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Coronary angiography is not enough

ESC Congress 2010

Invasive Coronary Imaging and Hemodynamics

The clinical seminar “angiography is not enough” was meant to bring new insight into invasive coronary imaging technique. It is well known that coronary angiography alone does not make it possible to judge the importance of ischemia or the detection of vulnerable plaque. On top of that, in case of coronary interventions (PCI), angiography is not always sufficient to judge the result.

Dr. G. Finet gave an overview on the role of intravascular ultrasound (IVUS). IVUS allows to judge plaque composition, plaque rupture and thrombus. This information is important in choosing the best therapeutic option for the patient. During PCI, IVUS is advocated for high risk PCI such as left main stenting but also to judge and treat potentially suboptimal angiographic results. IVUS can also be helpful during complications to find the best therapeutic solution.

Dr Stankovic gave an update on the role of virtual histology, a technique derived from IVUS allowing to judge more precisely the composition of the plaque (fibrotic, lipid core, calcium). This technique also makes it possible to analyse plaque at risk for rupture in case of large lipid core. In the setting of unstable syndromes the most critical lesion often precedes this lipid core and virtual histology therefore makes it possible to fully analyse and correctly treat the whole diseased segment. Finally, Dr. Stankovic reminded us of the PROSPECT trial that identified and followed up patients where plaque composition was analysed by virtual histology.

Dr Akasaka gave an overview on optimal coherence tomography (OCT), an emerging technique that has now found his way into many cath labs around the world. Because of the special resolution of OCT, more precise analysis of the vessel wall is possible. OCT makes it possible to judge uncovered stents struts much more precisely than IVUS does. He announced a recent paper on late bare metal stent thrombosis where the mechanism for thrombosis was neo plaque rupture within the stent.

Finally, Dr. Lerman made a plea for physiological lesion assessment. Only FFR (pressure measurements within the coronary artery) makes it possible to know the hemodynamic significance of a given lesion. He showed that FFR is adequate, safe and makes it possible to delay PCI if FFR is normal. In that respect, the FAME trial is of the utmost important, as it showed that even in multivessel disease, assessment of the whole coronary tree by FFR and stenting of the hemodynamically significant lesions only is superior from all aspects (safety, efficacy and costs) than routine stenting of all angiographic stenoses.




Coronary angiography is not enough

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.