Across 22 randomized trials and 15,964 patients, intravascular imaging-guided coronary stenting carried a relative risk (RR) of 0.55 for cardiac death compared with angiography-guided stenting (The Lancet, Stone et al. network meta-analysis 2024). In a 1,639-patient trial of complex lesions, target-vessel failure fell from 12.3% to 7.7% (NEJM, RENOVATE-COMPLEX-PCI 2023). Adoption is anything but uniform: IVUS guided 87.9% of acute coronary syndrome procedures in Japan by early 2021 (EuroIntervention, Takegawa et al. 2026), while US Medicare data showed intravascular imaging of any kind in 15.4% of procedures in 2019 (European Heart Journal, Fazel et al. 2023). For context on the hardware side, our ultrasound transducer market statistics cover the probe industry as a whole; this roundup stays inside the coronary artery. We aggregated data from The Lancet, the New England Journal of Medicine, the BMJ, the European Heart Journal, EuroIntervention, Circulation, JACC: Cardiovascular Interventions, and peer-reviewed technical reviews.
A few terms recur throughout. PCI (percutaneous coronary intervention) means opening a narrowed heart artery with a balloon and stent through a catheter. Angiography is the standard X-ray dye picture that shows only the outline of the artery’s channel. IVUS puts a miniature ultrasound probe inside the artery to see the vessel wall and plaque; OCT (optical coherence tomography) does the same with near-infrared light. Both are catheter-based hospital tools, a very different measurement problem from the wrist-worn sensors covered in our fitness tracker heart rate accuracy statistics. This article reports published research findings only and is not medical advice.
TL;DR
- Imaging-guided PCI: RR 0.55 for cardiac death and RR 0.71 for target lesion failure vs angiography (The Lancet, network meta-analysis 2024).
- Target-vessel failure 7.7% with imaging vs 12.3% with angiography, HR 0.64, in 1,639 complex-lesion patients (NEJM, RENOVATE-COMPLEX-PCI 2023).
- Target vessel failure at 1 year 4.0% with IVUS vs 7.3% with angiography in 3,505 ACS patients (The Lancet, IVUS-ACS 2024).
- Major adverse cardiac events at 5 years 5.6% with IVUS vs 10.7% with angiography in long lesions (JACC: Cardiovascular Interventions, IVUS-XPL 5-year 2019).
- Imaging guidance could mean 23 to 64 fewer cardiac deaths per 1,000 patients, depending on baseline risk (BMJ, Khan et al. meta-analysis 2023).
- OCT guidance noninferior to IVUS guidance: 2.5% vs 3.1% at 1 year (Circulation, OCTIVUS 2023).
- Intravascular imaging upgraded to Class I, Level A for complex lesions in the 2024 ESC guideline (Frontiers in Cardiovascular Medicine review 2025).
- IVUS-guided share of Japanese ACS PCI rose from 77.0% to 87.9% (EuroIntervention, Japanese National Database 2026).
- US Medicare intravascular imaging use rose from 9.5% in 2013 to 15.4% in 2019 (European Heart Journal, Fazel et al. 2023).
- IVUS axial resolution 100 to 200 µm vs 10 to 20 µm for OCT (Cardiology and Therapy review 2020).
- Plaque burden of 70% or more: HR 5.03 for later events from untreated lesions (NEJM, PROSPECT 2011).
- 8.0% of patients had an event from an untreated non-culprit lesion within the 3.7-year median follow-up (The Lancet, PROSPECT II 2021).
1. IVUS-Guided vs Angiography-Guided PCI: Randomized Trial Outcomes
The trial record is no longer a single positive study that could be a fluke. Four large randomized trials across Korea, China, Italy, Pakistan and the UK point the same way, and the most recent ones were run in the sickest patients: complex lesions and acute coronary syndromes. In complex lesions, RENOVATE-COMPLEX-PCI saw target-vessel failure fall from 12.3% to 7.7% (HR 0.64, 95% CI 0.45 to 0.89; P = 0.008) (NEJM, RENOVATE-COMPLEX-PCI 2023). Target-vessel failure here means a composite of cardiac death, a heart attack in the treated artery, or a repeat procedure on that artery driven by symptoms.
