The purpose of this study was to evaluate the accuracy of dual-axis rotational coronary angiography (DARCA) for coronary lesion assessment by directly comparing with intravascular ultrasound (IVUS). From October 2014 to December 2015, 40 patients (58 lesions) who had undergone both DARCA and IVUS were included in the image analysis. The minimum lumen diameter (MLD), lesion length, reference vessel diameter (RVD) and percent diameter stenosis at the same lesion, were identified and assessed. Significant correlation with IVUS was found for DARCA in either lesion length (r = 0.90, P < 0.001) or RVD (r = 0.81, P < 0.001) comparison. DARCA had fair correlation with IVUS for both MLD (r = 0.65, P < 0.001) and diameter stenosis (r = 0.48, P < 0.001). From the Bland–Altman plots, there was a good agreement between DARCA and IVUS regarding MLD (mean difference: −0.23 mm, 95 % limits of agreement: −0.96 to 0.50 mm) and RVD (mean difference: −0.15 mm, 95 % limits of agreement: −0.85 to 0.55 mm), while lesser agreement was found on lesion length (mean difference: −3.39 mm, 95 % limits of agreement: −12.63 to 5.85 mm) and diameter stenosis (mean difference: 4.82 %, 95 % limits of agreement: −17.05 to 26.68 %). There is an adequate correlation and agreement between DARCA and IVUS in coronary lesion assessment.