ESC Andreas Grüntzig Lecture in Interventional Cardiology.
Intracoronary imaging: From research tool to Class IA in the guidelines
30 Aug 2025
Active atherosclerosis researcher, experienced trialist and expert operator, Professor Carlo Di Mario (University of Florence - Florence, Italy), will give today’s ESC Andreas Grüntzig Lecture in Interventional Cardiology.
What are the key themes of your lecture?
Following the miniaturisation of probes to fit within coronary arteries,1 intracoronary imaging soon established itself as a powerful technique with important research and clinical uses. Initially, the advent of intravascular ultrasound (IVUS) was expected to facilitate procedures requiring careful guidance, such as directional or laser atherectomy. While these techniques are now used only infrequently because of their complexity, imaging is still essential in the detection and quantification of plaque calcium, the driver in the selection of appropriate tools for lesion modification (rotational or orbital atherectomy, intravascular lithotripsy). Refinements in image acquisition and processing paved the way for high-frequency IVUS and then optical coherence tomography (OCT) to be used more widely to guide percutaneous coronary interventions (PCI) with second-generation drug-eluting stents. The mortality benefits associated with imaging guidance over angiography are now incontrovertible for PCI guidance, based on 21 trials collected in a new meta-analysis of more than 18,000 patients.2
From barely being able to distinguish plaque from lumen, the resolution achievable with intracoronary imaging led to the identification of high-risk plaque features, such as lipid-rich plaques and thin-capped fibroatheromas,3–5 with the opportunity to apply the concept of plaque vulnerability in vivo. The introduction of near-infrared spectroscopy also provided the precision needed to quantify the lipid content. Together these modalities have increased our understanding of the mechanism of action of lipid-lowering therapies, demonstrating for the first time plaque regression and plaque stabilisation with increased thickness of the fibrous cap and reduction of the amount of lipid and macrophages.
What are the most important current opportunities and challenges?
The most recent 2024 ESC Guidelines give a Class IA recommendation to patients with complex lesions, an indication that might be considered reductive based on the positive results of trials in all-comers, including ULTIMATE and IVUS-ACS.6,7 While the use of intravascular imaging guidance for simple lesions could represent an opportunity, with IVUS/OCT currently used in only 20–30% of complex cases in Europe due its price tag and reimbursement issues, it might be acceptable to reserve it for complex cases that show the largest absolute reduction in target lesion failure. Another challenge that limits the penetration of intracoronary imaging in Europe is the difficulty of image interpretation and analysis, although automatic processing methods are helping to bridge this gap.
How do you think this field will evolve in the future?
We know that using intravascular imaging in the treatment of critical lesions improves prognosis, but what to do when high-risk plaque features are detected in plaques not yet limiting flow remains unclear. There is limited evidence that covering non-flow-limiting vulnerable lesions with stents improves long-term events but a focal treatment for a systemic disease such as atherosclerosis appears questionable.8 Finetuning our approach to prevention by reserving the most intense and expensive pharmacological interventions in patients with plaques with high-risk features may be the answer.9 Inflammation increases the risk of plaque instability but intravascular imaging currently has limited ability to detect it. New developments, such as near-infrared fluorescence, may help to select candidates for the use of novel anti-inflammatory drugs.
References
- Yock PG, et al. J Am Soc Echocardiogr. 1989;2:296–304.
- Stone GW, et al. Lancet. 2024;403:824–837.
- Nissen SE, et al. JAMA. 2006;295:1556–1565.
- Waksman R, et al. Lancet. 2019;394:1629–1637.
- Räber L, et al. JACC Cardiovasc Imaging. 2019;12:1518–1528.
- Zhang J, et al. J Am Coll Cardiol. 2018;72:3126–3137.
- Li X, et al. Lancet. 2024;403:1855–1865.
- Park SJ, et al. Lancet. 2024;403:1753–1765.
- Di Mario C, et al. Eur Heart J. 2016;37:1883–1890.
