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Abstract
Multidetector computed tomography (MDCT) has recently been used as a diagnostic tool for the evaluation of coronary artery morphology and stenosis. The accuracy of MDCT has improved as the number of detectors of MDCT has increased. A 64-MDCT reliably detects significant coronary artery stenosis with a sensitivity and specificity higher than 90%. With its high negative predictive value near 100%, 64-MDCT is very practical for excluding significant coronary artery disease and avoiding unnecessary invasive coronary angiography. Furthermore, preprocedural MDCT coronary angiography is useful to provide additional information and predict the procedural outcomes particularly in patients who have chronic total occlusion and those referred for percutaneous coronary intervention. Postprocedural MDCT coronary angiography usually involves evaluation of in-stent restenosis. Recently, drug-eluting stents are widely used and has notably reduced the rate of in-stent restenosis. However, the rate of in-stent restenosis of drug-eluting stents are still 5~10%. Considering the large number of patients who receive coronary artery stents, MDCT would be clinically useful as a noninvasive tool for the reliable detection of in-stent restenosis. Even with 64-MDCT, 30~40% of stents are not evaluable because the spatial and temporal resolutions are not sufficient for the detection of in-stent restenosis. With the 64-MDCT technology, the accessibility of in-stent restenosis mainly depends on stent size and severity of metal artifact of stents. Although the current MDCT does not permit reliable detection of in-stent restenosis, MDCT can be accepted as a first-line alternative to coronary angiography for the evaluation of stents, especially those with a large diameter such as left main coronary artery stents.
Figures and Tables
Figure 1
Total occlusion of left anterior descending artery. Coronary angiography shows total occlusion of the proximal left anterior descending artery (A). The 3-dimensional volume rendered CT image shows calcification along the occluded segments (B). The curved multiplanar image excellently shows not only the extent of total occlusion but also occluding mixed plaques with calcification and fibrous components (C)
Figure 2
Visualization of patent stent lumen and in-stent restenosis with coronary MDCT angiography. 64-MDCT shows a patent drug-eluting stent in the proximal left anterior descending artery (A). In a different patient, 64-MDCT shows in-stent restenosis in the distal right coronary artery (B). which reveals low-attenuated intra-luminal density
Figure 3
Coronary intervention in chronic total occlusion. A total occlusion is noted from the mid to distal left anterior descending artery (A). The total occlusion is passed by a guide wire with retrograde fashion through a collateral pathway (B). Stenting through the occluded segment is successfully performed (C)
Figure 4
In-stent restenosis in distal right coronary artery. A curved multiplanar MDCT angiography shows a stent at the distal right coronary artery, which was wrongly interpreted as patent (A). The coronary angiogram shows significant in-stent restenosis (B)
Figure 5
CT image reconstruction affecting evaluation of coronary stents. The image that is reconstructed with a sharpkernel for evaluation of stents (B) is superior in evaluation of in-stent lumen to the image that is reconstructed with a soft-kernel for angiographic images (A)
Figure 6
In-stent restenosis and peri-stent small aneurysms of drug-eluting stent. The 64-MDCT image shows in-stent restenosis (arrow) at the distal part with eccentric neointimal proliferation as a low density (A). The coronary angiogram confirms in-stent restenosis (B). Small peri-stent aneurysms are noted (arrowheads in A and B)
Figure 7
Stenting of left main artery and bifurcation. The stents in the left main and bifurcation shows low luminal density, which is suggesting significant restenosis (A). The coronary angiogram confirms significant restenosis of the stents (B)
Figure 8
Stent fracture. A stent was inserted at the proximal right coronary artery. In 2-year follow-up, a stent was inserted at the distal right coronary artery, where significant stenosis was newly developed (A). In 4-year follow up, stent fracture at the proximal segment is noted, which is well depicted in MDCT (arrow in B) and coronary angiography (arrow in C)
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