CTCA in lesion assessment, procedural guidance, and optimization. It emphasizes evidence from randomized trials demonstrating improved procedural and clinical outcomes with imaging-guided PCI. <i>A Created in BioRender. Padda</i>,<i> I. (2026)</i> <a href="https://BioRender.com/fv1n7ut">https://BioRender.com/fv1n7ut</a>.</p>

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Multimodal imaging in left main and bifurcation revascularization: contemporary evidence and comparative modalities review

  • 期刊论文

  • 发表日期：

    2026年4月16日

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  • Inderbir Padda,
  • Harshan Atwal,
  • Inderjeet Bharaj,
  • Khushal Choudhary,
  • Pruthvi C. Revaiah,
  • Charles Sineri

摘要

Left main (LM) and bifurcation coronary artery disease (CAD) are anatomically complex lesions which require detailed planning and precise execution for successful revascularization. Conventional angiography has limited ability to characterize plaque burden and complex bifurcation anatomy, prompting the use of adjunctive imaging. These limitations have driven the adoption of advanced intravascular imaging (IVI) modalities to enhance diagnostic accuracy and guide intervention. This review evaluates and compares the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), computed tomography coronary angiography (CTCA), and angiography in LM and bifurcation disease. A comprehensive analysis of anatomical challenges, lesion complexity, hemodynamic implications, and modality-specific advantages is provided. Key randomized controlled trials (ULTIMATE, ILUMIEN, OCTOBER, RENOVATE-COMPLEX-PCI) and real-world data are reviewed. IVUS remains the preferred modality for LM percutaneous coronary intervention (PCI), particularly for ostial and proximal lesions, due to its superior tissue penetration and correlation with physiologic indices such as minimal lumen area (MLA). OCT offers unmatched resolution and is valuable in distal LM bifurcations and complex bifurcation strategies. CTCA enhances preprocedural planning, especially for ostial and ambiguous lesions, while hybrid imaging techniques enable anatomical-physiological integration. Contemporary trials consistently demonstrate improved stent expansion, reduced major adverse cardiac events (MACE), and lower target vessel failure (TVF) with imaging-guided PCI versus angiography alone. While IVUS remains the gold standard, OCT and CTCA play complementary roles. Future directions include broader adoption of artificial intelligence (AI) enhanced imaging, fusion technologies, and standardized algorithms to improve outcomes, reduce variability, and promote cost-effectiveness in complex coronary interventions.

Graphical abstract

The graphical abstract summarizes the role of multimodality imaging in left main and bifurcation PCI, highlighting the limitations of angiography and the complementary roles of IVUS, OCT, and CTCA in lesion assessment, procedural guidance, and optimization. It emphasizes evidence from randomized trials demonstrating improved procedural and clinical outcomes with imaging-guided PCI. A Created in BioRender. Padda, I. (2026) https://BioRender.com/fv1n7ut.