Int J Cardiovasc Imaging (2014) 30:825–832 DOI 10.1007/s10554-014-0397-9
ORIGINAL PAPER
The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography Jerzy Pregowski • Cezary Kepka • Mariusz Kruk • Gary S. Mintz • Lukasz Kalinczuk • Michal Ciszewski • Lukasz Kochanowski • Rafal Wolny • Zbigniew Chmielak • Jan Jastrze˛bski • Mariusz Klopotowski • Joanna Zalewska Marcin Demkow • Maciej Karcz • Adam Witkowski
•
Received: 30 August 2013 / Accepted: 4 March 2014 / Published online: 13 March 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract To assess the anatomical background and significance of incomplete invasive coronary angiography (ICA) and to evaluate the value of coronary computed tomography angiography (CTA) in this scenario. The current study is an analysis of high volume center experience with prospective registry of coronary CTA and ICA. The target population was identified through a review of the electronic database. We included consecutive patients referred for coronary CTA after ICA, which did not visualize at least one native coronary artery or by-pass graft. Between January 2009 and April 2013, 13,603 diagnostic ICA were performed. There were 45 (0.3 %) patients referred for coronary CTA after incomplete ICA. Patients were divided into 3 groups: angina symptoms without previous coronary artery by-pass grafting (CABG) (n = 11,212), angina symptoms with previous CABG (n = 986), and patients prior to valvular surgery (n = 925). ICA did not identify by-pass grafts in 21 (2.2 %) patients and in 24 (0.2 %) cases of native arteries. The explanations for an incomplete ICA included: 11 ostium anomalies, 2 left main spasms, 5 access site problems, 5 ascending aorta aneurysms, and 2 tortuous take-off of a subclavian artery. However, in 20 (44 %) patients no specific reason for the incomplete ICA was identified. After coronary CTA revascularization was performed in 11 (24 %) patients: 6 successful repeat ICA and percutaneous J. Pregowski (&) C. Kepka M. Kruk L. Kalinczuk M. Ciszewski L. Kochanowski R. Wolny Z. Chmielak J. Jastrze˛bski M. Klopotowski J. Zalewska M. Demkow M. Karcz A. Witkowski Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland e-mail: [email protected] G. S. Mintz Cardiovascular Research Foundation, New York, NY, USA
intervention and 5 CABG. Incomplete ICA constitutes rare, but a significant clinical problem. Coronary CTA provides adequate clinical information in these patients. Keywords Incomplete coronary angiography Computed tomography Congenital coronary artery anomaly
Introduction Invasive coronary angiography (ICA) is the gold standard in the evaluation of native coronary arteries in patients with suspected coronary artery disease (CAD) or by-pass graft failure after coronary artery by-pass grafting (CABG). However, in very rare cases despite use of dedicated catheters and numerous attempts, it is not possible to visualize the complete coronary anatomy. The clinical significance of incomplete ICA is unknown, and further management in this clinical scenario remains undetermined by known consensus documents. Coronary computed tomography angiography (CTA), is free of several limitations associated with ICA (i.e. inadequate arterial access, anomalous anatomy) and allows visualization of coronary vessels with excellent diagnostic accuracy [1–5]. The aim of our study was to assess the clinical significance of incomplete ICA and to evaluate the value of routine use of coronary CTA in this clinical scenario.
Materials and methods This is a retrospective study performed in a single center with high volume catheterization laboratory and CT departments. All coronary CTA examinations are performed and evaluated by the interventional cardiologists
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(JP, CK, MK) actively working in the local catheterization laboratory. The data on the indications for all coronary CTA examinations are electronically recorded. Since Jan 2009 the patients in whom intended complete diagnostic ICA did not visualize at least one vessel or by-pass graft were routinely referred for coronary CTA. The target population was identified through a computer-assisted review of the electronic database containing indications for coronary CTA. The patients’ characteristics including coronary risk factors, pre-test probability of obstructive coronary artery disease and final decision regarding revascularization following adjunctive coronary CTA examination was then retrieved from patient hospitalization summaries that included complete diagnoses. The prospective coronary CTA registry conducted in our center started in April 2008 and was approved by the local IRB. The ICA was performed with Siemens angiograph (AXIOM ARTIS DFC, Forchheim, Germany). The data on access site, aortography, and amount of contrast and radiation was collected from the procedure reports. The coronary CTA examinations were performed with commercially available scanners: 64 slice Somatom Definition, (Siemens, Forchheim, Germany) or 128 raw Somatom Definition Flash, (Siemens, Forchheim, Germany). Prior to all coronary CTA scans, patients received sublingual nitrates in a dose of 0.8 mg. If the patient’s a heart rate exceeded 65/min intravenous boluses of metoprolol were given (sequential doses of 2.5 mg, maximal dose 10 mg). The reasons for ICA inconclusiveness were established by an experienced ICA and coronary CTA reader (JP) on the basis of the procedure reports and off-line ICA and coronary CTA dataset analyses. Statistics Continuous data are presented as means with standard deviation if normally distributed or as medians with interquartile ranges (IQR). Categorical variables were compared with a Chi square test.
