Intravascular Imaging–Guided Percutaneous Coronary Intervention: A Critical Appraisal of Evidence and Clinical Practice

Abstract

Intravascular imaging has emerged as a critical adjunct to percutaneous coronary intervention (PCI), providing detailed insights into coronary anatomy, plaque morphology, and stent optimization beyond conventional angiography. Despite advances in PCI, adverse outcomes such as stent thrombosis and restenosis persist, often related to suboptimal lesion assessment and stent deployment. This review critically evaluates contemporary evidence from randomized controlled trials, large registries, and meta-analyses comparing intravascular imaging–guided and angiography-guided PCI. Current data consistently demonstrate that imaging guidance, particularly with intravascular ultrasound (IVUS), improves procedural optimization and reduces adverse cardiovascular events, with the greatest benefit observed in complex coronary lesions. Optical coherence tomography (OCT) provides superior spatial resolution and enhances detection of stent-related complications, although its impact on clinical outcomes appears more context-dependent. While recent guidelines strongly endorse intravascular imaging in complex PCI, real-world adoption remains limited due to economic, procedural, and training-related barriers. Variation in study design and variability in imaging protocols further complicate interpretation of existing evidence. Intravascular imaging–guided PCI represents a transition toward precision-guided coronary revascularization. Future research should focus on standardized imaging strategies, long-term outcomes, and integration with emerging technologies to optimize patient selection and procedural outcomes.