COVER STORY
Angiographic
Characterization of
Lesion Morphology
Are the AHA/ACC and SCAI lesion classifications still useful?
BY LLOYD W. KLEIN, MD, AND RONALD J. KRONE, MD
A
ccurate characterization of the degree of risk
entailed in performing interventional proce-
dures is the key to optimal clinical decision
making. It has been recognized since the
inception of percutaneous coronary intervention (PCI)
that lesion morphology is a major determinant of both
clinical and technical success and a predictor of compli-
cations. It is intuitive that the way a lesion appears
angiographically reflects its specific composition, which
would suggest its likely response to mechanical manipu-
lation and catheter-based treatment. In addition to
identifying individual morphological factors that pre-
dict success, a risk prediction model can be developed
by combining these factors to facilitate quantification
of risk. Risk models are useful in offering a realistic
assessment to the patient and family, assisting the oper-
ator to evaluate technical concerns, and providing an
objective framework for benchmarking and quality
assurance.
In this article, the history of angiography-based risk
assessment models for coronary interventions is
reviewed in depth. The limitations inherent in a mor-
phologic approach to PCI risk assessment are consid-
ered, and the appropriate use of lesion classification in
modern practice is described. Finally, we address the
importance the practicing interventionist should place
on existing analytic systems, which includes both mor-
phologic characterization and clinical factors.
T H E A H A / ACC TA S K F O R C E C R I T E R I A
In the early days of balloon angioplasty, when compli-
cation rates were significantly higher than in contempo-
rary practice, deciding which patients and stenoses to
44 I CARDIAC INTERVENTIONS TODAY I JULY/AUGUST 2008
avoid and which to preferentially treat was a complex
problem rendered even more difficult by the apparent
randomness of relatively frequent adverse events.1
Initially, balloon angioplasty had complication rates of
10% to 15%; in modern practice, PCI is associated with
mortality and emergency bypass rates of less than 1%.2
This marked improvement in PCI outcomes is primarily
the consequence of advancements in technique,
devices, adjuvant medical therapy, and improved case
selection, all of which were developed to a large extent
specifically to treat the difficult lesion types identified
early in the angioplasty experience. The many innova-
tions in PCI technique and the resultant delivery of pre-
dictable and durable results are testaments to the his-
torical value of these classification schemes.
The first systematic attempt to identify angiographic
factors predictive of increased risk was made by the
National Heart, Lung, and Blood Institute Registry in
1984.3 Faxon and coworkers found that circumflex
artery location, lesion calcification, proximal tortuosity,
eccentric geometry, and a severe stenosis were associat-
ed with reduction in success, which was defined as
≥20% improvement in stenosis diameter. The severity of
the lesion and its geometry were especially critical in
the early experience; keep in mind that in 1983, a bal-
loon could traverse a lesion in just 75% of cases when it
was attempted. Hence, a subtotal lesion had just a 59%
likelihood of success in that registry, and the success
rate was only 37% for total occlusions. This background
is important: improvements in technique throughout
the evolution of PCI substantially altered the factors
that predict success, producing the “moving target” rec-
ognized today.

Combining this experience and the published work of
Gruentzig and others, the American College of
Cardiology (ACC) and the American Heart Association
(AHA) devised a lesion classification system intended to
predict PCI outcomes.4 The system grouped the individ-
ual criteria into three large categories based on antici-
pated rates of success (Table 1). Originally, it was
expected that low-risk type A lesions would have a suc-
cess rate of >85%, moderate-risk type B lesions were
predicted to have a 60% to 85% success rate, and high-
risk type C lesions had a <60% success rate. The charac-
teristics of each lesion class differed by degree of proxi-
mal tortuosity, angulation of the stenosed segment, the
length of the lesion, and the presence of total occlusion,
bifurcation lesions, or thrombus or friable vein graft
lesions. Notably, this classification system was never val-
idated or tested empirically for its accuracy or utility
before its publication as a guideline.
Ellis et al evaluated these criteria in more than 1,000
lesions from the Multivessel Angioplasty Prognostic
study.5 They found that angulated stenosis, high-grade
stenosis, chronic total occlusion lesions, bifurcation
stenosis, and male gender were associated with reduced
success rates; the other factors in the AHA/ACC system
were not predictive. Overall angiographic success
occurred in just 82.6% of patients, reflecting the state of
the art of that era. They confirmed the usefulness of the
ACC/AHA classification for predicting success in general
but found that actual rates of success ranged from 92%
for type A lesions to 60% for type C lesions. To improve
the clinical utility of the system, they introduced a
modification to the B lesion class, adding a class B2 for
patients who had more than one B criterion.
