Percutaneous coronary intervention (PCI) significantly improves the prognosis of patients with coronary artery disease. However, the long-term presence of permanent metallic stents may lead to adverse events, including late in-stent thrombosis, neoatherosclerosis, and impaired vasomotor function. Drug-coated balloons (DCBs) effectively relases the antiproliferative drugs to the vascular wall during balloon inflation. Since no permanent implant remains after balloon withdrawal, DCBs embody the " intervention without implantation" concept, and significantly reducing complications associated with long-term implant retention. Sirolimus-coated balloons (SCBs), as a next-generation of DCBs, exert both antiproliferative and anti-inflammatory effects. In recent years, SCBs have been increasingly used for the treatment of in-stent restenosis, in situ small-vessel coronary lesions, and certain complex coronary lesions, with accumulating evidence suggesting favorable safety and efficacy. Intravascular imaging facilitates precise evaluation of reference vessel diameter, plaque morphology, calcification severity, and effect of lesion pretreatment, whereas coronary functional assessment helps determine the ischemic relevance of target lesions and evaluate post-operative hemodynamic improvement. The integrated application of intravascular imaging and functional assessment may facilitate more precise lesion screening, operational strategy formulation, and treatment response evaluation in SCB-based interventions. This review summarizes the mechanisms of action, technical characteristics, and clinical applications advancements of SCBs guided by intravascular imaging and functional assessment. Furthermore, it also discusses the limitations of current evidence and unresolved clinical issues, aiming to provide a reference for individualized interventional decision-making in coronary artery disease.