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These techniques now provide detailed, real-time assessment of coronary artery structure, enabling precise stent sizing, calcium characterization, and optimization of percutaneous coronary interventions. Clinical trials and meta-analyses demonstrated that intravascular imaging-guided PCI significantly reduces restenosis, thrombosis, target lesion failure, and cardiac mortality compared with angiography-guided approaches. These achievements underpin the current Class I, Level A recommendations for intravascular imaging-guidance of complex PCI in the most recent ESC and ACC\/AHA\/SCAI guidelines. Intravascular imaging has also become instrumental in studying atherosclerosis regression, plaque vulnerability, and the effects of lipid-lowering therapies such as statins and PCSK9 inhibitors, allowing the implementation of personalized prevention and intervention strategies. Intravascular imaging remains grossly underused in clinical practice but better reimbursement, improved and mandatory training and the integration of artificial intelligence for image interpretation may facilitate a wider application.<\/jats:p>","DOI":"10.1093\/eurheartj\/ehag237","type":"journal-article","created":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T11:44:57Z","timestamp":1776944697000},"source":"Crossref","is-referenced-by-count":0,"title":["Intravascular imaging from research tool to guidelines: a 35-year long journey"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4461-2055","authenticated-orcid":false,"given":"Carlo","family":"Di Mario","sequence":"first","affiliation":[{"name":"Department of Clinical & Experimental Medicine, Careggi University Hospital , Largo Brambilla 3, Florence 50134 ,","place":["Italy"]},{"name":"Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, Florence 50134 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8144-0117","authenticated-orcid":false,"given":"Giulia","family":"Nardi","sequence":"additional","affiliation":[{"name":"Department of Clinical & Experimental Medicine, Careggi University Hospital , Largo Brambilla 3, Florence 50134 ,","place":["Italy"]},{"name":"Hospital Clinico San Carlos , Cardiology Department, Calle del Prof Martin Lagos, Madrid 28040 ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4226-1084","authenticated-orcid":false,"given":"Niccol\u00f2","family":"Ciardetti","sequence":"additional","affiliation":[{"name":"Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, Florence 50134 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8697-2692","authenticated-orcid":false,"given":"Alessio","family":"Mattesini","sequence":"additional","affiliation":[{"name":"Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, Florence 50134 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,10,6]]},"reference":[{"key":"2026100602452013200_ehag237-B1","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1016\/S0041-624X(67)80005-2","article-title":"Ultrasonic tomography of the heart: an intracardiac scan method","volume":"5","author":"Omoto","year":"1967","journal-title":"Ultrasonics"},{"key":"2026100602452013200_ehag237-B2","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1016\/0041-624X(72)90250-8","article-title":"An ultrasonic intracardiac scanner","volume":"10","author":"Bom","year":"1972","journal-title":"Ultrasonics"},{"key":"2026100602452013200_ehag237-B3","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1016\/0301-5629(88)90090-7","article-title":"Intra-arterial ultrasonic imaging for recanalization by spark erosion","volume":"14","author":"Bom","year":"1988","journal-title":"Ultrasound Med Biol"},{"key":"2026100602452013200_ehag237-B4","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1016\/S0894-7317(89)80090-2","article-title":"Two-dimensional intravascular ultrasound: technical development and initial clinical experience","volume":"2","author":"Yock","year":"1989","journal-title":"J Am Soc Echocardiogr"},{"key":"2026100602452013200_ehag237-B5","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1007\/bf01745149","article-title":"Clinical percutaneous imaging of coronary anatomy using an over-the-wire ultrasound catheter system","volume":"4","author":"Hodgson","year":"1989","journal-title":"Int J Card Imaging"},{"key":"2026100602452013200_ehag237-B6","doi-asserted-by":"publisher","first-page":"873","DOI":"10.1161\/01.cir.80.4.873","article-title":"Intravascular ultrasound cross-sectional arterial imaging before and after balloon angioplasty in vitro","volume":"80","author":"Tobis","year":"1989","journal-title":"Circulation"},{"key":"2026100602452013200_ehag237-B7","doi-asserted-by":"publisher","first-page":"913","DOI":"10.1161\/01.cir.83.3.913","article-title":"Intravascular ultrasound imaging of human coronary arteries in vivo. 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