atherosclerosis: clinical perspectives through imaging || invasive coronary angiography

77A.J. Taylor, T.C. Villines (eds.), Atherosclerosis: Clinical Perspectives Through Imaging, DOI 10.1007/978-1-4471-4288-1_6, © Springer-Verlag London 2013

E. Hulten , M.D., MPH (*) Non-Invasive Cardiovascular Imaging, Department of Medicine (Cardiovascular Division) and Radiology , Brigham and Women’s Hospital, Harvard Medical School , Boston , MA 02115 , USA e-mail: [email protected]

D. W. Carlson Jr , M.D. Department of Radiology , Fort Belvoir Community Hospital , Fort Belvoir , VA , 22060 , USA e-mail: [email protected]

6

Abstract

For several decades invasive coronary angiography has been the reference standard test for the assessment of coronary artery disease. The proper delineation of coronary artery disease extent and lesion quanti fi cation on invasive coronary angiography requires attention on the part of the opera-tor to clearly display the entire coronary arterial tree and coronary artery disease lesions, while avoiding artifact, vessel overlap and/or foreshorten-ing using this 2-dimensional imaging technique. The majority of coronary artery lesions visualized is assessed by visual estimation of lumen diame-ter stenosis. However, while visual estimation of diameter stenosis is prac-tical and generally accurate, coronary artery disease lesion severity may be improved with use of quantitative coronary angiography (QCA), intravas-cular ultrasound or with the use of fractional fl ow reserve to assess hemo-dynamic effects related to the stenosis in question. Although not a high risk procedure on a per-patient basis with a risk of major complications below 1 %, serious complications from invasive coronary angiography do occur, including arterial injury, arrhythmia, myocardial infarction, stroke and death. More common but less morbid risks include renal dysfunction, allergy to contrast media, bleeding, hematoma, arteriovenous fi stula, peripheral nerve injury, or risks of conscious sedation such as aspiration. Because of these risks noninvasive approaches to diagnostic coronary

Invasive Coronary Angiography

Eddie Hulten and Daniel William Carlson Jr

78 E. Hulten and D.W. Carlson Jr

Introduction and Methods of Invasive Coronary Angiography

First performed in humans in 1958, coronary • angiography has evolved to become the reference standard imaging technique for coronary ath-erosclerotic disease. Approximately 2,000,000 patients annually undergo coronary angiography in the United States. Indications for cardiac angiography for • patients with stable angina, non-ST elevation MI, and ST elevation MI are published and periodically updated by the American College of Cardiology and the American Heart Association [ 1– 5 ] . Invasive coronary angiography (ICA) is per-• formed on a fasting patient in a sterile fashion in a catheterization laboratory equipped with fl uoroscopy, hemodynamic monitoring, and monitors for angiographic display (Fig. 6.1 ). Coronary angiography involves cannulation • of coronary vessels using small, fl exible cath-eters (typically 4 thru 6 French catheter diam-eters for diagnostic coronary angiography) and injection of radio-opaque iodinated con-trast, allowing visualization of the coronary anatomy with x-ray fl uoroscopy. A variety of techniques and access sites may • be used to gain entry to the arterial system for the performance of ICA. Today, most ICA are performed using a modi fi cation of the

percutaneous femoral arterial approach originally suggested by Seldinger in 1953 (Fig. 6.2a, b ). While the common femoral artery is the most • common site for arterial access, however, the radial artery is increasingly being utilized as a site through which to perform invasive coro-nary angiography due to its inherent improved patient comfort due to ease of post-procedural hemostasis and studies demonstrating very high rates of operator success. Less commonly, a brachial arterial approach is employed. After gaining arterial access and placement of • an access sheath, a coronary catheter is advanced over a wire in a retrograde fashion into the ascending aorta and once the wire is removed, the coronary arteries are selectively engaged using fl uoroscopic guidance. The left and right coronary artery systems are then selectively engaged and injected with iodi-nated contrast for anatomic visualization. Anatomic visualization with invasive coronary • angiography offers the advantage beyond all other coronary imaging modalities of possible conversion to a therapeutic percutaneous cor-onary intervention (PCI), if clinical indicated. However, as an invasive procedure, coronary angiography also conveys a higher risk (rela-tive to other coronary imaging modalities) of death, myocardial ischemia and infarction, and arterial injury such as dissection, aneu-rysm, or arteriovenous fi stula.

angiography have evolved, but do not allow for additional diagnostic or therapeutic maneuvers such as intravascular ultrasound, fractional fl ow reserve, or percutaneous coronary intervention (Table 6.1). Angiographic data including lesion location, severity, and anatomy correlate with prog-nosis for future events both with and without coronary intervention using scales such as the Duke Prognostic Score and Syntax scale. For all these reasons, invasive coronary angiography remains vitally important for visualization of coronary artery disease.

