Conventional sirolimus-eluting stent (SES) implantation typically follows balloon predilation. The impact of direct SES implantation on in-stent neointimal hyperplasia and the adjacent reference segments has not been evaluated. The aim of this study was to analyze direct and conventional SES implantation techniques by angiography and serial intravascular ultrasound. Fifty-three patients with single de novo coronary lesions underwent successful conventional (n = 26) and direct (n = 27) SES implantation. At 6-month follow-up, similar in-stent late luminal loss and decreased neointimal hyperplasia volume were seen in the 2 groups, preserving the luminal dimensions at the edges of the stents.