Quantitative coronary angiography: Clinical applications
- Morton J Kern, MD, MSCAI, FAHA, FACC
Morton J Kern, MD, MSCAI, FAHA, FACC
- Professor of Medicine
- University of California, Irvine
A reduction in the coronary artery luminal cross-sectional diameter, estimated by visual inspection of the radiocontrast lumenogram during angiography, has been utilized to formulate predictions about clinical presentations and stress-induced reductions in coronary blood flow. Anatomic and physiologic approaches to coronary artery disease are complementary and at times will yield contradictory results. (See "Clinical use of coronary artery pressure flow measurements".) As a result, quantitative approaches to the angiographic evaluation of coronary anatomy are occasionally employed in some laboratories.
There are a number of clinical applications for quantitative coronary arteriography (QCA) including predicting restenosis after angioplasty, comparing the results of different interventional techniques, and evaluating the natural history of coronary artery disease. These issues will be reviewed here, beginning with the limitations of visual and QCA, while the technical aspects of QCA are discussed separately. (See "Quantitative coronary angiography: Technical issues".)
LIMITATIONS OF VISUAL CORONARY ARTERIOGRAPHY
The rationale for performing quantitative coronary arteriography (QCA) is based upon the limitations of visual coronary arteriography. The greatest advantage of QCA is its theoretical freedom from observer influences and bias, minimizing significant potential intraobserver and interobserver variability [1-3]. In prospective studies, the potential for observer error with visual analysis from a coronary angiogram has been estimated to exceed 35 percent .
The extent of the variability is related in part to the severity of the lesion under scrutiny; lesser degrees of variation are reported for stenoses that represent either less than 20 percent or more than 80 percent of the vessel diameter . Visual analysis generally leads to overestimation of severe stenoses, and to underestimation of more modest degrees of luminal narrowing .
There is also significant discordance between visual estimates of luminal narrowing and the functional significance of stenosis . The functional significance of coronary stenotic lesions is governed not only by degree of stenosis, but also by such features as the shape, length, and eccentricity of the lesion, collateral routes of perfusion, and vasomotor tone among others [7-10]. These physical constraints and resultant flow characteristics contribute to the disparity between the angiographic and corresponding physiologic assessment of disease severity .
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