ANGIOSCOPIC EVALUATION OF ANGIOGRAPHICALLY COMPLEX CORONARY LESIONS

Coronary angioscopy (CA) provides direct visualization of the endolumi nal surface of coronary vessels. The usefulness of CA during coronary angioplasty of angiographically complex lesions remains to be establis hed. This study was designed to determine the value of CA to elucidate the underlying substrate of angiographically complex lesions. Forty-s even consecutive patients with angiographically complex lesions were s tudied with CA before coronary intervention. Mean age of the group was 59 +/- 9 years; six patients were women. Forty (85%) patients had uns table angina. Complex angiographic lesions included coronary occlusion s (n = 23) (14 with Thrombolysis in Myocardial Infarction coronary flo w grade 0 and nine with flow grade 1), lesions with intraluminal filli ng defects suggestive of thrombus or ulceration (n = 8), and lesions t hat were highly eccentric (n = 16). Items analyzed with CA included re d thrombus (lining or protruding) and plaque color (yellow, white, or mixed). In all patients, CA visualized the protruding material causing the angiographic appearance. At this site CA detected red thrombus in 34 (72%) patients (14 protruding, 20 lining) and atherosclerotic plaq ue in 45 (96%) patients. At the site of the angiographically complex l esion, plaque was classified as predominantly yellow in 24 patients, m ixed in 12, and white in nine. The incidence of thrombus on CA was hig her for occluded vessels (91%) or lesions with intraluminal filling de fects or ulceration (87%) than in eccentric lesions (37%) (p < 0.05). However, plaque coloration was not significantly different among these three angiographic subgroups. Initial procedural success (without ste nt requirement) was lower in lesions showing protruding thrombus on CA (64% vs 91%, p < 0.05). Thus most angiographically complex lesions co ntain thrombus. On CA red thrombus was more frequently identified on o ccluded vessels and lesions with filling defects or ulceration than in eccentric lesions. Yellow or mixed plaques are common in these patien ts, suggesting lipid-laden plaques as the underlying pathologic substr ate of angiographically complex lesions.