Intracoronary ultrasound (ICUS) provides valuable information on the distribution and composition of atherosclerotic plaque. For this reason its use for guidance of interventional procedures has been advocated. Recently, on-line systems of three-dimensional reconstruction have been introduced and offer great potential for guidance of interventional procedures since valuable details on longitudinal architecture of the plaque under treatment are obtained. In this article we review the current clinical application of three-dimensional (3-D) ICUS and report our experience with the use of an on-line 3-D ICUS system for guidance of interventional procedures. In our experience 3-D reconstruction of ICUS proved to be a feasible method facilitating device selection and guidance of catheter based interventions.