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Kim, Choi, Suh, and Lee: Cardiac Multidetector Row CT before Percutaneous Coronary Intervention as a Treatment Guide for Chronic Total Occlusion
Cardiovascular Radiology

Journal of the Korean Society of Radiology 2015; 72(3): 147-155.

Published online: 6 March 2015

DOI: https://doi.org/10.3348/jksr.2015.72.3.147

Cardiac Multidetector Row CT before Percutaneous Coronary Intervention as a Treatment Guide for Chronic Total Occlusion

Dong Hun Kim, MD1, Dong Hyun Choi, MD2, Jon Suh, MD3, Nae Hee Lee, MD3

1Department of Radiology, Chosun University Hospital, Gwangju, Korea.

2Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea.

3Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.

Corresponding author: Dong Hun Kim, MD. Department of Radiology, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 501-717, Korea. Tel. 82-62-220-3543, Fax. 82-62-228-9061, dhk1107@hanmail.net

Received 17 September 2014       Accepted 2 December 2014

Copyright © 2015 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The goal of this study was to investigate imaging results from a coronary CT angiography (CCTA) in chronic coronary total occlusion (CTO) before percutaneous coronary intervention (PCI).

Materials and Methods

In 74 patients with CTO, 34 patients was evaluated by using a 64-row multidetector CT scanner prior to the PCI and 40 control subjects with CTO, who only took PCI, were included. The multiplanar reformation of the heart chambers and three-dimensional CT images were used for determining an optimal view. We analyzed and evaluated the success rates of PCI, length of occluded vessel, calcified plaques, occluded side-branches, tapered occlusion, > 45° angulation of occluded artery, and myocardial density < 50 Hounsfield unit (HU).

Results

Success rates of PCI in the two groups, the control group and the experimental group, were not statistically different (p > 0.05). The mean length of occluded arteries was measured as 25 ± 11 mm and 26 cases (74%) had an occlusion length > 2 cm. Calcified plaques proximal to occlusion were detected in 19 cases (54%). Occluded side branches, tapered occlusion, > 45° angulation of occluded artery, and myocardial density < 50 HU were in 11 cases (32%), 9 cases (27%), 6 cases (18%), and 5 cases (15%), respectively.

Conclusion

Although there was no correlation between the CCTA findings before PCI and the success rate of PCI, common findings of CCTA in CTO included an occlusion length > 2 cm and calcified plaques proximal to occluded arteries.

Keywords: Computed Tomography, Angiography, Coronary Vessels, Obstruction, Chronic Total Occlusion

Figures and Tables

Fig. 1

A 54-year-old male with chronic total occlusion in right coronary artery (RCA) and procedure by parallel wire technique.

A. A curved multiplanar reconstruction image of CT angiography shows occlusion of the proximal RCA (solid arrows) with concentric plaque (dashed arrows).
B. Volume rendering image shows easily occluded segment of RCA (solid arrow) and calcified plaque (dashed arrow).
C. Right coronary angiography shows two wires well. One wire (solid arrow) is placed in the dissection plane as guide marker and a second wire (dashed arrow) is a passing wire with the same path parallel to the first wire (solid arrow).
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Fig. 2

A 43-year-old male with chronic total occlusion in left circumflex coronary artery (LCX) and recanalization by intravascular ultrasonogram (IVUS) guided wiring technique.

A, B. In a curved multiplanar reconstruction image of CT angiography (A) and volume rendering image (B), there are short occluded segment (solid arrows) and nodal branch of LCX, just proximal to occlusion (dashed arrows). In this situation such as blunt stump with side branch, failure of guide wire crossing is common. Therefore, IVUS use can be very helpful for completing the procedure.
C. Left coronary angiography shows main wire (solid arrow) and IVUS probe (dashed arrow), well. Asterisk indicates nodal branch of LCX.
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Fig. 3

A 78-year-old male with chronic total occlusion in the proximal left anterior coronary artery (LAD) and procedure by retrograde wire crossing technique. A curved multiplanar reconstruction image (A) and volume rendering image (B) show occlusion of the proximal LAD (solid arrows). LAD os has blunt stump and reverse tapered opacification is seen in the distal segment of occlusion (dashed arrow). Right coronary angiography showed collaterals from the right coronary artery (RCA) to the LAD via septal channels (not shown). The retrograde (solid arrow indicates the RCA os) guidewire through septal branch is located in the LAD, just distal to occluded segment (C). During drilling occluded segment, left coronary angiography shows short occluded LAD segment (solid arrow in D). Finally, the guidewire passed through the occluded segment (not shown).

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Table 1

Baseline Clinical Characteristics

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Variable CTO without CT (n = 40) CTO with CT (n = 34) p-Value
Age (years) 64 ± 12 64 ± 11 0.888
Male:female 30 (75%):10 (25%) 26 (76.5%):8 (23.5%)
Hypertension 25 (62.5%) 25 (73.5%) 0.183
Smoking 12 (30.0%) 10 (29.4%) 0.834
Diabetes mellitus 15 (37.5%) 14 (41.2%) 0.903
Hypercholesterolemia 2 (5.0%) 4 (11.8%) 0.340
CTO vessels (RCA:LAD:LCX) 15:16:9 18:9:6
Unstable angina 34 (85.0%) 28 (82.4%) 0.713
Previous PCI:CABG 4:0 6:0
Ejection fraction (%) 50.0 ± 8.3 55.8 ± 11.5 0.014

Note.-CTO without CT means CTO patient with only coronary angiography. CTO with CT means CTO patient with coronary angiography and CT scan.

CABG = coronary artery bypass graft, CTO = chronic total occlusion, LAD = left anterior coronary artery, LCX = left circumflex coronary artery, PCI = percutaneous coronary intervention, RCA = right coronary artery

Table 2

Lesion Characteristics on CTA and Procedural Characteristics (Recanalization)

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Variable CTO without CT (n = 40) CTO with CT (n = 34) p-Value
CT angiography
 Length in occluded segments (mm) 25 ± 11
  < 10 n = 2
  10-19 n = 7
  20-29 n = 16
  30-39 n = 6
  ≥ 40 n = 3
 Calcified plaque (centric:eccentric) in CT 13 (38.2%):6 (17.6%)
 Decreased myocardial perfusion (< 50 HU) 11 (27.5%) 5 (14.5%)
Conventional coronary angiography
 Calcified plaque 8 (23.5%)
 Occluded side branch 15 (37.5%) 11 (32.4%)
 Tapered occlusion 12 (30%) 9 (26.5%)
 ≥ 45° angulation of the target artery 5 (12.5%) 6 (17.6%)
Percutaneous coronary intervention n = 40 n = 24
 Successful recanalization 38 (95.0%) 20 (83.3%) 0.125
 Procedure time (minutes) 55 ± 28 40 ± 23 0.037

Note.-CTA = CT angiography, CTO = chronic total occlusion, HU = Hounsfield unit

Notes

This work was supported by a grant from the Clinical Medicine Research Institute of the Chosun University Hospital (2012).

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