The pattern inside the composites matters. In ULTIMATE and IVUS-XPL, the gap was driven mostly by fewer repeat procedures, while RENOVATE-COMPLEX-PCI also showed cardiac death at 1.7% vs 3.8%. The question has shifted from whether imaging changes outcomes to which patients gain enough to justify the extra procedure time. Long-term IVUS-XPL data (TCTMD report on the 5-year IVUS-XPL results, 2019) also showed the benefit kept growing after year one: major adverse cardiac events between years 1 and 5 were 2.8% vs 5.2% (P = 0.031).
| Metric | Value | Source |
|---|---|---|
| Target-vessel failure, imaging-guided vs angiography-guided complex PCI (median 2.1 years) | 7.7% vs 12.3% (HR 0.64, 95% CI 0.45 to 0.89; P = 0.008) | NEJM, RENOVATE-COMPLEX-PCI 2023 |
| Cardiac death, imaging-guided vs angiography-guided | 1.7% vs 3.8% | NEJM, RENOVATE-COMPLEX-PCI 2023 |
| Clinically driven repeat procedure on the treated artery, imaging vs angiography | 3.4% vs 5.5% | NEJM, RENOVATE-COMPLEX-PCI 2023 |
| Target vessel failure at 1 year in acute coronary syndrome patients, IVUS vs angiography (3,505 patients, 58 centres) | 4.0% vs 7.3% (HR 0.55, 95% CI 0.41 to 0.74; P = 0.0001) | The Lancet, IVUS-ACS 2024 |
| Target vessel failure at 3 years, IVUS vs angiography (1,448 all-comer patients) | 6.6% vs 10.7% (HR 0.60, 95% CI 0.42 to 0.87) | JACC: Cardiovascular Interventions, ULTIMATE 3-year (Gao et al.) 2020 |
| Definite or probable stent thrombosis (a clot inside the stent) at 3 years, IVUS vs angiography | 0.1% vs 1.1% (P = 0.02) | JACC: Cardiovascular Interventions, ULTIMATE 3-year 2020 |
| Major adverse cardiac events at 5 years in long lesions (stent length 28 mm or more), IVUS vs angiography | 5.6% vs 10.7% (P = 0.001) | JACC: Cardiovascular Interventions, IVUS-XPL 5-year (Hong et al.) 2019 |
| Ischemia-driven repeat procedure on the treated lesion at 5 years, IVUS vs angiography | 4.8% vs 8.4% (P = 0.007) | JACC: Cardiovascular Interventions, IVUS-XPL 5-year 2019 |
Context note: RENOVATE-COMPLEX-PCI randomized 1,639 patients in a 2:1 ratio (1,092 to imaging, 547 to angiography) and allowed either IVUS or OCT, so it tests imaging guidance as a strategy rather than IVUS alone. In ULTIMATE, 78.5% of patients presented with acute coronary syndrome, and only 53% of IVUS patients met all three predefined “optimal result” criteria (TCTMD report on ULTIMATE 3-year results, 2020). The IVUS-XPL and ULTIMATE long-term reports are older than three years. Most recent available data: JACC: Cardiovascular Interventions, 2019 and 2020.
2. Meta-Analyses: How Big Is the Pooled Effect?
Individual trials can disagree on which endpoint moved. Pooled data settle the direction. The 2024 Lancet network meta-analysis found an RR of 0.55 for cardiac death (95% CI 0.41 to 0.75; p=0.0001) and 0.75 for all-cause death (95% CI 0.60 to 0.93; p=0.0091) across 22 trials and a weighted mean follow-up of 24.7 months (The Lancet, Stone et al. network meta-analysis 2024). That mortality signal is what pushed imaging out of the “optional optimization tool” category.
