ΠΟΤΕ Ο ΕΠΕΜΒΑΤΙΚΟΣ ΚΑΡΔΙΟΛΟΓΟΣ ΧΡΕΙΑΖΕΤΑΙ ΤΗ ΒΟΗΘΕΙΑ ΤΗΣ ΑΞΟΝΙΚΗΣ ΣΤΕΦΑΝΙΟΓΡΑΦΙΑΣ. Σωτήρης Πατσιλινάκος Καρδιολόγος

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1 ΠΟΤΕ Ο ΕΠΕΜΒΑΤΙΚΟΣ ΚΑΡΔΙΟΛΟΓΟΣ ΧΡΕΙΑΖΕΤΑΙ ΤΗ ΒΟΗΘΕΙΑ ΤΗΣ ΑΞΟΝΙΚΗΣ ΣΤΕΦΑΝΙΟΓΡΑΦΙΑΣ Σωτήρης Πατσιλινάκος Καρδιολόγος

2 CARDIAC CT: The wave of the future

3 GOLD STANDARD: CORONARY ANGIOGRAPHY

4 Δεν μπορώ να βγάλω άκρη. Μήπως να τον στείλουμε για CT; Θα αστειεύεσαι!! Εδώ κάναμε ολόκληρη στεφανιογραφία. Τι παραπάνω;

5 ΑΞΙΟΛΟΓΗΣΗ ΠΑΘΗΣΗΣ ΣΤΕΛΕΧΟΥΣ

6 Left Main Coronary Artery

7 Left Main, LAD, & Circumflex LAD Circumflex Obtuse Marginal

10 LM compressed by enlarged PA (1)

11 ΟΕΜ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΑΓΓΕΙΑ ΧΩΡΙΣ ΣΗΜΑΝΤΙΚΕΣ ΒΛΑΒΕΣ

12 30 ασθενείς με στένωση <50% στην στεφανιογραφία Η CT-QCA ανέδειξε 50 (19 μαλακές, 12 μικτές και 19 ασβεστωμένες) πλάκες σε 26ασθενείς Η CΑ-QCA ανέδειξε 11 πλάκες

15 ΑΝΩΜΑΛΗ ΕΚΦΥΣΗ ΣΤΕΦΑΝΙΑΙΩΝ ΑΓΓΕΙΩΝ

16 Anomalous RCA

17 Anomalous RCA

18 Anomalous CX

19 Anomalous CX

20 Anomalous CX

23 Anomalous LM from PA

24 ΣΥΡΙΓΓΙΑ ΣΤΕΦΑΝΙΑΙΩΝ ΑΓΓΕΙΩΝ

25 CX fistula to RA

26 CX fistula to RA

27 CX fistula to RA

28 ΑΞΙΟΛΟΓΗΣΗ ΑΘΗΡΩΜΑΤΙΚΗΣ ΠΛΑΚΑΣ ΚΑΙ ΤΟΥ ΕΝΔΟΑΓΓΕΙΑΚΟΥ ΑΥΛΟΥ

29 Coronary Plaques The sensitivity of CCT is greater for calcified (94%) than for mixed (78%) or soft (53%) plaques and is mostly limited to large-caliber vessels Compared with IVUS, CCT tends to underestimate the noncalcified plaque volume but to overestimate the calcified plaque volume

30 PLAQUE COMPONENTS Plaque composition rather than the degree of lumen stenosis determines the risk of plaque rupture. AHA has categorized plaques: - Vulnerable or high-risk plaques have thin fibrous cap with extracellular lipid core. - Severely stenotic plaques usually have increased smooth muscle cells and collagen at the core with little lipid component. These are less likely to rupture. Not visible by catheterization, but is being explored with CT angio.

33 Plaques

34 Plaques

35 Plaques

36 Plaques

37 Plaques

38 Plaques

39 Assessment of left main coronary artery atherosclerotic burden using 64-slice CT coronary angiography: correlation between dimensions and presence of plaques. - Cademartiri F - Radiol Med - 01-APR-2009; 114(3): Increased LM diameters are associated with the presence of atherosclerosis. MDCT CA indicates relevant features of LM atherosclerotic burden, as rupture and subsequent thrombosis of vulnerable plaques may develop from lesions characterised as nonsignificant at conventional CA.

40 Plaques (soft)

Coronary Imaging 66 year old patient S/P

arrows) resulting in a relatively normal

The volume rendered images (bottom left)

41 Coronary Imaging 66 year old patient S/P CABG. Venous bypass graft to OM branch demonstrates a focal aneurysm (yellow arrows) which contains mural thrombus (pink arrows) resulting in a relatively normal contrast enhanced lumen. The volume rendered images (bottom left) only displays the lumen thus missing the thrombosed portion of the aneurysm. Coronary catheterization also only looks at the lumen and thus also would likely miss the finding.

