Rapid three-dimensional quantification of high-intensity plaques from coronary atherosclerosis T1-weighted characterization to predict periprocedural myocardial injury.

BACKGROUND: High-intensity plaque (HIP) on magnetic resonance imaging (MRI) has been documented as a powerful predictor of periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI). Despite the recent proposal of three-dimensional HIP quantification to enhance the predictive capability, the conventional pulse sequence, which necessitates the separate acquisition of anatomical reference images, hinders accurate three-dimensional segmentation along the coronary vasculature. Coronary atherosclerosis T1-weighted characterization (CATCH) enables the simultaneous acquisition of inherently coregistered dark-blood plaque and bright-blood coronary artery images. We aimed to develop a novel HIP quantification approach using CATCH and to ascertain its superior predictive performance compared to the conventional two-dimensional assessment based on plaque-to-myocardium signal intensity ratio (PMR). METHODS: In this prospective study, CATCH MRI was conducted before elective stent implantation in 137 lesions from 125 patients. On CATCH images, dedicated software automatically generated tubular three-dimensional volumes of interest on the dark-blood plaque images along the coronary vasculature, based on the precisely matched bright-blood coronary artery images, and subsequently computed PMR and HIP volume (HIPvol). Specifically, HIPvol was calculated as the volume of voxels with signal intensity exceeding that of the myocardium, weighted by their respective signal intensities. PMI was defined as post-PCI cardiac troponin-T > 5 × the upper reference limit. RESULTS: The entire analysis process was completed within 3 min per lesion. PMI occurred in 44 lesions. Based on the receiver operating characteristic curve analysis, HIPvol outperformed PMR for predicting PMI (C-statistics, 0.870 [95% CI, 0.805-0.936] vs. 0.787 [95% CI, 0.706-0.868]; p = 0.001). This result was primarily driven by the higher sensitivity HIPvol offered: 0.886 (95% CI, 0.754-0.962) vs. 0.750 for PMR (95% CI, 0.597-0.868; p = 0.034). Multivariable analysis identified HIPvol as an independent predictor of PMI (odds ratio, 1.15 per 10-µL increase; 95% CI, 1.01-1.30, p = 0.035). CONCLUSIONS: Our semi-automated method of analyzing coronary plaque using CATCH MRI provided rapid HIP quantification. Three-dimensional assessment using this approach had a better ability to predict PMI than conventional two-dimensional assessment.

Coronary High-Intensity Plaques at T1-weighted MRI in Stable Coronary Artery Disease: Comparison with Near-Infrared Spectroscopy Intravascular US.

Background The histologic nature of coronary high-intensity plaques (HIPs) at T1-weighted MRI in patients with stable coronary artery disease remains to be fully understood. Coronary atherosclerosis T1-weighted characterization (CATCH) enables HIP detection by simultaneously acquiring dark-blood plaque and bright-blood anatomic reference images. Purpose To determine if intraplaque hemorrhage (IPH) or lipid is the predominant substrate of HIPs on T1-weighted images by comparing CATCH MRI scans with findings on near-infrared spectroscopy (NIRS) intravascular US (IVUS) images. Materials and Methods This study retrospectively included consecutive patients who underwent CATCH MRI before NIRS IVUS between December 2019 and February 2021 at two facilities. At MRI, HIP was defined as plaque-to-myocardium signal intensity ratio of at least 1.4. The presence of an echolucent zone at IVUS (reported to represent IPH) was recorded. NIRS was used to determine the lipid component of atherosclerotic plaque. Lipid core burden index (LCBI) was calculated as the fraction of pixels with a probability of lipid-core plaque greater than 0.6 within a region of interest. Plaque with maximum LCBI within any 4-mm-long segment (maxLCBI4 mm) greater than 400 was regarded as lipid rich. Multivariable analysis was performed to evaluate NIRS IVUS-derived parameters associated with HIPs. Results There were 205 plaques analyzed in 95 patients (median age, 74 years; interquartile range [IQR], 67-78 years; 75 men). HIPs (n = 42) at MRI were predominantly associated with an echolucent zone at IVUS (79% [33 of 42] vs 8.0% [13 of 163], respectively; P < .001) and a higher maxLCBI4 mm at NIRS (477 [IQR, 258-738] vs 232 [IQR, 59-422], respectively; P < .001) than non-HIPs. In the multivariable model, HIPs were independently associated with an echolucent zone (odds ratio, 24.5; 95% CI: 9.3, 64.7; P < .001), but not with lipid-rich plaque (odds ratio, 2.0; 95% CI: 0.7, 5.4; P = .20). Conclusion The predominant substrate of T1-weighed MRI-defined high-intensity plaques in stable coronary artery disease was intraplaque hemorrhage, not lipid. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Stuber in this issue.

