8 MEDICAMUNDI 47/2 August 2003

the coronary arterial tree, derived from analysis of
two-dimensional angiographic data.
The goal of each angiographic image is to view as
much of the coronary tree as possible, while at the
same time minimizing vessel overlap and
foreshortening of vessel segments in areas of interest.
Due to marked individual variation, however, many
views provide little or none of the visual information
needed for diagnosis and therapy. If the operator is
not satisfied with the angiographic data obtained at
first, he or she may then ‘optimize’ the images by
taking more angiograms from different angles, based
on his or her individualized mental impression of
the coronary arterial tree. The quality and content
of the angiographic images is, therefore, dependent
on the visual skills and experience of the
angiographer. Furthermore, angiograms obtained
in this fashion are not standardized. When
angiograms are shared among referring physicians
or transferred between medical centers, the
information contained within the selected images
only reflects what the original angiographer saw or
was satisfied in seeing. These images are crucial for
treatment decisions and may lead a patient down
the path to surgery, percutaneous revascularization,
or medical therapy.
When it comes to the planning and execution of
percutaneous coronary interventions, a more
sophisticated understanding of the three-dimensional
coronary tree is required. The visual skills of the
operator working in the world of two-dimensional
images become a critical determinant of procedure
outcome. Cardiologists, who are now under
tremendous time constraints in a field of ever-
increasing complexity, need advances in angio-
graphic imaging technology that remove some of
their day-to-day burden, and improve safety for their
patients. The development of rotational angiography
and three-dimensional (3D) coronary modeling are
two such advancements which are poised to
significantly improve the safety and efficacy of
coronary angiography/interventions, and pave the
way for future applications in non-cardiac angio-
graphic imaging and imaging systems integration.
Percutaneous coronary interventions have grown
over the past two decades to become the most widely
employed revascularization method for the treatment
of coronary artery disease.
With the advent of drug-eluting stents and other
new devices, the frequency of percutaneous
revascularization procedures is expected to double in
the coming years. Driven by advances in technology,
interventional procedures are also becoming
increasingly more complex.
Today we can successfully treat very ill patients with
two or three complex coronary blockages during a
single procedure. But the demands on interventional
cardiologists today are immense. The large volume
of highly complex intravascular procedures reflects
a growing need for vascular imaging technology to
provide rapid, efficient, and accurate information,
while at the same time improving patient and
operator safety.
Over the years, studies of intravascular ultrasound,
angioscopy and pathologic analysis have
demonstrated the limited diagnostic accuracy of
traditional angiography. Traditional angiography has
been unable to provide reliable data on the degree
of lumen narrowing, lesion length, and plaque
morphology, particularly in the presence of complex
or eccentric lesions [1-7]. Sub-optimal projections
and incomplete exploitation of the angiographic
information obtained from traditional angiographic
images may explain at least some of the diagnostic
inaccuracy. But despite the importance of the
information, there has been little advancement in
the technique of image acquisition and the post-
acquisition processing of images since the advent of
coronary angiography in the 1960’s.
X-ray based angiography (biplane or single plane),
using operator-selected ‘fixed’ views, has been the
primary method of performing coronary
angiography since its inception. Angiographic
views have traditionally been chosen on the basis of
‘expert opinion’, and experience based on the
operator's three-dimensional mental perception of
Rotational angiography and 3D coronary modeling:
revolutions in the cardiac cath lab
J.T. Maddux
1
, S.-Y.J Chen
1
, B.M.G. Groves
1
, J.C. Messenger
1
, O. Wink
2
and J.D. Carroll
1
1
Department of
Cardiology, University
of Colorado Health
Sciences Center,
Denver CO, USA.
2
Philips Medical
Systems.
Coronary
interventions
require a good
understanding of
the three-
dimensional
coronary tree.
Percutaneous
coronary
intervention is the
most widely
employed
revascularization
method.
MEDICAMUNDI 47/2 August 2003 9
The rotational acquisition run allows the
cardiologist to efficiently review a large stream of
‘upfront’ data that was quickly gathered during the
diagnostic study. For instance, during a typical
screening rotational angiography protocol, 360
different images are obtained. This compares with
only 6 to 10 separate images obtained using
traditional angiography. Single-image analysis from
the rotational angiogram can be performed by
stopping the playback at any given gantry angle along
the pre-defined trajectory. This provides the
physician with significantly more information about
the coronary tree than would be the case with
traditional angiographic images. And, as an
operator-independent method of image acquisition,
rotational angiography allows physicians to share
a vast amount of standardized angiographic
Rotational angiography
Recently, a new image acquisition technique has been
introduced, in the form of rotational angiography
(RA). The technique is performed on the Philips
Integris Allura monoplane system, which has been
specifically developed for the acquisition of
standard and rotational images of the coronary and
peripheral vasculature.
