INTRACORONARY imaging has demonstrated important clinical benefits in percutaneous coronary intervention (PCI), according to evidence from a review of large, randomised trials.
Based on data from eight international randomised studies enrolling more than 1,000 patients each, the review evaluated the impact of imaging-guided PCI in a range of patient populations and lesion types.
The introduction of intracoronary imaging into PCI has represented a major advance in the management of patients with atherosclerotic coronary artery disease.
However, uncertainty has persisted regarding the routine use of imaging guidance because potential procedural benefits may be offset by increased costs and longer procedure times.
The review assessed evidence from eight large international randomised trials that investigated PCI guided by either optical coherence tomography or intravascular ultrasonography.
According to the authors, individual trial results and pooled analyses generally demonstrated prognostic advantages with imaging-guided PCI compared with angiography guidance alone.
Notable exceptions were reported in two studies, highlighting ongoing variability between trial findings.
The clinical value of intracoronary imaging appeared to increase alongside lesion complexity.
True bifurcation lesions, long coronary lesions, and left main coronary interventions were identified as settings associated with the greatest benefits.
The review also noted that intracoronary imaging may be particularly useful when treating culprit lesions in patients with acute coronary syndrome.
Additionally, patients with diabetes mellitus or chronic kidney disease were reported to derive prognostic benefits when intracoronary imaging was used to guide PCI in complex lesions.
These observations may help clinicians identify patient groups most likely to benefit from routine imaging guidance.
The authors suggested that several procedural factors contributed to improved outcomes with intracoronary imaging.
Imaging-guided procedures were associated with the use of larger and longer stents, more aggressive post-dilatation, greater stent expansion, and better lesion coverage, without an increase in procedural complications.
The review emphasised that achieving prespecified criteria for optimal PCI, particularly adequate stent expansion and complete lesion coverage, is likely central to the observed clinical benefits.
While these targets may improve outcomes, the authors stressed that procedural safety should remain the overriding consideration during intervention.
Overall, the findings support a growing role for intracoronary imaging in guiding PCI decision making and optimising outcomes in appropriately selected patients.
Biccirè FG et al. Intracoronary imaging in percutaneous coronary intervention: why, when, how and which from large, randomized trials. Nat Rev Cardiol. 2026;DOI:10.1038/s41569-026-01342-3.
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