Successful bypass restenting across the struts of an occluded subintimal stent in chronic total occlusion using a retrograde approach.

Recently, subintimal angioplasty has been introduced as a bailout strategy to improve the success rate of PCI for vessels with CTO. However, the long-term outcome of subintimal angioplasty has not been determined, and a limitation of subintimal angioplasty is the uncertainty in making the re-entry point. We report two cases, where occlusive in-stent restenosis occurred in a stent implanted in the subintimal space of the RCA that had CTO. These two cases were successfully treated with bypass restenting across the struts of an occluded subintimal stent using a retrograde approach. A retrograde wire crossed the occluded segment through the lumen along the outside of the stent and reentered the inside of the stent across the stent struts. The reverse CART technique followed by multiple restenting across the stent struts restored antegrade flow. Follow-up angiography demonstrated the patency of the RCA.

Approach for chronic total occlusion with intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking technique: single center experience.

BACKGROUND: Controlled antegrade and retrograde subintimal tracking (CART) or reverse CART techniques is the final step for percutaneous revascularization of coronary chronic total occlusion (CTO), but it still represents technical challenges and risk in interventional procedures. OBJECTIVES: Our purpose was to utilize intravascular ultrasound (IVUS)-guided reverse CART approach for percutaneous revascularization of CTO in our heart center, focusing on its safety, efficacy, and latest technical developments. METHODS: From November 2006 to November 2012, 49 patients with CTO failed to antegrade and/or retrograde percutaneous revascularization of CTO from true lumen to true lumen were enrolled in and underwent IVUS guided reverse CART approach. RESULTS: The mean J-CTO score of cases was 2.5. IVUS guidance was successfully implemented in 95.9%; IVUS identified that 61.7% of retrograde wires were located at intimal space, and 59.5% of antegrade wires were located at subintimal space. A Corsair channel dilator was used in 77.6% of cases. The success rates of technique and procedure were 95.9% and 93.9%, respectively; the technical minor complications were observed in 10.2% of cases, without significant clinic outcomes; 2.0% of cases occurred with a major adverse cardiac event of non-ST-elevation myocardial infarction; and no case occurred with target vessel revascularization or death. The mean length of stent implanted in a single CTO vessel was 51.3 mm. No patient appeared with radiation dermatitis and contrast-induced rise of creatinine. CONCLUSIONS: IVUS guided reverse CART approach is effective and safe for percutaneous revascularization of complex CTO, with a high success and a low complication rate. It is feasible to develop this approach for percutaneous revascularization of complex CTO. However, suitable case selection and lately device handling by experienced operators are the crucial points of success.

Complementary Roles of Near-Infrared Spectroscopy and Intravascular Ultrasound in the Prediction of Periprocedural Myocardial Injury.

