Despite the accumulation of randomised data demonstrating improved outcomes with intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI), utilisation is uncommon in most countries. This systematic review maps geographical and temporal trends in IVI use using PCI registry and government data.

A systematic review adhering to the PRISMA framework was conducted to identify provincial, national, and international data sets reporting real-world IVI rates published between 2014 and 2024.

A total of 36 publications from 24 countries were included, totalling 9,459,897 patients. Intravascular ultrasound was the preferred imaging modality, with optical coherence tomography accounting for <10% of IVI. Most countries reported low rates of IVI uptake, however, significant increases over time were observed. Rates varied significantly between and within regions and countries. Asia had the highest mean utilisation rate (35.4%; standard deviation, 35.9), followed by the Americas (9.3%; 5.7), Europe (5.7%; 4.9), and Oceania (4.5%; 2.6).

Significant variability in IVI utilisation was observed across regions and countries. Most countries reported low IVI rates; however, adoption increased over time in most areas. Local variables such as health care system characteristics, physician preferences, and financial considerations appear to inform IVI rates more than clinical factors.