Quantitative coronary arterial stenosis assessment by multidetector CT and invasive coronary angiography for identifying patients with myocardial perfusion abnormalities.

BACKGROUND: Semi-quantitative stenosis assessment by coronary CT angiography only modestly predicts stress-induced myocardial perfusion abnormalities. The performance of quantitative CT angiography (QCTA) for identifying patients with myocardial perfusion defects remains unclear. METHODS: CorE-64 is a multicenter, international study to assess the accuracy of 64-slice QCTA for detecting ≥50% coronary arterial stenoses by quantitative coronary angiography (QCA). Patients referred for cardiac catheterization with suspected or known coronary artery disease were enrolled. Area under the receiver-operating-characteristic curve (AUC) was used to evaluate the diagnostic accuracy of the most severe coronary artery stenosis in a subset of 63 patients assessed by QCTA and QCA for detecting myocardial perfusion abnormalities on exercise or pharmacologic stress SPECT. RESULTS: Diagnostic accuracy of QCTA for identifying patients with myocardial perfusion abnormalities by SPECT revealed an AUC of 0.71, compared to 0.72 by QCA (P = .75). AUC did not improve after excluding studies with fixed myocardial perfusion abnormalities and total coronary arterial occlusions. Optimal stenosis threshold for QCTA was 43% yielding a sensitivity of 0.81 and specificity of 0.50, respectively, compared to 0.75 and 0.69 by QCA at a threshold of 59%. Sensitivity and specificity of QCTA to identify patients with both obstructive lesions and myocardial perfusion defects were 0.94 and 0.77, respectively. CONCLUSIONS: Coronary artery stenosis assessment by QCTA or QCA only modestly predicts the presence and the absence of myocardial perfusion abnormalities by SPECT. Confounding variables affecting the relationship between coronary anatomy and myocardial perfusion likely account for some of the observed discrepancies between coronary angiography and SPECT results.

Intravascular ultrasound assessment and endoluminal stenting of a stenosis in a 50-month-old coronary polytetrafluoroethylene graft.

We report the assessment and management of an 81-year-old patient with a rare stenosis in a 50-month-old polytetrafluoroethylene coronary graft. We concluded that atheromatous plaque was the cause for the stenosis based on the lesion location within the graft and its characteristics by intravascular ultrasound. Differential diagnoses are discussed under consideration of the literature. The lesion was successfully treated using endoluminal stenting.

Quantification of lumen stenoses with known dimensions by conventional angiography and computed tomography: implications of using conventional angiography as gold standard.

BACKGROUND: Quantitative coronary angiography (QCA) has inherent limitations for displaying complex vascular anatomy, yet it remains the gold standard for stenosis quantification. OBJECTIVE: To investigate the accuracy of stenosis assessment by multi-detector computed tomography (MDCT) and QCA compared to known dimensions. METHODS: Nineteen acrylic coronary vessel phantoms with precisely drilled stenoses of mild (25%), moderate (50%) and severe (75%) grade were studied with 64-slice MDCT and digital flat panel angiography. Fifty-seven stenoses of circular and non-circular shape were imaged with simulated cardiac motion (60 bpm). Image acquisition was optimised for both imaging modalities, and stenoses were quantified by blinded expert readers using electronic callipers (for MDCT) or lumen contour detection software (for QCA). RESULTS: Average difference between true and measured per cent diameter stenosis for QCA was similar compared to MDCT: 7 (+/-6)% vs 7 (+/-5)% (p=0.78). While QCA performed better than MDCT in stenoses with circular lumen (mean error 4 (+/-3)% vs 7 (+/-6)%, p<0.01), MDCT was superior to QCA for evaluating stenoses with non-circular geometry (mean error 10 (+/-7)% vs 7 (+/-5)%, p<0.05). In such lesions, QCA underestimated the true diameter stenosis by >20% in 9 of 27 (33%) vs 1 of 29 (3%) in lumen with circular geometry. CONCLUSIONS: QCA often underestimates diameter stenoses in lumen with non-circular geometry. Compared to QCA, MDCT yields mildly greater measurement errors in perfectly circular lumen but performs better in non-circular lesions. These findings have implications for using QCA as the gold standard for stenosis quantification by MDCT.

Effect of stent design on reduction of elastic recoil: a comparison via quantitative intravascular ultrasound.

The increase in minimum lumen diameter achieved by coronary stent placement can be further enhanced by reducing the immediate recoil that occurs after stent deployment. The effect of various stent designs-flexible coils, slotted tubes, and a locking stent-on minimization of postdilation stent recoil was evaluated using an in vitro model of circumferential compression. The stents were expanded to 7 atm (3.82 +/- 0.02 mm); as pressure was reduced, lumen diameter and cross-sectional area (CSA) were determined by on-line intravascular ultrasound imaging (30 MHz) positioned inside the dilating balloon (n = 10-15 inflation-deflation cycles). Stent recoil was assessed by calculation of percent change in CSA from 7 atm to negative balloon pressure: -33.1 +/- 5.6% (GR-II) and -22.4 +/- 3.8% (Wiktor) in the coil stents; -20.0 +/- 4.2% (JJIS coronary), -8.4 +/- 2.6% (JJIS biliary), and -6.9 +/- 1.5% (Multilink) in the slotted tube stents; and -1.9 +/- 3.2% in the Navius ZR1 locking stent (P < 0.05 vs. Multilink, P < 0.0001 vs. others). A range of resistances to recoil is demonstrated by this model, with coil stent designs undergoing greater elastic recoil than slotted tube stent designs. The locking stent design demonstrated the greatest radial strength and the most reduction in elastic recoil.

Axial movement of the intravascular ultrasound probe during the cardiac cycle: implications for three-dimensional reconstruction and measurements of coronary dimensions.

BACKGROUND: Motion of the intravascular ultrasound (IVUS) probe within the coronary artery from cardiac contraction may result in artifacts during 3-dimensional ultrasound image reconstruction and inaccurate measurements of coronary compliance. The purpose of this study was to establish whether longitudinal movement of the IVUS transducer in the coronary artery occurs and to quantify such motion. METHODS: In 31 patients we positioned IVUS transducers at 59 coronary branch points: 41 in the left anterior descending coronary artery, 11 in the left circumflex coronary artery, and 7 in the right coronary artery. In each image sequence the branching vessel oscillated in and out of the imaging plane during the cardiac cycle, confirming longitudinal transducer movement. The extent of movement was estimated by IVUS from the dimension of the branch vessel traversed. In addition, angiographic visualization and measurement of IVUS probe motion was performed at 17 branch points in 12 patients. RESULTS: Average longitudinal transducer movement as measured by IVUS was 1.50 +/- 0.80 mm (n = 46, range 0.5 to 5.5 mm). Because IVUS could not account for probe motion that exceeded the vessel branch diameter, the values obtained represent minimum movement. Average probe motion as assessed by cineangiography in a subset of 12 patients was 2.43 +/- 1.42 mm (range 0.57 to 6.56 mm). CONCLUSIONS: This study establishes that longitudinal movement of IVUS transducers within coronary vessels occurs during the cardiac cycle. Because documented extent of motion may be sufficient to influence analysis, IVUS images are best obtained with electrocardiographic gating.