The rotational technique, which has been developed
at the University of Colorado in collaboration with
Philips Medical Systems, uses high-speed isocentric
rotation of the C-arm imaging assembly over a large
arc to acquire up to 120 different images of the left
or right coronary artery during a single injection of
contrast. Typically, 120° rotations or ‘rolls’ (e.g.
60° LAO to 60° RAO) are completed at a rate of
30°/s for each four-second image acquisition
(Figure 1).
Pre-defined cranial or caudal orientation is also
frequently added to the rotational image acquisition.
For example, a typical screening coronary
angiographic study completed in our cath lab consists
of a 25° cranial and a 25° caudal rotational
acquisition of the left coronary artery and a single
25° cranial rotational acquisition of the right coronary
artery. Rotational ventriculography is then performed
using a 60° LAO to 30° RAO anteroposterior roll
with a two-second end delay for calculating the left
ventricular ejection fraction.
One major advantage of using a rotational technique
is that it provides a robust operator-independent
acquisition of angiographic information, allowing
for standardization of coronary angiography (Table 1).
̆
Figure 1.
Rotational coronary
angiography image
acquisition using a
protocol referred to
as a ‘spin’ with gantry
traveling at 55°/second.
Advantages Disadvantages
More perspectives of the coronary tree Larger field-of-view needed with current image intensifier technology
Produces 3D visual effect No quantification of 3D features
Less reliance on operator’s visual skills Determining optimal views still operator-dependent
Standardized imaging platform Acquisition protocols may be different for specific needs
Less radiation
Less contrast agent
Calibrated for accurate lesion % DS* and
length without a catheter-based system
* Per cent diameter stenosis.
̇
Table 1.
Advantages and
disadvantages of
rotational coronary
angiography.
10 MEDICAMUNDI 47/2 August 2003
and execution of percutaneous coronary
interventions.
Using current X-ray techniques, the complex three-
dimensional spatial relationships of the coronary
arterial tree are displayed as two-dimensional
images. Multiple standard images obtained from
different projection angles allow the angiographer
to mentally reconstruct the 3D structure of the
coronary arterial tree. He or she must then attempt
to quantify critical 3D anatomical values, and then
perform percutaneous intervention on the 3D
coronary tree using the 2D ‘shadow’ image.
Helping the interventionalist to solve these problems
of visualization, and improving patient outcome, are
the two main reasons why 3D coronary modeling
and reconstruction are potentially of immense value.
Over the last decade, 3D coronary reconstruction
algorithms using a pair of angiographic images
acquired from a standard single-plane or biplane
imaging system have been developed and validated
[11-14]. We have subsequently introduced the term
‘modeling’ for this form of 3D data set creation, as
opposed to ‘reconstruction’, which is used to
describe the multiview, CT-based algorithm (Table
2). These algorithms have made it possible to
achieve accurate and reproducible patient-specific
3D displays of the coronary structures.
The majority of the early work was aimed at
validating methodology, analyzing coronary artery
structure and motion, and evaluating the impact of
intracoronary devices on coronary shape. The
primary goal, however, has always been to develop
a seamless on-line tool which can be used in the
clinical arena to improve operator decision making,
reduce procedure time, and improve procedure safety
and outcome. Today, a rapid online 3D coronary
modeling tool using rotational angiographic images
has been developed and validated in a collaborative
data. The rotational acquisition mode for
diagnostic studies is also a safer and more efficient
mode of surveying a patient's coronary artery
tree, as it uses less radiation and contrast while
providing significantly more angiographic
information [8-10].
In addition to providing more angiographic
information, rotational angiography may, in fact,
significantly improve the diagnostic accuracy of
coronary angiography in patients with coronary
stenoses. The rotating two-dimensional image gives
a three-dimensional impression of the coronary tree,
as all the related structures move together.
Rotational angiography may provide more complete
information on coronary blockages, and detect
eccentric coronary stenoses, or stenoses involving
coronary bifurcation points that are not adequately
displayed with the traditional ‘fixed-view’
angiographic modality.
