Characterization of Complex Coronary Artery Stenosis Morphology by Coronary Computed Tomographic Angiography

OBJECTIVES: This study sought to assess the ability of coronary computed tomography angiography (CTA) in identifying complex coronary stenosis morphology before invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). Background: Complexity of stenosis morphology affects PCI success. Whether CTA can detect the entire spectrum of recognized complex stenosis morphologies has not been investigated.

METHODS: All nonbypassed, nonstented, >or=2-mm-diameter native coronary arterial segments in 85 consecutive patients who underwent ICA <or=30 days after CTA were assessed. Two blinded CTA readers qualitatively and quantitatively evaluated all lesions >or=70% stenotic by visual inspection and characterized each as type C or nontype C, according to the modified American College of Cardiology morphology criteria for estimating PCI risk. Results were compared with ICA data similarly analyzed by 2 blinded interventional cardiologists. The PCI procedure duration and contrast use were compared between type C and nontype C lesions identified on both ICA and CTA.

RESULTS: CTA detected 84 of 93 lesions (90%) causing >or=70% stenosis on ICA and correctly characterized 42 of 53 lesions (79%) found to concurrently show type C morphology on ICA. Type C features most frequently missed by CTA were ostial involvement (5 cases) and lesion length >20 mm (7 cases). Major branch involvement was the most frequent false-positive type C feature (12 cases). Mean PCI duration in patients with and without type C lesions on CTA were 42.4 +/- 24.7 min and 21.5 +/- 13.3 min (p = 0.009), respectively; mean total contrast used were 263 +/- 150 ml and 140 +/- 47 ml (p = 0.007), respectively.

CONCLUSIONS: In vessels segments >or=2 mm in diameter, CTA can predict lesions likely to reach >or=70% stenosis on ICA and provide added value in discerning complex morphologies associated with these lesions. Presence of complex, severely obstructive lesions on CTA is associated with higher contrast use and greater procedure length during PCI. Tyrann Mathieu Womens Jersey

PMID: 19679283

Posted in Computed Tomography, Invasive Imaging and tagged , , .

3 Comments

  1. In the context of this paper, the potential role of 3-dimensional imaging with CT for procedural planning should be considered. This has recently been discussed a lot in the context of transcatheter valve repair/implantation but also in the context of PCI e.g. total occlusion.
    There are software programs allowing prediction of orthogonal views for the cath lab. However, the clinical impact is unclear and current consensus guidelines do not recommend CTA for patients with high suspicion of obstructive CAD.

  2. As mentioned above by Dr. Schoenhagen, the clinical implications of the findings in this paper may not be immediately applicable as the population studied does not apply to the current recommended guidelines.

    However, very interesting information is presented. In the discussion, the authors note that even in a population with high suspicion for CAD (and with a mean calcium score of 734), 35% of the >75% stenosis were caused by non-calcified lesions. One of the 2 theories presented to explain this phenomenon is that perhaps the presence of stenotic non-calcified plaque in patients with a high calcium score is associated with clinical findings suggesting worsening of coronary disease status, prompting referral to CTA.

    Can we combine this concept with the recently published paper by Motoyama et al. (https://www.thepreparedminds.com/archives/34) that concluded that patients demonstrating positively remodeled coronary segments with low-attenuation plaques on CT angiography were at a higher risk of ACS developing over time?

  3. Another recent publication assessing the diagnostic accuracy of MDCT vs. conventional catheterization in high-risk patients can be found at PMID: .

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