Coordination gap
The answer is roughly known; the field just hasn't synchronized practice.
Resolves via: Guideline update + dissemination
Make imaging mandatory and every complex PCI gets slower and costlier; make it optional and some patients lose the stent optimization that prevents repeat procedures.
Active since Nov 2024
The debate
11 clinicians quoted on the record
The weight of prior evidence shows intravascular imaging improves stent sizing and expansion, and the neutral trials likely reflect underpowering or skilled operators, not a real absence of benefit.
“The data goes against what we propose is best clinical practice.”
“I do not believe the results of either OPTIMAL or IVUS-CHIP should alter guidelines.”
+ 4 more on this side
When recent trials can't consistently show benefit, routine mandates add time, cost, and contrast without proven payoff, so imaging belongs where lesion complexity truly demands it.
“Obviously, it is related to years and years of experience to reach a certain level of confidence where you can have the choice of deciding whether it’s mandatory or it’s just a plus.”
“Once we are very skilled in PCI, probably we can use IVUS just in a selected proportion of our patients.”
+ 2 more on this side
Where the experts land
6–4 on record · 1 unplaced
Image every complex case · 6
On the record, unplaced · 1
Reserve for highest-risk · 4
“I do not believe the results of either OPTIMAL or IVUS-CHIP should alter guidelines.”
Where the field stands
Common ground
Imaging improves stent results in complex lesions compared with angiography alone.
The crux
Should imaging be routine for all complex PCI, or kept for the highest-risk cases, especially when skilled operators or a physiology-first strategy already get good results?
Still unknown
Trials that sort benefit by operator skill and lesion type, with long-term follow-up comparing physiology-first and imaging-first strategies, would settle it.
On the record
Their own words — position stated as published
“We have yet to fully establish how to leverage the unique information provided by intravascular imaging.”
Adnan Kastrati · Interventional cardiologist · ACC ↗
Where do you land?
No votes yet — the measured split appears at 10.
Where the evidence stands
FLAVOUR long-term follow-up (2025) found similar hard outcomes with FFR vs IVUS, fewer index PCIs with FFR, but more late TVR. FLAVOUR II (ACC 2025/Lancet) found angiography-derived FFR noninferior to IVUS at 12 months with fewer stents. ESC now gives intravascular imaging Class I for complex PCI. Operators still split on physiology-first deferral versus imaging-first optimization.
What's settled
4What's still open
4How this gets settled
Guideline to move
The 2025 ACC/AHA/SCAI Guideline for the Management of ACS has elevated the recommendation for IVI to the highest level, assigning a Class I, Level of Evidence A endorsement for IVUS or OCT guidance during PCI in ACS patients with left main or other complex lesions to reduce ischemic events.
What tips it: Whereas most evidence is generated in Asian-Pacific populations, its global adoption remains low.
Who could settle it
Know an expert who could settle this? Suggest one →
Who this affects
Who could fund or run it
Institutions that could fund, run, or adopt
Sources & verification
+ 29 more, each dated and verification-tagged
Who we found publicly on the record — a snapshot, not a poll of the field. Larger dots are deciders; dashed dots are scan-reported, not yet verified.