Results Between January 2009 through April 2013 there were 13,603 diagnostic ICA performed in our center. The major indications for ICA were: suspected CAD in patients without previous CABG in 11,212 patients, suspected disease progression or by-pass graft failure in 986 patients after CABG, assessment of coronary arteries before valvular cardiac surgery in 925 patients, and as part of the diagnosis of heart failure or cardiomyopathy or after heart transplantation in 480 patients. Out of these 13,603 diagnostic ICA 45 (0.3 %) patients were referred for an
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Fig. 1 The flowchart of the study population
additional coronary CTA because ICA did not visualize complete coronary anatomy i.e. at least one native artery or by-pass graft. The flowchart for study population is presented as Fig. 1. There were 33 males, and the mean age was 67.3 ± 12.8 years. Baseline patients’ characteristics are provided in Table 1. Inconclusive non-selective aortography was performed in 6 patients. The radiation dose during ICA was 1,127 ± 877 mGy, dose area product was 9,751 ± 15,397 lGy m2, fluoroscopy time was 16 ± 8 min and contrast volume was 112 ± 68 ml. The radiation dose defined as dose length product during coronary CTA was 1,349 ± 774 mGy cm and the contrast volume was 103 ± 18 ml. The following technical problems during ICA were identified: 11 coronary artery ostium anomalies (most often high take-off of the right coronary artery), 2 cases of suspected left main spasm, 5 cases with peripheral access site problems, 5 cases of ascending aorta or sinus of Valsalva aneurysm, and 2 cases of tortuous take-off of subclavian artery. In 20 (44 %) subjects including 19 patients after CABG, despite careful examination of ICA and CTA images there was no specific reason identified for incomplete ICA. Case examples are provided in Figs. 2, 3, 4, 5, 6. Overall, lack of specific technical difficulties was more common in patients in whom a venous by-pass graft could not be identified (Table 2). After coronary CTA evaluation, further decision to perform revascularization was made in 11 (24 %) patients. In 6 patients repeated ICA was successful guided by information provided by coronary CTA, and percutaneous intervention was performed. In 5 cases CABG (adjunctive to aortic valve replacement in 2 patients) was done solely on the basis of coronary CTA data.
