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Characterization of Complex Coronary Artery Stenosis Morphology by Coronary Computed Tomographic Angiography. Brett M. Wertman, Victor Y. Cheng, Saibal Kar, Heidi Gransar, Ryan A. Berg, Hursh Naik, Rajendra Makkar, John D. Friedman, Jay N. Schapira, Daniel S. Berman

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  1. Characterization of Complex Coronary Artery Stenosis Morphology by Coronary Computed Tomographic Angiography Brett M. Wertman, Victor Y. Cheng, Saibal Kar, Heidi Gransar, Ryan A. Berg, Hursh Naik, Rajendra Makkar, John D. Friedman, Jay N. Schapira, Daniel S. Berman Cedars-Sinai Medical Center, Los Angeles, CA

  2. Disclosures • Funding from the Lincy Foundation (Beverly Hills, California) • Conflicts of interest: None

  3. Background 1 • Contemporary clinical trials1-4 have adopted ≥ 70% diameter stenosis on invasive coronary angiography (ICA) as threshold to qualify for randomization to revascularization 1 RITA-2 trial participants. RITA-2. Lancet 1997;350:461-8. 2 Hueb W, et al. MASS-II. J Am Coll Cardiol 2004;43:1743-51. 3 McFalls EO, et al. N Engl J Med 2004;351:2795-804. 4 Boden, WE, et al. COURAGE. N Engl J Med 2007;356:1503-16.

  4. Background 2 • Stenosis morphology is an important determinant in PCI complication rate1,2 1 Ellis SG, et al. Circulation 1990;82:1193–1202. 2 Ellis SG, et al. Circulation 1991;84:644–653. • Published experience of CCTA performance in complex coronary lesions undergoing PCI have primarily focused on total occlusions3-5 3 Yokoyama N, et al. Catheter Cardiovasc Interv 2006;68:1-7. 4 Soon KH, et al. J Interv Cardiol 2007;20:359-66. 5 Mollet NR, et al. Am J Cardiol 2005 Jan 15;95(2):240-3.

  5. Aims • Determine capability of CCTA in characterizing complex stenosis morphologies • Determine utility of complex stenosis morphology on CCTA in predicting PCI procedure duration and contrast use

  6. Methods • 85 consecutive patients who underwent ICA within 30 days after CCTA • CCTA on a Siemens DSCT scanner 1 PO/IV metoprolol for HR > 70 2 Sublingual NTG 3 Gated, noncontrast CCS 4 Gated, contrast enhanced (92 ml), helical acquired angiography

  7. Methods: CCTA Reconstruction • 0.6 mm thickness, 0.3 mm increment • End-systole: 40% of R-R • Diastole: 65%, 70%, 75%, 80% or R-R • Manual ECG editing for arrhythmic artifact • Sharp kernel if stent present or CCS > 100

  8. Methods: CCTA CCTA Interpretation • Consensus by 2 blinded readers • Vital Images workstation • Native segments ≥ 2.0 mm in diameter • Stented and bypassed segments excluded • Oblique multiplanar reformation and oblique maximal intensity projection preferred

  9. Methods: CCTA CCTA Interpretation Severe stenosis defined by ≥ 70% diameter stenosis on long-axis visual evaluation (see example figures) Quantification of stenosis severity performed independently Proximal LCX Mid RCA

  10. Methods: CCTA CCTA Interpretation Complex stenosis defined by any ACC/AHA Type-C morphology criteria (Ellis SG, et al.) 1) Ostial involvement 2) Major branch involvement 3) Marked vessel tortuosity proximal to lesion 4) > 90º angle at lesion site 5) > 20 mm lesion length 6) Total occlusion

  11. Methods: ICA Acquisition • Standard technique • GE digital X-ray, AGFA Heartlab workstation Data collection • Occurrence of PCI • PCI duration (minutes) • Total contrast use (ml)

