BACKGROUND: Histological examination of the effects of balloon angioplasty have been described from in vitro experiments and a limited number of pathologic specimens. Intravascular ultrasound imaging permits real time cross-sectional observation of the effect of balloon dilation on the atherosclerotic plaque in vivo. METHODS AND RESULTS: The morphological effects of coronary angioplasty were visualized at 66 lesions in 47 patients immediately after balloon dilatation with an intravascular ultrasound imaging catheter. Cross-sectional images were obtained at 30 frames per second as the catheter passed along the length of the artery. Quantitative and qualitative assessments of the dilated atherosclerotic plaque were made from the angiograms and the ultrasound images. Six morphological patterns after angioplasty were appreciated by ultrasound imaging. Type A consists of a linear, partial tear of the plaque from the lumen toward the media (seven lesions); Type B is defined by a split in the plaque that extends to the media (12 lesions); Type C demonstrates a dissection behind the plaque that subtends an arc of up to 180 degrees around the circumference (18 lesions); Type D was a more extensive dissection that encompasses an arc of more than 180 degrees (four lesions); and Type E may be present in either concentric (Type E1, 14 lesions) or eccentric (Type E2, 11 lesions) plaque and is defined as an ultrasound study without any evidence of a fracture or a dissection in the plaque. There was a large amount of residual atheroma in each type of morphology (7.8 +/- 2.9 mm2, 61.6 +/- 15.4% of cross-sectional area); there was no difference, however, in lumen or atheroma cross-sectional area among these six patterns. There was a good correlation between ultrasound and angiography for the recognition of a dissection. Calcification was seen in only 14% of lesions on angiography, whereas most lesions (83%) revealed calcification on ultrasound imaging. As determined by intravascular ultrasound, calcified plaque was more likely to fracture in response to balloon dilatation than noncalcified plaque (p less than 0.01). Thirteen of 66 lesions (20%) developed clinical and angiographic restenosis. Restenosis was more likely to occur when the original dilatation left a concentric plaque without a fracture or dissection (Type E1, 50% incidence) compared with a mean restenosis rate of 12% in the remaining morphological patterns (p = 0.053). CONCLUSIONS: Intravascular ultrasound provides a more complete quantitative and qualitative description of plaque geometry and composition than angiography after balloon angioplasty. In addition, intravascular ultrasound identified a subset of atherosclerotic plaque that has a higher incidence of restenosis. This information could be used prospectively to consider other therapeutic options in this subset. Intravascular ultrasound provides a method to describe the effects of angioplasty that will be useful in comparing future coronary intervention studies.