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HU versus 47–71 HU) [ 74 – 77 ] However, the variability of density measurements within plaque types is large and numerous factors, including the degree of intraluminal contrast attantuation as well as various image reconstruction parameters inﬂ uence the density that is measured by CT within coronary plaques [ 78 , 79 ]. Therefore, accurate clas- siﬁ cation of plaque composition by coronary CTA is not currently possible. On the other hand, some parameters that are more readily available from CT might also contribute to the detection of “vulnerable” plaques. They include a “spotty” pattern of calciﬁ cation, and a large degree of positive remodelling [ 80 – 83 ].

Some characteristics of coronary atherosclerotic plaque that can determined by CT, such as positive remodeling (see Fig. 9.13 ) and low CT attenuation of the atherosclerotic material (below 30 HU), are associated with the occurrence of future acute coronary syndromes [ 83 ]. However, the pres- ence and extent of coronary atherosclerotic plaque seems to be a more robust marker of risk than individual plaque characteristics. Several studies and data based on large registries have been able to demonstrate a prognostic value of atherosclerotic lesions detected by coronary CT angiography both in symptomatic and asymptomatic individuals. An analysis of the clinical CONFIRM registry, including more than 23,000 patients, conﬁ rmed the prognostic value of coronary CT angiography, where the presence of coronary stenoses, but also the presence of non-obstructive plaque was associated with an increased risk of mortality [ 48 ]. However, the hazard ratio for non-obstructive plaque was relatively low

(HR 1.6; 95 % CI 1.2–2.2). Other trials and analyses conﬁ rm similar ﬁ ndings [ 84 , 85 ]. The problematic issue is that while absence of plaque is clearly associated with an extremely good prognosis, the presence of some non-obstructive plaque is very frequent in the population and the positive predictive value regarding future cardiovascular events is very low [ 85 ]. Also, a relevant incremental prognostic value of contrastenhanced coronary CT angiography over coronary calcium measurements has so far not convincingly been demonstrated [ 86 ]. Therefore, coronary CT angiography for the identiﬁ ca- tion of coronary atherosclerotic plaque is currently not recommended for risk assessment purposes in asymptomatic individuals.

Anomalous Coronary Arteries

Coronary CT angiography is an excellent tool to investigate patients with known or suspected congenital coronary artery anomalies (Figs. 9.14 and 9.15 ). Coronary CT angiography can classify both the origin and also the often complex course of anomalous coronary vessels [ 87 – 91 ]. While the necessity for contrast agent injection and radiation exposure are certain drawbacks of CT imaging as compared to MR, which is also a potential diagnostic tool in coronary artery anomalies, the ease of data acquisition and the predictability with which a high-resolution data set with optimal image quality for evaluation can be expected make coronary CT angiography a method of choice for the workup of known or suspected anomalous coronary vessels. Obviously, the use of low-dose image acquisition protocols is recommendable in the often young patients who undergo evaluation for anomalous coronary arteries.

Guidelines and Recommendations

A group of US-based professional societies (both cardiology and radiology) has jointly issued a statement of “Appropriateness Criteria” for cardiac CT in the year 2010 (see Table 9.6 ). The document lists clinical situations in which coronary CTA could be applied, and rates them as inappropriate, appropriate, or uncertain [ 92 ]. Such situations include the use of CT coronary angiography to rule out coronary artery stenoses in patients who are symptomatic, but who have a non-interpretable or equivocal stress test, who are unable to exercise, or who have a non-interpretable ECG. Furthermore, the document considers the use of coronary CT angiography appropriate for patients with new onset heart failure and for patients who present witch acute chest pain and an intermediate pre-test likelihood of coronary artery disease, but who have a normal ECG and absence of enzyme elevation (see Table 9.5 ) [ 92 ]. Finally, the use of CT

Fig. 9.13 Pronounced positive remodeling of a non-obstructive, noncalciﬁ ed coronary atherosclerotic plaque of the right coronary artery ( arrows )

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Fig. 9.14 Visualization of a coronary anomaly by CT. Due to its three- dimensional nature, coronary CT angiography allows excellent delineation of the origin and course of anomalous coronary arteries. This patient has an anomalous left main coronary artery arising from the right coronary sinus and travelling anterior to the pulmonary artery, with subsequent division into the left anterior descending and

left circumﬂ ex coronary artery. This infrequent anomaly is clinically harmless. ( a ) Two-dimensional CT image in transaxial orientation which shows the position of the anomalous left main coronary artery anterior to the pulmonary artery ( arrows ). ( b ) Three-dimensional reconstruction. The arrows point at the anomalous left main coronary artery

a b

Fig. 9.15 “Interarterial” versus “sub-pulmonary” course of an anomalous left main coronary artery. ( a ) Patient with an anomalous left main coronary artery ( arrows ) that arises from the right coronary sinus and follows an “interarterial” course between the ascending aorta and right pulmonary artery. In this location (see inset ), there is potential danger of ischemia due to kinking or compression of the left main

coronary artery. Surgical correction, irrespective of symptoms, is frequently suggested. ( b ) Patient with an anomalous left main coronary which also arises from the right coronary sinus but then travels below the pulmonary artery, embedded in the septum (“subpulmonary” or “transseptal” course, see arrows ). This anomaly is typically considered less harmful

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angiography is considered “appropriate” to evaluate patients with anomalous coronary arteries [ 92 ]. CT angiography for screening purposes is not endorsed.

O f ﬁ cial guidelines issued by the European Society of Cardiology assign a “Class IIa” recommendation (“should be considered”) to coronary CTA in patients with suspected stable coronary artery disease [ 93 ] and patients with acute chest pain but absence of ECG changed and enzyme elevation [ 62 ]. United States guidelines on non-ST-elevation acute coronary syndromes, jointly issued by the ACC and AHA [ 61 ], assign a “Class IIa” recommendation to coronary CTA and state that:

In patients with possible ACS and a normal ECG, normal cardiac troponins, and no history of CAD, it is reason-

able to initially perform (without serial ECGs and troponins) coronary CT angiography to assess coronary artery anatomy (Level of Evidence: A) or rest myocardial perfusion imaging with a technetium-99 m radiopharmaceutical to exclude myocardial ischemia (Level of Evidence: B)

ACC/AHA guidelines on stable coronary disease, in their last version dated 2012, provide the following recommendations regarding the use of coronary CTA [ 94 ]:

Class IIa (“Should be considered”)

Patients unable to exercise, with low to intermediate

pretest probability of ischemic heart disease

Table 9.6 Appropriateness of coronary CT angiography in various clinical situations [ 92 ]

Non-acute symptoms possibly representing an ischemic equivalent – no stress test done ECG interpretable and able to exercise Low pre-test likelihood (<10 %) Uncertain Intermediate pre-test likelihood (10–90 %) Appropriate High pre-test likelihood (>90 %) Inappropriate ECG uninterpretable or unable to exercise Low or intermediate pre-test likelihood Appropriate High pre-test likelihood Uncertain Non-acute symptoms, prior ECG exercise test Normal but continued symptoms Appropriate Abnormal Intermediate duke treadmill score Appropriate Low or high duke treadmill score Inappropriate Non-acute symptoms, prior stress imaging procedure Equivocal Appropriate Mildly positive Uncertain Moderately or severely positive Inappropriate Discordant ECG exercise and stress imaging results Appropriate New or worsening symptoms with a past stress imaging study Past study normal Appropriate Past study abnormal Uncertain Acute symptoms with suspicion of ACS (urgent presentation) Deﬁ nite MI Inappropriate “Triple Rule Out” for acute chest pain of uncertain cause (differential diagnosis includes

pulmonary embolism, aortic dissection, and ACS)

Uncertain

Cardiac biomarkers normal or equivocal and ECG normal or uninterpretable Low or intermediate pre-test likelihood Appropriate Intermediate pre-test likelihood Appropriate Patient with previous revascularization by CABG and Symptoms, assessment of bypass patency required Appropriate No symptoms, surgery <5 years ago Inappropriate No symptoms, surgery ≥5 years ago Uncertain Patient with previous revascularization by PCI and Symptoms, stent <3 mm Inappropriate Symptoms,, stent ≥3 mm Uncertain No symptoms, left main stent ≥3 mm Appropriate No symptoms, other stents Inappropriate

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Patients with intermediate pretest probability of ischemic

heart disease and an inconclusive exercise test, ongoing symptoms in spite of a normal exercise test, as well as patients unable to undergo stress testing by myocardial perfusion imaging or stress echocardiography

Class IIb (“might be reasonable”)

Patients able to exercise, with intermediate pretest prob-

ability of ischemic heart disease

Summary and Outlook

In spite of the impressive and continuously improving image quality, coronary CT angiography does not currently constitute a general replacement for invasive, catheter-based diagnostic coronary angiography. A somewhat lower spatial and temporal resolution as compared to invasive angiography, the requirement for regular and low heart rates, and the necessity for breathhold cooperation will preclude CT angiography in a relevant fraction of patients who require a workup for coronary artery disease. In addition, coronary CT angiography performs less well in patients with diffuse, severe disease, with substantial coronary calciﬁ cation, or with small coronary arteries (as encountered, for example, in some individuals with diabetes). For these cases and all situations where the need for a revascularization procedure is expected based on clinical grounds, an invasive approach and catheter-based angiography will remain the best diagnostic option.

However, there are numerous patients with a lower pre- test likelihood of disease and with characteristics that promise high image quality and diagnostic accuracy. In these patients, coronary CTA, if performed expertly, is a superb test to rule out the presence of coronary artery stenosis and avoid the need for any further testing. Data on the prognostic value of coronary CTA will continue to accumulate and the continuous technical improvements of CT hardware will make coronary CTA ever more robust and accurate. It can therefore be expected that the role of coronary CTA in clinical cardiology will continue to expand. The challenges to meet will include the identiﬁ cation of the speciﬁ c patient groups that beneﬁ t most from coronary CTA, assuring the widespread availability of high-end CT hardware, and the incorporation of training in coronary CTA into the curriculum of cardiology training.

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Coronary CT Angiography After Revascularization

Joachim Eckert , Marco Schmidt , Thomas Voigtländer , and Axel Schmermund

Abstract

Because of the high number of coronary revascularizations clinicians frequently have to assess bypass or stent function in patients presenting with chest pain or other symptoms suggesting dysfunction. Predominantly, invasive coronary angiography is performed for this purpose. In the last decade innovations in CT scanners, protocols and reconstructions have led to a remarkable increase in diagnostic accuracy of coronary CT angiography for the assessment of coronary bypass grafts and stents whereas radiation exposure has signiﬁ cantly decreased. Occlusions of bypass grafts and occlusive in-stent stenoses can be ruled out with a high negative predictive value approaching 100 %.

Keywords

Coronary CT angiography • Stents • Bypass grafts

Background

Coronary artery revascularization is one of the most frequent medical procedures. In the year 2009 about 350,000 percutaneous coronary interventions (PCI) were performed and 200,000 patients underwent bypass surgery in the United States [ 1 ]. In clinical practice, patients after coronary revas- cularization frequently present with symptoms suggesting progression of coronary artery disease (CAD). Physicians have to reevaluate the patency of the coronary arteries, especially concerning an in-stent-stenosis or occluded bypass grafts. These patients often undergo invasive coronary angiography (ICA) even though there is no evidence of ischemia. As an alternative to ICA, coronary computed tomography angiography (CCTA) plays an increasing role for obtaining reliable information on coronary anatomy noninvasively.

Bypass Grafts

Venous Grafts: Anatomy and Natural History

Venous bypass grafts still represent the majority of all grafts used for bypass surgery. Due to differences in anatomy and surgical techniques, their patency rates are inferior to internal mammary artery grafts [ 2 , 3 ]. Three modes of venous bypass graft degeneration have been described which occur at different time points after surgery. Within hours to weeks after surgery, technical deﬁ ciencies and thrombotic activation lead to early thrombotic occlusion in approximately 5–10 % of the grafts [ 4 ]. Over the course of the following year, intimal hyperplasia and thrombosis appear to be the major mechanisms, accounting for an overall occlusion rate of 10–15 % within the ﬁ rst year [ 4 , 5 ]. Finally, after the ﬁ rst year, mechanisms known from native coronary artery atherosclerosis predominate. Bypass attrition between postoperative years 1 and 5 appears to be minimal. After year 5, atherothrombotic occlusion of venous grafts accounts for a reduced patency rate. It has traditionally been estimated to range between 40 and 60 % at 10–12 years [ 4 , 6 ]. However, data from the Veteran Affairs Cooperative Study indicate that venous grafts which

J. Eckert , MD (*) • M. Schmidt , MD • T. Voigtländer , MD A. Schmermund , MD Department of Cardiology , Cardioangiologisches Centrum Bethanien , Im Prueﬂ ing 23 , Frankfurt , Hessen 60389 , Germany e-mail: j.eckert@ccb.de; m.schmidt@ccb.de;

t.voigtlaender@ccb.de; a.schmermund@ccb.de

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are open 1 week after surgery have a patency rate of 68 % after 10 years [ 2 ]. The presence of angiographic stenoses between 50 and 99 % of graft diameter appears to be 17–22 % at 10 years [ 2 ]. As opposed to native coronary arteries and arterial grafts, venous bypass grafts tend to develop an extensive thrombotic burden and occlude quite rapidly once a high-grade stenosis has formed.

Arterial Grafts: Anatomy and Natural History

The left internal mammary artery (“IMA”) is most often used as arterial graft. Arterial vessels are by design much better adapted to systemic blood pressure values and shear stress than venous vessels, and this translates into improved patency rates [ 2 , 3 ]. IMA grafts patent at 1 week after surgery had a 10 year patency rate of 88 % in the Veterans Affairs Cooperative Study [ 2 ]. As with venous grafts, recipient vessel location and status inﬂ uence graft survival. Survival is best for grafts to the left anterior descending coronary artery and a native vessel diameter ≥ 2 mm [ 2 ]. Interestingly, IMA grafts sewed to a recipient vessel with < 50 % diameter stenosis may have a very high rate of occlusion, probably due to competing ﬂ ow through the native vessel [ 7 ]. Regarding CT imaging, the smaller lumen diameter of arterial grafts and frequent use of metal clips represent a challenge for diagnostic image quality.

Non-invasive CT Examination

Venous bypass grafts are typically larger in diameter than the native large epicardial coronary arteries (approximately 4 – 10 mm versus 2 – 5 mm), and they are less subjected to cardiac motion. Accordingly, even with older-generation (“non-cardiac”) CT machines, investigators examined contrast enhancement along the course of the graft to establish bypass patency [ 8 , 9 ]. Due to the inherent limitations of non- gated scanning with relatively long acquisition times, overall diagnostic accuracy regarding bypass graft patency remained at approximately 90 %, with better results for (larger) vein grafts than for the arterial grafts. It was not possible to identify potential non-occlusive high-grade bypass body stenoses, the distal anastomosis of grafts, or the native coronary arterial run-off. The advent of electron-beam computed tomography (EBCT) as the ﬁ rst dedicated cardiac CT scanner and the development of non-invasive coronary angiography beginning in 1994 allowed for visualization of coronary bypass grafts and three-dimensional representation of the graft vessels [ 10 ]. Still, however, image quality was in part insufﬁ cient for detailed analysis of small diameter grafts or the complex anatomy of native vessels and the anastomosis region. Also, artifacts related to metal clips and breathing / arrhythmias hampered image quality. Despite these limitations, EBCT bypass angiography was used for some years for detecting venous bypass graft occlusion or stenosis

Fig. 10.1 64-row MDCT 3-dimensional image reconstruction shows two patent venous grafts coursing to a right coronary artery and an obtuse marginal branch (Courtesy of Dr. Dieter Ropers, University Clinic Erlangen-Nürnberg, Germany)

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