The ULTIMATE trial evaluated the difference in target vessel failure (TVF) three years after 1448 patients were randomized to intravascular ultrasound (IVUS) guidance versus angiography guidance during implantation of second-generation drug-eluting stent (DES). This is the largest trial of IVUS-guided PCI ever undertaken. At three years, IVUS-guided DES implantation was associated with significantly lower rates of TVF and stent thrombosis (ST). The absolute risk reduction was 4.1%, which means the number needed to treat (NNT) was 25 to avoid one TVF. IVUS guidance has been linked previously to superior MACE outcomes, including TVF, but this long-term follow-up study adds substantially to our understanding of how IVUS guidance can translate into clinical benefits. Unfortunately, IVUS requires additional time, instrumentation and is not currently reimbursed leading to a low utilization rate across in the United States.