Coronary Radiology (eBook)

Foreword 5
Preface 6
Table of contents 8
1 Coronary Anatomy 10
1.1 Introduction 10
1.2 Physiological and Anatomical Bases 11
1.3 Normal Coronary Anatomy 14
1.3.1 Left Coronary Anatomy 15
1.3.1.1 Left Main Coronary Artery 15
1.3.1.2 Left Anterior Descending Coronary Artery 15
1.3.1.3 The Circumflex Artery 16
1.3.2 Right Coronary Anatomy 16
1.3.2.1 Right Coronary Artery 16
1.3.2.2 Determination of Dominance 17
1.4 Visualization of the Normal Coronary Artery Tree 17
1.4.1 Anatomy on Catheter Coronary Angiography 17
1.4.2 Anatomy on Multi-detector CT 17
1.5 Anomalies of the Coronary Artery Tree 27
1.5.1.1 Coronary Artery Fistula 27
1.5.1.2 Anomalous Origin of a Coronary Artery from the Pulmonary Trunk 28
1.5.1.3 Myocardial Bridging 29
1.5.2 Vessels Originating from the Contralateral Side, With an Interarterial Course 29
1.5.2.1 Right-Sided Left Coronary Artery 29
1.5.2.2 Left-Sided Right Coronary Artery 29
1.5.2.3 Congenital Coronary Anomalies Not Causing Myocardial Ischemia 32
References 33
2 Invasive Coronary Imaging 34
2.1 Conventional Catheterisation 34
2.1.1 The Development of Cardiac Catheterisation 34
2.1.1.1 Cardiac and Coronary Catheters 35
2.1.1.2 Cardiac Catheterisation Laboratories 36
2.1.1.3 Radiation Safety and Exposure 36
2.1.1.4 Coronary Contrast Injection 37
2.1.1.5 Views for Coronary Angiography 37
2.1.1.6 Quantifi cation of Coronary Angiography 37
2.1.2 Normal Coronary Anatomy 38
2.1.3 Arterial Dominance 38
2.1.3.1 Normal Variants 38
2.1.3.2 Muscle Bridge 38
2.1.3.3 Coronary Artery Anomalies Presenting in the Adult 39
2.1.4 Coronary Abnormalities Presenting in Infancy and Childhood 39
2.1.4.1 Coronary Fistulae 39
2.1.5 Risks of Coronary Angiography 40
2.1.5.1 Selection of Patients for Coronary Angiography 40
2.1.5.2 Development of Coronary Revascularisation 41
2.1.6 Percutaneous Coronary Intervention 41
2.1.6.1 Concomitant Pharmacological Therapy 45
2.1.6.2 Long-Term Outcome 46
2.1.6.3 Comparison with Bypass Surgery 47
2.1.6.4 Percutaneous Coronary Intervention Versus Conservative Therapy 47
2.1.7 Alternative Strategies to the First Line Use of Coronary Angiography 47
References 47
2.2 Quantitative Coronary Arteriography 50
2.2.1 Introduction 50
2.2.2 Analog or Digital Image Acquisition and Analysis 52
2.2.3 Brief History of Quantitative Coronary Arteriography 52
2.2.4 Basic Principles of Quantitative Coronary Arteriography 53
2.2.4.1 Basic Principles of Automated Contour Detection 53
2.2.4.2 Calibration Procedure 55
2.2.4.3 Coronary Segment Analysis 55
2.2.4.4 The Flagging Procedure 56
2.2.4.5 Complex Vessel Morphology 58
2.2.4.6 Densitometry 59
2.2.4.7 Standardized QCA Methodology for Assessing Brachytherapy Trials 60
2.2.4.8 Standardized QCA Methodology for Drug-Eluting Stent Analyses 60
2.2.4.8.1 Definition and Assessment of the Segments Based on Markers or Physical Landmarks 60
2.2.4.8.2 Definition and Assessment of the Segments Based on Biologically Relevant Landmarks 61
2.2.4.8.3 Definition and Assessment of the “Normal” Segment 62
2.2.4.8.4 Definition and Assessment of the Related Parts 62
2.2.4.8.5 Data Collection and Reporting for Drug-Eluting Stent Trials 63
2.2.4.9 Ostial Analysis 63
2.2.4.10 Bifurcation Analysis 65
2.2.5 Guidelines 66
2.2.5.1 Guidelines for Catheter Calibration 66
2.2.5.2 Guidelines for QCA Acquisition Procedures 67
2.2.6 QCA Validation 68
2.2.6.1 Plexiglass Phantom Studies 68
2.2.6.2 In Vivo Plexiglass Plugs 69
