Intravascular Imaging-Guided or Angiography-Guided Complex PCI: Is it Time For a Change in Practice?

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been associated with improved clinical outcomes compared with angiography-guided PCI in randomized trials.1-3 Previous studies have also demonstrated the utility of optical coherence tomography (OCT) as an adjunct to PCI.4 As a result, the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) revascularization guidelines5 gave a Class 2a recommendation for use of intravascular imaging (IVI) during coronary PCI,6 and a state-of-the-art review by the ACC's Interventional Council recommended the adjunctive use of IVI for complex lesion subsets.6 Nonetheless, larger randomized trials demonstrating the benefit of IVI as an adjunct to contemporary PCI are necessary.

The RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) was a large multicenter trial that compared IVI-guided PCI with angiography-guided PCI in patients with complex coronary lesions.7 A total of 1,639 patients with complex coronary lesions were randomized in a 2:1 fashion to either IVI (IVUS or OCT)–guided or angiography-guided PCI. Protocols for image acquisition and criteria for optimization of implanted stents were prespecified. Procedural success was 99%. At a median follow-up of 2.1 years, the primary endpoint of target-vessel failure was significantly lower in the IVI group than in the angiography group (7.7 vs. 12.3%; hazard ratio, 0.64; 95% confidence interval, 0.45-0.89; p = 0.008). A composite of cardiac death or target-vessel myocardial infarction was lower in the IVI-guided PCI group, with no difference in procedure-related safety events between groups. Given that this study was exclusive to Korean patients, its results may be less generalizable to other patient populations. In addition, 80% of the trial population were men; it would be interesting to see whether women with smaller coronary arteries may in fact benefit more from IVI use.

The results of the trial support the routine use of IVI for PCI guidance in complex coronary lesions—a stance that was recently adopted by the ACC's Interventional Council.6 On the basis of these data, it is perhaps time to revisit the class of guideline recommendation given to the use of IVI during PCI, especially for complex lesions. Despite data supporting its use, IVI use in the United States remains low at approximately 15-20%. Current barriers to the adoption of IVI include familiarity with image interpretation and cost, both of which will likely require training and advocacy to overcome.


  1. Gao XF, Ge Z, Kong XQ, et al.; ULTIMATE Investigators. 3-year outcomes of the ULTIMATE trial comparing intravascular ultrasound versus angiography-guided drug-eluting stent implantation. JACC Cardiovasc Interv 2021;14:247-57.
  2. Kim BK, Shin DH, Hong MK, et al.; CTO-IVUS Study Investigators. Clinical impact of intravascular ultrasound-guided chronic total occlusion intervention with zotarolimus-eluting versus biolimus-eluting stent implantation: randomized study. Circ Cardiovasc Interv 2015;Jul:[ePub ahead of print].
  3. Hong SJ, Kim BK, Shin DH, et al.; IVUS-XPL Investigators. Effect of intravascular ultrasound-guided vs angiography-guided everolimus-eluting stent implantation: the IVUS-XPL randomized clinical trial. JAMA 2015;314:2155-63.
  4. Ali ZA, Maehara A, Généreux P, et al.; ILUMIEN III: OPTIMIZE PCI Investigators. Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial. Lancet 2016;388:2618-28.
  5. Lawton JS, Tamis-Holland JE, Bangalore S, et al.; Writing Committee Members. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79:e21-e129.
  6. Truesdell AG, Alasnag MA, Kaul P, et al.; ACC Interventional Council. Intravascular imaging during percutaneous coronary intervention: JACC state-of-the-art review. J Am Coll Cardiol 2023;81:590-605.
  7. Lee JM, Choi KH, Song YB, et al.; RENOVATE-COMPLEX-PCI Investigators. Intravascular imaging-guided or angiography-guided complex PCI. N Engl J Med 2023;388:1668-79.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: ACC Annual Scientific Session, ACC23, Percutaneous Coronary Intervention, Myocardial Infarction, Angiography, Coronary Angiography, Ultrasonography, Interventional, Stents

< Back to Listings