Non-Invasive Imaging: Applying Findings During Your PCI

V Martin-Yuste MD, PhDvmartiny@clinic.ub.es

ITC. Hospital Clinic Barcelona. Spain

MDCT AND CTO: Which morphological parameters can

we analyze?

Stump morphology

Diameter of the patent vessel, distal vessel

Occlusion length

Tortuosity

Presence of side branches

Calcification

Diameter of the patent vessel

Distal vessel

Anterograde injection

Occlusion length measurement

Retrograde injection

Angiography

Occlusion length measurement

Occlusion length measurement

20 mm

Bending between CTO and patent vessel

Bending in CTO body

Distal vessel analysis and presence of side branch

Plaque composition/ calcium quantification

99 HU156 HU127 HU

Plaque composition/ calcium quantification

247 HU409 HU212 HU

What do we know about MDCT and CTO?

What do we know about MDCT AND CTO?

45 patients Predictor factors of PCI failure

Occlusion length > 15 mm Blunt stump Severe calcification (>130 HU affecting >50% wall vessel)

Multivariate analysis the only independent predictor of procedural success was the absence of severe calcification

Mollet et al Am J Cardiol. 2005;95(2):240-243.

What do we know about MDCT AND CTO? 110 CTO lesions Morphological parameters analyzed:

Target vessel bending Shrinkage Severe calcification (density of calcium >500 HU affecting around 360º of

the wall vessel) Presence of side branches Stump morphology Occlusion length in-stent restenosis

Independent predictors of failure to cross the occlusion with the wire: Severe tortuosity: 57% vs 95%, p<0.0001 Shrinkage: 44% vs 88%, p=0.0005 Severe calcification: 71% vs 88%, p=0.0356

Ehara et al . J Invasive Cardiol 2009, 21: 575-582

What do we know about MDCT AND CTO? 64 patients 72 CTO , 64 slice MDCT Procedural success rate: 76%

Calcium parameters analyzed: Regional calcium volume Regional calcium score (calcified area x HU (1: 130-190; 2:

200-299;3: 300- 399;4 >400) Relative calcium area (% calcium area/vessel area) at the

most calcified cross section of CTO Regional calcium equivalent mass Total calcium score

Cho et al. Int J Cardiol 2010: 5;14581): 9-14

Cho et al. Int J Cardiol 2010: 5;14581): 9-14

What do we know about MDCT AND CTO?

We performed a MDCT in 69 patients with CTO Morphological parameters analyzed

Diameter of the proximal and distal patent vessel Occlusion length Bending Presence of side branches Stump morphology calcification

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

Calcification Global calcium score

Calcium score of the occluded segment

Entry point Middle part Distal point

Distribution around the circumference of the

vessel (arc):

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

Prox. Middle Distal

ARCCALCIUM

25% 100% 75%

HU 85 186 933

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

N Global N=73 success (n=51) Failure (n=22) p

CTO length 68 22.6± 16.6(3-90)

22 ± 17.2 24 ± 15.5 0.46

Lesion length 66 44.2 ± 24.8(7-100)

42.5 ±(25.1 48.4± 24 0.39

Homocolaterals 72 13 (18.1%) 7(14%) 6 (27.3%) 0.2

Heterocolaterals 69 45 (65.2 %) 29 (60%) 16 (76%) 0.28

Entry point 62 0.56

Tapered 28 (45.2%) 19 (42.2%) 9 (53%)

Blunt 34 (54.8) 26 (57.8) 8 (47)

Diameter proximal vessel , mm

72 3.6 ± 0.8 3.5 ± 0.7 3.8± 0.9 0.2

Diameter distal vessel, mm

56 2.3± 0.5 2.32 ± 0.5 2.35 ± 0.3 0.4

Proximal branch 73 47 (64.4%) 33 (64.7%) 14 (63.6%) 0.9

Distal branch 70 41 (58.6%) 27 (56.3%) 14 (63.6%) 0.61

Global Calcium score

36 824± 796 743 ± 717 (n=27) 1040 ± 1013 (n=9) 0.47

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

N Global N=73 Success (n=51)

Failure (n=22) p

HU entry point 69 219.5 ± 195 (50-1270) 194.6 ±146 280.5±278 0.1HU distal 68 152 ±102 (23-688) 156.1± 109 141 ± 83 0.67HU middle point 69 180.6± 133 (6-933) 186.6 ± 153 165.7± 64 0.63Arc Calcium prox. 66 0.048No 26 (39.4) 21 (47.7) 5 (22.7)<50% 30 (45.5) 18 (40.9) 12 (54.5)>50% 10 (15.2) 5 (11.4) 5 (22.7)Arc Calcium distal 66 0.95No 31 (47) 20 (45.5) 11 (50)<50% 26 (39.4) 19 (43.2) 7 (31.8)>50% 9 (13.6) 5 (11.4) 4 (18.2)Arc Calcium middle 66 0.037No 32 (48.5) 24 (54.5) 8 (36.4)

<50% 30 (45.5) 16 (36.4) 14 (63.6)

>50% 4 (6.1) 4 (9.1) 0

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

Martin et al. Rev Esp Cardiol. 2012 Apr;65(4):334-40.

Conclusions

Calcification is the most important predictor of PCI failure

It is not possible to obtain a complete high quality study in all patients/lesions analyzed by MDCT

The anatomical information acquired is important but not determinant in a significant number of patients, so we can not recommend the routine use of this technique: Difficult cases To understand the cause of previously failed cases

In order to establish the correct indications a randomized study is needed