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The most important role of coronary angiography is to delineate coronary lesions that cause inducible ischaemia. It remains the primary tool influencing the decision to undertake revas‐ cularization and patient outcomes [1] [2-4]. However, there are inherent limitations to diag‐ nostic angiography. These pitfalls include difficulties delineating eccentric plaque (that can be underappreciated in the absence of multiple angiographic views), difficulty assessing le‐ sions of moderate severity, the assessment of overall plaque burden and the composition, appreciation of ostial lesions, culprit lesion assessment in acute infarct patients and side branch analysis in bifurcation lesions. Heavily calcified lesions can also produce hazy angio‐ graphic appearances which often leaves the operator at a loss to determine the actual true lumen path and in some circumstances even misdiagnose calcification as “pseudothrom‐ bus” [5]. This latter phenomenon significantly changes the approach to intervention. The ar‐ tery can be put at risk of perforation in the absence of adequate lesion preparation or wire induced dissection as calcified plaque is often undermined, complex and much more diffi‐ cult to wire than soft thrombus.

Improving the Utility of Coronary Angiography: The Use of Adjuvant Imaging and Physiological Assessment