Two Neutral IVUS Trials in Complex PCI—And One Positive—Spark Debate

Why It Matters

The mixed results could reshape how hospitals allocate resources for IVUS training and influence future guideline updates, directly affecting patient outcomes in complex coronary disease.

Key Takeaways

• DKCRUSH VIII cut 1‑year target‑vessel failure by 60%
• OPTIMAL and IVUS‑CHIP showed no outcome advantage for IVUS
• Operator expertise influences whether IVUS improves PCI results
• US IVUS use (~15‑20%) lags behind Japan (85‑90%)
• Guidelines still give class 1A IVUS recommendation for complex lesions

Pulse Analysis

Intravascular ultrasound has long been hailed as a precision tool for complex coronary interventions, earning a class 1A recommendation in the latest US acute coronary syndrome guidelines. The technology offers high‑resolution cross‑sectional images that reveal plaque composition, vessel size, and calcium burden—information that angiography alone cannot provide. However, the three high‑profile trials presented at ACC 2026 illustrate that the mere presence of IVUS does not guarantee better outcomes; the context of its use matters as much as the imaging itself.

DKCRUSH VIII stood out because investigators applied IVUS throughout the procedure, using the data to refine the double‑kissing crush technique and achieve optimal stent expansion in 75% of cases. This systematic integration translated into a 60% relative risk reduction for target‑vessel failure. By contrast, OPTIMAL and IVUS‑CHIP enrolled experienced centers where angiography‑guided operators already performed meticulous lesion preparation, and IVUS rarely prompted a change in strategy. The neutral findings suggest that when baseline procedural quality is high, the incremental benefit of imaging diminishes, underscoring the critical role of operator skill and decision‑making.

For the broader interventional community, the take‑home message is twofold: first, IVUS should be viewed as a decision‑support tool that requires active interpretation and procedural adaptation, not a passive imaging adjunct. Second, the stark disparity in adoption—15‑20% of U.S. PCIs versus 85‑90% in Japan—highlights a training gap that could be addressed through dedicated curricula and simulation. As more data emerge, clinicians will need to balance the cost and learning curve of IVUS against its proven advantage in specific lesion subsets, ensuring that guideline recommendations translate into real‑world improvements in patient care.