From Coronary Artery to Kidney: Redefining the Goals of Intracoronary Imaging–Optimized Percutaneous Coronary Intervention

Contrast-associated nephropathy has long been treated as an acceptable trade-off in interventional cardiology — a complication acknowledged but rarely prioritized. For decades, the field has lived with the uncomfortable reality that a technically flawless cardiac procedure can leave a patient with measurably worse function in another organ – the kidney – sometimes permanently. In current days, when diabetes, hypertension, and chronic kidney disease (CKD) are reaching “pandemic” levels, that resignation is no longer defensible. The most direct modifiable determinant of this injury — contrast volume — is now addressable, and intravascular ultrasound (IVUS) sits at the center of that solution.

The case for IVUS in complex coronary intervention is well established. It redefines how we size stents, assess expansion, and identify underexpansion, malapposition, edge dissections, and residual plaque burden. But its value extends beyond the technicalities of lesion complexity: in the right hands and with deliberate intent, IVUS transforms the same procedure into a substantially more renal-sparing one. The tool that optimizes coronary angioplasty can simultaneously protect the kidney — provided we choose to use it that way.

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