Intravascular ultrasound imaging has been recognized as a sensitive tool to study early transplant vasculopathy lesions. An early examination performed soon after transplantation allows one to study donor atherosclerosis. Further, serial follow-up imaging with meticulous site matching provides important information regarding the progression of donor atherosclerosis and the development of transplant vasculopathy lesions. This review highlights the contribution of intravascular imaging in understanding the transplant coronary artery disease. This review also outlines various methodologies employed by different investigators, and stresses the strengths and weaknesses of these methodologies for correct interpretation as well as comparison of data from different studies.