Other investigators also found that the AHA/ACC
classification was not especially accurate as a predictor
of outcomes and identified several critical limitations.
Moushmoush et al6 found, in cases of multivessel angio-
plasty, that there was no significant difference in out-
comes between types A and B1 lesions, or B lesions gen-
erally. The main distinction was with type C lesions, in
which inability to cross the lesion, rather than the
occurrence of complications, was the determining fea-
ture. Certain morphologies predicted lack of success,
whereas others were associated with more complica-
tions. Myler et al7 found that angioplasty of grafts was
especially risky and unpredictable, reflecting the unpre-
dictability of the occurrence of “no reflow” related to
distal embolization. They also noted that lesions con-
taining two or more type C lesions were especially haz-
ardous. Tan et al8 performed a careful prospective eval-
uation of 729 patients using two independent observers
unaware of PCI outcome at the time of the lesion
COVER STORY
TABLE 1. CHARACTERISTICS OF
ACC/AHA TYPE A, B, AND C LESIONS
Type A Lesions: (High Success, >85%; Low Risk)
• Discrete (<10 mm length)
• Concentric
• Readily accessible
• Nonangulated segment <45º
• Smooth contour
• Little or no calcification
• Less than totally occlusive
• Not ostial in location
• No major branch involvement
• Absence of thrombus
Type B Lesions (Moderate Success, 60% to 85%;
Moderate Risk)
• Tubular (10–20 mm length)
• Eccentric
• Moderate tortuosity of proximal segment
• Moderately angulated, 45º–90º
• Irregular contour
• Moderate to heavy calcification
• Ostial in location
• Bifurcation lesions requiring double guidewires
• Some thrombus present
• Total occlusion <3 months old
Type C Lesions (Low Success, <60%; High Risk)
• Diffuse (>2 cm length)
• Excessive tortuosity of proximal segment
• Extremely angulated, >90º
• Inability to protect major side branch
• Degenerated vein grafts with friable lesions
• Total occlusion >3 months old
Adapted from Ryan TJ et al. Circulation. 1988;78:486-502.4
review. These procedures, performed from 1990 to
1993, had an overall success rate of 91%, with major
complications in 3.3%. In a careful comparison of the
ACC/AHA lesion subclasses, they found no difference
between classes A and B1. Although there was a statisti-
cally significant difference between B1 and B2 lesions,
the absolute difference in success rate was not nearly as
substantial as predicted. Abrupt closure occurred in
2.1%, 2.6%, and 5% of type A, B, and C lesions, respec-
tively; again, only the C class was significantly lower.
They also evaluated the success and failure rates of indi-
vidual criteria within a class and found that the impact
of individual criteria varied considerably. Type B charac-
teristics had a success rate ranging from 74% to 95%
and an abrupt closure rate ranging from 2.2% to 14%.
Type C characteristics had a success rate ranging from
JULY/AUGUST 2008 I CARDIAC INTERVENTIONS TODAY I 45
 COVER STORY
Figure 1. Success rates with ACC/AHA system. Adapted from
Krone et al.15
57% to 88% and an abrupt closure rate ranging from 0%
to 16%. Longer lesions, calcified lesions, diameter steno-
sis of 80% to 99%, and presence of thrombus were pre-
dictive of a lower success rate. Longer lesions, angulated
lesions, diameter stenosis of 80% to 99%, and calcified
lesions were predicted an abrupt closure. The investiga-
tors concluded that the AHA/ACC classification scheme
was “outdated and needs to be changed for application
in current angioplasty practice.”
