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Objectives: Atherosclerotic remodeling of the coronary artery may lead to compensatory enlargement or to shrinkage. Post-mortem data suggest a relation between compensatory enlargement and histopathological markers of plaque vulnerability. In patients that required a coronary intervention, we investigated retrospectively the relation between the angioscopic appearance and the remodeling mode of the culprit lesion. Methods: In 34 patients, coronary angioscopy and intracoronary ultrasound (ICUS) imaging was performed across the culprit lesion before the intervention. Only single de novo lesions were included. With angioscopy, lesions with a smooth surface without thrombus were classified as smooth, whereas lesions with an irregular surface with or without thrombus were classified as complex. With ICUS, remodeling of the culprit lesions was determined by the relative cross-sectional vessel area (lesion vessel area/reference vessel area)100%. Lesions were divided into three groups: compensatory enlargement (relative vessel area 105%), no-remodeling (relative vessel area between 95 and 105%) and shrinkage (relative vessel area 95%). Results: In 22 patients good images were obtained with both imaging modalities. More complex lesions were compensatory enlarged compared to shrunken lesions, whereas more smooth lesions were shrunken compared to compensatory enlarged lesions, 8/9 versus 2/7 and 5/7 versus 1/9, respectively (p=0.035). Conclusions: In patients selected for coronary intervention, angioscopic complex atherosclerotic lesions were found predominantly in compensatory enlarged arterial segments, whereas smooth lesions were found predominantly in shrunken arterial segments.