The BMJ meta-analysis, built on 20 trials, reached a near-identical cardiac death estimate but did not find a statistically significant drop in all-cause death (RR 0.81, 95% CI 0.64 to 1.02) (BMJ, Khan et al. systematic review and meta-analysis 2023). The difference between the two is a reminder that a pooled all-cause mortality benefit sits close to the edge of statistical certainty, while the cardiac death and stent thrombosis signals are more robust. The BMJ authors also translated the relative effects into absolute numbers per 1,000 patients, which is the figure that matters for planning.
| Metric | Value | Source |
|---|---|---|
| Randomized trials and patients pooled (intravascular imaging vs angiography guidance) | 22 trials, 15,964 patients | The Lancet, Stone et al. network meta-analysis 2024 |
| Target lesion failure, imaging vs angiography | RR 0.71 (95% CI 0.63 to 0.80; p<0.0001) | The Lancet, Stone et al. network meta-analysis 2024 |
| Stent thrombosis, imaging vs angiography | RR 0.52 (95% CI 0.34 to 0.81; p=0.0036) | The Lancet, Stone et al. network meta-analysis 2024 |
| Myocardial infarction (heart attack) of any type, imaging vs angiography | RR 0.83 (95% CI 0.71 to 0.99; p=0.033) | The Lancet, Stone et al. network meta-analysis 2024 |
| Randomized trials and patients pooled in the BMJ analysis | 20 trials, 11,698 patients | BMJ, Khan et al. meta-analysis 2023 |
| Cardiac death, imaging vs angiography | RR 0.53 (95% CI 0.39 to 0.72) | BMJ, Khan et al. meta-analysis 2023 |
| Fewer cardiac deaths per 1,000 patients treated with imaging guidance (low to high SYNTAX anatomical risk, five-year baseline) | 23 to 64 fewer | BMJ, Khan et al. meta-analysis 2023 |
| Fewer repeat procedures on the treated lesion per 1,000 patients (low to high SYNTAX risk) | 35 to 48 fewer | BMJ, Khan et al. meta-analysis 2023 |
Context note: both meta-analyses pool IVUS and OCT trials under “intravascular imaging”. SYNTAX is a score of how anatomically complex a patient’s coronary disease is; the higher the score, the larger the absolute benefit the BMJ authors estimated.
3. OCT Comparators: ILUMIEN IV, OCTOBER and OCTIVUS
OCT is IVUS’s closest competitor, and its trial results add nuance rather than repetition. ILUMIEN IV, an OCT-vs-angiography trial with 2,487 patients, found no significant difference in 2-year target-vessel failure (7.4% vs 8.2%; HR 0.90, 95% CI 0.67 to 1.19; P = 0.45), even though OCT produced a larger minimum stent area (the narrowest cross-section inside the deployed stent) (NEJM, ILUMIEN IV 2023). Better-looking stents did not automatically translate into fewer events in that population.
OCTOBER, limited to complex bifurcation lesions (where a branch splits off the main artery), did show a benefit for OCT guidance (NEJM, OCTOBER trial (Holm et al.) 2023). And OCTIVUS, the head-to-head trial, found the two modalities interchangeable on its primary endpoint, with fewer major procedural complications in the OCT arm (Circulation, OCTIVUS 2023). The practical reading: the benefit seems to come from imaging-informed decisions in complex anatomy, not from one specific imaging physics.
