Aim. To evaluate the results of coronary intravascular ultrasound (IVUS) in elderly and senile patients in various clinical situations. Materials and methods. The study included 155 patients aged >60 years, 118 of whom underwent elective percutaneous coronary interventions (PCI), and 37 patients were emergently hospitalized for non-ST-elevation myocardial infarction (NSTEMI). The group of elective PCI was divided into 2 following subgroups: the study group (n=58) — IVUS-guided coronary stenting, and the control group (n=60) — angiography-guided PCI. Stenting was performed based on previously performed diagnostic coronary angiography (CAG). Remote treatment results were assessed over 5 years. All patients of the NSTEMI group after diagnostic CAG underwent preoperative IVUS. We assessed the reasons for IVUS, the rate of management changes based on IVUS data, as well as immediate outcomes after endovascular treatment. Results. The most frequent adverse event after elective PCI in patients of older age groups was repeat revascularization in the target vessel system, the risk of which was maximum by 3 years of follow-up and decreased by 5 years (odds ratio (OR) 5,09 after 1 year, OR 9,32 after 3 years and OR 5,62 after 5 years). Similar changes were revealed for the total number of cardiovascular events (OR 1,9 after 1 year, OR 3,1 after 3 years and OR 2,4 after 5 years), the risks of acute myocardial infarction (OR 2,0 after 1 year, OR 4,07 after 3 years and OR 2,1 after 5 years) and stent restenosis (OR 3,0 after 1 year, OR 7,12 after 3 years and OR 5,62 after 5 years). No differences in total mortality were found in the study and control subgroups of elective interventions (OR 0,98 after 1 year, OR 1,47 after 3 years, and OR 1,27 after 5 years, p>0,05). In older patients with NSTEMI, IVUS influenced the management strategy changes in 81% of cases, while in 5,4% of cases its use resulted in refusal of PCI, and in 70,3%, infarction-related lesions were confirmed according to IVUS data. In addition, IVUS in the treatment of patients with NSTEMI demonstrated significant differences in the angiographic and IVUS characteristics of vessel diameters (2,95±0,53 vs 3,6±0,56 mm, p=0,034) and the rate of incomplete stent apposition (11,1 vs 88,9%, p=0,002). Conclusion. The use of IVUS in myocardial revascularization in elderly and senile patients in various clinical situations significantly reduces the rate of long-term recurrent cardiovascular events, and also affects the management strategy and immediate outcomes of stenting. © 2025 Elsevier B.V., All rights reserved.