The introduction of stents and other devices in the
late 1990s represents the beginning of the modern era
of intervention. Two studies evaluated whether lesion
morphology remained predictive in this era. Zaacks et
al9,10 showed that success rates in the A, B1, and B2
classes were similar, ranging from 96.3% to 95.1%,
whereas the success rate with class C lesions was 88.2%
(P <.0001). They found that total occlusion and vessel
tortuosity, both criteria for C classification, predicted
procedure failure but not complications, whereas
thrombus, bifurcation lesions, inability to protect a
major side branch, and degenerated vein grafts were
strongly associated with increased complications. Ellis et
al11 also tested the relationship between lesion charac-
teristics and complications in the early stent era. After
evaluating 27 candidate variables, nine were found to
be useful to predict complications, most of which were
present in the AHA/ACC classification. However, several
variables not included in the AHA/ACC criteria were
predictive (eg, filling defects), whereas others that are in
the classification system were not valuable.
THE SCAI SIMPLIFIED
C L A S S I F I C AT I O N S C H E M E
Based on these publications, it was clear 15 to 20
years ago that the B and C lesion categories as originally
proposed were quite heterogeneous and required
amendment based on clinical practice.12 Furthermore, it
46 I CARDIAC INTERVENTIONS TODAY I JULY/AUGUST 2008
Figure 2. Success rate by ACC/AHA lesion class and patency.
Adapted from Krone et al.15
placed together disparate forms of lesion complexity
and vessel anatomy that were not based on clinical
experience or intuition. It was suggested widely that
analyzing specific lesion morphologic characteristics,
rather than applying a general lesion classification score,
might be more useful in assessing risk. Yet the
AHA/ACC did not adjust the classification system sig-
nificantly in subsequent updates,13,14 despite its increas-
ing obsolescence. This was potentially catastrophic
because it ignored the markedly improved outcomes
that new interventional devices, superior pharmacolog-
ic adjuncts, and improved catheter and guidewire tech-
nology had made possible. It also threatened the poten-
tial of developing a sound statistical method to predict
adverse events.
Consequently, the data from the Society of Coronary
Angiography and Interventions Registry (SCAI), collect-
ed in 41,071 single-vessel interventions performed from
1993 to 1996, were used to evaluate the predictive abili-
ty of the ACC/AHA lesion classification system and to
determine if an improved predictive model could be
developed.15 It was demonstrated that vessel patency
has a profound influence on success rates: when classes
B and C are divided into patent and occluded within
each class, no other variable was nearly as predictive.
Additionally, it was confirmed that both B and C classes
are rather diverse with regard to risk. There is no differ-
ence in success rates between the A class lesion and the
patent B class lesion, whereas the success rate of the
patent C class lesion is actually better than the occlud-
ed B class lesion. As a result, the classification system
was restructured into four groups, distinguishing only
the C or non-C classification and whether or not the
lesion was patent or occluded. The SCAI classification
retains its predictive value in the stent era, as shown in
a subsequent evaluation with nearly contemporary PCI
techniques in the ACC-National Cardiovascular Data

I entering clinical status, the lesion class adds little to the
II
III
IV
Figure 3. Success rate by SCAI lesion class. Adapted from
Krone et al.15
Registry (NCDR).16 The ACC/AHA lesion classification
was applied to 61,926 patients undergoing single-vessel
PCI: it was found to be less accurate in predicting major
complications compared with the SCAI lesion classifica-
tion (Figures 1 through 4). The c-statistic for major
complications after PCI, however, was modest for all
systems (0.599 for original ACC/AHA, 0.624 for modi-
fied ACC/AHA, and 0.665 for SCAI lesion classification).
Conversely, the predictive accuracy was better for pre-
dicting success, especially with the SCAI modification
(0.69, 0.708, 0.75 for original, modified ACC/AHA lesion
classification, and SCAI classification, respectively).
The SCAI simplified classification scheme is therefore
far superior as a predictive model of coronary interven-
tion than the AHA/ACC classification system and is a
powerful tool. It produces a better prediction of proce-
dure success and a somewhat improved prediction of
complications than the more complex ACC/AHA lesion
classification system. In addition, the categories are
more homogeneous, hierarchical stratifications of risk
of complications and procedural success. It has
remained the standard tool to evaluate lesion morphol-
ogy both in clinical trials and interventional practice.
O P T I M A L R I S K S T R AT I F I C AT I O N O F
CO RO N A RY I N T E RV E N T I O N
Nevertheless, the NCDR study16 made obvious that
any risk prediction model based entirely on lesion mor-
phology has a substantial inherent weakness. The ability
of lesion morphology to predict the major complica-
tions of myocardial infarction, urgent coronary artery
bypass grafting, or hospital death in the contemporary
PCI era is limited.12 Furthermore, although the SCAI
lesion classification predicts complications to a moder-
ate degree, a critical relationship exists that cannot be
overlooked: complex lesion morphology is associated
COVER STORY
with acuity of presentation. As is intuitive, the more
complex the lesion, the more acutely ill the patient.
