OBJECTIVES: Intravascular ultra-sound (IVUS) allows physicians to generate a superior image of coronary arteries during percutaneous coronary interventions (PCI), providing a tomographic, 360-degree view of the arterial wall from the inside, which allows a more accurate and complete assessment than is possible with angiography.  The purpose of this study was to understand the cost-effectiveness of IVUS compared with traditional angiography techniques in drug-eluting stent (DES) implantation, from the perspective of the Italian health system. METHODS: A Markov model was developed to extrapolate the comparative costs and outcomes of a theoretical population of 1000 patients undergoing DES implantation with traditional angiography alone, or in conjunction with IVUS.  The model assesses cardiac events, including revascularisations and myocardial infarctions from a health system perspective.  Outcomes with and without IVUS were based on a meta-analysis by Zhang et al (2013). Because of limited clinical evidence to inform the long-term outcomes of IVUS compared with angiography, the model either assumes the benefit of IVUS is conferred only in the first year of treatment, or that the benefit is maintained permanently. RESULTS: Using IVUS during PCI cost an average of €542 per patient, and yields an additional 0.022 quality adjusted life years (QALYs) per patient.  In a population of 1,000 patients, IVUS led to a reduction of 6.7 revascularisations and 5.9 less myocardial infarctions (MI) over the lifetime of a patient.  When the revascularisation and MI benefit of IVUS is assumed to extend for the patient’s lifetime, angiography with IVUS costs €38 per patient and yields an additional 0.09 QALYs over a patient’s lifetime; avoiding 13.4 MIs and 12.3 revascularisations per 1,000 patients.  CONCLUSIONS: IVUS appears to be a cost-effective addition to traditional angiography in DES placement in Italy, with the increased upfront cost of IVUS offset by reduced cardiac events in IVUS-treated patients over time.