| Metric | Value | Source |
|---|---|---|
| Target-vessel failure at 2 years, OCT-guided vs angiography-guided (2,487 patients) | 7.4% vs 8.2% (HR 0.90, 95% CI 0.67 to 1.19; P = 0.45) | NEJM, ILUMIEN IV 2023 |
| Minimum stent area after PCI, OCT vs angiography | 5.72 vs 5.36 mm² (difference 0.36 mm², 95% CI 0.21 to 0.51; P < 0.001) | NEJM, ILUMIEN IV 2023 |
| Stent thrombosis within 2 years, OCT vs angiography | 0.5% vs 1.4% | NEJM, ILUMIEN IV 2023 |
| Major adverse cardiac events in complex bifurcation PCI, OCT vs angiography (1,201 patients, median 2 years) | 10.1% vs 14.1% (HR 0.70, 95% CI 0.50 to 0.98; P = 0.035) | NEJM, OCTOBER 2023 |
| Procedure-related complications in bifurcation PCI, OCT vs angiography | 6.8% vs 5.7% | NEJM, OCTOBER 2023 |
| Primary endpoint at 1 year, OCT-guided vs IVUS-guided PCI (2,008 patients) | 2.5% vs 3.1% (P < 0.001 for noninferiority) | Circulation, OCTIVUS 2023 |
| Major procedural complications, OCT vs IVUS | 2.2% vs 3.7% (P = 0.047) | Circulation, OCTIVUS 2023 |
Context note: OCTIVUS also reported contrast-induced kidney injury (kidney damage linked to the X-ray dye) at 1.4% with OCT vs 1.5% with IVUS (P = 0.85), so in that trial the two modalities did not differ on this safety measure.
4. Guideline Class of Recommendation: From Optional to Class I
Guidelines grade recommendations by class (Class I is the strongest, meaning “recommended”; Class IIa means “reasonable”; Class IIb means “may be considered”; Class III means “not recommended”) and by level of evidence (Level A means multiple randomized trials or meta-analyses). The 2024 ESC guideline moved IVUS or OCT guidance for anatomically complex lesions, in particular left main stem, true bifurcations and long lesions, to Class I, Level A, as tabulated in a 2025 history of the field by Abusnina, Garcia-Garcia, Mintz, Waksman and colleagues (Frontiers in Cardiovascular Medicine, Coronary intravascular imaging: a piece of history 2025).
The North American shift took longer. The 2011 ACC/AHA/SCAI PCI guideline rated IVUS for guiding stenting only Class IIb, and the 2021 revascularization guideline raised it to Class IIa. The same review table lists Class I, Level A for IVUS or OCT guidance in acute coronary syndrome patients undergoing left main or complex stenting under 2025 ACC/AHA/SCAI guidance, and a 2025 review in the Methodist DeBakey Cardiovascular Journal likewise notes that guidelines “have upgraded intracoronary imaging guidance by IVUS or optical coherence tomography to class I” (Methodist DeBakey Cardiovascular Journal, Khan, Kleiman and Shah 2025). The randomized data in sections 1 and 2 are the evidence base behind that step.
| Metric | Value | Source |
|---|---|---|
| 2024 ESC guideline: IVUS or OCT guidance for complex lesions (left main, true bifurcations, long lesions) | Class I, Level A | Frontiers in Cardiovascular Medicine review (Abusnina et al.) 2025 |
| 2024 ESC guideline: IVUS to assess intermediate left main stenoses before revascularization | Class IIa, Level B | Frontiers in Cardiovascular Medicine review 2025 |
| 2025 ACC/AHA guidance: IVUS or OCT in acute coronary syndrome with left main or complex stenting | Class I, Level A | Frontiers in Cardiovascular Medicine review 2025 |
| 2021 ACC/AHA/SCAI revascularization guideline: IVUS for stenting guidance, especially left main or complex lesions | Class IIa, Level B | Frontiers in Cardiovascular Medicine review 2025 |
| 2011 ACC/AHA/SCAI PCI guideline: IVUS may be reasonable to guide stenting, especially left main | Class IIb, Level B | Frontiers in Cardiovascular Medicine review 2025 |
| Direction of the latest guideline change for intracoronary imaging guidance by IVUS or OCT | Upgraded to Class I | Methodist DeBakey Cardiovascular Journal, Khan et al. 2025 |
Context note: the review table labels the 2025 North American entry as an ACC/AHA/SCAI recommendation; the guideline published in 2025 that covers this population is the ACC/AHA/ACEP/NAEMSP/SCAI acute coronary syndromes guideline. See the Data watch note in Methodology.
