Yoichiro Sugizaki, MD, PhD¹

Percutaneous coronary intervention has evolved substantially from balloon angioplasty to contemporary drug-eluting stent implantation. Yet, even in the modern era, angiography remains an imperfect guide because it displays only the contrast-filled lumen and provides limited information about vessel size, plaque composition and distribution, or post-stenting findings. This gap has driven the growing use of intravascular imaging as a tool to translate coronary anatomy into procedural strategy in daily catheterization laboratories.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) provide complementary perspectives during percutaneous coronary intervention. IVUS offers deep vessel-wall penetration and robust assessment of vessel dimensions, plaque burden, remodeling, and left main or ostial anatomy, whereas OCT provides near-histological resolution for evaluating lumen morphology, thrombus, calcium thickness, stent apposition, tissue protrusion, and edge injury. Contemporary randomized trials and meta-analyses support imaging-guided percutaneous coronary intervention over angiography guidance alone, particularly in complex lesions, although neither modality is universally superior. The practical value of imaging therefore depends on matching the modality to the clinical settings, lesion subset, and procedural constraints.

This state-of-the-art review summarizes current evidence and proposes a practical framework for intravascular imaging-guided drug-eluting stent implantation. We discuss how pre-intervention imaging informs lesion preparation, landing-zone selection, and stent sizing, and how post-intervention imaging identifies underexpansion, geographic miss, edge dissection, malapposition, and tissue protrusion. Specific attention is given to calcified lesions, acute coronary syndromes, bifurcation disease, left main disease, aorto-ostial lesions, intramural hematoma or spontaneous coronary artery dissection, and chronic kidney disease. A structured, lesion-specific approach to intravascular imaging may help refine procedural decision-making, support safer optimization, and improve the durability of drug-eluting stent implantation across diverse clinical settings.

Received 15 May 2026 | Revised 2 June 2026 | Accepted 23 June 2026

J Med Assoc Thai 2026;109(9):772-90

DOI: 10.35755/jmedassocthai.2026.9.04546