Using Coronary CTA to Guide Intervention for CTO CRT 2008 Washington, DC
Wm Guy Weigold, MD Director, Cardiac CT Washington Hospital Center
Conflict of Interest Wm. Guy Weigold, MD
I disclose the following financial relationships:
- Consulting Fees: Bracco, Partners Imaging - Research Support: Philips Medical Systems, Shina Systems
Traditional Approach
Diagnosis
Intervention
No Intervention
The Cath Lab of the Future
Diagnosis Planning
No Intervention
Intervention Only
Decisions Regarding Intervention on CTO Based on Angiographic Variables
• Discrete lesion / Long lesion • Concentric / Eccentric All of these Variables Can Be • Straight segment / Tortuous segment Visualized andsegment Assessed by 3D • Ease of access to Coronary CTA • Calcification • Side branch presence / location
Limitations of Traditional Coronary Angiography
Requires invasive study “Lumenogram” Plaque characterization requires IVUS
Projection images
(vessel overlap and foreshortening)
Multiple injections & runs for optimal viewing angle
Coronary CTA Provides an Alternative
Non-invasive
Plaque characterization (calcification)
3D Volume of Anatomic Data
(No Overlap)
Volume Data Can Be Infinitely Manipulated
How Coronary CTA is Interpreted & Utilized Lesion Length Lesion Curvature Lesion Access
Side Branch Locations
S.B. Origin Angle
Distal Vessel Caliber
CTO Plaque Character
Value of Preprocedure MSCT to Predict the Outcome of PCI of CTO
PCI characteristics
Mollet NR, Hoye A, Lemos PA, et al. AJC 2005;95:240-243
Angiographic and MSCT Predictors of Procedural Failure
Variable OR (95% CI) P-value
Tapered stump (angio)
Occlusion length >15mm (MSCT)
0.09 (0.02-0.48)
<0.01
8.77 (1.58-48.76)
0.01
Severe calcification (MSCT)
7.62 (1.33-43.74)
0.02
Mollet NR, Hoye A, Lemos PA, et al. AJC 2005;95:240-243
Length, Calcification, Side Br, SB Angle, Distal Vessel
LAD & Diagonal
RCA
LAD & Diagonal
LAD & Diagonal
Angioplasty
100% RCA
Circumflex
100% CX 100% CX
CX after partial wire crossing
Initial image
Courtesy Shina Systems
Registration result
Plaque location and type
Lesion length
(12.6mm )
Courtesy Shina Systems
Suggested stent size and positioning
Courtesy Shina Systems
Initial image
Courtesy Shina Systems
Registration result Composition
Pathway
Courtesy Shina Systems
Initial image
Courtesy Shina Systems
Planning
Courtesy Shina Systems
Catheterization result
Courtesy Shina Systems
Conclusions
• Coronary CTA is highly sensitive for the detection of CAD & stenosis • Beyond diagnosis, Cor CTA may provide information useful for the planning of PCI • Especially in PCI of CTO, the ability to visualize the plaque and the distal vessel will prove useful in planning the intervention • The goals:
• • • • Better patient selection Decreased time / contrast in the lab Decreased complications Better patient outcomes