IVUS‑CHIP and OPTIMAL: IVUS‑Guided vs. Angiography‑Guided PCI

Two new randomized trials presented at ACC.26 and published in NEJM found that routine IVUS‑guided PCI was not superior to angiography‑guided PCI in either complex coronary artery disease or unprotected left main coronary artery disease (LM‑CAD). 

In IVUS‑CHIP, among 2,020 patients with complex lesions, target‑vessel failure was similar with IVUS guidance and angiography alone. In OPTIMAL, among 806 patients with unprotected LM‑CAD, the patient‑oriented composite of death, MI, stroke, or revascularization was also comparable between strategies.

In IVUS‑CHIP, the IVUS approach took longer and required more post‑stent balloon optimization, but did not lower target‑vessel failure at a mean 19 months (14% vs. 11%; HR 1.25). 

In OPTIMAL, event rates for death, MI, and revascularization were likewise similar at a median 2.09 years, with no clear safety advantage for IVUS guidance. The trials suggest that while intracoronary imaging remains valuable, routine use of IVUS for all complex or left‑main PCI may not be necessary, especially when procedures are performed by experienced operators at high‑volume centers.