Intravascular Ultrasound (IVUS) and Optical Coherence Tomography (OCT) are the leading intravascular imaging modalities used in coronary lesion assessment during percutaneous coronary intervention (PCI). This study compares diagnostic accuracy, clinical outcomes, imaging resolution, and procedural utility of IVUS versus OCT in moderate to severe coronary stenosis. Data were collected from 350 patients undergoing PCI at tertiary centers across India and the UK between 2022 and 2024. Results indicate that OCT offers superior resolution (10–20 μm) enabling precise stent edge visualization and thrombus characterization, whereas IVUS provides deeper penetration, making it more suitable for large vessels and heavily calcified lesions. The study concludes that optimal selection of modality depends on lesion characteristics, clinical objective, and procedural context.