Comparisons of the image content of rotational
coronary angiography and that of traditional
angiography are the subject of studies at the University
of Colorado and other centers.
Rotational angiography, by itself, is currently
limited to diagnostic angiography. Percutaneous
coronary interventions are still performed using a
‘fixed-view’ two-dimensional image format, with
the operator's visual skills remaining central to the
performance of the procedure.
3D coronary reconstruction and modeling
Three-dimensional coronary reconstruction/modeling
is an exciting new technology that has been developed
to aid interventional coronary procedures. The
marriage of rotational angiography with rapid,
online 3D coronary reconstruction/modeling will
provide the perfect platform for accurate planning
Modeling Reconstruction
Centerline based Volumetric based
2D views needed to create 3D model Multiple views needed to create 3D reconstruction
Some user interaction No user interaction
Adaptable to most X-ray systems Requires rotational angiography
Ready for clinical use in all vascular trees Ready for clinical use if vascular tree does not move
(i.e. non-coronary)
̈
Table 2.
3D coronary modeling
vs. reconstruction.
Rotational
acquisition is a
safe and efficient
mode of surveying
the coronary tree.
Rotational angio
with 3D
reconstruction/
modeling is the
perfect platform
for coronary
interventions.
MEDICAMUNDI 47/2 August 2003 11
interpretation of the angiographic information
during device delivery and placement. In an age of
sophisticated and expensive coronary interventions,
the ability to accurately size and position
intracoronary devices is paramount in determining
the cost and outcome of the procedure.
3D QCA
Current 2D analytical tools are used in the
quantitative assessment of vessel segment length
and diameter, but can be affected by vessel overlap
and foreshortening. To quantify a coronary stenosis
accurately, it must be seen in profile, free from
foreshortening and overlap. The current 2D
quantitative coronary analysis has proven to be a
rather inaccurate method for assessing stenosis
effort between the University of Colorado and
Philips Medical Systems [15].
Diagnostic rotational angiograms from the Philips
Integris Allura monoplane system are used for the
3D coronary model creation in the cardiac cath lab,
without the use of calibration objects. The procedure
of modeling the coronary arteries can be completed
in about 5 to 10 minutes. The 3D computer models
can then be manipulated by the operator, either via
a joystick or a mouse, to further evaluate the spatial
relationships of the vascular bed, coronary motion,
and specific details of coronary segments of interest,
without the need for further contrast agent or
radiation.
Quantitative 3D measurements can also be
performed, and may prove to be more accurate than
the current 2D quantitative methodology. With the
increasing use of coronary angiography, it would be
beneficial to have tools that improve both
quantitative analysis and visualization in a patient-
specific fashion, in order to assist decision making
during coronary interventions, as well as to facilitate
the study of the impact of intracoronary devices on
vessel geometry (Table 3).
Optimal view mapping
Catheter-based interventions can only be optimally
performed once the 2D angiographic visualization
problems of vessel overlap and foreshortening have
been successfully solved.
Traditional angiography provides multiple selected
views in which overlap and foreshortening are
subjectively minimized by the operator. To aid
operators in determining the optimal working view
for conducting percutaneous coronary
interventions, an Optimal View

Map (Figure 2)
has been developed for use with the 3D modeling
tool. Once the arterial segment of interest (e.g. a
coronary stenosis) is selected, a set of gantry
angulations minimizing segment foreshortening are
calculated automatically. Multiple computer-
generated projection images with minimum
foreshortening are then created. The operator can
then make a selection from a series of optimized
views to guide subsequent angiographic acquisition
prior to performing the coronary intervention.
During the coronary intervention, the operator can
use the 3D reconstruction to help aid in the
Geometric/anatomic measurements that are
misrepresented in 2D
• Lengths
• Tortuosity/curvature
• Bifurcation angles
Prediction of optimal views
• Minimization of overlap
• Minimization of lesion foreshortening
• Pathway to lesion
• Radiation cost of views
Advanced analysis
• Vessel motion and device analysis
• Spatial relationships of other structures for advanced
interventions
̆
Figure 2.
Optimal View mapping.
Simulation of all
possible views with
computer assistance
in solving traditional
angiographic problems
such as vessel
foreshortening and
overlap. The 3D model
is rotated to the gantry
position marked by
the target cursor on
the color-coded map
of foreshortening of
the proximal LAD
lesion (green line on
model).