BACKGROUND: Lipid-rich plaque detected by near-infrared spectroscopy (NIRS) and attenuated plaque detected by intravascular ultrasound (IVUS) predict periprocedural myocardial injury (MI) following percutaneous coronary intervention (PCI). Although echolucent plaque detected by IVUS was reported to be associated with a no-reflow phenomenon in acute myocardial infarction, it remains unclear whether echolucent plaque is predictive of periprocedural MI following elective PCI. We aimed to elucidate whether echolucent plaque is independently associated with periprocedural MI after elective PCI and whether the predictive ability for periprocedural MI is improved by the combination of NIRS and IVUS. METHODS: This retrospective study included 121 lesions of 121 patients who underwent elective NIRS-IVUS-guided stent implantation. Periprocedural MI was defined as post-PCI cardiac troponin T > 70 ng/L. A maximum 4-mm lipid core burden index > 457 was regarded as lipid-rich plaque. Echolucent plaque was defined as the presence on IVUS of an echolucent zone and attenuated plaque as an attenuation arc > 90°. RESULTS: Periprocedural MI occurred in 39 lesions. In multivariable analysis, echolucent plaque, attenuated plaque, and lipid-rich plaque were independent predictors of periprocedural MI. Adding echolucent plaque and attenuated plaque to lipid-rich plaque improved the predictive performance (C statistic 0.825 vs 0.688; P = 0.001). Periprocedural MI increased with the number of predictors: 3% [1/39], 29% [10/34], 47% [14/30], and 78% [14/18] for 0, 1, 2, and 3 predictors, respectively (P < 0.001). CONCLUSIONS: Echolucent plaque is a major predictor of periprocedural MI, independently from lipid-rich plaque and attenuated plaque. Compared with NIRS alone, the combination of NIRS with IVUS signatures improves the predictive ability.

Quantification of Low-Attenuation Plaque Burden from Coronary CT Angiography: A Head-to-Head Comparison with Near-Infrared Spectroscopy Intravascular US.

Purpose: To determine the association between low-attenuation plaque (LAP) burden at coronary CT angiography (CCTA) and plaque morphology determined with near-infrared spectroscopy intravascular US (NIRS-IVUS) and to compare the discriminative ability for NIRS-IVUS-verified high-risk plaques (HRPs) between LAP burden and visual assessment of LAP. Materials and Methods: This Health Insurance Portability and Accountability Act-compliant retrospective study included consecutive patients who underwent CCTA before NIRS-IVUS between October 2019 and October 2022 at two facilities. LAPs were visually identified as having a central focal area of less than 30 HU using the pixel lens technique. LAP burden was calculated as the volume of voxels with less than 30 HU divided by vessel volume. HRPs were defined as plaques with one of the following NIRS-IVUS-derived high-risk features: maximum 4-mm lipid core burden index greater than 400 (lipid-rich plaque), an echolucent zone (intraplaque hemorrhage), or echo attenuation (cholesterol clefts). Multivariable analysis was performed to evaluate NIRS-IVUS-derived parameters associated with LAP burden. The discriminative ability for NIRS-IVUS-verified HRPs was compared using receiver operating characteristic analysis. Results: In total, 273 plaques in 141 patients (median age, 72 years; IQR, 63-78 years; 106 males) were analyzed. All the NIRS-IVUS-derived high-risk features were independently linked to LAP burden (P < .01 for all). LAP burden increased with the number of high-risk features (P < .001) and had better discriminative ability for HRPs than plaque attenuation by visual assessment (area under the receiver operating characteristic curve, 0.93 vs 0.89; P = .02). Conclusion: Quantification of LAP burden improved HRP assessment compared with visual assessment. LAP burden was associated with the accumulation of HRP morphology.Keywords: Coronary CT Angiography, Intraplaque Hemorrhage, Lipid-Rich Plaque, Low Attenuation Plaque, Near-Infrared Spectroscopy Intravascular Ultrasound Supplemental material is available for this article. See also the commentary by Ferencik in this issue.© RSNA, 2023.

Percutaneous intervention in a patient with a single coronary artery arising from the right coronary sinus of valsalva.

A single coronary artery (SCA) arising from the sinus of Valsalva and supplying the entire heart is a rare congenital anomaly. According to the modified Lipton's classification, R-1 is by far the most rare subtype of SCA, with an incidence of 0.0008% in patients undergoing coronary angiography. We present a case with an unreported anomaly, classified as Lipton R-I subtype, which initially followed the normal course of the right coronary artery. The posterior descending artery then proceeded as the distal and middle sections of the left anterior descending artery, while the posterolateral branch proceeded as the left circumflex artery and finally terminated as the proximal left anterior descending artery. The patient underwent percutaneous intervention in the posterolateral branch for an acute coronary syndrome.

