Angiographic views used for percutaneous coronary interventions: A three‐dimensional analysis of physician‐determined vs. computer‐generated views

Abstract

The goal of this study was to determine the severity of vessel foreshortening in standard angiographic views used during percutaneous coronary intervention (PCI). Coronary angiography is limited by its two-dimensional (2D) representation of three-dimensional (3D) structures. Vessel foreshortening in angiographic images may cause errors in the assessment of lesions or the selection and placement of stents. To date, no technique has existed to quantify these 2D limitations or the performance of physicians in selecting angiographic views. Stent deployment was performed in 156 vessel segments in 149 patients. Using 3D reconstruction models of each patient's coronary tree, vessel foreshortening was measured in the actual working view used for stent deployment. A computer-generated optimal view was then identified for each vessel segment and compared to the working view. Vessel foreshortening ranged from 0 to 50% in the 156 working views used for stent deployment and varied by coronary artery and by vessel segment within each artery. In general, views of the mid circumflex artery were the most foreshortened and views of the right coronary artery were the least foreshortened. Expert-recommended views frequently resulted in more foreshortening than computer-generated optimal views, which had only 0.5% +/- 1.2% foreshortening with < 2% overlap for the same 156 segments. Optimal views differed from the operator-selected working views by > or = 10 degrees in over 90% of vessels and frequently occurred in entirely different imaging quadrants. Vessel foreshortening occurs frequently in standard angiographic projections during stent deployment. If unrecognized by the operator, vessel foreshortening may result in suboptimal clinical results. Modifications to expert-recommended views using 3D reconstruction may improve visualization and the accuracy of stent deployment. These results highlight the limitations of 2D angiography and support the development of real-time 3D techniques to improve visualization during PCI.

Reconstruction of coronary arteries from X-ray angiography: A review

“…Optimal view selection using reconstructions is a remarkable example of these integration efforts. Optimal views obtained without additional radiation or contrast can help with the stent positioning (Green et al, 2005;Eng et al, 2013). In a similar fashion, tomographic reconstructions can be used to simulate intracoronary images to provide further guidance for stent positioning (Schoonenberg et al, 2009b).…”

Clinical Feasibility of a Fully Automated 3D Reconstruction of Rotational Coronary X-Ray Angiograms

“…1,8 The safety and feasibility of the 180°selective coronary rotational angiographic acquisition technique was documented, and the frequency of successful, automatic reconstructions yielding high-quality 3D images that displayed clinical value was encouraging. Most reconstructions were designated as high quality, even though the algorithm was not modified to account for suboptimal acquisitions from delayed injection or early termination of contrast that accounted for several low-quality ratings.…”

“…In general, standard angiography relies on the expertise of the operator to acquire multiple views of suspect regions with a trial-and-error technique to optimize visualization and minimize foreshortening of diseased segments. 1 Certain features such as eccentric plaques, vessel tortuosity, and bifurcation angles often are appreciated only by acquiring multiple images from different views and may be suboptimally evaluated if the proper angiographic view is not acquired. 1 Three-dimensional images of the coronary tree from computed tomography or MRI have been proposed as an alternative strategy.…”

“…1 Certain features such as eccentric plaques, vessel tortuosity, and bifurcation angles often are appreciated only by acquiring multiple images from different views and may be suboptimally evaluated if the proper angiographic view is not acquired. 1 Three-dimensional images of the coronary tree from computed tomography or MRI have been proposed as an alternative strategy. [2][3][4] On the other hand, the ubiquitous use of x-ray for PCI indicates that generating 3D information from the x-ray data may represent the most accessible and cost-effective approach for the interventional suite.…”

Comparison of 3-dimensional and 2-dimensional quantitative coronary analysis measuring intracoronary lengths in patients undergoing diagnostic coronary angiography

“…The software has standard QCA functionality, providing information regarding the stenotic lesion, such as percentage of luminal narrowing, length and eccentricity of the lesion. It may provide accurate measurements of intracoronary lengths and 3D mapping of the coronary arteries, facilitating visualization of vessel curvature, elimination of foreshortening and measurement of vessel length [4,11]. This has been increasingly important in the drug-eluting stent era, when appropriate coverage of lesion with the stent is imperative to avoid edge restenosis [12], as well as to decrease the risk of stent thrombosis, which was found to correlate with stent length [13][14][15][16][17].…”