Comprehensive assessment of multivessel disease with physiological vessel mapping and IVUS- angiography co-registration

Contemporary intracoronary techniques allowing longitudinal physiological and anatomical vessel assessment of coronary vessels improve complex percutaneous coronary intervention (PCI) planning. A patient with stable angina and previous stenting in the LAD was referred for bifurcation left main (LM) stenting based on an angiogram interpreted as showing severe ostial stenosis of the left circumflex (Figure 1A) and an FFR of 0.76 in the LAD (Figure 1A). During pre-PCI planning with physiological assessment, an iFR in the grey zone (0.86–0.93) of 0.92 in the circumflex prompted an FFR measurement giving a value of 1.00 (Figure 1A). Furthermore, longitudinal pressure mapping with iFR scout (Volcano, Verrata) demonstrated that there was no drop across the left main bifurcation and that the significant lesion was limited to the previously stented portion of the LAD (Figure 1A). IVUS co-registration (Volcano, Eagle Eye) confirmed that the LM minimal luminal area was 6.2 mm² and that the pressure drop in the LAD was secondary to stent underexpansion and neoatherosclerosis (see Supplementary material online, Video S1). Following high-pressure pre-dilatation, two everolimus-eluting stents (3.0 × 24 and 3.5 × 20 mm) were implanted. Post-PCI pressure interrogation showed a final iFR of 0.92 and FFR of 0.86 (Figure 1B). The comparison of iFR pullback curves before (Figure 1A) and after stenting (Figure 1B) demonstrated resolution of the pressure drop across the treated segment while IVUS showed adequate stent expansion and apposition. Pressure mapping was key to correcting the initial impression of LM stenosis while IVUS co-registration was useful to decide on stent size and length and distal landing zone. This case demonstrates the feasibility of repeated physiological and IVUS imaging using systems with integrated longitudinal analysis and co-registration possibilities.

Figure 1.

(A) Pre-PCI angiographic appearance, IVUS frame and iFR pullback. (B) Post-PCI angiographic result, FFR result and iFR pullback.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: J.E. is a speaker at educational events and a consultant for Boston Scientific, Philips Volcano. All other authors have nothing to disclose.