Antegrade approach to stumpless chronic total occlusion of ostial left anterior descending artery: first using a side branch cutting technique.

The approach to a chronic total occlusion (CTO) still remains one of the most technical challenges in percutaneous coronary intervention (PCI). CTO lesions with a blunt entry point, calcification, and failure of a previous approach, are the independent predictors of CTO-PCI failure. Here we report a successful antegrade approach for reattempted CTO-PCI of a left anterior descending artery (LAD) with unknown, calcified ostium. We used a novel side branch cutting technique, combined with intravascular ultrasound-guided wiring and parallel wire techniques. Considering the ramus artery as a side branch and dilating it with a cutting balloon was a crucial part of the strategy for achieving overall procedural success using this approach. This is the first report describing a side branch cutting technique in CTO-PCI. The combined application of multiple antegrade techniques, using the latest devices, might provide an effective and safe approach for complex CTO-PCI.

Successful IVUS-guided reentry from iatrogenic coronary arteriovenous fistula related to wire perforation following wiring of a totally occluded vessel.

We experienced a rare case in which a guidewire was advanced into a coronary vein through an arteriovenous fistula caused by wire perforation. The patient, who had chronic total occlusion (CTO) of the left circumflex coronary artery, was treated successfully with a procedure guided by intravascular ultrasound (IVUS). The IVUS-guided parallel-wire technique allowed recrossing of the guidewire into the distal true lumen of the CTO by identifying the anatomy of the occluded segment and the appropriate re-entry point. Angiography demonstrated that the fistula was completely sealed after stent deployment, and there was no extravasation.

Impact on clinical outcomes of predilatation using the kissing-balloon technique for crossover stenting in true coronary bifurcation lesions.

BACKGROUND: Provisional crossover stenting has the potential risk of side-branch (SB) compromise, which may result in periprocedural myocardial infarction. Predilatation is a useful technique to prevent SB compromise. OBJECTIVES: The aim of this study was to assess the safety and efficacy of predilatation using the kissing-balloon technique (preKBT) during provisional crossover stenting compared with sequential predilatation on clinical outcomes in true coronary bifurcation lesions. METHODS: We retrospectively evaluated 204 consecutive non-left main true bifurcation lesions (182 patients) in whom provisional crossover stenting was performed with preKBT (preKBT group, n = 144) or sequential predilatation (sequential group, n = 60) from March 2006 to February 2012. RESULTS: There were 30 lesions (20.8%) in the preKBT group that developed SB ostial dissection compared with 8 lesions (13.3%) in the sequential group (P=.241). There was no SB flow impairment or SB access failure due to SB ostial dissection. SB compromise (Thrombolysis in Myocardial Infarction <3) immediately after crossover stenting occurred in 5 lesions (3.5%) in the preKBT group versus 7 lesions (11.7%) in the sequential group (P=.043). Major adverse cardiac events at 6-8 months of follow-up were observed in 5 lesions (3.5%) in the preKBT group versus 8 lesions (13.3%) in the sequential group (P=.022). CONCLUSIONS: Regardless of more complex bifurcation lesions in the preKBT group, preKBT successfully prevented SB compromise due to crossover stenting without unfavorable complications and improved the mid-term clinical outcome compared with sequential PTCA in patients with non-left main, true coronary bifurcation lesions.

Combined treatment of trans-catheter coil embolization and modified covered stent implantation for ruptured saphenous vein graft aneurysm in patient with recurrent congestive heart failure.

This is the case of an 85-year-old woman, who developed a large aneurysm of the saphenous vein graft to the left circumflex coronary artery with a fistulous communication to the left atrium (LA) after being asymptomatic for 18 years post-coronary artery bypass graft surgery. She suffered from recurrent congestive heart failure due to the extra abnormal flow and pressure overload to the LA. Because of high risk of re-operation, we performed a combined treatment of trans-catheter coil embolization and modified covered stent implantation. After successful treatment, cardiac multi-slice computed tomography revealed almost completely decreased trans-fistulous flow to the LA.