Which trials have compared culprit-only versus complete revascularization using intravascular imaging such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) to assess unstable plaque?

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Last updated: September 18, 2026 • View editorial policy

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Trials Comparing Culprit vs Complete Revascularization Using Intravascular Imaging to Assess Unstable Plaque

Based on the available evidence, there are NO randomized controlled trials that specifically compared culprit-only versus complete revascularization strategies while using IVUS or OCT to assess unstable plaque characteristics as the primary study design. The provided evidence does not contain any trials with this specific design.

What the Evidence Actually Shows

Trials Using Intravascular Imaging (But Not Comparing Revascularization Strategies)

The evidence includes multiple trials using IVUS/OCT for PCI guidance, but these compare imaging-guided vs angiography-guided PCI, not culprit vs complete revascularization strategies:

OCT-Guided PCI Trials:

  • DOCTORS (2015): 240 patients with NSTEMI, OCT vs angiography guidance 1
  • OCTACS (2015): 50 patients with ACS, OCT vs angiography guidance 1
  • ILUMIEN III (2016): 158 patients, compared OCT vs IVUS vs angiography 1
  • OPINION (2017): 412 patients, OCT vs IVUS guidance 1

IVUS-Guided PCI Trials:

  • IVUS-XPL (2015): 1,400 patients with long lesions, IVUS vs angiography 1
  • ULTIMATE: All-comers with complex lesions, IVUS vs angiography 1
  • CTO-IVUS: Chronic total occlusions, IVUS vs angiography 1
  • ROCK II (2021): 730 patients, IVUS/OCT vs angiography 1

Trials Comparing Revascularization Strategies (But Not Using Imaging for Plaque Assessment)

One study addressed complete vs incomplete revascularization with IVUS, but not for unstable plaque assessment:

  • A 2015 observational study of 2,132 patients with multivessel CAD compared complete vs incomplete revascularization, with subgroup analysis by IVUS use. However, IVUS was used for procedural guidance, not to identify or characterize unstable plaques 2

Recent Multimodality Imaging Trial

NIRVUS Trial (2026): This is the closest to your question—it used NIRS-IVUS-OCT in 104 patients with acute MI to assess lipid-rich plaque (LRP) and its impact on vascular healing. However, this was not a culprit vs complete revascularization comparison; it compared multimodality imaging guidance vs angiography guidance 3

Key Distinction

The fundamental issue is that intravascular imaging in existing trials has been used for:

  1. Procedural optimization (stent sizing, expansion, apposition)
  2. Post-PCI assessment (strut coverage, healing)

NOT for:

  • Identifying non-culprit unstable plaques to guide revascularization strategy decisions
  • Comparing culprit-only vs complete revascularization based on plaque vulnerability

Clinical Context

While imaging can identify vulnerable plaque features (thin-cap fibroatheroma, lipid-rich plaque, plaque rupture), no trials have prospectively used these findings to randomize patients to different revascularization strategies (culprit-only vs complete) 1, 3.

References

2
Research

The effect of complete percutaneous revascularisation with and without intravascular ultrasound guidance in the drugeluting stent era.

EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 2015

3
Research

Multimodality Intravascular Imaging Guidance (NIRS-IVUS-OCT) Compared to Angiography-Guided Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction: The NIRVUS Trial.

Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 2026

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