Keywords

Coronary angiography • Cardiac catheterization • Quantitative coronary angiography • Coronary artery disease • Percutaneous coronary intervention • Intracoronary stents • Angioplasty • Coronary artery bypass surgery

796 Invasive Coronary Angiography

In addition, coronary angiography requires • exposure to ionizing radiation (mean effective dose 6 mSv for diagnostic invasive coronary angiography) [ 6 ] and can result in iodinated contrast anaphylaxis or contrast induced neph-ropathy [ 7 ] . In spite of these risks, which are generally low • on a per-patient basis, invasive coronary angiography has remained as the reference standard for coronary artery disease diagnosis and severity quanti fi cation since the 1960s Table 6.1 . Multiple views (Fig. • 6.3a, b ) of the coronary anatomy are typically taken due to commonly-encountered overlapping vessels and vessel foreshortening (erroneous perception of a shortened arterial segment due to camera angle) and in order to clearly distinguish arti-fact from true coronary artery lesions. A typical progression of camera views • includes:

– Left Coronary Artery 1. Right anterior oblique (RAO)-caudal to

visualize the left main, proximal LAD, and proximal circum fl ex

2. RAO-cranial to visualize the mid and distal LAD without overlap of septal or diagonal branches

3. LAO-cranial to visualize the mid and distal LAD in an orthogonal projection

4. LAO-caudal to visualize the left main and proximal circum fl ex

– Right Coronary Artery 1. LAO to visualize the proximal right cor-

onary artery (RCA) 2. RAO-cranial to visualize the posterior

descending and posterolateral branches 3. Lateral to visualize the mid-RCA [ 8 ]

Quanti fi cation and Accuracy

Visual Estimation

Angiographer visual estimation of luminal • stenosis is the most widely used method for quanti fi cation of coronary artery disease dis-tribution and stenosis severity during ICA (Fig. 6.4 ). The reliability of percent stenosis estimation • compared with post-mortem studies is high: 79–93 % agreement is reported in studies that compared arterial segments with autopsy [ 9, 10 ] . Discrepant fi ndings tend to under-esti-mate luminal stenosis due to circumferential stenosis, eccentric coronary lesions, distal segment, and poor vessel contrast opaci fi cation or visualization. Overestimates of plaque may additionally occur due to overlapping vessels, foreshortening, and coronary spasm [ 9, 10 ] .

Ouput to VCR and ADC

Video camera TV monitors

Analog todigital

converter(ADC) VCR

X-ray source

Generator

Imageintensifier

Fig. 6.1 Cardiac catheter-ization lab equipment. X-rays are emitted from the source and travel through the patient to the image intensi fi er (Reproduced with permission of Elsevier from Libby et al. [ 23 ] )


a

b

Fig. 6.2 ( a , b ) Femoral artery landmarks. ( a ) Angiogram sheath in femoral artery in anteropos-terior projection. ( b ) Correct positioning is seen relative to angiographic landmarks: 1 common femoral artery, 2 bifurcation of profunda, 3 super fi cial femoral artery, 4 Midpoint of femoral head, 5 Iliac-symphysis pubis ridge (inguinal ligament line) (Reproduced with permission of Elsevier from Kern [ 24 ] )


Although practical at identifying signi fi cant • stenoses, angiographer estimation of the pre-cise percent stenosis has been proven to be subject to operator bias and intra- and inter-operator variability (a standard deviation of 18 % luminal stenosis) [ 11 ] . Error in the assessment of coronary artery • stenosis severity has been demonstrated to be reduced through discussion among multiple observers [ 11, 12 ] . Coronary angiography provides detailed • anatomic imaging but no functional assess-ment of myocardial ischemia as with cer-tain other imaging modalities such as stress echocardiography or nuclear imaging. Also, estimation of atherosclerotic lesion stenosis severity requires comparison of the lumen stenosis to an adjacent contrast- fi lled lumi-nal segment which may have occult plaque not detectable by angiography, thereby underestimating the size of the stenosis of interest.

