acc v porg

Coronary Atherosclerosis with Multislice CT:What is beyond coronary atherosclerosis

Konstantin NikolaouTobias Jakobs

Bernd Wintersperger

Radiology

Alexander Becker

Andreas Knez

Alexander Leber

Cardiology

Michael Muders

Pathology

Christoph R Becker

Calcified & Noncalcified Plaques

CTA Inclusion Criteria

• Asymptomatic patients• CV risk factors• Positive calcium scan

• Symptomatic patients• No CAD history• Atypical chest pain• Inconsistent stress test< 100 mg CaHA

Patient Preparation

82 bpm

• -blocker• R/o Contra

indications• Informed consent• Metoprolol

• 50 - 100 mg orally• 30 - 90 min prior

• HR 50 - 60 bpm

65 bpm

Coronary CTA Parameters

• Testbolus 20 ml @ 4 ml/sTestbolus 20 ml @ 4 ml/s• 120 ml (300 mg iodine) @ 3 ml/s 120 ml (300 mg iodine) @ 3 ml/s

+ NaCl 60 ml @ 3 ml/s + NaCl 60 ml @ 3 ml/s• 500 ms gantry rotation500 ms gantry rotation• 120 kV, 300 mA120 kV, 300 mA• 4 x 1 mm collimation4 x 1 mm collimation• 3 mm/s table feed3 mm/s table feed• 40 s breath hold40 s breath hold

ECG Tube Current Modulation

Pitch<0,4

250 ms 250 ms250 ms

100%

20%

mAs

CTA Radiation Exposure

mSv

Left Coronary Artery (RAO)

Coronary Angiography MDCT & VRT

LAO 60Coronary Angiography MDCT & VRT

Right Coronary Artery (LAO)

Detection of Coronary Stenoses

MDCT Coronary Angiography

Coronary StenosesCTA & Angiography

Author Journal PPV NPV n.a. n

Niemann Lancet2001

81% 97% 30% 35

Achenbach Circulation2001

59% 98% 32% 64

Mean/sum 70% 98% 31% 99

CTA Limitations

• Artifacts• Cardiac motion• Breathing• Blooming

• Poor opacification• Small vessel

Solutions

< Rot. time & blocker • Cardiac motion artifacts

< Scan times• Breathing artifacts• CM utilization

< Slice thickness• Small vessels• Blooming artifact

16 Detector Row CT Angiography

• 200 ms• 9 Lp/cm• 0.8 mm• 20 s breath hold• 60 ml CM

Coronary Plaque Imaging

MDCT Coronary Angiography

Non Calcified Plaque Density

Coronary Atherosclerosis

Calcified Nodule

Wall changes Occlusion

ThrombusFibrocalcified Plaque

Stenoses

Intimal Thickening

Atheroma

Healing Hemorrhage

Rupture/Erosion

Atheroma

• 38 YOM• Non specific complain• Risk Factors

– Cholesterin– Smoker

• No calcium

50 HU

50 HU

Calcified Nodule

• 62 YOM• Suspicion of CAD• 12 mg CaHA

Fibrocalcified Plaque

100 HU

Thrombus

• 42 YOM• Epigastric chest pain• Risk Factors

– Hypertension– Smoker

• No calcium

20 HU

Thrombus

Acute Posterior Wall Infarction

Myocardial Infarction Scar

anteriorLAD

lateralLCx

posteriorRCA

CT Plaque Density

Lipid Fibrose50 ± 12 HU 89 ± 31 HU

p = 0.018

Lipid Fibrosis

CTA vs IVUSSchröder Heart 2001;85:576

Carotid AtherosclerosisEstes 1998 J Cardiovasc Surg 39:527

Plaque DistributionLeber 2001 Circulation

Non-calcified

13%

Mixed33%

Calcified54%

Myocardial Infarctionn = 12

122 Plaque

Stable Anginan = 12

135 PlaqueNon-

calcified6%

Mixed14%

Calcified80%

Summary

• Detection of stenoses– Calcium– Small vessels

• Characterization of plaques• Identify atheromas• Follow up under therapy

• Acute coronary event• Intracoronary thrombus• Myocardial infarction

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