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Background Intravascular imaging (IVI), using intravascular ultrasound (IVUS) and optical coherence tomography (OCT), enhances vessel evaluation, stent sizing, and optimisation during percutaneous coronary intervention (PCI), especially for anatomically complex lesions. Current ESC/EAPCI guidelines strongly recommend using IVI for complex PCI procedures, including long lesions and complex branch points. Nevertheless, the actual implementation of IVI differs among centers and operators, and its local use relative to guideline-supported indications is often unknown. This audit was conducted to evaluate local IVI usage in routine PCI practice and assess alignment with current ESC/EAPCI standards.Methods This retrospective single-centre audit included all consecutive adult PCI patients at a high-volume tertiary cardiac centre from April 2023 to April 2020. A total of 4,779 PCI procedures were analysed. The local catheter laboratory’s electronic recording system, utilised for routine clinical documentation and submissions to the BCIS and NICOR registries, was used to extract data.PCI procedures were classified into IVI-guided (utilising IVUS and/or OCT) and angiography-guided categories. The audit evaluated whether IVI-guided PCI correlated with larger implanted stent and balloon sizes and longer treated coronary segments, in comparison to angiography-guided PCI. The collected data encompassed IVUS/OCT utilisation, the largest stent/balloon diameter, the longest treated coronary segment length, the procedural pathway, the operator’s identifier, and baseline patient parameters documented at the time of PCI.Device-level analyses were confined to procedures which recorded stent/balloon diameter and treated segment length, omitting diagnostic-only or aborted cases. Numerical procedural variables had a non-normal distribution and are shown as mean ± standard deviation and median (interquartile range). Comparisons between IVI-guided and angiography-guided PCI were conducted using non-parametric statistical tests, while correlations were evaluated using Spearman’s rank correlation coefficient. Imaging utilisation at the operator level was examined exclusively among 12 high-volume operators to mitigate small-sample bias; all operations were included in the overall analyses.Results A total of 4,779 PCI procedures were analysed. Mean age was 66.1 ± 11.6 years (median 66, range 28-95), with 76.9% male patients (3,674). IVUS/OCT was used in 1,114 procedures (23.3%). IVI-guided PCI was associated with the implantation of larger stent/balloon diameters and the treatment of longer coronary segments, consistent with the IVI-informed optimisation of stent sizing and lesion coverage. Median stent/balloon diameter was 4.0 [3.5–4.0] mm in IVI-guided PCI compared with 3.5 [3.0–3.5] mm in angiography-guided PCI (p<0.001), while median treated segment length was 30 [20–38] mm versus 23 [18–30] mm, respectively (p<0.001).A positive correlation was observed between stent/balloon diameter and treated segment length (Spearman’s ρ = 0.21, p < 0.001). Imaging utilisation reached 60.5% in very long treated segments (>60mm). Substantial inter-operator variation in intravascular imaging utilisation persisted despite restriction to 12 high-volume operators.Conclusion Intravascular imaging was used in approximately one-quarter of PCI procedures and was associated with implantation of larger-diameter stents and treatment of longer coronary segments, reflecting preferential use in more anatomically complex PCI. This pattern of practice reflects ESC/EAPCI guideline recommendations of IVI use in complex coronary interventions.Recommendations Implement a local standard for routine intravascular imaging in predefined complex PCI (including long segments and complex bifurcations), improve structured lesion complexity documentation, benchmark high-volume operators, and re-audit at 6 months to assess utilisation and practice variation.