5. Utilization by Country: Japan vs the United States vs Europe
No other number in this field shows a bigger gap between evidence and practice. In Japan’s nationwide National Database, IVUS guided 87.9% of first-time PCI for acute coronary syndrome by the end of the 2014 to 2021 study window, up from 77.0% (EuroIntervention, Takegawa et al. 2026). In the same dataset, 297,944 patients had IVUS-guided PCI, compared with 32,044 angiography-guided and 22,748 OCT-guided procedures.
The United States sits far lower, and use depends heavily on who holds the catheter. Among 1,189,470 Medicare PCI patients, the median operator used intravascular imaging in only 3.92% of cases (European Heart Journal, Fazel et al. 2023). In heart attack patients specifically, the National Inpatient Sample showed IVUS use rising from 3.4% to 8.7% between 2008 and 2019 (International Journal of Cardiology: Heart and Vasculature, Park et al. 2023). The barrier is economic as much as clinical: in an EAPCI/CVIT physician survey, 77.9% of European respondents cited high cost (EuroIntervention, Koskinas et al. EAPCI/CVIT survey 2018).
| Metric | Value | Source |
|---|---|---|
| IVUS-guided share of first-time PCI for acute coronary syndrome in Japan, start vs end of April 2014 to March 2021 | 77.0% to 87.9% | EuroIntervention, Takegawa et al. (Japanese National Database) 2026 |
| OCT-guided share of the same Japanese ACS procedures, start vs end of the period | 4.7% to 6.9% | EuroIntervention, Takegawa et al. 2026 |
| IVUS-guided share in a Japanese multicenter registry of 8,721 consecutive PCI patients | 83.8% | JSCAI, Kuno et al. 2024 |
| Intravascular imaging (IVUS or OCT) use in US Medicare PCI, overall | 10.5% of 1,189,470 patients | European Heart Journal, Fazel et al. 2023 |
| Intravascular imaging use in US Medicare PCI, 2013 vs 2019 | 9.5% vs 15.4% | European Heart Journal, Fazel et al. 2023 |
| IVUS use in US PCI for myocardial infarction, 2008 vs 2019 (2,881,746 procedures) | 3.4% vs 8.7% (OCT 0.6% in 2019) | Int J Cardiol Heart Vasc, Park et al. (National Inpatient Sample) 2023 |
| Physicians using intravascular imaging in more than 15% of their PCI cases, Japan vs Europe | 96.6% vs 10.4% | EuroIntervention, EAPCI/CVIT survey (Koskinas et al.) 2018 |
| High cost cited as a barrier to intravascular imaging, Europe vs Japan | 77.9% vs 57.1% | EuroIntervention, EAPCI/CVIT survey 2018 |
Context note: these are observational associations, not trial results. Still, imaging-guided PCI in Japan was associated with lower ACS recurrence (IVUS HR 0.76, 95% CI 0.71 to 0.82) in the national database study, and in US Medicare data with fewer repeat PCIs (adjusted HR 0.74, 95% CI 0.73 to 0.75). The latest US figures stop at 2019 and the survey dates from 2017 fieldwork. Most recent available data: European Heart Journal 2023 and EuroIntervention 2018.
6. Imaging Resolution: What the Probe Can Actually See
Resolution explains why IVUS and OCT are used for different jobs. Axial resolution is the smallest detail the system can separate along the beam’s direction; lateral resolution is the same measure across the beam. OCT resolves 10 to 20 µm axially, roughly ten times finer than the 100 to 200 µm quoted for IVUS, but IVUS reaches up to 10 mm into tissue vs 1 to 2.5 mm for OCT (Cardiology and Therapy, Oosterveer et al. 2020). IVUS sees the full depth of a thick plaque and the outer vessel boundary used for stent sizing; OCT sees the thin fibrous cap on the surface.