2.2.6.3 Inter- and Intra-observer and Short- and Medium-term Variabilities 69
2.2.6.4 Inter-laboratory Variability 69
2.2.7 Applications of QCA: Off -Line and On-Line 70
2.2.8 Future QCA Directions 71
2.2.9 In Conclusion 72
References 72
2.3 Clinical Intracoronary Ultrasound 75
2.3.1 Introduction 75
2.3.2 Intracoronary Ultrasound Catheters 75
2.3.3 Intracoronary Imaging of the Normal Coronary Artery 79
2.3.4 Intracoronary Ultrasound of Coronary Atherosclerosis 81
2.3.5 IVUS and Vulnerable Plaque 88
2.3.6 IVUS for In-Stent Restenosis 90
2.3.7 IVUS for Intermediate Lesions 91
2.3.8 IVUS and Transplant Coronary Artery Disease 92
2.3.9 Limitations of Intracoronary Ultrasound 92
2.3.10 Conclusion 95
References 95
2.4 Quantitative Coronary Ultrasound (QCU) 98
2.4.1 Introduction 98
2.4.2 ICUS Image Acquisition 98
2.4.2.1 Interventional Laboratory “Hardware” Set-Up 99
2.4.2.2 Image Acquisition 99
2.4.3 Quantitative Analysis 100
2.4.3.1 QCU Developments 101
2.4.4 Limitations 103
2.4.5 Future Developments 104
2.4.6 Conclusion 104
References 104
3 Non-Invasive Coronary Imaging 106
3.1 Multi-Detector Row Computed Tomography – Technical Principles, New System Concepts, and Clinical Applications 106
3.1.1 Introduction 106
3.1.2 Technical Principles of ECG-Synchronized Cardiac Scanning with MDCT 108
3.1.2.1 Technology Overview 108
3.1.2.2 ECG-Triggered Sequential MDCT Scanning and Image Reconstruction 111
3.1.2.3 ECG-Gated Spiral MDCT Scanning and Image Reconstruction 112
3.1.2.4 Evaluation of Spatial Resolution 115
3.1.2.5 Evaluation of Temporal Resolution 116
3.1.3 New System Concepts 117
3.1.3.1 CT Systems with Area Detectors 117
3.1.3.2 Dual Source CT (DSCT) 119
3.1.4 Clinical Applications 123
3.1.4.1 Quantification of Coronary Artery Calcification 123
3.1.4.2 CT Angiography of the Coronary Arteries 123
3.1.4.3 Detection of Coronary Artery Stenosis 127
3.1.4.4 Evaluation of Atherosclerotic Plaque 129
3.1.4.5 Evaluation of Cardiac Function 130
3.1.4.6 Cardio-thoracic Examinations 131
3.1.5 Advanced Image Post-Processing 132
References 137
3.2 Developments in MR Coronary Angiography 142
3.2.1 Technical Development 143
3.2.2 Pulse Sequences and K-space Trajectories 144
3.2.3 Image Contrast 145
3.2.4 Flow Quantification 147
3.2.4.1 Coronary Wall Imaging 147
3.2.6 Clinical Results 148
3.2.7 Future Developments 149
References 152
3.3 Clinical Implementation of Coronary Imaging 155
3.3.1 Introduction 155
3.3.2 Patient Preparation for Non-invasive Coronary Angiography with CT 155
3.3.3 Contrast Media Administration 156
3.3.4 Image Post-Processing Technique 157
3.3.5 Diagnosis of Coronary Artery Disease 158
3.3.6 Indications for CT Coronary Angiography 159
3.3.7 Coronary Morphology and Myocardial Function 161
3.3.8 Evaluation of Coronary Artery Bypass Grafts 161
3.3.9 Evaluation of Coronary Artery Stents 161
3.3.10 Plaque Detection 163
3.3.11 Radiation Dose 163
3.3.12 Conclusion 164
References 165
3.4 MDCT in Acute Coronary Syndrome 170
3.4.1 Introduction 170
3.4.2 Pathogenesis 171
3.4.3 Risk Stratification 172
3.4.4 Calcium Scoring in Patients with ACS 173
3.4.5 CTA for the Diagnosis of ACS 174
3.4.6 CTA for the Differential Diagnosis in ACS 175
3.4.7 Current Recommendations and Guidelines 176
3.4.8 Conclusion 176
References 177
3.5 Coronary CT Angiography Guidance for Percutaneous Transluminal Angioplasty 179
3.5.1 General Principles 179
3.5.2 CTA Protocol for PCI Guidance of Complex CA Lesions 181
3.5.2.1Coronary Angiography 181
3.5.2.2 Protocol of Coronary CTA 182
