Three-dimensional (3D-) reconstruction of intravascular ultrasound (IVUS) images is a recently introduced technical method which has rapidly grown in science and clinical practice. In the catheterization laboratory it is particularly important to obtain the 3D-reconstruction on-line, since the dimensions measured and the plaque attributes displayed may guide the therapeutic decision. Off-line reconstruction, however, provides very accurate and reproducible area and volume measurements of lumen and plaque and is thus exceptionally qualified for studying progression/regression of atherosclerosis or restenosis after catheter-based interventions. Complementary 3D-reconstruction methods, revealing specific advantages and limitations, meet the requirements by slightly different technical approaches, but each 3D-reconstruction of two-dimensional IVUS images requires some basic procedural steps. The IVUS images can be acquired during continuous or ECG-gated withdrawals of the IVUS imaging catheter. The latter permits even to visualize the cyclic pulsation of the reconstructed arteries. As an alternative approach a sensing device recognizes the insertion depth of the IVUS catheter and permits reliable measurements even during manual handling of the IVUS catheter. A discrimination between the blood-pool and structures of the vascular wall, performed in the digitized images, can be achieved by the application of different techniques. This processing step which is called segmentation and the image acquisition are particularly crucial with regards to the final quality of the 3D-reconstruction. Currently there are still limitations of 3D-IVUS, but a new approach combining data obtained from 3D-IVUS and biplane angiography offers a promising potential to solve most of the remaining problems in the future. Thus, three-dimensional IVUS offers a great clinical and scientific potential since it provides spatial visualization of vascular pathology, longitudinal and volumetric measurement of luminal and plaque dimensions, and facilitated guidance of catheter-based interventions. Assuming a technical development similar to the progress of the previous years. 3D-IVUS has a realistic chance to gain significant importance and to become a routine technique in the future.