Frequency is the lever that narrows the gap: higher ultrasound frequency means finer detail but shallower penetration, and intracoronary catheters work at tens of megahertz. The 2025 Methodist DeBakey review states that systems offering up to 60 MHz provide axial resolution below 40 µm, against a typical 80 to 100 µm for conventional systems, whose mechanical (rotating single-transducer) catheters usually run at 40 to 45 MHz. That puts high-definition IVUS within striking distance of OCT’s surface detail while keeping ultrasound’s depth. Readers following how software is being layered on top of these images can compare the broader AI medical imaging statistics.
| Metric | Value | Source |
|---|---|---|
| Axial resolution, OCT vs IVUS | 10 to 20 µm vs 100 to 200 µm | Cardiology and Therapy, Oosterveer et al. 2020 |
| Typical lateral resolution, OCT vs IVUS | 20 µm vs 200 µm | Cardiology and Therapy, Oosterveer et al. 2020 |
| Maximum tissue penetration, IVUS vs OCT | 10 mm vs 1 to 2.5 mm | Cardiology and Therapy, Oosterveer et al. 2020 |
| Image acquisition (pullback) speed, OCT vs IVUS (review table) | Up to 25 mm/s vs 0.5 mm/s | Cardiology and Therapy, Oosterveer et al. 2020 |
| Operating frequency, mechanical (rotating single-transducer) IVUS catheter vs phased-array (multiple fixed transducers) IVUS catheter | 40 to 45 MHz vs about 20 MHz | Methodist DeBakey Cardiovascular Journal, Khan et al. 2025 |
| Conventional IVUS axial and lateral resolution, and tissue penetration | About 80 to 100 µm axial; about 200 to 250 µm lateral; 6 to 12 mm penetration | Methodist DeBakey Cardiovascular Journal, Khan et al. 2025 |
| Axial resolution of IVUS systems with transducer frequencies up to 60 MHz | Less than 40 µm | Methodist DeBakey Cardiovascular Journal, Khan et al. 2025 |
| Automated IVUS pullback speed, traditional vs newer systems | 0.5 to 1.0 mm/s vs up to 10 mm/s | Methodist DeBakey Cardiovascular Journal, Khan et al. 2025 |
Context note: the two reviews disagree on conventional IVUS axial resolution (100 to 200 µm vs about 80 to 100 µm), which reflects different catheter generations and frequencies rather than an error in either. The 2020 review predates the current high-definition catheters. Most recent available data for the comparative table: Cardiology and Therapy, 2020.
7. Plaque and Vulnerable-Plaque Detection: The PROSPECT Studies and PREVENT
The vulnerable-plaque story is where IVUS moves from guiding a stent to predicting the future. In PROSPECT, a non-culprit plaque (one not treated at the index procedure) with a plaque burden of 70% or more carried an HR of 5.03 (95% CI 2.51 to 10.11) for a later event (NEJM, PROSPECT (Stone et al.) 2011). Plaque burden means the share of the vessel cross-section taken up by plaque, something an angiogram’s outline of the channel cannot show. The lesions that later caused events looked mild on angiography, with a mean baseline diameter stenosis of 32.3%.
Prediction is not the same as precision. In PROSPECT II, which added near-infrared spectroscopy (a light-based measure of lipid content) to IVUS, lesions with both a large plaque burden and a large lipid core had a 4-year event rate of 7.0% per lesion (The Lancet, PROSPECT II (Erlinge et al.) 2021). Put the other way, 93.0% of those highest-risk lesions (100% minus 7.0%) did not cause an event within four years. The PREVENT trial then tested whether treating such plaques preventively helps, and reported a lower 2-year composite event rate with preventive PCI than with medication alone (The Lancet, PREVENT 2024).