3.5.2.3 Post Processing 182
3.5.2.4 Integration of CAG and CT Data in the Cath Lab 185
3.5.3 CT Guidance of Chronic Total Occlusion 185
3.5.4 CT Guidance of Coronary Ostia 186
3.5.5 CT Guidance of Bifurcation Lesions 187
3.5.5.1 The Limits of Coronary Angiography 187
3.5.5.2 Example of a Lesion on the Main Branch and the LAD/LCX Bifurcation 190
3.5.5.2.1 CAG and CTA Assessment Prior to the Procedure 190
3.5.5.2.2 Performance of the Procedure 192
3.5.5.2.3 Results 192
3.5.6 Conclusion 193
References 193
3.6 Use of Multidetector Computed Tomography for the Assessment of Acute Chest Pain: Guidelines of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology 194
3.6.1 Preamble 194
3.6.2 How to Manage Chest Pain: The Emergency Department Perspective 195
3.6.2.1 Acute Coronary Syndrome 196
3.6.2.2 Pulmonary Embolism 197
3.6.2.3 Acute Aortic Syndromes 197
3.6.2.4 Alternative Diagnoses 198
3.6.3 Triple Rule-Out 199
3.6.4 CT Protocol 199
3.6.4.1 Scanner Technology 199
3.6.4.2 Preparation for the CT Scan 199
3.6.4.3 Calcium Scoring 200
3.6.4.4 CTA Protocol 201
3.6.4.5 Dedicated CTA 201
3.6.4.6 Global Assessment (Triple Rule-Out) 202
3.6.5 Imaging Evaluation and Post Processing 202
3.6.6 Physician Requirements 203
3.6.7 Future Directions 203
3.6.8 Summary 204
References 204
4 Non-Invasive Measurement of Coronary Atherosclerosis 207
4.1 Pathophysiology of Coronary Atherosclerosis and Calcification 207
4.1.1 Normal Artery Histology and Cell Function 207
4.1.2 Endothelial Dysfunction and the Pathogenesis of Atherosclerotic Plaques 208
4.1.3 Calcification of Plaques 209
4.1.4 Calcification and Plaque Rupture 210
References 211
4.2 Detection and Quantification of Coronary Calcification 213
4.2.1 Introduction 213
4.2.2 Fluoroscopy 213
4.2.3 Conventional Computed Tomography 215
4.2.4 Electron-Beam Computed Tomography 216
4.2.5 Multidetector Computed Tomography 219
4.2.6 Intravascular Ultrasound 220
4.2.7 Magnetic Resonance Imaging 221
References 221
4.3 Measuring Coronary Calcium 224
4.3.1 Introduction 224
4.3.2 Scoring Algorithms 224
4.3.3 Calcium Scoring In Vivo 225
4.3.4 Calcium Scoring In Vitro 227
4.3.5 Combining In Vivo and In Vitro 231
4.3.6 Implications 232
4.3.7 Conclusion 232
References 232
4.4 Coronary Calcium as an Indicator of Coronary Artery Disease 235
4.4.1 Coronary Calcium as an Indicator of Atherosclerosis 235
4.4.2 Coronary Calcium – Prediction of Coronary Heart Disease Events 236
4.4.3 Progression of Coronary Calcium 238
4.4.4 Guidelines for and Practical Use of Coronary Calcium Assessment 241
References 243
4.5 Epidemiology of Coronary Calcification 246
4.5.1 The Prevalence of Coronary Calcification 246
4.5.2 Cardiovascular Risk Factors and Coronary Calcification 247
4.5.3 Ethnic Diff erences in Coronary Calcification 252
4.5.4 Coronary Calcification and Risk of Manifest Atherosclerotic Disease 252
4.5.5 Coronary Calcification and Measures of Extracoronary Atherosclerosis 256
4.5.6 Progression and Regression of Coronary Calcification 257
References 260
4.6 Coronary Artery Calcium Screening: Current Status and Recommendations from the European Society of Cardiac Radiology and North American Society for Cardiovascular Imaging 265
4.6.1 Introduction 266
4.6.2 Coronary Artery Calcium as a Predictor of Cardiac Events 266
4.6.3 CAC as an Indicator of Coronary Artery Luminal Stenosis 267
4.6.4 Clinical Comparison of MDCT and EBT for Coronary Artery Calcium Score Measurement 267
4.6.5 Review of Current Guidelines on Coronary Artery Calcification 267
