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. 

All Editors: David A. Cox, MD, MSCAI, Allison G. Dupont, MD, FSCAI, Kirk N. Garratt, MD, MSc, MSCAI, Cindy L. Grines, MD, MSCAI, Andrew J. Klein, MD, FSCAI, and Jordan Safirstein, MD, FSCAI.