Intracoronary imaging to assess atherosclerosis and to guide percutaneous coronary intervention

Intracoronary imaging has become an important tool for the in vivo assessment of coronary atherosclerosis and for guiding percutaneous coronary intervention. By enabling high-resolution visualization of coronary anatomy, these modalities allow for more accurate lesion characterization, precise stent sizing, and optimized procedural strategies. In recent years, multiple randomized controlled trials have demonstrated that imaging-guided percutaneous coronary intervention reduces major adverse cardiac events (including cardiac death, myocardial infarction, and repeat revascularization), particularly in complex clinical and anatomical settings. This state-of-the-art review synthesizes contemporary evidence supporting the use of intravascular ultrasound and optical coherence tomography to guide percutaneous coronary intervention and improve clinical outcomes, drawing from recent trial data and current guideline recommendations. Special emphasis is placed on complex lesion subsets, such as left main coronary artery disease and other complex bifurcation lesions, calcified lesions, long lesions, and scenarios involving patients at heightened risk, such as those with acute coronary syndrome. Finally, this review considers the strengths and limitations of intracoronary imaging, as well as unresolved questions and priority areas for future research aimed at further improving patient outcomes.