Optical coherence tomography (OCT) is the current state-of-the-art intravascular imaging technique which so far has been mainly used for research purpose. The clinical impact of an OCT-guided percutaneous coronary intervention is a field of controversy, although recent non randomized data has shown its potential clinical benefit. Many features that are clearly visualized by OCT are missed by both angiography and other intravascular imaging techniques due to their limited resolution. On the contrary, OCT allows visualization of detailed morphological characteristics of both atherosclerotic plaque and stent. This may translate in an improved clinical outcome of OCT-guided procedures. This article reviews the current evidence supporting a possible clinical effect of OCT guidance during coronary interventions.