Introduction to

QAngioXA 3D
Single Vessel Analysis

Confidential 2016
 General introduction
• Frame selection
• 3D modeling
• QFR calculation
• Frame counting for higher QFR accuracy

Confidential 2016
 Frame selection
• ED phase
– How to recognize in left coronary series
• Coronaries in maximum expansion, in the upper location of image
• Just before the contraction of LV, to be recognized by opening of
the aortic valve
• 1 or 2 images before valve opening
– How to recognize in RCA series
• 1 or 2 images before valve opening
• ECG support
– Mostly ~QRS , but there can be a delay between
angiogram and ECG

Confidential 2016
 3D Modelling
• Offset correction
• Start- and endpoint locations
– Initial positions
– Move them
– Zoom and check
• Contour and path line correction
– Fix the path line
– Correction points (adding and removing)
– End of contour
– Hide workspace
– Enlarge viewport
Confidential 2016
 Offset correction point

User indicates the same anatomical landmark to correct for offset (like respiration)

Based on EuroPCR presentation by

Niels Holm, Aarhus University Hospital, Skejby, Denmark 2015 Medis ©
 Always use checkpoints

Indicate the location of two side branches (one in each view) and check if the
corresponding support lines cross the same side branch in the other image. This
steps helps in fine tuning offset correction.
Confidential 2015
 Start of the analysis segment

The user indicates start point in first view. Automatically the corresponding
point is found in the other view
Based on EuroPCR presentation by
Niels Holm, Aarhus University Hospital, Skejby, Denmark 2015 Medis ©
 End of analysis segment

After indicating the endpoint in the first view, the corresponding point is found
and pathlines and contours are detected automatically using our standard 2D algorithms
Based on EuroPCR presentation by
Niels Holm, Aarhus University Hospital, Skejby, Denmark 2015 Medis ©
 Segment for 3D modelling
Startpoint
• Left main

Left main ostial lesion cannot be analyzed. Should be excluded.

 Segment for 3D modelling
Startpoint
• LAD
① ②

Startpoint ①：If there is an occlusion in Left Main

Startpoint ②：If there is no occlusion in Left Main, or
If contouring of LM is difficult due to the vessel overlap
 Segment for 3D modelling
• Diagonal Startpoint

Endpoint

Segment can be started in LAD, but the reference should fit

the diameter of Diagonal.
※Choose other coronary at QFR computation step
 Segment for 3D modelling
• LCx

Startpoint

Start at the bifurcation with LAD. Do not include Left Main

 Segment for 3D modelling
• RCA

Startpoint

RCA ostial lesion cannot be analyzed. Should be excluded.

 Segment for 3D modelling
Key points

• Startpoint should be in principle at Proximal end

• Startpoint should be indicated at the tip of the catheter. Do
not go more proximal than the tip of the catheter.
(Contouring and frame counting are difficult)
• In the analysis of LAD, if there is severe vessel overlap or
contrast cloud at Left main, put startpoint at LAD/LCx
bifurcation.
 3D reconstruction

3D modelling of the vessel is performed in 2 seconds

Based on EuroPCR presentation by
Niels Holm, Aarhus University Hospital, Skejby, Denmark 2015 Medis ©
Wrong correspondence

Confidential 2015
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 3D Diameter Function

• The 3D vessel reconstruction uses an ellipse shape for the

cross section arterial lumen reconstruction. Therefore a
minimum and maximum diameter size of the vessel can be
determined per position (2 graphs).

Arrows: Min and Max diameter

Dots: Support points of 2D art contour
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 3D Diameter Function

• The 3D vessel reconstruction uses a circle shape for the cross

section reference vessel reconstruction, therefore only one
diameter size can be determined per position (1 graph line)

Arrows: One size diameters

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 Reference contours and diameters

In case of diffuse lesions, the automatic reference diameter

function might be found too low. Either use normal areas or
a fixed proxmal reference.
Confidential 2015
 Reference contours and diameters

Check the original acquisitions, and find the proximal and

distal location of normal (most healthy) locations.

Confidential 2015
 Normal reference areas

Normal areas can be moved and adjusted in length.

Interaction is allowed in the diameter function and on the images

Confidential 2015
 Fixed proximal reference

Proximal reference is adjustable in location and diameter.

European advice for LAD prox: Male 3.5 mm and female 3.0 mm.

Confidential 2015
 Requirement Reference Diameter
Function
The obtained reference diameter values should be
realistic according to gender.
For example:
• The reference diameter at the ostium of the LAD
should be
Larger than 3.0 mm for women
Larger than 3.5 mm for men

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 QFR frame counting
• Frame counting checks:
– Only contrast in the catheter
– Catheter properly located / engaged
– Brisk injection
– No ‘leakage’ of contrast before brisk injection
– Is the flow more or less constant?
– Proper visibility of the ‘bolus front’

Confidential 2016
 QFR frame counting

Frame 32 Frame 41

User indicates the frames in which the front of the contrast bolus
enters and exits the segment of analysis to calculate the flow speed

Based on EuroPCR presentation by

Niels Holm, Aarhus University Hospital, Skejby, Denmark 2015 Medis ©
QFR frame counting

Volumetric flow rate =

3D QCA lumen volume /
contrast transport time
 QAngio XA 3D Limitations
• The two 2D Angio images used for the 3D vessel
reconstruction need to be taken with at least 25°
difference in viewing angle
• See Help/Limitations or the User manual for
information on:
– The safety and effectiveness of the QFR measurement
has not been evaluated for patients with the following
conditions:…
– QFR measurements cannot be performed accurately
under the following conditions:…

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 QAngio XA 3D Limitations
• The accuracy of the QFR measurement has not been
evaluated for patients with the following conditions:
– Unstable angina pectoris
– Acute myocardial infarction
– Hyperdynamic heart
– Atrial fibrillation
– Ostial Left Main Coronary Artery or ostial Right Coronary Artery
stenosis
– True bifurcation lesions (111 Medina classification)
– Vessels with retrograde fillings
– Grafted coronary arteries
– Grafts
– Non-coronary arteries
– Myocardial bridge

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 QAngio XA 3D Limitations
• QFR measurements cannot be performed accurately under the following
conditions:
– Too much overlap of other vessels with the lesion or areas just around the
lesion in the target vessel in one or both angiographic acquisitions.
– Too much foreshortening of the target coronary artery in one or both
angiographic acquisitions.
– One or more severe lesions might lead to very low QFR value, much lower
then the corresponding FFR. Clinical decision will be the same (significant
lesion: treatment)
(Causes:
• QFR is tuned for intermediate lesions and not severe lesions.
• FFR is not correct in severe lesions (location of the flow obstructing wire and some other
reasons.)

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 Image Acquisition Guide for QFR

❖ Acquire cine runs shortly after administering I/C Nitro glycerine. A brisk, continuous injection of contrast is
recommended. Make sure the entire catheter is filled with contrast, before injection.
❖ Acquire cine for at least 3 cardiac cycles. Avoid table panning and patient movements.
❖ 2 views at least 25 degrees apart are needed. Ensure the entire target vessel is well opacified in these two
projections.
❖ Use a minimum of 12fps for cine. Do not change the angulation, table height or SID during cine.
❖ Avoid vessel overlap and foreshortening