4.6.5.1 Risk Assessment in Asymptomatic Persons 267
4.6.5.2 The Focus of Current Guidelines on CAC Scoring 268
4.6.6 Indications for CAC Scoring in Asymptomatic Individuals 269
4.6.7 Atherosclerotic Disease Quantification in Patients with Chest Pain 270
4.6.7.1 Implications for Therapy 271
4.6.7.2 Limitations 271
4.6.7.3 Summary 271
4.6.8 Race and Calcium Score 271
4.6.9 The Value of Coronary Artery Calcium in the Elderly Population 272
4.6.10 Summary 273
4.6.11 Diabetes Mellitus and Coronary Artery Calcium 273
4.6.12 Summary 274
4.6.13 Renal Failure and Coronary Artery Calcium 274
4.6.14 Summary 275
4.6.15 The Value of the ZERO Calcium Score – Asymptomatic Patients 275
4.6.16 The Value of ZERO Calcium Score – Symptomatic Patients 277
4.6.16.1 Calcium Score and Prediction of Obstructive Coronary Artery Disease on Angiography 277
4.6.17 Summary 277
4.6.17.1 The Value of Zero Calcium Score to Rule Out CAD in Symptomatic Patients: Comparison to Treadmill Stress Testing and Nuclear Stress Tests 278
4.6.17.2 The Value of Zero Calcium Score inPatients Presenting with Acute Chest Pain to the Emergency Department 278
4.6.18 Calcium Score Progression: Interpretation 279
4.6.19 Serial Testing Paradigm 279
4.6.20 Reproducibility of CAC CT and Its Determinants 279
4.6.20.1 Clinical Thresholds of Coronary Artery Calcium Progression 280
4.6.21 Clinical Interpretation of Changes in Coronary Artery Calcium 281
4.6.21.1 Rates of Coronary Artery Calcium Progression and Its Determinants 281
4.6.21.2 Results of Randomized Clinical Trials on Effect of Statin Therapy on Coronary Artery Calcium Progression 282
4.6.22 Cardiovascular Prognosis Related to Coronary Artery Calcium Progression 283
4.6.23 Summary 284
4.6.24 Standardization of the Calcium Score Measured Using Different CT Systems 284
4.6.25 Infl uence of Scoring Parameter Settings of Underlying Software Algorithms on Calcium Scoring 286
4.6.26 Radiation Exposure 287
4.6.27 Conclusions 288
References 288
5 Multi-Dimensional Computed Cardiac Visualization 294
5.1 Introduction 294
5.2 Visualization Techniques 295
5.2.1 Two-Dimensional Slice Viewing 295
5.2.1.1 Native Multi-planar Reformation 295
5.2.1.2 Oblique Multi-planar Reformation 296
5.2.1.3 Curved Multi-planar Reformation 296
5.2.1.4 Stretched Multi-planar Reformation 296
5.2.2 Maximum Intensity Projection 299
5.2.3 Thin Slab Maximum Intensity Projection 301
5.2.4 Surface Rendering 301
5.2.5 Volume Rendering 302
5.3 Intra-coronary Visualization 306
5.4 Visualization of Four-Dimensional Data 308
5.5 Clinical Applications 309
5.5.1 Coronary Calcification 309
5.5.2 Coronary Anatomy 309
5.5.3 Coronary Stenosis and Atherosclerotic Plaque 310
5.5.4 Coronary Stent Evaluation 314
5.5.5 Cardiac Function 316
5.5.6 Myocardial Perfusion and Late-Enhancement Analysis 317
5.5.7 Combined Analysis of Coronary Arteries and Myocardium 318
5.6 Artifacts and Pitfalls 319
5.6.1 Technique-Related Problems 319
5.6.2 User-Related Problems 323
5.6.2.1 Missegmentation 323
5.6.2.2 Improper Choice of Techniques 323
5.6.6.3 Misplacement of Selection Tools 323
5.7 Conclusion 323
5.8 Digital Storage and Distribution 324
5.9 History of Cardiac X-Ray Management 324
5.10 Standardized File Formats 325
5.10.1 DICOM Extensions for Cardiology Data 325
5.10.2 Image Compression 326
5.10.3 Matrix Size Reduction 327
5.10.4 Data Size Reduction 327
5.11 PACS Development 328
5.12 Conclusion 330
References 330
Subject Index 336
List of Contributors 345