̇
Table 3.
Clinically important
tasks that can be
performed from 3D
models and
reconstructions
The ability to
size and position
coronary devices
is paramount.
12 MEDICAMUNDI 47/2 August 2003
and the number of different intracoronary devices
being used (stents, Rotoblator, Cutting Balloon,
IVUS etc.) there comes a need for an improved
understanding of these anatomic characteristics,
which are crucial in determining the coronary
geometry and the success of device delivery. The
impact of these anatomic features is very important
in determining the outcomes of percutaneous
coronary interventions. For example, it has been
shown that proximal vessel tortuosity is a key
determinant for the outcome of percutaneous
intervention [17]. Further, it has been demonstrated
that stent implantation at segment flexion points
increases the rate of angiographic restenosis [18].
Most recently, the longitudinal straightening effects
of stents have been found to be independent predictors
of both clinical and angiographic restenosis [19].
With the advent of drug-eluting stents, deformation
of vessel geometry may play a very important role
severity and lesion length [16]. On the other hand,
intravascular ultrasound, which is considered the
most accurate method for assessing coronary
stenosis severity and lesion length, is an additional
invasive procedure which carries risk and expense
above the angiographic procedure. There is,
therefore, a significant need for an accurate method
of quantitative analysis applied to 3D models and
reconstructions. The three-dimensional quantitative
assessment of volumes, lengths and diameters of
coronary vascular branches and segments from
rotational angiographic projections is one such
method which may significantly improve the
accuracy of current 2D QCA techniques (Figure 3).
Feasibility of device delivery
At present, many anatomic characteristics such as
tortuosity, vessel bifurcation angles and torsion are
qualitatively assessed in only two dimensions. With
the increasing complexity of coronary interventions,
̈
Figure 3.
3D quantification of
vessel length,
tortuosity, and
bifurcation angles of
the right coronary
artery.
1. Define current clinical challenges and emerging percutaneous cardiovascular interventions in the cardiac catheterization
laboratory.
2. Identify issues of patient selection, procedure performance, and outcome assessment that can be facilitated by
rotational acquisition of images, 3D models/reconstructions, and 3D based analysis tools.
3. Develop, test, validate, and implement new tools in the clinical environment.
4. Perform outcomes analysis to document improvements in key areas such as patient safety, procedure success rate, and
procedural efficiency.
̈
Table 4.
Development process
of the University of
Colorado’s 3D
imaging program
‘Integrating
Interventional
Cardiology and
Computer Science’.
Proximal vessel
tortuosity is a key
determinant for
the outcome of
percutaneous
intervention.
MEDICAMUNDI 47/2 August 2003 13
being applied to creating models of the coronary
venous circulation to aid biventricular pacemaker
lead insertion, and to modeling cardiac chambers
and the great vessels. There is also great promise in
the integration of these 3D anatomical models with
other imaging technologies. For example, combining
data from a 3D coronary reconstruction with nuclear
plaque thermography or IVUS plaque composition
data.
Conclusions
Rotational angiography and 3D coronary
reconstruction/modeling are two exciting new
technologies which complement each other and are
likely to have a significant impact on the safety,
outcome and cost of percutaneous coronary
interventions in the near future. As shown in Table
4, these new imaging technologies are based on real
patient needs and are being tested to prove their
impact on clinical outcomes.
in drug delivery variability and restenosis rates.
Importantly, a priori selection of devices based on
patient-specific arterial geometry characteristics may
allow more judicious use of this expensive equipment.
A robust 3D method for analysis of the changes in
coronary shape and motion at any time point during
the cardiac cycle has been developed, and may have
additional value in procedure decision making,
procedure outcome, and in reducing costs [20].
Future applications
The number of X-ray based vascular interventions
is growing rapidly, and these new technologies
facilitate the process of acquiring and effectively
using images. As non-invasive coronary imaging
with CT and MRI becomes more prevalent, the
tools for using invasively acquired images can be
transferred to these platforms as well. Beyond the
applications of 3D coronary modeling in coronary
interventions, this 3D methodology is currently
̆
Figure 4.
Philips Integris Allura
Monoplane System.
Reproduced by
courtesy of Philips
Medical Systems.
Rotational angio
with 3D
reconstruction/
modeling will
benefit safety,
outcome and
costs.
14 MEDICAMUNDI 47/2 August 2003
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