  12. Methods: ICA ICA Interpretation • Consensus by 2 blinded readers • Severe stenosis defined by ≥ 70% diameter stenosis on visual inspection • Type-C morphology assessment similar to CCTA • Quantification of stenosis severity performed independently

  13. Methods: Statistics • Continuous variables • Means ± Standard Dev • Ranges • Comparing PCI time and contrast use: • Analysis of covariance (ANCOVA) with adjustments for age and BMI • Analysis of log-transforms performed to satisfy ANCOVA assumptions

  14. Results Population • 74% men • 84% referred either to follow-up on prior SPECT (44%) or for symptoms (40%) • Mean age: 67 ± 11 years • Mean BMI: 27.7 ± 4.6 kg/m2 • Mean Agatston calcium score: 734 ± 873 • Mean heart rate at CCTA: 59 (39 to 112)

  15. Results • 940 segments in 328 arteries were evaluated • 93 segments had ≥ 70% stenosis on ICA by visual inspection • Median stenosis severity 73.3% • 101 segments had ≥ 70% stenosis on CCTA by visual inspection • Median stenosis severity 77.3%

  16. Results CCTA performance in ≥ 70% stenoses • Detected 84 of 93 lesions (90%) • Detected 49 of 52 patients (94%) • False positive in 17 segments and 8 patients

  17. Results * For left main, threshold was ≥ 50% stenosis

  18. Results CCTA performance in ≥ 70% stenotic Type-C stenoses • Detected 42 of 53 lesions (79%) • Detected 31 of 35 patients (89%) • False positive in 7 segments and 3 patients

  19. Results CCTA detection of specific Type-C morphologies • Correctly identified 46 of 62 lesions (74%) • Most frequent false positive: branch involvement (12 cases) • Most frequent miss: lesion length > 20 mm (7 cases)

  20. Results

  21. Examples of Type-C Morphologies on CCTA Ostial LAD involvement Proximal RCA total occlusion LAD Left main plaque crossing LCX and involving ostial LAD LCX

  22. Ostial LAD involvement Proximal RCA total occlusion LAD LAD Left main plaque crossing LCX and involving ostial LAD LCX

  23. Results PCI, Procedure Time, and Contrast Use • PCI performed in 36 patients for 46 lesion (none for total occlusion) • Procedure time available in 34 patients • Contrast use available in 31 patients • Type-C morphology on CCTA was associated with significantly increased procedure duration and contrast use

  24. Results * Adjusted for age and body-mass index † p-values obtained after log-tranforming PCI time and contrast use.

  25. Main Discussion Points • Step-wise assessment of ≥ 70% stenosis followed by presence of Type-C morphology on CCTA emulates real-life evaluation during ICA • Our data showed CCTA detects ≥ 70% stenosis with additional value of identifying Type-C features

  26. Main Discussion Points • Why did CCTA miss long lesions? • Underestimation of true lesion length by standard oblique displays of CCTA • Why did CCTA overcall branch involvement? • Limitations of spatial resolution • ICA underestimated lesion complexity?

  27. Main Discussion Points • Type-C morphology on CCTA was significantly associated with longer PCI procedural time and contrast use • Alerts clinician to higher risk of contrast-induced nephropathy from PCI • Interventionalist may better plan PCI with advanced knowledge of lesion complexity

  28. Limitations • Modest sample size • Referral bias • Severe stenosis on CCTA  more ICA referral • Severe noncalcified lesions  more ICA referral • Contributed to high prevalence of disease • Proximal tortuosity and highly angular lesions not represented • Consensual reading not community practice • Visual assessment has propensity for overestimation

  29. Conclusions • Using a visual cut-off of ≥ 70% diameter stenosis in vessels segments ≥ 2 mm in diameter, CCTA can predict lesions likely to reach ≥ 70% stenosis on ICA and discern associated complex morphologies • Presence of complex, severely obstructive lesions on CCTA predicts greater contrast use and longer procedure duration during PCI

  30. Recommendation • CCTA readers should routinely describe the morphology of each detected severe stenosis

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