This retrospective analysis of 7,641 PCI procedures (2015–2022) compared intravascular ultrasound–guided PCI (IVUS-guided) with angiography-guided PCI (AG) using propensity matching. IVUS use increased from 10.9% to 63% during the study period. Compared to AG, IVUS-guided cases used less contrast but required longer fluoroscopy time and exhibited higher in-hospital complication rates. At one year, IVUS-guided patients had higher rates of follow-up procedures, including repeat PCI and CABG, while incident diagnoses remained similar between groups. Subgroup analysis of complex lesions showed that IVUS-guided cases continued to have increased follow-up interventions. Although IVUS improves lesion assessment, these findings raise questions about patient selection, procedure complexity, and resource utilization. Longer-term outcome studies are needed to clarify clinical and cost implications of expanded IVUS adoption.