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Objective: Intravascular ultrasound (IVUS) is not routinely performed in the real-world practice, and the benefits of IVUS-guided drug-eluting stent (DES) implantation in patients with complex coronary lesions remains unclear. This updated meta-analysis attempts to evaluate the clinical outcomes of the IVUS guidance in these patients. Methods: We searched potential eligible citations from the PubMed, EMBASE, Medline, and other internet sources. The primary endpoint were major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). The risk of definite/probable stent thrombosis (ST) was chosen as the safety endpoint. Results: Nine randomized trials including a total of 3,612 patients with complex coronary lesions were finally analyzed. Compared to angiography guidance, IVUS-guided DES implantation was associated with significantly lower incidence of MACE [odds ratios (OR) 0.57, 95% confidence intervals (CI): 0.45-0.72, p<0.001; I2=0.0%, p=0.674], cardiac death (OR 0.42, 95% CI: 0.21-0.82, p=0.010; I2=0.0%, p=0.961), MI (OR 0.65, 95% CI: 0.44-0.95, p=0.027; I2=41.8%, p=0.089), TVR (OR 0.55, 95% CI: 0.38-0.79, p=0.001; I2=0.0%, p=0.916), target lesion revascularization (TLR) (OR 0.58, 95% CI: 0.41-0.82, p=0.002; I2=0.0%, p=0.888), and ST (OR 0.48, 95% CI: 0.24-0.93, p=0.029; I2=0.0%, p=0.733). Conclusion: The updated meta-analysis demonstrates that DES implantation under IVUS guidance leads to a significant reduction in MACE, cardiac death, MI, TVR, TLR, and ST among patients with complex coronary lesions. [ABSTRACT FROM AUTHOR]