Visual estimation versus different quantitative coronary angiography methods to assess lesion severity in bifurcation lesions

Objectives To compare visual estimation with different quantitative coronary angiography (QCA) methods (single‐vessel versus bifurcation software) to assess coronary bifurcation lesions. Background QCA has been developed to overcome the limitations of visual estimation. Conventional QCA however, developed in “straight vessels,” has proved to be inaccurate in bifurcation lesions. Therefore, bifurcation QCA was developed. However, the impact of these different modalities on bifurcation lesion severity classification is yet unknown Methods From a randomized controlled trial investigating a novel bifurcation stent (Clinicaltrials.gov NCT01258972), patients with baseline assessment of lesion severity by means of visual estimation, single‐vessel QCA, 2D bifurcation QCA and 3D bifurcation QCA were included. We included 113 bifurcations lesions in which all 5 modalities were assessed. The primary end‐point was to evaluate how the different modalities affected the classification of bifurcation lesion severity and extent of disease. Results On visual estimation, 100% of lesions had side‐branch diameter stenosis (%DS) >50%, whereas in 83% with single‐vessel QCA, 27% with 2D bifurcation QCA and 26% with 3D bifurcation QCA a side‐branch %DS >50% was found ( P < 0.0001). With regard to the percentage of “true” bifurcation lesions, there was a significant difference between visual estimate (100%), single‐vessel QCA (75%) and bifurcation QCA (17% with 2D bifurcation software and 13% with 3D bifurcation software, P < 0.0001). Conclusions Our study showed that bifurcation lesion complexity was significantly affected when more advanced bifurcation QCA software were used. “True” bifurcation lesion rate was 100% on visual estimation, but as low as 13% when analyzed with dedicated bifurcation QCA software.