Int J Cardiovasc Imaging (2014) 30:825–832 Table 1 Patients’ demographics and clinical characteristics
827
Patients with angina symptoms without previous CABG, n = 15
Patients prior to valvular surgery, n = 9
Patients with angina symptoms with previous CABG n = 21
P value
Age, (years ± SD)
65.2 ± 13.8
62.6 ± 17.9
70.1 ± 8.6
0.2
Men, n
9
7
17
0.4
Prior myocardial infarction, n
2
0
11
0.004
Congestive heart failure, n
0
8
11
\0.001
Hypertension, n
11
5
16
0.4
Diabetes mellitus, n
4
2
10
0.3
Hypercholesterolemia, n
12
8
21
0.1
Fig. 2 High take-off of the right coronary artery in a patient with aortic stenosis. a Angiography of the left coronary artery. Arrows point at calcifications in the aortic valve and aorta. Right coronary artery could not be visualized. b The CTA reconstruction showing very high take-off of the right coronary artery from the anterior aortic wall (white arrow) and a significant stenosis (red arrow). c ‘‘Angio-like’’ CTA reconstruction of the aortic root and coronary arteries; black arrows point at calcifications in aortic wall and aortic valve. d Curved multi-planar reconstruction of the right coronary artery; red arrow points at a significant stenosis
Incomplete ICA in patients prior to valvular surgery There were 24 patients without previous CABG including 9 patients who were scheduled for aortic valve replacement
(AVR). The indications for AVR were stenosis (8 patients) or regurgitation (1 patient). The reasons for an incomplete ICA were ascending aorta aneurysm in 5 patients, radial artery spasm in 1 patient without alternative femoral
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Fig. 3 Single coronary artery originating from the right sinus of Valsalva. a Angiography of the right coronary artery with visualized anomalous origin of the left circumflex artery (white arrow); left anterior coronary descending artery was not found. b and c CTA reconstructions showing that both left circumflex (white arrow) and left anterior descending artery (red arrow) originate from the proximal part of the right coronary artery. d curved multi-planar
reconstruction showing proximal part of the single coronary artery with left anterior descending artery indicated with red arrow and left circumflex with white arrow. The possible explanation for unsuccessful visualization of the left anterior descending artery is its very proximal origin from anatomical right coronary artery (more proximal than left circumflex) and occlusion of left anterior descending artery ostium with the tip of the right Judkins catheter
access, and a high take-off of the right coronary artery in 3 patients. The coronary CTA identified significant coronary artery lesions requiring revascularization in 2 (22 %) patients who also underwent revascularization during AVR surgery based solely on the coronary CTA data.
problem in 4 patients. In a single patient there was no obvious reason for an incomplete ICA. In 4 (27 %) patients coronary CTA identified a significant stenoses in arteries not visualized by ICA. All 4 subjects had clinical indications for revascularization: 2 presented with non- ST segment elevation myocardial infarction and 2 with typical symptoms of stable angina pectoris. Three patients were treated with CABG because of multi-vessel disease, and 1 right coronary artery with a high take-off was successfully stented using the coronary CTA data for procedure planning.
Incomplete ICA in patients with angina without previous CABG Out of 15 patients without previous CABG in whom ICA was incomplete there were 13 subjects with high and 2 subjects with intermediate pre-test probability of obstructive coronary artery disease. In 14 cases we identified 8 coronary ostia anomalies (4 high right coronary artery take-off, 1 right coronary artery originating from the left sinus, 1 single coronary artery, and 2 origination of left coronary artery from the right sinus of Valsalva); 2 cases of left main coronary artery spasm; and vascular access
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Incomplete ICA in patients with previous CABG There were 21 (2.2 %) patients with an incomplete ICA after previous CABG (graft age 9.2 ± 5.0 years) in whom a saphenous vein graft or left internal mammary artery (LIMA) could not be identified. In two cases the LIMA
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Fig. 4 Significant stenosis in a saphenous vein graft to the marginal branch. Upper panels Initial coronary angiography. a Proximal occlusion of the vein graft to the right coronary artery. b Patent graft to the left anterior descending artery (black arrow). During coronary angiography no other grafts were found. Middle panels Clinically driven (recurrent angina symptoms) CTA performed after coronary angiography. c Patent graft to the left anterior descending artery (black arrow) and stenotic graft to the marginal branch (red arrow points at stenosis site). d Occluded graft to the right coronary artery (white arrow). Lower panel. e Curved multi-planar reconstruction of the vein graft to the marginal branch (red arrow points at stenosis site). f During repeated catheterization driven by CTA, results the stenotic graft was identified (red arrow points at stenosis site) and subsequently treated with stent implantation
could not be visualized because of tortuous course of the left subclavian artery while in 19 cases there was no specific reason for lack of the venous graft visualization. The coronary CTA examination showed a patent LIMA in 2 patients, a highly stenotic venous graft in 2 patients, at least 1 occluded venous graft in 7 patients, and widely patent venous grafts in 10 patients. Based on the coronary CTA
data and clear clinical indications (non-ST segment elevation myocardial infarction in 2 subjects and recurrence of stable angina symptoms in 3 subjects) additional ICA with subsequent stent implantation into 2 venous grafts and 3 native coronary arteries supplied by occluded grafts was performed using the coronary CTA data with regards to the graft origin prior to the procedure.
