New strategies for intravascular imaging and physiological assessments in the cath lab
Advances in intravascular imaging and physiology assessment are reshaping how interventional cardiologists plan and optimize percutaneous coronary intervention (PCI) procedures, but workflow challenges continue to limit adoption, according to Haroon Faraz, MD, director of interventional cardiology and cardiovascular research at Hackensack University Medical Center. He spoke with Cardiovascular Business at TCT 2025 in San Francisco about how new technology will hopefully address some of those challenges.
"Penetration of any modality that adds extra steps is always a limitation. How many interventionalists at large in the community are actually using these imaging modalities? It's really shameful to say that less than one-third of procedures are being done with these imaging modalities, which is not how we should treat patients because plaque is very complex," Faraz explained. "If you're not using an intravascular imaging modality, the PCI is not optimal."
Intravascular ultrasound (IVUS), optical coherence tomography (OCT) and invasive pressure wire fractional flow reserve (FFR) are considered gold standards to improve outcomes, but there are reasons why these techniques are not being used. Costs are an issue, for example, as are the many minutes these technologies can add to procedure times. The hope is that newer technologies can help improve workflows and lead to wider adoption.
Faraz presented on these topics in TCT sessions, highlighting the use of newer imaging platforms designed to overcome the limitations of traditional modalities. He spoke on the latest imaging modality, near infrared spectroscopy (NIRS) deep OCT from Spectrawave. While IVUS has imaging quality and OCT has limited tissue depth penetration, he said that NIRS deep OCT helps improve intravasular visualization. It also adds NIRS, which can differentiate the type of plaque on the vessel walls, highlighting soft lipid plaques in yellow on the edge of the OCT images so operators know where the edges of vulnerable coronary lesions are located, which is not evident on OCT, IVUS or angiography alone.
He explained that IVUS and OCT each provide partial views of coronary pathology, while newer technologies aim to combine depth and surface-level detail.
“The deep OCT kind of combines both modalities and gives you depth as well as clarity of plaque characterization,” Faraz said. It also adds a way to identify lipid-rich plaques and better inform decision making in the cath lab. FFR also contributes a lot to the understanding of coronary disease, especially the hemodynamics of diffuse disease. However, he noted that not knowing the full story of the lesions by using intravascular imaging or FFR leads to poorer outcomes according to several studies.
"We have learned in the last few years that in spite of patients getting PCI, getting a stent, 25% are going to still remain symptomatic with some form of angina," Faraz said.
A new FDA-cleared epicardial physiology pressure pullback gradient (PPG) FFR tool from Abbott may help address this issue by better differentiating focal from diffuse disease and guiding optimization decisions after stent deployment.
Faraz said wire-based FFR has traditionally been underused in part because of added steps and procedural risk. New angiography-derived FFR (angio-FFR) platforms like Cathworks now offer a noninvasive alternative to using pressure wires. The technology analyzes a recorded contrast injection on angiography and calculates the FFR flow data and presents it on a graphic formate with a 3D reconstruction of the vessel segment and color coding to show the drops in blood pressure.
“So putting a pressure wire down comes at a price,” he said. “No matter how great we are, there will be some percentage of patients who will get harmed by the putting a wire down. So I think Cathworks adds tremendous value.”
However, he acknowledged that some current angio-FFR systems can slow procedures down due to extra data processing and vessel outlining requirements.
Despite growing evidence supporting imaging-guided PCI, Faraz said adoption remains low.
The future of cath labs
Looking ahead, Faraz believes a better integration of imaging, physiology and pre-procedural planning will be key. He also sees coronary CT angiography (CCTA) and artificial intelligence playing key roles going forward.
“I think that's where the future is going to be,” Faraz said, envisioning decision-support tools that combine plaque morphology, physiology and workflow considerations to improve outcomes and reduce the persistent problem of post-PCI angina.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]