Debate: Intravascular imaging in percutaneous revascularization procedures. For an optimized and still selective approach

QUESTION: Clinical practice guidelines have raised the recommendation level for the use of intravascular imaging during percutaneous revascularization procedures for complex lesions to class I. Can you briefly explain the basis for this change? ANSWER: The change of recommendation made in the European Society of Cardiology (ESC) guidelines to class I and evidence level A for the management of chronic coronary syndrome1 is based on 5 main references: 3 randomized clinical trials published in 2023 in the N Engl J Med,2-4 which included a total of 5327 patients, and 2 meta-analyses published in the J Am Coll Cardiol (2023)5 and Lancet (2024),6 with a total of 38,648 patients. These trials showed a reduction in major cardiovascular adverse events and target vessel failure compared with the angiography-guided procedure alone. Although only 1 of the randomized clinical trials2 did not show statistically significant benefits in the clinical endpoint of target vessel failure, it did show improvements in stent minimal area assessment by imaging, which were significantly greater in patients treated with optical coherence tomography (OCT). The studies mentioned in the guidelines were conducted in populations with complex lesions, including bifurcations,3,4 chronic total occlusions,2,4 diffuse disease (≥ 38 mm2 or ≥ 28 mm2), severe calcification,2,4...