Debate: Intravascular imaging in the treatment of complex lesions. Rationale for routine use

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Complex coronary artery lesions and left main coronary artery disease undergoing percutaneous coronary intervention. Intervention: Intravascular imaging-guided percutaneous coronary intervention (IVUS and OCT) vs. Angiography-guided percutaneous coronary intervention.

Nieves Gonzalo

doi:10.24875/recice.m26000625

October 19, 2026REC interventional cardiology (English Edition)Open Access

Debate: Intravascular imaging in the treatment of complex lesions. Rationale for routine use

View Full Paper

Ask AI

Bookmark

Share

Key result

Intravascular ultrasound guidance did not significantly reduce primary composite endpoints in the OPTIMAL (n=806) or IVUS-CHIP (n=2,020) trials, where adequate optimization occurred in only 48%.

Why the study?

Does intravascular imaging-guided percutaneous coronary intervention improve clinical outcomes compared to angiography-guided percutaneous coronary intervention in patients with complex coronary lesions?

Key Points

To review the rationale for routine intracoronary imaging during complex percutaneous coronary intervention and contextualize recent neutral results from European randomized clinical trials.
Expert commentary analyzing procedural characteristics, design features, and patient subsets from two recent open-label randomized trials, OPTIMAL (N=806) and IVUS-CHIP (N=2020).
Evaluation of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) imaging modalities across complex lesion subsets, including left main disease, bifurcations, and calcified vessels.
In OPTIMAL (N=806; left main disease, mean SYNTAX score 30), no significant difference occurred between IVUS and angiography for the composite endpoint of stroke, myocardial infarction, revascularization, and all-cause mortality (all-cause mortality ~15%).
Both trials showed IVUS increased procedural time by >30% and revealed minimal differences in stent size, postdilation rates, or rotational atherectomy (6%-7%), with imaging frequently conducted only after stenting.

Structured PICO

Does intravascular imaging-guided percutaneous coronary intervention improve clinical outcomes compared to angiography-guided percutaneous coronary intervention in patients with complex coronary lesions?

P

Population

Patients with unprotected left main coronary artery disease (OPTIMAL, n=806) or complex coronary lesions (IVUS-CHIP, n=2,020) undergoing percutaneous coronary intervention at experienced European centers.

I

Intervention

Intravascular imaging-guided percutaneous coronary intervention (intravascular ultrasound [IVUS] or optical coherence tomography [OCT])

C

Comparator

Angiography-guided percutaneous coronary intervention

Limitations

High proportion of multivessel disease and high all-cause mortality (~15%) in OPTIMAL may have diluted the isolated effect of IVUS on the left main coronary artery
Optimization criteria in OPTIMAL were derived from older Asian studies and may not fully apply to European populations
Low rate of adequate stent optimization achieved in IVUS-CHIP (only 48% met predefined criteria)
Low utilization of advanced plaque-modification techniques (rotational atherectomy in 6%-7%) despite severe calcification in ~40% of IVUS-CHIP lesions
Limited impact of imaging on operator behavior, with imaging frequently performed only after stenting
Limited external validity outside of high-volume European centers with extensive baseline experience in intracoronary imaging

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Despite neutral primary outcomes in the recent European OPTIMAL and IVUS-CHIP trials, routine intravascular imaging remains indicated for complex and left main coronary lesions when appropriately selected and interpreted to actively guide treatment.

Abstract

No abstract yet. The journal hasn't published one we can show.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Nieves Gonzalo (2026) conducted an editorial in Complex coronary artery lesions and left main coronary artery disease undergoing percutaneous coronary intervention. Intravascular imaging-guided percutaneous coronary intervention (IVUS and OCT) vs. Angiography-guided percutaneous coronary intervention was evaluated. Intravascular ultrasound guidance did not significantly reduce primary composite endpoints in the OPTIMAL (n=806) or IVUS-CHIP (n=2,020) trials, where adequate optimization occurred in only 48%.

synapsesocial.com/papers/6aee6c1971a7594806220d68 https://doi.org/10.24875/recice.m26000625

View Full Paper

Ask AI

Bookmark

Share

Debate: Intravascular imaging in the treatment of complex lesions. Rationale for routine use

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Debate: Intravascular imaging in the treatment of complex lesions. Rationale for routine use

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading