Rafał Wolny

Comparison of Usefulness of Percutaneous Coronary Intervention Guided by Angiography plus Computed Tomography Versus Angiography Alone Using Intravascular Ultrasound End Points

The aim of our study was to assess the impact of coronary computed tomographic angiographic (CTCA) guidance on outcomes of percutaneous coronary intervention (PCI). The study was a randomized single-center trial. Consecutive eligible patients with CTCA-detected significant coronary lesions who were scheduled for PCI were randomized to an angiographically guided versus an angiographically plus computed tomographically guided (ACTG) group. In the ACTG group the operator preliminarily planned PCI based on computed tomographic angiogram. The coprimary end points were minimal stent area and minimal reference lumen area assessed in all patients with intravascular ultrasound performed after achieving optimal angiographic results. Seventy-one patients (50 men, mean age 65 ± 8 years) were randomized. After invasive angiography, PCI of 32 lesions (30 patients) in the ACTG and in 32 lesions (30 patients) in the angiographically guided group was performed. A stented segment length was longer and nominal stent diameter tended to be larger in the ACTG group (23.8 ± 6.7 vs 19.5 ± 6.5 mm, p = 0.01; 3.27 ± 0.44 vs 3.09 ± 0.41 mm(2), p = 0.110). Minimal stent area tended to be larger (6.62 ± 2.01 vs 5.80 ± 2.02 mm(2), p = 0.100) and the smallest peri-stent reference lumen area was significantly larger in the ACTG group (6.76 ± 3.01 vs 5.0 ± 1.62 mm(2), p = 0.006) with a smaller plaque burden (50 ± 16% vs 58 ± 13%, p = 0.025). In conclusion, CTCA analysis before PCI significantly influences treatment strategy and results in better lesion coverage as defined by intravascular criteria.

Comparison of Intravascular Ultrasound, Quantitative Coronary Angiography, and Dual-Source 64-Slice Computed Tomography in the Preprocedural Assessment of Significant Saphenous Vein Graft Lesions

The correlation between cardiac computed tomographic (CT) and intravascular ultrasound (IVUS) assessment of saphenous vein graft (SVG) lesions has not been studied. The aim of this study was to evaluate the accuracy of dual-source computed tomography in quantitative assessment of significant SVG lesions scheduled for percutaneous coronary intervention (PCI). Preintervention dual-source CT (DSCT) scans were performed in consecutive patients before PCI of the SVG lesion. All subjects underwent IVUS examination of the target lesion before stent implantation. Lesion characteristics were described using dual-source computed tomography, quantitative coronary angiography, IVUS, and visual estimation. Luminal areas and diameters, lesion lengths, and DSCT suggested stent dimensions were compared. Twenty-two SVG lesions were assessed in 22 patients. Minimal lumen area measured by IVUS was larger than by dual-source computed tomography (3.5 ± 1.2 vs 3.0 ± 1.2 mm(2), p = 0.04), although there was close correlation between measurements (R = 0.7, p = 0.007). Proximal and distal reference lumen diameters by IVUS and dual-source computed tomography were similar (3.3 ± 0.4 vs 3.4 ± 0.6 mm, p = 0.5, and 3.4 ± 0.6 vs 3.5 ± 0.6 mm, p = 0.4, respectively) and were well correlated (R = 0.85, p <0.0001, and R = 0.81, p <0.0001, respectively). Lesion length by IVUS averaged 18.3 ± 6.1 versus 17.6 ± 5.3 mm by dual-source computed tomography (p = 0.1). There was good correlation between mean reference lumen diameter by dual-source computed tomography and diameter of the implanted stent (R = 0.84, p = 0.0009) and a very good correlation between stent length and lesion length as assessed by dual-source computed tomography (R = 0.9, p <0.0001). In conclusion, DSCT measurements in SVGs correlate with IVUS so that DSCT scan data before PCI of an SVG lesion may be helpful in stent size selection.

Coronary computed tomography angiography in planning of percutaneous coronary interventions in bifurcation lesions – study design and rationale

Percutaneous treatment of coronary bifurcations is a complex issue due to numerous possible techniques and high risk of complications. Because of increasing interest in non-invasive imaging in interventional cardiology and growing quality of obtained images, we designed a prospective, randomized, single-blinded trial to evaluate the role of coronary computed tomography angiography (CCTA) in the planning of percutaneous coronary interventions (PCI) of bifurcation lesions. Eighty eligible patients scheduled for PCI of bifurcations in stable coronary artery disease will undergo additional CCTA examination and will be randomized 1: 1 to either planning of PCI using angiography and CCTA or to PCI planning with use of angiography alone. Primary endpoints will include PCI strategy (one or two stents), technique, size of implanted stents and direct angiographic effect of the procedure. Immediate PCI effect measured with intravascular ultrasound (IVUS) and the effect on fractional flow reserve (FFR) in the side branch (in a subgroup of patients), as well as plaque morphology assessed in CCTA, patient radiation exposure and amount of contrast will be compared in secondary analysis. The study is intended to clarify the influence of CCTA analysis on the technique and direct effect of PCI of bifurcations and to provide evidence on the relevance of performing a CCTA scan prior to PCI of bifurcation lesions.

Early occlusion of the non-infarct-related coronary artery following successful primary percutaneous coronary intervention in ST-elevation myocardial infarction

We present a clinical case of early occlusion of the non-infarct-related artery (non-IRA) in a patient with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Several hours after successful percutaneous treatment of the occluded right coronary artery the patient developed a second myocardial infarction, which was caused by acute occlusion of the left anterior descending artery, which had a significant lesion in the proximal segment. The lesion was diagnosed during the first catheterization, but was left untreated. We discuss the potential advantages and risks associated with the ad-hoc multivessel PCI strategy in STEMI.

Relation between coronary plaque calcium deposits as described by computed tomography coronary angiography and acute results of stent deployment as assessed by intravascular ultrasound

Introduction The findings from intravascular ultrasound studies on the impact of calcium deposits on the results of stent implantation are conflicting. Aim To evaluate whether calcium deposits as assessed by (CTCA) influence results of stent deployment. Material and methods The study population comprised 60 patients (43 male; age 64.2 ±8.6 years) who underwent CTCA before stent implantation. Lesion calcium score, total calcium length, and maximal area and maximal thickness of calcium deposits within the lesion segment were assessed. Plaques were divided into those with calcium score ≥ median (group 1), calcium score < median (group 2), and without calcium (group 3). Intravascular ultrasound (IVUS) was performed after attainment of optimal angiographic results of the stent procedure. Focal and diffuse stent expansion was defined as either minimum stent area (MSA) or mean stent area over the length of the stent divided by reference lumen area. Results The proximal reference segments of lesions with higher calcium score contained a larger plaque burden (47 ±12% vs. 41 ±9% vs. 34 ±18%, p = 0.02) – respectively for groups 1, 2, and 3. Positive correlation was observed between lesion calcium score and frequency of post-dilation (R = 0.28, p = 0.03). There was no difference in focal stent expansion (71 ±14% vs. 65 ±15% vs.71 ±15%, p = 0.3) or diffuse stent expansion (92 ±30% vs. 85 ±30% vs. 93 ±38%, p = 0.7) comparing groups 1, 2, and 3. Lesion calcium score, total length of calcium, and maximum area and thickness of calcium deposits did not correlate with focal or diffuse stent expansion. Conclusions Lesions with a higher CTCA calcium score had larger reference plaque burden after stent implantation and more likely required post-dilation, but final stent expansion as assessed by IVUS was not affected by the amount of CTCA calcium provided an angiographically optimal result was achieved.

TCT-387 Morphological Correlates of Symptomatic Progression After Coronary Computed Tomography Angiography-derived High Risk Lesions Are Assessed by Optical Coherence Tomography

Low attenuation plaque (LAP) by coronary computed tomography angiography (CTA) is known to predict coronary ischemic events. We hypothesized that in stable pts in whom CTA showed LAP and who were subsequently treated by PCI after worsening ischemia, OCT may reveal evidence of recent plaque rupture

TCT-836 Unique Calcification Patterns in the Left Main Bifurcation in Patients After Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) accelerates calcium (Ca) proximal to the anastomosis of a patent graft. Optical coherence tomography (OCT) is uniquely able to assess coronary Ca. OCT imaging of the LM bifurcation from either the LAD or LCX was performed in 76 pts with at least one patent

Acute myocardial infarction due to embolisation from the thrombosed coronary artery fistula between the right coronary artery and the left atrium

A 24-year-old woman without previous medical history was admitted to hospital in third hour of acute chest pain. ST-segment elevation in inferior leads was found in the electrocardiogram examination (Fig. 1). Acute myocardial infarction was diagnosed, and the patient underwent immediate coronary angiography, which revealed normal left coronary artery (LCA) (Fig. 2) and thrombotic occlusion in the mid segment of the right coronary artery (RCA) (Fig. 3A). Moreover, an additional thrombosed vessel originating from the proximal segment of the RCA was identified (Fig. 3A). Aspiration thrombectomy was performed and TIMI 3 flow was restored in the RCA (Fig. 3B, C), with full relief of symptoms. No atherosclerotic lesion was identified at the occlusion site (Fig. 3C). The operator attempted opening the vessel originating from the proximal RCA, but the guidewire could not cross it (Fig. 3D). The procedure was stopped and after three days the patient was discharged on dual antiplatelet therapy. Within three weeks the patient was again urgently hospitalised for the same symptoms. Immediately before the angiography the chest pain relieved and angiographic examination showed normal LCA and good result of the previous intervention in the RCA. The morphology of the additional thrombosed vessel originating from the RCA also remained unchanged. Coronary computed tomography angiography (CTA) was scheduled in the tertiary hospital (Fig. 4A–D) showing thrombosed coronary fistula (blue arrow) between the RCA and the left atrium. A portion of the thrombus was protruding to the left atrium (Fig. 4, black arrow). After a Heart Team discussion, the risk of surgical or percutaneous closure of the fistula was assessed as very high, due to the possibility of systemic embolisation. Finally, the decision was made to treat the patient medically with oral anticoagulation. So far, after five years of follow-up, the patient remains asymptomatic. Coronary artery fistulae are rare congenital anomalies found in coronary artery imaging, with an incidence of around 0.1–0.2%. Myocardial infarction caused by embolisation from a thrombus formed inside a fistula is an extremely rare event. In the presented case the operator wrongly assumed that the thrombosed vessel was an anomalous circumflex artery originating from the RCA and attempted (fortunately unsuccessfully) crossing of the vessel with the angioplasty guidewire. The manipulation within the thrombosed fistula may have caused the risk of systemic embolisation because the thrombus was already protruding into the left atrium. This case also shows the value of CTA examination, which led to the final diagnosis of the fistula and the treatment decision. Visualisation of a thrombus protruding into the left atrium discouraged any interventional treatment and indicated the need for anticoagulation.

Ruptured plaque in the left main coronary artery. A benign phenomenon

Intravascular ultrasound (IVUS) allows precise determination of left main coronary artery (LMCA) stenosis. However, in some lesions not only stenosis is of significance, but also the plaque complexity. We present a patient with no-flow limiting LMCA complex lesion. The 51-year-old patient was referred to elucidate the LMCA lesion. His previous history included conservatively treated acute coronary syndrome (ACS) of the inferior wall (several years ago). His first coronary angiography revealed patent right coronary artery (RCA) and non-significant, however angiographically complex plaque in the mid-distal LMCA segment (Fig. 1A, B, 2A). The second ACS due to acute RCA occlusion was treated with bare metal stent implantation to RCA (Fig. 1C, D). Control angiography performed four months later revealed proximally occluded RCA and still present complex LMCA lesion (Fig. 1E, F). IVUS showed eccentric plaque with an empty cavity within the plaque communicating with the lumen and the cavity maximal area of 3.5 mm2. The LMCA cross-section area at this point was 11 mm2 (Fig. 2B–D). Additionally, the angle between the maximum plaque cavity and the left circumflex artery take-off was nearly 180 degrees. Both the RCA occlusion and the complex LMCA lesions were left without interventional treatment. The patient underwent platelet reactivity testing, which did not show any clopidogrel resistance. Pharmacological treatment included dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel. During 14 months of follow-up the patient did not eperienced any adverse cardiovascular event. One may hypothesise that the counter-flow rupture of the plaque (RP) can cause more blood stream turbulences (as in this case), thus promoting thrombus formation, than no-counter-flow rupture. However, there is no evidence for prophylactic rupture sealing by stent implantation (especially as this patient experienced previous RCA stent occlusion). A previous case series suggested that conservative treatment of no-flow limiting lesions with the RP feature is relatively safe. In the study by Rioufol et al. [Circulation, 2004; 110: 2875–2880] half of the 28 RPs had healed at 22 ± 13 months IVUS follow-up. Interestingly, no RP-related factors promoting the healing process were identified. Nonetheless, some issues should be raised. First, the RP cavity in this study was much smaller than in our patient, and the RP cavity even in the non-healed RPs group decreased (from 1.8 mm2 to 0.2 mm2). We did not have baseline IVUS in our patient. The angiographic appearance of the RP cavity, however, did not seem to diminish over the period of seven months (Fig. 1B, F). Secondly, this and other reports did not include patients with RP confined only to LMCA, but also in non-LMCA epicardial arteries. Thirdly, in some RP cases, DAPT may not be enough to prevent thrombus formation and acute artery occlusion. Finally, total LMCA occlusion is potentially catastrophic, especially when (as in our case) no circulatory support from the very proximally occluded RCA exist. Thus, optimal pharmacological treatment, including the length of DAPT and its composition (aspirin plus clopidogrel or more potent antiplatelet drugs), remains unclear. Figure 2. A. Magnification of left main coronary artery; B–D. Corresponding intravascular ultrasound cross-sections with ruptured plaque cavity — seven o’clock (C) Figure 1. Chronologically presented coronary angiographies. A. Patent right coronary artery (RCA); B. Complex left main coronary artery (LMCA) plaque; C. Acute RCA occlusion; D. Opened RCA with stent implantation; E. Chronically occluded RCA; F. Unchanged LMCA plaque A

Comparison of Plaque Burden and Vessel Remodeling in Obstructive Saphenous Vein Graft Lesions as Assessed by Intravascular Ultrasound and Dual-source Computed Tomography.

Purpose: The aim of our study was to compare plaque burden and vessel remodeling of obstructive saphenous vein graft (SVG) lesions as assessed by dual-source computed tomography (DSCT) and intravascular ultrasound (IVUS). Materials and Methods: Preintervention DSCT examination and IVUS were performed in consecutive patients before percutaneous treatment of the SVG lesion. SVG vessel and lumen areas were measured with use of DSCT and IVUS at the minimal lumen area (MLA) site and at proximal and distal reference sites. Plaque burden was defined as the ratio of plaque and vessel area. Remodeling index was defined as the ratio of the SVG area at the MLA site to the mean reference SVG area. Results: Twenty-four obstructive SVG lesions were imaged with DSCT and IVUS before stent implantation in 24 patients. The SVG cross-sectional area at the MLA site measured by IVUS and DSCT was similar (17.0±4.5 vs. 17.3±5.3 mm2, P=0.6) and well correlated (R=0.77, P<0.001). Similarly, plaque burden and remodeling index assessments did not differ significantly between the 2 imaging modalities (79.0%±4.0% vs. 81.0%±8.0%, P=0.18, and 1.09±0.22 vs. 1.07±0.32, P=0.7 for IVUS vs. DSCT for plaque burden and remodeling, respectively). The correlation between IVUS-assessed and DSCT-assessed plaque burden and remodeling index was moderate to good (R=0.55, P=0.01 and R=0.77, P<0.001, respectively, for plaque burden and remodeling index). Conclusions: There is moderate to good correlation between DSCT and IVUS in the assessment of vessel remodeling and plaque burden in obstructive SVG lesions. Noninvasive assessment and monitoring of SVG disease is feasible using DSCT.