Quantitative Coronary Angiography (QCA)

The use of digital measurement of luminal • narrowing and computer assisted quantitative coronary angiography (QCA) have been shown to increase the accuracy of coronary atherosclerotic plaque measurement (inter-observer standard deviation of percent stenoses 0.9–4.9 %) (Fig. 6.5 ).

QCA may not be routinely employed in every-• day practice, except to evaluate stenoses of unclear severity, as its use is time-intensive and most angiographers do not feel that it signi fi cantly adds to their trained visual assess-ment [ 13 ] .

Patterns of Disease

Angiographic extent of coronary atherosclero-• sis is, in large part, predicted by the quality of symptoms, particularly the typicality of angina, and clinical risk factors (male gender, family history of coronary artery disease, smoking, elevated blood pressure, high cholesterol, dia-betes, physical inactivity) [ 14– 18 ] . With regard to patient history, patients with • de fi nite angina, probable angina, or non-speci fi c chest pain have decreasing rates of angiographic lesions, respectively, and this varies by age [ 19 ] . Acute plaque rupture on invasive coronary • angiograph is typically visualized as a discrete intraluminal fi lling defect with de fi ned bor-ders and is largely separated from the adjacent wall. Contrast staining may or may not be present (Fig. 6.6a, b ). Coronary artery dissections appear as a linear • lucency and may contain thrombus, and result in reduced distal fl ow due to compromise of the true lumen. Coronary artery dissections most commonly occur as a complication of percuta-neous coronary interventions; however, they rarely may present spontaneously as a rare cause of acute coronary syndrome, especially among peripartum women (Fig. 6.7a, b ). Coronary ectasia is often seen on invasive cor-• onary angiography and is de fi ned as a focally irregular and dilated vessel contour. A coro-nary artery aneurysm is coronary segment > 1.5 times the normal reference vessel diameter (Fig. 6.8a, b ). Prior to catheterization, operator knowledge • of bypass graft anatomy is very helpful to minimize procedural time and contrast expo-sure. Some surgeons place coronary artery

Table 6.1 Catheter angiography vs. noninvasive imaging

Advantages Disadvantages

Percutaneous intervention possible

0.5–1 % Risk major complication [ 7, 8 ]

Possible use of fractional fl ow reserve (FFR) and intravascular ultrasound (IVUS)

May be more costly

Monitored environment Contrast media reactions Diagnostic “gold standard”

Risks of sedation No ischemic correlation without FFR


bypass graft markers to guide future angiogra-phers to the graft ostium:

The left internal mammary artery (LIMA) –(Fig. 6.9 ) is a commonly utilized bypass conduit that originates from left subclavian artery. Its course to the target vessel is often tortuous. It is the most durable of all bypass graft conduits and is typically grafted to LAD, often with a jump segment to promi-nent native coronary diagonal branch.

Saphenous vein grafts (SVG) (Fig. – 6.10a, b ), harvested from the lower leg of the patient, originate from ascending thoracic aorta and may be grafted to any suitable native vessel territory. These grafts often are large in cali-ber and may be identi fi ed for the angiogra-pher with the use of a graft marker.

Other less commonly utilized CABG conduits • include the right internal mammary artery (RIMA), radial artery, and the gastroepiploeic artery.

LAO cranial

LAO caudal

APcaudal

APcranial

RAOcranial

RAOcaudal

LMCA

LAD

LCx

LAD

S

LMCALCx

OMBLAO straight

RCA

AMBPDA

PLV

PLVRCA

AMBPDA

Conus branch

RCAPDA

LAO cranial

RAO straight

D

LCx

LAD

LCxLMCA

S

LAD

LCx

LCx

OMB

S

LAD

LAD

a b

Fig. 6.3 ( a , b ) Standard views of the left and right coronary artery system. LAO left anterior oblique, AP anterior-posterior, RAO right anterior oblique (Reproduced with permission of Elsevier from Libby et al. [ 23 ] )


An aortogram may be necessary to fi nd graft • ostia or to document the occluded proximal portion of an occluded graft.

