Comparative Effectiveness of Mechanical Circulatory Support Devices in Patients Undergoing Complex High-Risk Percutaneous Coronary Interventions (CHIP): A Systematic Review and Network Meta-Analysis

Background: Patients undergoing complex high-risk percutaneous coronary interventions (CHIP) are prone to hemodynamic instability, and the optimal mechanical circulatory support (MCS) strategy for this population remains unclear. Aims: This systematic review and network meta-analysis aimed to compare the short-term safety and efficacy of various MCS strategies in CHIP. Methods: We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for studies comparing different MCS strategies in CHIP patients with short-term endpoints. The primary efficacy outcome was in-hospital or 30-day mortality. Safety outcomes included MCS-related complications, specifically bleeding and stroke. The MCS strategies evaluated were intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), IMPELLA, VA-ECMO + IABP, and VA-ECMO + IMPELLA (ECPELLA). A random-effects Bayesian network meta-analysis was performed, integrating both direct and indirect comparisons. Results: Twelve studies involving a total of 75,274 patients were included. Both IABP (OR: 0.33; 95% CI: 0.13–0.91) and IMPELLA (OR: 0.44; 95% CI: 0.21–0.96) were associated with significantly lower short-term mortality compared to VA-ECMO. No significant differences were observed among other strategies. Rank probability analysis suggested that IABP had the highest probability of being the most effective strategy for reducing short-term mortality. Regarding safety outcomes, IABP was associated with a significantly lower bleeding risk compared to VA-ECMO (OR: 0.18; 95% CI: 0.04–0.82), VA-ECMO + IABP (OR: 0.18; 95% CI: 0.03–0.87), ECPELLA (OR: 0.12; 95% CI: 0.02–0.70), and IMPELLA (OR: 0.21; 95% CI: 0.05–0.75), with no significant difference in stroke risk across strategies. Conclusions: Among available MCS strategies for CHIP patients, IABP appears to be associated with improved short-term survival and a lower risk of bleeding, without an increased risk of stroke. These findings support IABP as a potentially preferable support option, warranting further validation in prospective clinical trials.