| Metric | Value | Source |
|---|---|---|
| Cumulative major adverse cardiac events at 3 years after acute coronary syndrome (697 patients imaged with IVUS) | 20.4% | NEJM, PROSPECT 2011 |
| Events attributed to culprit (originally treated) lesions vs non-culprit lesions | 12.9% vs 11.6% | NEJM, PROSPECT 2011 |
| Hazard ratio for later events, plaque burden of 70% or more | HR 5.03 (95% CI 2.51 to 10.11; P<0.001) | NEJM, PROSPECT 2011 |
| Hazard ratio for later events, minimal lumen area of 4.0 mm² or less / thin-cap fibroatheroma (a lipid plaque under a thin fibrous cap) | HR 3.21 (95% CI 1.61 to 6.42) / HR 3.35 (95% CI 1.77 to 6.36) | NEJM, PROSPECT 2011 |
| Patients with an event from an untreated non-culprit lesion (898 patients, 3,629 lesions, median 3.7 years) | 8.0% (95% CI 6.2 to 10.0) | The Lancet, PROSPECT II 2021 |
| Lesion-level adjusted odds ratio for events, highly lipid-rich lesions vs others | 7.83 (95% CI 4.12 to 14.89) | The Lancet, PROSPECT II 2021 |
| 4-year event rate, lesions with both large plaque burden and large lipid core: per lesion vs per patient | 7.0% vs 13.2% | The Lancet, PROSPECT II 2021 |
| Primary composite outcome at 2 years, preventive PCI of imaging-defined vulnerable plaques vs medical therapy alone (1,606 patients) | 0.4% vs 3.4% (absolute difference -3.0 percentage points, 95% CI -4.4 to -1.8; p=0.0003) | The Lancet, PREVENT 2024 |
Context note: PREVENT enrolled lesions that did not limit blood flow (fractional flow reserve, a pressure-wire measure, above 0.80) across 15 hospitals in South Korea, Japan, Taiwan and New Zealand. Its individual components were less clear-cut: death was 0.5% vs 1.3% (95% CI for the difference -1.7 to 0.2), which does not exclude no difference. The original PROSPECT study is 15 years old. Most recent available data for IVUS-only natural history: NEJM, 2011.
Summary: Intravascular Ultrasound (IVUS) by the Numbers
| Metric | Value | Source |
|---|---|---|
| Cardiac death, imaging-guided vs angiography-guided PCI (22 trials) | RR 0.55 (95% CI 0.41 to 0.75) | The Lancet, network meta-analysis 2024 |
| Cardiac death, imaging vs angiography (20 trials) | RR 0.53 (95% CI 0.39 to 0.72) | BMJ, Khan et al. meta-analysis 2023 |
| Fewer cardiac deaths per 1,000 patients with imaging guidance | 23 to 64 | BMJ, Khan et al. meta-analysis 2023 |
| Target-vessel failure in complex PCI, imaging vs angiography | 7.7% vs 12.3% | NEJM, RENOVATE-COMPLEX-PCI 2023 |
| Target vessel failure at 1 year in ACS, IVUS vs angiography | 4.0% vs 7.3% | The Lancet, IVUS-ACS 2024 |
| Target vessel failure at 3 years, IVUS vs angiography | 6.6% vs 10.7% | JACC: Cardiovascular Interventions, ULTIMATE 2020 |
| Major adverse cardiac events at 5 years in long lesions, IVUS vs angiography | 5.6% vs 10.7% | JACC: Cardiovascular Interventions, IVUS-XPL 2019 |
| Target-vessel failure at 2 years, OCT vs angiography | 7.4% vs 8.2% (P = 0.45) | NEJM, ILUMIEN IV 2023 |
| Major adverse cardiac events in bifurcation PCI, OCT vs angiography | 10.1% vs 14.1% | NEJM, OCTOBER 2023 |
| Primary endpoint at 1 year, OCT vs IVUS | 2.5% vs 3.1% | Circulation, OCTIVUS 2023 |
| Intravascular imaging for complex lesions in the 2024 ESC guideline | Class I, Level A | Frontiers in Cardiovascular Medicine review 2025 |
| IVUS-guided share of Japanese ACS PCI, 2014 to 2021 | 77.0% to 87.9% | EuroIntervention, Takegawa et al. 2026 |
| Intravascular imaging use in US Medicare PCI, 2019 | 15.4% | European Heart Journal, Fazel et al. 2023 |
| Physicians using imaging in more than 15% of cases, Japan vs Europe | 96.6% vs 10.4% | EuroIntervention, EAPCI/CVIT survey 2018 |
| Axial resolution, OCT vs IVUS | 10 to 20 µm vs 100 to 200 µm | Cardiology and Therapy review 2020 |
