Percutaneous coronary intervention (PCI) of the unprotected left main coronary artery is a highly complex procedure because of the large amount of myocardium at risk and the potential consequences of inadequate stent expansion or malapposition. Intravascular ultrasound (IVUS) enables better lesion characterization, more accurate stent sizing, and the detection of intraprocedural complications. Consequently, multiple studies and meta-analyses support its use in this setting. However, this editorial, published in The New England Journal of Medicine, reviews the findings of the recently published OPTIMAL trial, which questions whether the routine use of IVUS provides additional clinical benefit in patients undergoing PCI of the unprotected left main coronary artery.
The primary endpoint of the study was the composite of stroke, myocardial infarction, any repeat revascularization, or death from any cause during the maximum available follow-up. A total of 806 patients were enrolled and randomly assigned in a 1:1 ratio to IVUS-guided PCI (401 patients) or angiography-guided PCI alone (405 patients), with a median follow-up of 2.9 years.
All patients were treated with contemporary drug-eluting stents, using provisional single-stent implantation as the default strategy, while two-stent techniques were reserved for more complex bifurcation anatomies at the operator’s discretion. In the IVUS group, a predefined optimization protocol was followed to ensure adequate stent expansion and apposition.
The results showed that the systematic use of IVUS did not reduce the primary endpoint. The primary event occurred in 135 patients (33.7%) in the IVUS group and in 125 patients (30.9%) in the angiography group (HR 1.11; 95% CI 0.87–1.42; p=0.40). Likewise, no significant differences were observed in the incidence of death, myocardial infarction, or repeat revascularization between the two strategies. Unexpectedly, stroke occurred more frequently in the IVUS group (3.0% vs. 1.0%; HR 3.11; 95% CI 1.00–9.65).
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The editorial authors also emphasize that only 29.3% of IVUS-guided procedures required changes based on intracoronary imaging findings, likely reflecting the high level of expertise of the participating operators and, at least in part, explaining the lack of additional clinical benefit.
Conclusion: The Clinical Value of IVUS Appears to Depend More on Its Impact on Procedural Strategy Than on Its Routine Use
In conclusion, the editorial interprets the OPTIMAL trial as not supporting the routine use of IVUS in all procedures involving the unprotected left main coronary artery, particularly when performed by highly experienced operators. Nevertheless, the authors stress that these findings do not diminish the value of intracoronary imaging. Instead, they suggest that its clinical benefit depends on whether the information obtained effectively changes the procedural strategy and contributes to optimizing the final stent implantation result.
Original Title: Seeing the Left Main Coronary Artery Clearly — Is IVUS Always Necessary?
Reference: Frederick Welt, MD. New England Journal of Medicine. 2026;394:2266-2268. Editorial.
