Navigating the Coronary Circulation:

Angiography vs IVUSPearls and Pitfalls

Navigating the Coronary Circulation:

Angiography vs IVUSPearls and Pitfalls

Philippe L. L’Allier, MD

Montreal Heart Institute Tuesday, March 27, 2007

Philippe L. L’Allier, MD

Montreal Heart Institute Tuesday, March 27, 2007

Angiography:the old friendAngiography:the old friend

2D Longitudinal Lumen Imaging

•% Stenosis (QCA)•“Normal” Reference Diameter

Angiography: the good and the badAngiography: the good and the bad

Good

Extensively used > 60 years

Entire coronary anatomy, including small and distal vessels

Excellent PPV Validated QCA Helpful in clinical

decision making

Bad

Relative % stenosis Reference segment

assessment Eccentricity Post PTCA/dissections Limited correlation with

physiology

Quantitative coronary angiographyReference-catheter

Quantitative coronary angiographyReference-catheter

Quantitative coronary angiographyEdge detection

Quantitative coronary angiographyEdge detection

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0(mm )

1.0

2.0

3.0

4.0

5.0

6.0

(mm )

op d

r

Quantitative coronary AngiographyQuantitative coronary Angiography

Pitfall: lesion eccentricityPitfall: lesion eccentricity

Pitfall: lesion eccentricityPitfall: lesion eccentricity

Vascular Remodelling (Glagov’s phenomenon)

Vascular Remodelling (Glagov’s phenomenon)

IVUS ImagingIVUS Imaging2D Cross-Sectional

Imaging

IVUS: the good and the bad

IVUS: the good and the bad

Good

Tomographic views Vessel wall + lumen

visualization Excellent NPV+PPV Validated quantitative

software Plaque characterization

Bad

Need to instrument vessels

Limited to proximal segments

Cost Not as well validated for

clinical decision making Limited correlation with

physiology Not always perpendicular

to vessel axis

IVUS Imaging:Plaque Surface and Volume

IVUS Imaging:Plaque Surface and Volume

LongitudinalPlane

TransversePlane

IVUS IVUS

3D Reconstruction:%change atheroma volume

ACC 2007:

- ERASE- ILLUSTRATE

IVUS Pitfall:Imaging plane not perpendicular to vessel axis

IVUS Pitfall:Imaging plane not perpendicular to vessel axis

Distal LMTDistal LMT

Distal LMTDistal LMT

<6.0 mm2

FibrousFibrousSoftSoft

Superficial CaSuperficial Ca Deep calcificationDeep calcification

Potentially unstable coronary lesion

Echolucent

ConclusionsConclusions

• Angio remains the most widely and conveniently used coronary imaging modality

• IVUS has helped better use/understand angiography

• Not IVUS vs Angio, more Angio ± IVUS

• Need to understand the pitfalls of each technique and use them appropriately