| Axial resolution of IVUS up to 60 MHz | Less than 40 µm | Methodist DeBakey Cardiovascular Journal 2025 |
| Hazard ratio for later events, plaque burden of 70% or more | 5.03 | NEJM, PROSPECT 2011 |
| Patients with events from untreated non-culprit lesions | 8.0% | The Lancet, PROSPECT II 2021 |
| 2-year primary outcome, preventive PCI vs medical therapy | 0.4% vs 3.4% | The Lancet, PREVENT 2024 |
Methodology and Sources
- The Lancet, Stone et al., intravascular imaging-guided vs angiography-guided PCI network meta-analysis, 2024
- BMJ, Khan et al., intravascular imaging vs angiography guided PCI systematic review and meta-analysis, 2023
- NEJM, RENOVATE-COMPLEX-PCI trial, 2023
- The Lancet, IVUS-ACS randomised trial, 2024
- TCTMD report on ULTIMATE 3-year results (JACC: Cardiovascular Interventions, Gao et al.), 2020
- TCTMD report on IVUS-XPL 5-year results (JACC: Cardiovascular Interventions, Hong et al.), 2019
- NEJM, ILUMIEN IV trial, 2023
- NEJM, OCTOBER trial, 2023
- Circulation, OCTIVUS randomized clinical trial, 2023
- Frontiers in Cardiovascular Medicine, Abusnina et al., Coronary intravascular imaging: a piece of history, 2025
- Methodist DeBakey Cardiovascular Journal, Khan, Kleiman and Shah, IVUS imaging-guided PCI: evidence and practical implications, 2025
- EuroIntervention, Takegawa et al., intravascular imaging-guided PCI in ACS (Japanese National Database), 2026
- JSCAI, Kuno et al., IVUS long-term benefits in a Japanese multicenter registry, 2024
- European Heart Journal, Fazel et al., intravascular imaging temporal trends and outcomes in the USA, 2023
- International Journal of Cardiology: Heart and Vasculature, Park et al., IVUS and OCT trends in PCI for myocardial infarction, 2023
- EuroIntervention, Koskinas et al., EAPCI/CVIT clinical practice survey on intracoronary imaging, 2018
- Cardiology and Therapy, Oosterveer et al., OCT current applications review, 2020
- NEJM, PROSPECT natural-history study, 2011
- The Lancet, PROSPECT II, 2021
- The Lancet, PREVENT trial, 2024
- Data watch: (1) The guideline class rows come from the Frontiers review’s Table 1, which labels the 2025 North American Class I, Level A entry as an ACC/AHA/SCAI revascularization recommendation; the 2025 guideline covering acute coronary syndromes is the ACC/AHA/ACEP/NAEMSP/SCAI document (JACC/Circulation, February 2025), whose full text was behind access checks during research, so readers should confirm the exact wording there. (2) The Methodist DeBakey review quotes the Fazel Medicare study as covering 2009 to 2017, while the study abstract reports trends for 2013 to 2019; we use the abstract. A separate Medicare figure of 5.6% IVUS use for 2009 to 2017 appears in TCTMD coverage and is not directly comparable. (3) Trial percentages such as PROSPECT II’s 8.0% and OCTOBER’s 10.1% are Kaplan-Meier cumulative estimates, so they do not equal raw event counts divided by enrolled patients. (4) The Lancet and BMJ meta-analyses pool different trial sets (22 vs 20 trials) and disagree on whether all-cause death fell significantly. (5) Conventional IVUS axial resolution is quoted as 100 to 200 µm in one review and about 80 to 100 µm in another. (6) Japanese utilization figures come from a national database and a multicenter registry, US figures from Medicare and inpatient samples; the two countries do not publish an identical measure. Newer US utilization data after 2019 and longer-term PREVENT follow-up are the figures most likely to change this picture.
Last updated: October 24, 2026. We update this roundup quarterly, and the next refresh is expected when the next ACC/AHA coronary revascularization guideline update or the next long-term follow-up of RENOVATE-COMPLEX-PCI or IVUS-ACS is published.