43 ΝΟΣΟΣ KAWASAKI

44 Usefulness of 64-slice MDCT for follow-up of young children with coronary artery aneurysm due to Kawasaki disease: initial experience. - Peng Y - Eur J Radiol - 01-MAR-2009; 69(3): To evaluate the initial application and value of 64-slice multidetector CT as an alternative diagnostic modality in the follow-up of young children with coronary artery aneurysm due to Kawasaki disease. 12 children (mean age 5.1 years, range years) for follow-up (time range from 1.1 to 5.1 years) of known Kawasaki disease and coronary artery aneurysm underwent 64-slice MDCT ECG-gated coronary angiography. A total of 30 coronary artery aneurysms were identified with measured mean of 7.5+/-3.8 mm in diameter, and of 12.4+/-9.1 mm in longitudinal lengths. The affected segments included LM7/12(58.3%), 9/12(75%) of LAD1, 4/12(33.3%) of LAD2, 2/12(16.7%) of LCX1; 6/12(50%) of RCA1, 9/12(75%) of RCA2 and 4/12(33.3%) of RCA3, including affected two segments in 9 tumors and three segments in 1 tumor. Calcifications were found in 5 aneurysms and 3/5 with thrombosis; six stenotic segments were found. ECHO failed to detect 8 tumors with 2/8 in LAD, 1/8 in LCX and 5/8 in RCA, and those included 4 small aneurysms. The use of 64-slice MDCT angiography proved valuable for monitoring young children with Kawasaki disease. Further study is necessary to specify the sensitivity and specificity of MDCT in the follow-up.

45 ΕΛΕΓΧΟΣ ΤΩΝ STENT ΜΕΤΑ ΑΠΟ PCI

46 STENT PATENCY Recent studies regarding detection of significant coronary artery stenosis: -Sensitivity 92-95% -Specificity 86-93% -Negative predictive value 97%

47 STENT PATENCY LIMITATIONS Quantification of stenoses Fast heart rate motion artifact Arrhythmias Heavily calcified vessels With improving technology, these soon will not be a major factor.

48 Stent LAD

49 Severely stenosed, but patent stent String of contrast?

51 LAD Stent from Top to Bottom (1 mm)

52 LAD Stent from Front to Back (1 mm)

53 ΑΝΕΥΡΕΣΗ ΚΑΙ ΑΞΙΟΛΟΓΗΣΗ ΜΟΣΧΕΥΜΑΤΩΝ ΜΕΤΑ ΑΠΟ CABG

54 STUDY 52 patients, average age of 63, with combined 166 bypass grafts. CT angio obtained 15 +/- 5 days prior to cath 165/166 grafts assessable by CT angio. Hi-grade stenosis in patent grafts: 96% sensitive, 100% specific. Occlusion: 100% specific and sensitive Chiurlia E., Menozzi M., Ratti C., Romagnoli R., Modena M., Follow-up of Coronary Artery Bypass Graft Patency by Multislice Computed Tomography. American Journal of Cardiology. May Vol. 95, Nr. 9.

55 GR occluded

56 GR TO RCA

58 GR LIMA TO LAD

59 GR LIMA TO LAD

60 GR LIMA TO LAD

61 GR LIMA TO LAD

62 ΧΡΟΝΙΕΣ ΟΛΙΚΕΣ ΑΠΟΦΡΑΞΕΙΣ ΚΑΙ ΣΧΕΔΙΑΣΜΟΣ PCI

63 The role of coronary CT angiography in chronic total occlusion intervention Stephen C W Cheung1, Michael C L Lim2, Carmen W S Chan3 PCI in CTO is often a technically challenging procedure Manipulation of wires and devices through a CTO during PCI without any means to visually identify vessel-wall boundaries involves an inherent risk of complications such as arterial dissection, perforation and cardiac tamponade. Primary goal of CCTA for imaging in CTOs involves identifying the presence and locations of CTO as well as predicting the potential clinical benefits derived from revascularisation of the occluded segment. Secondary goal includes preprocedural planning to shorten procedure times, visualisation of the procedure in predicting the ease with which a CTO can be crossed and the frequency of procedure-related complications such as contrast nephropathy and radiation skin injury. Postprocedural assessment of the revascularised arterial segments and Long-term follow-up on the patency of coronary stents.

