Major advances have occurred during the last decade in the management of coronary arterial and valvular diseases using catheter-based treatment modalities. These methods, however, are still plagued by technical difficulties in the performance of the procedures because of the lack of appropriate guidance, and complications because of difficulties in patient selection. This review article deals with the various problems related to percutaneous balloon valvuloplasty and coronary angioplasty, outlines the specific needs in terms of guidance and discusses the possible guiding potential of intravascular ultrasound imaging methods.