1. Navigating the Coronary Circulation: Angiography vs IVUS Pearls 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

2. Angiography: the old friend 2D Longitudinal Lumen Imaging % Stenosis (QCA) “Normal” Reference Diameter

3. Angiography: 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

4. Quantitative coronary angiography Reference-catheter

5. Quantitative coronary angiography Edge detection

6. Quantitative coronary Angiography

7. Pitfall: lesion eccentricity

9. Vascular Remodelling (Glagov’s phenomenon)

11. IVUS Imaging 2D Cross-Sectional Imaging

12. 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

13. IVUS Imaging: Plaque Surface and Volume Longitudinal Plane Transverse Plane

14. IVUS 3D Reconstruction: %change atheroma volume ACC 2007: - ERASE - ILLUSTRATE

15. IVUS Pitfall : Imaging plane not perpendicular to vessel axis

18. Distal LMT

19. <6.0 mm2

20. Fibrous Soft Superficial Ca Deep calcification

21. Potentially unstable coronary lesion Echolucent

22. Conclusions 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