Because complications are related to patient acuteness,
especially the presence of acute myocardial infarction,
lesion classification is only a weak independent predic-
tor for complications. In multivariate analysis, after
model in predicting complications. For patients with a
myocardial infarction, death is more likely in those with
initially occluded vessels, regardless of non-C or C class
(SCAI class III or IV), although the emergency CABG
rate is highest in patients with patent class C lesions.
These findings confirmed those of Harrell et al, who
demonstrated definitively that clinical factors are pre-
eminent in predicting complications.17 With the weak
exception of type C lesions, anatomic parameters added
no further information to that provided by clinical sta-
tus, such as cardiogenic shock, acute myocardial infarc-
tion, renal failure, or congestive heart failure.
It was therefore apparent that developing a solely
morphologic-based method to predict PCI risk was not
possible. Hence, for optimal risk stratification, the SCAI
scheme has to be used in association with clinical
parameters. This was the concept behind its inclusion in
the NCDR model of mortality risk.18 C lesions are also
incorporated as one factor in the Mayo Clinic model.19
However, lesion morphology is not included in either
the New York State20 or the Michigan21 models. The
constitution of these well-validated models shows the
particular value, and its relative lack, of lesion morphol-
ogy in the current interventional era.
For example, Singh and colleagues compared the
Mayo Clinic model to the original AHA/ACC classifica-
tion.19 They found that the Mayo Clinic risk score pro-
vides significantly better prediction for cardiovascular
complications, but the ACC/AHA classification is a bet-
ter predictor of angiographic success.
BENEFITS AND CHALLENGES OF
R I S K PR E D I C T I O N M O D E L S
The original concept of a simple score based on
lesion morphology was to reflect the technical difficulty
of the procedure and consequently the likelihood of
success or complications; it was intended to be a
resource to the operator in the prudent selection of
patients. In contemporary practice, few if any operators
calculate such scores routinely. However, familiarity with
those lesion morphologies imparting increased risk is
widespread, and reference to these schemes, either
informally or directly in specific cases, is still a valuable
tool. Additionally, many physicians use the general con-
cepts to explain to patients and their families when risk
JULY/AUGUST 2008 I CARDIAC INTERVENTIONS TODAY I 47
 COVER STORY
Figure 4. Complications by ACC/AHA lesion class. Adapted
from Krone et al.15
is increased and what can be done to minimize the con-
sequences.
The most important current use is as a benchmarking
tool for operators and programs. The overall perform-
ance of the individual laboratory or operator can be
evaluated according to the difficulty of the cases select-
ed.22 Objective classification of risk permits comparison
of the individual operator and laboratory with a general
experience obtained from registry data. It also permits
stratification of patients in large studies to account for,
or control for, the complexity of the actual procedures.
In practice, however, the goal of accurately predicting
PCI results in individual cases has proven elusive.
Coronary intervention has proven to be a dynamic field
in which success and complication rates present a mov-
ing target, sometimes so fast that the procedure has
been improved before the original data can be pub-
lished. The initially expected wide range of performance
in lesions of differing complexity, as predicted by the
original 1988 classification,4 has been compressed sub-
stantially due to improved technology and operator
skills. In addition, developments in adjunctive pharma-
cology have further reduced the risks and improved suc-
cess rates. Furthermore, specific lesion characteristics,
which limit successful intervention by standard tech-
niques, are targeted by device manufacturers as chal-
lenges to overcome. Thus, balloons have become smaller
to aid in crossing tighter lesions, more flexible to negoti-
ate tortuous vessels, and stronger to permit use of high-
er pressures in calcified lesions. Devices to remove
atheromas or burr through calcified lesions have been
developed and, of course, stents have been perfected to
protect against vessel collapse, dissection, and acute
occlusion.
