Abstract
BACKGROUND: Intravascular imaging (IVI) improves outcomes in complex percutaneous coronary intervention (PCI) and is recommended by the latest guidelines. However, data about its real-world application remain limited. METHODS: We conducted a retrospective audit of 300 consecutive PCI cases. Lesions were classified as complex if they involved > 1 of the following characteristics: bifurcation, severe calcifications, chronic total occlusion, long lesions, ostial location, and involvement of the left main artery. IVI use was analyzed by lesion subtype and individual operator. RESULTS: Of 300 consecutive PCI cases, 146 (49%) were classified as complex PCI. IVI was used in 53% of complex PCIs and 23% of noncomplex PCIs. Among patients undergoing complex PCI, IVI was most frequently performed in chronic total occlusions (86%) and left main disease (76%), but its use remained below 50% for bifurcations, severe calcified lesions, and long lesions. IVI-guided PCI was associated with higher contrast use (215 ± 78 vs 179 ± 65 mL, P = 0.003) and longer procedural duration (72 ± 32 vs 51 ± 22 minutes, P < 0.001) and varied widely across operators, ranging from 0%-79% in the overall population (P < 0.001) to 0%-90% in complex lesions (P = 0.004). Notably, IVI adoption declined with increasing operator age (odds ratio, 0.88 per +1 year; 95% confidence interval 0.78-0.98), whereas it increased with lesion complexity (odds ratio 2.34 per additional complexity feature; 95% confidence interval 1 1.62-3.39). CONCLUSIONS: Despite current evidence and guideline recommendations, IVI use showed notable variation across operators. Standardizing IVI utilization through education, protocols, and system-level support are essential to promoting guideline-concordant practice.