64 EMERGING FIELD OF CARDIAC CT

66 ΒΛΑΒΕΣ ΔΙΧΑΣΜΟΥ ΚΑΙ ΣΧΕΔΙΑΣΜΟΣ PCI

68 Detection and characterization of coronary bifurcation lesions with 64-slice computed tomography coronary angiography. - Van Mieghem CA - Eur Heart J - 01-AUG-2007; 28(16): Σε 323 ασθενείς έγινε αξιολόγηση της βλάβης του διχασμού και αποφασίστηκε ο σχεδιασμός της PCI και ο πιθανός αριθμός stents

69 Multislice CT coronary angiography for the detection of burden, morphology and distribution of atherosclerotic plaques in the left main bifurcation. - Rodriguez-Granillo GA - Int J Cardiovasc Imaging - 01-JUN-2007; 23(3): At the left main bifurcation, atherosclerotic plaques are commonly located at the ostial LAD and opposite to the flow divider. The angle of the left main bifurcation and the presence of plaques within the bifurcation are closely related.

70 The bifurcation study using 64 multislice computed tomography. - Kawasaki T - Catheter Cardiovasc Interv - 1-APR- 2009; 73(5): LMT bifurcation have a higher rate of steep angled bifurcation in humans, it is therefore necessary to take the bifurcation angle into consideration in the case of LMT stenting. These data suggest that a bifurcation study using MSCT can clarify the 3D structure of coronary bifurcation and may provide useful information for bifurcation stenting.

ΣΕ ΠΟΙΕΣ ΠΕΡΙΠΤΩΣΕΙΣ ΜΕΤΑ ΤΗ ΣΤΕΦΑΝΙΟΓΡΑΦΙΑ ΕΙΝΑΙ ΧΡΗΣΙΜΗ Η CT ; ΑΞΙΟΛΟΓΗΣΗ ΠΑΘΗΣΗΣ ΣΤΕΛΕΧΟΥΣ ΟΕΜ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΑΓΓΕΙΑ ΧΩΡΙΣ ΣΗΜΑΝΤΙΚΕΣ ΒΛΑΒΕΣ ΑΝΩΜΑΛΗ ΕΚΦΥΣΗ ΣΤΕΦΑΝΙΑΙΩΝ ΑΓΓΕΙΩΝ ΣΥΡΙΓΓΙΑ ΣΤΕΦΑΝΙΑΙΩΝ

71 ΣΕ ΠΟΙΕΣ ΠΕΡΙΠΤΩΣΕΙΣ ΜΕΤΑ ΤΗ ΣΤΕΦΑΝΙΟΓΡΑΦΙΑ ΕΙΝΑΙ ΧΡΗΣΙΜΗ Η CT ; ΑΞΙΟΛΟΓΗΣΗ ΠΑΘΗΣΗΣ ΣΤΕΛΕΧΟΥΣ ΟΕΜ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΑΓΓΕΙΑ ΧΩΡΙΣ ΣΗΜΑΝΤΙΚΕΣ ΒΛΑΒΕΣ ΑΝΩΜΑΛΗ ΕΚΦΥΣΗ ΣΤΕΦΑΝΙΑΙΩΝ ΑΓΓΕΙΩΝ ΣΥΡΙΓΓΙΑ ΣΤΕΦΑΝΙΑΙΩΝ ΑΓΓΕΙΩΝ ΑΞΙΟΛΟΓΗΣΗ ΑΘΗΡΩΜΑΤΙΚΗΣ ΠΛΑΚΑΣ ΚΑΙ ΕΝΔΟΑΓΓΕΙΑΚΟΥ ΑΥΛΟΥ ΝΟΣΟΣ KAWASAKI ΕΛΕΓΧΟΣ ΤΩΝ STENT ΜΕΤΑ ΑΠΌ PCI ΑΝΕΥΡΕΣΗ ΚΑΙ ΑΞΙΟΛΟΓΗΣΗ ΜΟΣΧΕΥΜΑΤΩΝ ΜΕΤΑ ΑΠΟ CABG ΧΡΟΝΙΕΣ ΟΛΙΚΕΣ ΑΠΟΦΡΑΞΕΙΣ ΚΑΙ ΣΧΕΔΙΑΣΜΟΣ PCI ΒΛΑΒΕΣ ΔΙΧΑΣΜΟΥ ΚΑΙ ΣΧΕΔΙΑΣΜΟΣ PCI

72 ΕΝΤΑΞΕΙ! Καλά τα είπες τελικά, όπως συμφωνήσαμε.

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