A critical challenge to any classification system involving
morphology assessment is reproducibility of sometimes
highly subjective appearances. The Angiographic Core Lab
48 I CARDIAC INTERVENTIONS TODAY I JULY/AUGUST 2008
of the Bypass and the Angioplasty Investigation (BARI)22,23
incorporated second interpretations by an experienced
investigator blinded to his first reading. The reproducibility
of the intraobserver interpretation of individual features of
the lesions was evaluated. There was an excellent ability to
separate C lesions from A and B lesions, but only moderate
reproducibility separating A lesions from B from C lesions,
and moderate reproducibility identifying angulation. There
was fair to poor correlation for the other lesion characteris-
tics that were evaluated. Kleiman and colleagues reported
interobserver variability of classifying lesions into the
ACC/AHA ABC system.24 Two experienced operators each
evaluated 150 lesions and compared their results. There
was agreement in classification as A, B, or C lesions in only
61% of patients. The distinction between C and non-C
lesions was reproducible at an acceptable level; agreement
in differentiating C from non-C was 81%. Still, this does
show significant interobserver variability even among expe-
rienced operators as part of a research study; in actual prac-
tice, when evaluation of operator skill is partly tied to such
interpretations and the PCI outcome is not blinded, the
capability for “gaming the system” is apparent.
A major problem that has never been formally
addressed is that certain lesion types that remain signifi-
cant challenges can be classified in a much more sophis-
ticated manner than the existing classification schemes
allow. Bifurcation lesions can be classified in several
effective ways that surpass those developed 20 years
ago.25 Complete occlusions, thrombus, and vein grafts
still remain impressive challenges to the intervention-
ist,26,27 and each has a dedicated body of investigation
detailing methods of preventing and protecting against
complications specific to those lesion types. PCI in the
setting of cardiogenic shock28 and in elderly patients29,30
poses significant risks that are not fully recognized by
morphologic-based methods as currently constructed.
Yet another concern is that nearly all currently validat-
ed risk stratification scores are essentially mortality pre-
diction models. Because mortality is an uncommon out-
come relative to other adverse events of PCI, perhaps
emphasis on only this outcome is misplaced. Although
the Mayo Clinic and NCDR models have been shown to
be effective in predicting all major adverse cardiac
events, they are not optimized for this purpose.
Furthermore, although these scores are accurate in pre-
dicting procedural complications, no predictive model
can ameliorate the effect of chance and unanticipated
circumstances innately encountered in invasive treat-
ments. Finally, although current models accurately evalu-
ate procedural risk, they do not address the potential
benefit; consequently, they cannot substitute for clinical
judgment in the absence of an accurate risk-benefit cal-

culation. Perhaps this flaw can be addressed as appropri-
ateness criteria for revascularization are developed.
CO N C L USI O N
The value of the original AHA/ACC classification system
was substantial as a general guide to the relatively inexperi-
enced operators of 2 decades ago. Its publication as part of
the first PCI guideline encouraged the development of
techniques specific for certain high-risk morphologies and
succeeded in reducing the risks in those circumstances.
However, it probably was never highly predictive of out-
comes—its intended purpose. Its utility is even further
ambiguous today with further advancement in procedural
techniques, operator experience, and availability of stents.
The SCAI simplified classification retains some usefulness as
both a clinical and investigative tool. However, morpholog-
ic assessment is no longer a central predictor of PCI out-
comes. Major limitations are its reliance on subjective
angiographic lesion assessment with considerable interob-
server variability and exclusion of important clinical and
acuity of presentation variables that have considerable
influence on the outcome of a PCI procedure. These sys-
tems have been supplanted by and assimilated into a series
of statistically validated risk assessment models that incor-
porate patient-related conditions, acuteness of presenta-
tion, and angiographic- and procedure-related characteris-
tics. There remains a need for more detailed models that
include sophisticated morphologic characterization
derived from large experiences in specific settings that
remain particularly high risk, such as acute myocardial
infarction, vein graft lesions, bifurcations, and thrombus. ■
Lloyd W. Klein, MD, is Professor of Medicine, Rush
Medical College, Chicago, Illinois. He has disclosed that he
holds no financial interest in any product or manufacturer
mentioned herein. Dr. Klein may be reached at lloyd-
klein@comcast.net.
Ronald J. Krone, MD, is Professor of Medicine,
Washington University School of Medicine, St. Louis,
Missouri. He has disclosed that he holds no financial inter-
est in any product or manufacturer mentioned herein. Dr.
Krone may be reached at rkrone@wustl.edu.
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