IVUS versus Angiographic-Guided PCI in Long Coronary Lesions (TULIP Trial)

The TULIP (Thrombocyte activity evaluation and Effects of Ultrasound guidance in Long Intracoronary stent Procedures) trial randomized 144 patients undergoing stent implantation for long coronary stenoses (≥20 mm) to IVUS guidance or angiographic guidance alone, with clinical follow-up at 6 months.

IVUS-guided stent implantation produced better minimum lumen diameter, greater stent expansion, and lower residual stenosis than angiography-guided PCI. At 6-month follow-up, major adverse cardiac events (MACE) and target lesion revascularization were numerically lower in the IVUS group, with the difference reaching significance for target lesion revascularization.

TULIP was an early demonstration that IVUS-guided PCI optimizes stent deployment in complex lesions beyond what angiography alone can achieve. Angiography shows only the silhouette of the lumen — IVUS reveals plaque distribution, true vessel dimensions, and stent expansion. In long lesions, where underexpansion risk is highest, the difference in guidance quality translates into fewer restenosis events.

This finding has been confirmed in larger subsequent trials (OPINION, ULTIMATE) and is now reflected in guidelines recommending IVUS guidance for complex PCI.

We rate the evidence moderate. A small but well-designed RCT establishing the benefit of IVUS-guided PCI for long coronary lesions — an important early trial in a now-validated principle.