Similar to the assessment of native coronary • arteries, angiographers should meticulously assess the entire graft (take-off, body, and touch-down to the native coronary artery) in multiple views. In addition, the angiographer should pay particular attention to the ante-grade fi lling of the native coronary artery target. Coronary calci fi cation can be visualized on • x-ray fl uoroscopy as an area of dark, opaque material often outlining the coronary artery (“skeleton”) seen prior to contrast injection. Similarly, stents are most easily visualized • prior to the injection of contrast, appear as a similar opacity to calcium but with orga-nized struts. During coronary angiography, in-stent or in-segment restenosis may be noted within or near the intracoronary stent (Fig. 6.10a, b ). Angiographic predictors of successful intrac-• oronary stent placement are listed in Table 6.2 .

Fig. 6.4 Obstructive lesion in the proximal left anterior descending ( LAD ) artery in a patient who presented with anterior wall ST elevation myocardial infarction

Fig. 6.5 77% diameter (95 % area) stenosis of the proximal left anterior descending ( LAD ) artery by Quantitative Coronary Angiography ( QCA )


Prognosis

Coronary angiography provides clinicians • with the information necessary to determine whether a patient with angina, myocardial infarction (MI), or acute coronary syndrome (ACS) without MI is best managed medically or should be recommended to undergo coro-nary revascularization utilizing either intrac-oronary stent placement or coronary artery bypass graft surgery (CABG).

In general, stenosis involving more proximal • segments of the coronary arterial tree (espe-cially the left main coronary artery, Fig. 6.11a, b ) and increasing numbers of coronary artery territories convey increased risk for adverse patient outcomes:

From a systemic review of seven random- –ized trials comparing medical management to CABG, patients with left main coro-nary artery stenosis > 50 %, proximal LAD stenosis > 70 %, or signi fi cant stenosis

a b

Fig. 6.6 ( a ) Right coronary artery ( RCA ) with acute plaque rupture and thrombus from the mid RCA to distal and posterolateral branch. ( b ) After thrombus aspiration and stenting

a b

Fig. 6.7 ( a ) Spontaneous left anterior descending ( LAD ) coronary artery dissection in a 34 year old postpartum woman who presented with ST-segment elevation myo-

cardial infarction. ( b ) The lesion was treated with stenting due to failure of medical therapy


involving three major epicardial coronary arteries on ICA have signi fi cant 5, 7, and 10 year mortality reduction with bypass surgery (Table 6.3 ). Among all patients with coronary artery –disease, those with depressed left ven-tricular ejection fraction (LVEF) bene fi t most signi fi cantly from CABG.

For the assessment of prognosis, coronary • artery stenosis severity is typically de fi ned as:

Obstructive: > 50 % stenosis in the left –main coronary artery or > 70 % lumen stenosis of a major epicardial artery. Non-obstructive. Does not meet the above –de fi nition of obstructive disease. Of note, lesions of intermediate severity –(50–70 % lumen diameter stenosis; Fig. 6.12 ), when not known by pre-catheterization testing to cause ischemia, may be further characterized with the use of intracoronary ultrasound or fractional fl ow reserve test-ing to measure the hemodynamic impact of the lesion in question. No angiographic coronary artery disease. It –is important to note that occasionally areas that appear normal on two-dimensional coronary angiography have mild degrees of coronary artery disease not appreciated by the “lumen-o-gram” that invasive coronary angiography provides.

