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16:45 Martin - Non Invasive Imaging
- 1. Non-Invasive Imaging: Applying Findings During Your PCI V Martin-Yuste MD, PhD vmartiny@clinic.ub.es ITC. Hospital Clinic Barcelona. Spain
- 2. MDCT AND CTO: Which morphological parameters can we analyze?
- 3. Stump morphology Diameter of the patent vessel, distal vessel Occlusion length Tortuosity Presence of side branches Calcification
- 4. Diameter of the patent vessel Distal vessel
- 5. Anterograde injection Occlusion length measurement Retrograde injection Angiography
- 8. Bending between CTO and patent vessel
- 9. Bending in CTO body
- 10. Distal vessel analysis and presence of side branch
- 11. Plaque composition/ calcium quantification 99 HU 156 HU 127 HU
- 12. Plaque composition/ calcium quantification 247 HU 409 HU 212 HU
- 13. What do we know about MDCT and CTO?
- 14. What do we know about MDCT AND CTO? 45 patients Predictor factors of PCI failure Occlusion length > 15 mm Blunt stump Severe calcification (>130 HU affecting >50% wall vessel) Multivariate analysis the only independent predictor of procedural success was the absence of severe calcification Mollet et al Am J Cardiol. 2005;95(2):240-243.
- 15. What do we know about MDCT AND CTO? 110 CTO lesions Morphological parameters analyzed: Target vessel bending Shrinkage Severe calcification (density of calcium >500 HU affecting around 360º of the wall vessel) Presence of side branches Stump morphology Occlusion length in-stent restenosis Independent predictors of failure to cross the occlusion with the wire: Severe tortuosity: 57% vs 95%, p<0.0001 Shrinkage: 44% vs 88%, p=0.0005 Severe calcification: 71% vs 88%, p=0.0356 Ehara et al . J Invasive Cardiol 2009, 21: 575-582
- 16. What do we know about MDCT AND CTO? 64 patients 72 CTO , 64 slice MDCT Procedural success rate: 76% Calcium parameters analyzed: Regional calcium volume Regional calcium score (calcified area x HU (1: 130-190; 2: 200-299;3: 300- 399;4 >400) Relative calcium area (% calcium area/vessel area) at the most calcified cross section of CTO Regional calcium equivalent mass Total calcium score Cho et al. Int J Cardiol 2010: 5;14581): 9-14
- 17. Cho et al. Int J Cardiol 2010: 5;14581): 9-14
- 18. What do we know about MDCT AND CTO? We performed a MDCT in 69 patients with CTO Morphological parameters analyzed Diameter of the proximal and distal patent vessel Occlusion length Bending Presence of side branches Stump morphology calcification Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 19. Calcification Global calcium score Calcium score of the occluded segment Entry point Middle part Distal point Distribution around the circumference of the vessel (arc): Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 20. Prox. Middle Distal ARC CALCIUM 25% 100% 75% HU 85 186 933 Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 21. N Global N=73 success (n=51) Failure (n=22) p CTO length 68 22.6± 16.6 (3-90) 22 ± 17.2 24 ± 15.5 0.46 Lesion length 66 44.2 ± 24.8 (7-100) 42.5 ±(25.1 48.4± 24 0.39 Homocolaterals 72 13 (18.1%) 7(14%) 6 (27.3%) 0.2 Heterocolaterals 69 45 (65.2 %) 29 (60%) 16 (76%) 0.28 Entry point 62 0.56 Tapered 28 (45.2%) 19 (42.2%) 9 (53%) Blunt 34 (54.8) 26 (57.8) 8 (47) Diameter proximal vessel , mm 72 3.6 ± 0.8 3.5 ± 0.7 3.8± 0.9 0.2 Diameter distal vessel, mm 56 2.3± 0.5 2.32 ± 0.5 2.35 ± 0.3 0.4 Proximal branch 73 47 (64.4%) 33 (64.7%) 14 (63.6%) 0.9 Distal branch 70 41 (58.6%) 27 (56.3%) 14 (63.6%) 0.61 Global Calcium score 36 824± 796 743 ± 717 (n=27) 1040 ± 1013 (n=9) 0.47 Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 22. N Global N=73 Success (n=51) Failure (n=22) p HU entry point 69 219.5 ± 195 (50-1270) 194.6 ±146 280.5±278 0.1 HU distal 68 152 ±102 (23-688) 156.1± 109 141 ± 83 0.67 HU middle point 69 180.6± 133 (6-933) 186.6 ± 153 165.7± 64 0.63 Arc Calcium prox. 66 0.048 No 26 (39.4) 21 (47.7) 5 (22.7) <50% 30 (45.5) 18 (40.9) 12 (54.5) >50% 10 (15.2) 5 (11.4) 5 (22.7) Arc Calcium distal 66 0.95 No 31 (47) 20 (45.5) 11 (50) <50% 26 (39.4) 19 (43.2) 7 (31.8) >50% 9 (13.6) 5 (11.4) 4 (18.2) Arc Calcium middle 66 0.037 No 32 (48.5) 24 (54.5) 8 (36.4) <50% 30 (45.5) 16 (36.4) 14 (63.6) >50% 4 (6.1) 4 (9.1) 0 Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 23. Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.
