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Background: No/slow flow after percutaneous intervention(PCI) for acute coronary syndromes (ACS) is common. Whether a comprehensive intravascular ultrasound (IVUS) analysis of atherosclerotic plaque can define characteristics which predict suboptimal flow following PCI is largely unknown., Objectives: To identify IVUS correlates of suboptimal flow in patients with ACS undergoing PCI., Materials & Methods: We performed a prospective multicentre, investigator initiated study. Patients with ACS, who underwent IVUS guided PCI were enrolled. Clinical, angiographic and imaging characteristics of patients who developed suboptimal flow after PCI were analysed and compared with patients with normal flow., Results: Between October 2021 and August 2022, we enrolled 187 patients (195 lesions) with ACS who underwent IVUS guided PCI. Mean age of patients was 58 ± 10.4 years; Incidence of slow/no reflow in our study was 14/195 (7.2 %). Presentation as ST elevation myocardial infarction, presence of angiographically complex lesion type (type B2/C) and pre procedural TIMI flow 0 were significantly more in patients who developed suboptimal flow after PCI. Pre PCI plaque attenuation length (9.51 mm Vs 4.35 mm p = 0.037), lesion site positive remodelling (Odds ratio 6.4 : 95 % CI; 1.1-38.4 p = 0.042) were predictors of slow flow.Post PCI length of plaque prolapse (9.73 mm Vs 6.58 mm p = 0.029) correlated with slow flow., Conclusions: Plaque characteristics on IVUS in patients with ACS helps to identify patients who may develop suboptimal flow following PCI., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sajan Narayanan reports financial support was provided by Society for coronary imaging and physiology (SCIP). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier, a division of RELX India, Pvt. Ltd.)