• Angiogram has limitations and is only a luminogram.
• Intracoronary imaging (IVUS and OCT) gives a complete picture of the vessel including plaque morphology, disease burden, vessel size, landing zone identification and appropriate device selection. Post-PCI imaging is extremely useful to optimize results and to identify complications not seen by routine angiography.
• A recent large meta-analysis of imaging vs. only angiography, which included 31 studies with 17,882 patients has shown significant reduction in all-cause death, MI, TLR and stent thrombosis with IVUS guidance. PCI guidance using either IVUS or OCT was associated with a significant reduction of MACE.
• Although it is not mandatory to use imaging in all cases, every operator should have exposure to one of the imaging modality - IVUS or OCT even if either imaging modality is not available in their cath lab. Even when imaging is not used, exposure to imaging helps the operator to make better angiography-only based decisions. IVUS trained eyes select larger diameter stents even when IVUS is not used.
• Ideally if imaging is available, it is important to strongly consider imaging in all complex PCI subsets, which has been shown to have huge benefits on long-term outcome.
• The operator should ideally consider imaging in all cases. But it may not be feasible considering the socioeconomic status and hence it may be prudent to have a very low threshold for imaging in all cases when in slightest doubt.

Image! Identify! Impeccable result