- 24. Conclusions Calcification is the most important predictor of PCI failure It is not possible to obtain a complete high quality study in all patients/lesions analyzed by MDCT The anatomical information acquired is important but not determinant in a significant number of patients, so we can not recommend the routine use of this technique: Difficult cases To understand the cause of previously failed cases In order to establish the correct indications a randomized study is needed
Notes de l'éditeur
- The title of my talk is Non-invasive imaging: applying findings during your PCI. I’ll focus on the role of the multidetector comtuted tomography in planning coronary chronic total occlusion PCI
- Percutaneous recanalization of CTO remains a challenge due to its procedural complexity. The inability to cross the occlusion with the wide wire is the most common cause of failure. CT scanning allows non invasive evaluation of the occluded segment. My presentation is divided in two parts: 1. first I ‘ll show you the different anatomical characteristics that can be assessed by a CT scan 2. then we’ll review the scientific evidence of CT scan usefulness on PCI CTO lesions
- Which morphological aspects are important for interventional cardiologist? Those typically associated with failure and those that can help us plan a strategy during the revascularization. Normally Stump morphology Diameter of the patent vessel and quality of the distal vessel Occlusion length Bending Presence of side branches Calcification We’ll see some examples
- The measurement of the diameter of the patent vessel is more accurate when using CT Scanning because it’s capable of showing the coronary wall. The true diameter of the vessel is underestimated by angiography due to negative remodeling that usually affects vessels with a CTO The quality of the distal vessel is also important because it can change an anterograde approach to a retrograde one if there is diffuse distal disease
- Sometimes it’s very difficult or even impossible to see the true length of the occluded segment when using angio, a simultaneous injection is needed to see it clearly
- But we can overcome this difficulty by using a CT scan, this is the scan of the previous patient, it’s easy to measure the length of the occlusion, it was only 6 mm
- here is another example
- We can also analyze the tortuousity; which means the bending between the CTO and the patent vessel like in this picture that shows a severe bending between the patent proximal right coronary artery and the CTO body
- And also the bending through the course of the CTO body like this example, which is impossible to see on an angio
- It’s also relevant to make clear the presence of side branches near the occluded segment. This picture shows 2 branches arising proximally and distally from the occluded segment.
- When the CT scan shows a density higher than 120 HU it’s accepted there is a significant amount of calcium in the plaque .The Quantification of calcium in cto is determinant because it’s associated with PCI failure. This is an example of a relatively soft plaque ,
- This one is harder, especially in the middle part where it reaches 400 HU
- now we’ll begin with the second part of the speech: what has been publish on CT scanning?
- I ‘ll focus only on the studies on true cto using the European consensus definition: a cto must last more than 3 months and the flow must be TIMI 0 Mollet published the first study on CT scanning and CTO: looking for the Value of preprocedure CT scanning to predict the outcome of PCI CTO. They included 45 patients with cto Predictor factors of PCI failure were the three you can see, but in the Multivariate analysis the only independent predictor of procedural success was the absence of severe calcification
- The study by Ehara was the first in which only CTO experts operators were accepted to conduct the trial, which means they have done more than 100 procedures and mastered retrograde approach 110 CTO lesions were analized The main Morphological parameters analyzed are listed The independent predictors of failure were: Severe tortuosity Negative remodeling Severe calcification: in the multivariate analysis the same factors remained significant
- A few years later Cho published a study that focuses on calcium detection and its quantification It included 64 patients The analysis of calcium was quite complex, here you can see all the elements analyzed
- The occlusion was longer in the PCI-failure group than in the PCI-success group The total calcium scores (“Agatston score”) were higher in the failure group but without statistical significance Regional calcium-related parameters were higher in the PCI failure group. Multivariate regression analysis showed that only relative calcium area was a significant determinant of PCI failure It was the first report to demonstrate an association between quantitatively measured calcium content in CTO lesions and procedural success rate
- In 2012 we published our experience. The aim of our study was to assess the value of CT scanning to predict the success of guidewire crossing in PCI CTO and then to help us better select patients more prone to success. We included 69 patients with 77 cto The morphological parameters analyzed were the most common used. We paid special attention to calcium distribution
- Here’s how the calcium was analyzed: 1 we analyzed the global calcium score on the coronary tree 2 the density of calcium at the entry point , the middle and the distal part of the cto 3 And the distribution of calcium around the wall of the occluded segment: we categorized the information as follows: 0.25.50.75.and.100%
- here is one example of that
- Using anterograde approach the success rate was 62% Two experts blind to the coronary angiography analyzed the CT images I don’t want you to read that really! The main results of the CT are the following: 1 the first thing I would like to highlight is that we are not able to obtain a perfect study in all our patients, some data is missing because of technical issues 2 classical determinant factors of failure as length of the occlusion, blunt stump, presence of side branches…. Did not reach statistical significance in our study 3 failed patients had their arteries more calcified than successful ones but this data does not reach statistical significance
- entry point is harder than the middle or the distal portion of CTO but does not affect success rate only the presence of calcium affecting more than the 50% of the circumference of the occluded vessel at the entry point and in the middle part of the cto body are significantly associated with failure of the procedure
- in the multivariate analysis the only parameter statistically significant was the arc of calcium in the middle part affecting more than 50% of the circumference of the vessel
- To conclude 1. Calcification is the most important predictor of PCI failure but even though density of calcium is relevant the most determinant factor is the calcium distribution around the wall vessel and MDCT is the technology with the highest sensitivity and specificity to analyze that feature 2. But On the other hand we have to keep in mind that it is not possible to obtain a complete high quality study in all patients/lesions analyzed by MDCT 3. Although the anatomical information acquired is important, it is not determinant in a significant number of patients, so we cannot recommend the routine use of this technique: I use it mainly on: Difficult cases: that means patients with previous CABG (for me one of the most difficult) or those with unfavorable anatomic characteristics 2 .Previous failed cases when I can’t figure out the failure mechanisms