Angiographic Prognosis Scales

The Duke Prognostic Score has demonstrated • that the proximity, severity, and extent of cor-onary artery stenoses predict a patient’s out-comes [ 20 ] and guides the selection of the

a b

Fig. 6.8 ( a ) Dilated, ectatic proximal left anterior descending artery. ( b ) Mid right coronary artery (RCA) aneurysm

Fig. 6.9 Right anterior oblique ( RAO ) cranial view of left internal mammary artery ( LIMA ) graft to the distal left anterior descending ( LAD ) coronary artery


optimal treatment strategy: medical treatment alone, percutaneous revascularization, or sur-gical revascularization. More recently, investigators have demon-• strated that the use of a semi-quantitative coro-nary artery disease severity scale, such as the Syntax Score [ 21 ] , may also characterize a patient’s cardiovascular risk and guide operator

decision-making regarding the best method of revascularization (surgical vs. percutaneous) based on the presence and severity of the follow-ing important angiographic variables: number of angiographic coronary lesions; complete occlu-sions; bifurcation and/or trifurcation lesions; ostial lesions; vessel tortuosity; lesion length > 20 mm; lesion calci fi cation; and thrombus.

a b

Fig. 6.10 ( a ) Saphenous vein graft ( SVG ) markers; the graft has minimal disease. ( b ) Degenerated SVG with 95 % stenosis prior to successful percutaneous coronary intervention ( PCI )

Table 6.2 Angiographic lesion characteristics that predict successful PCI and complication risk [ 26 ]

Characteristic

Type A Type B Type C

PCI success > 85 % PCI success 60–85 % PCI success < 60 % Low risk Moderate risk High risk

Length Discrete (<10 mm) Tubulur (10–20 mm) Diffuse (>2 cm) Shape Concentric Eccentric Eccentric Accessibility Easy More dif fi cult More dif fi cult Tortuosity Non-tortuous Moderate tortuosity of proximal segment Excessive tortuosity of proximal

segment Angle Non-angulated Moderately angulated, >45° but < 90° Extremely angulated > 90° Contour Smooth Irregular Irregular Calcium Little or no Moderate to heavy Heavy % Stenosis Non-occlusive Total occlusion < 3 months old Total occlusion > 3 months old Thrombus Absent Some present Present Location Not ostial Ostial Ostial Side branches

No major branch involved

Bifurcation lesion requiring double guidewire

Inability to protect major side branches

Other Degenerated vein grafts with friable lesions


Conclusion

In summary, coronary angiography remains • the gold standard imaging modality for the diagnosis and quanti fi cation of coronary artery disease. Although as an invasive technique it carries • additional risk, the detailed coronary ana-tomic visualization is heretofore unequaled (although cardiac CTA is an emerging competitor). Cardiac catheterization and angiography • also allow the clinician the option to assess right and left heart hemodynamics, to improve lesion severity characterization in indeterminate lesions using intravascular

ultrasound or fractional fl ow reserve, to perform peripheral angiography, and allows for the potential of percutaneous coronary revascularization. Coronary angiography is performed on • millions of patients each year; however, efforts such as improvements in non-invasive testing and patient pre-test assessment are warranted to reduce the high numbers of patients referred for ICA who ultimately are found to have no signi fi cant coronary artery disease on invasive coronary angiog-raphy. Speci fi cally, in a recent survey of United States catheterization labs, among patients without previously known coronary

a b

Fig. 6.11 ( a ) Right anterior oblique ( RAO ) cranial view prior to contrast injection of multiple prior stents in the left anterior descending ( LAD ) and left circum fl ex ( LCX )

arteries. ( b ) Long segment of prior right coronary artery ( RCA ) stent with in-stent restenosis

Coronary angiography

Odds ratio of death for patients undergoing CABG vs. medical therapy p-value

One vessel disease 0.54 (95 % CI 0.22–1.33) 0.18 Two vessel disease 0.84 (95 % CI 0.54–1.32) 0.45 Three vessel disease 0.58 (95 % CI 0.42–0.80) <0.001 Left main artery 0.32 (95 % CI 0.15–0.70) 0.004

Adapted with permission of Elsevier from Yusuf et al. [ 25 ] Any of the above lesion bene fi ts signi fi cantly from CABG if there is proximal LAD disease or LV dysfunction

Table 6.3 Odds ratio of death for patients undergoing CABG vs. medical therapy


artery disease referred for invasive coro-nary angiography only approximately 30 % of patients ultimately had evidence of obstructive coronary disease on coronary catheterization [ 22 ] .

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Fig. 6.12 LAO Caudal view of distal left main stenosis, diffuse left anterior descending ( LAD ) disease, and com-plete total occlusion of the proximal left circum fl ex artery. The patient was referred to bypass surgery


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atherosclerosis: clinical perspectives through imaging || invasive coronary angiography

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