Weekly Journal Scan: IVUS in complex PCI—the importance of procedural guidance and achievement of optimization criteria

Comment on ‘Intravascular Ultrasound-Guided or Angiography-Guided Complex High-Risk PCI’, which was published in the New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2601521. Coronary angiography remains the cornerstone of PCI, yet its ability to guide optimal stent implantation is inherently limited by its two-dimensional luminographic nature, providing limited information regarding plaque morphology, vessel wall architecture, calcium distribution, or procedural suboptimal findings, such as stent underexpansion, malapposition, or edge dissection.2 Intravascular imaging modalities, particularly IVUS and optical coherence tomography (OCT), overcome many of these limitations by enabling detailed visualization of coronary anatomy and procedural results, thereby facilitating accurate vessel sizing, lesion preparation, and stent optimization.3 Over the past decade, accumulating randomized evidence involving more than 15 000 patients from both Western and East Asian countries showed that imaging-guided PCI improve cardiovascular outcomes.4–9 In a large meta-analysis by Stone et al., imaging-guided PCI was associated with a 29% reduction in target lesion failure compared with angiography-guided PCI at a mean follow-up of approximately 25 months.10 Imaging guidance was also associated with substantial reductions in cardiac death (45%), target-vessel MI (18%), target lesion revascularization (28%), and stent thrombosis (48%). Importantly, both IVUS- and OCT-guided PCI yielded similar benefits, with no significant difference observed between the two imaging modalities.10