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Fig. 5 Non-coronary sinus aneurysm in a patient with aortic regurgitation. a Angiogram of the left coronary artery; white arrows point at calcifications in the sinus wall. b Unsuccessful attempt to intubate the right coronary artery; white arrow point at calcifications in the sinus wall. c CTA reconstruction showing the aneurysm of the non-coronary sinus; red arrow points at origin of the right coronary
artery. d ‘‘Angio-like’’ CTA reconstruction showing heavy calcifications in the sinus of Valsalva (white arrow) and origin of the right coronary artery (red arrow). e CTA reconstruction of the aortic root with origin of the right coronary artery indicated with red arrow. f Curved multi-planar reconstruction or the right coronary artery with significant stenoses indicated with green arrows
Discussion
However, these criteria do not refer to the specific clinical scenario of the incomplete coronary angiography. Difficult intubation of a coronary artery or by-pass graft ostium and hazardous maneuvers with the diagnostic catheter are risk factors for ostium and aortic dissection [8]. In patients with extensive atherosclerosis in the ascending aorta, this may also result in stroke, transient ischemic attack, or peripheral embolization [9, 10]. We observed a transient ischemic attack in one of our patients. Moreover, high contrast volume used during numerous attempts of ostium intubation may increase risk of renal failure especially in patients after CABG who are often older with numerous comorbidities. The results of our study suggest that in case of increasing difficulties during the invasive diagnostic process it may be prudent to stop the procedure and refer the patient for coronary CTA examination. In three quarters of patients this approach resulted in further medical treatment alone as no significant lesion was found; and in 24 % of patients, an obstructive lesion was identified that led to a coronary CTA-guided revascularization. The alternative approach could be non-selective aortic root angiography. Prior to the introduction of coronary CTA into clinical practice, it was the only option when ICA was incomplete. However, non-selective aortography has several limitations: (1) it may confirm vessel patency, but not exclude presence of significant stenosis and (2) the
The unique findings of our study are: (1) nearly one quarter of patients with incomplete ICA may eventually require coronary revascularization (2) coronary CTA is a reliable and valuable tool for deciding on, and planning revascularization strategy after incomplete ICA. The usefulness of coronary CTA after inconclusive ICA was suggested by Hecht et al. based on the results obtained in a small group of 14 patients examined in a single CT lab [6]. However, the group described by Hecht et al. comprised patients selected for coronary CTA after incomplete ICA based on the unknown criteria which could result in selection bias (i.e. more symptomatic patients could be included). Our study enrolled unselected, consecutive patients routinely referred for coronary CTA after incomplete ICA out of over 13,600 cases. Moreover, due to the three times larger study sample we could evaluate more clinical scenarios in which ICA was incomplete and assess in more details the specific coronary anomalies responsible for ICA incompleteness. As to our knowledge, no other previous reports exist that described the causes and proposed further management in cases of incomplete coronary angiography. Current appropriateness criteria for utilization of coronary CTA support its use for the assessment of coronary anomalies and saphenous vein graft patency [7].
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Fig. 6 High right coronary artery take-off from the left sinus of Valsalva. a The angiogram of the left coronary artery with short significant stenoses indicated with white arrows. b Aortography showing origin of the right coronary artery (white arrow); following aortography despite use of several catheters the right coronary artery was not intubated. c and e CTA reconstructions showing anomalous
high take-off of the right coronary artery from the left sinus of Valsalva. d Curved multi-planar reconstruction of the right coronary artery originating from the aorta with course of the proximal segment between aorta and pulmonary trunk (red arrow). f The cross-section of the right coronary artery at the minimal lumen area site (MLA = 3 mm2). The patient was referred for triple by-pass surgery
Table 2 Reasons for incomplete coronary angiography according to patients’ subgroup Patients with angina symptoms without previous CABG, n = 15
Patients prior to valvular surgery, n=9
Patients with angina symptoms with previous CABG, n = 21
Coronary ostium anomaly, n
8
3
0
Vascular access problems, n
4
1
0
Subclavian artery tortuosity, n Coronary ostium spasm, n
0 2
0 0
2 0
Ascending aorta aneurysm, n
0
5
0
No specific reason for Incomplete CA, n
1
0
19
P value
\0.0001
CABG coronary artery by-pass grafting, CA coronary angiography
anatomical information from single plane aortography is less detailed than from CTA. While both aortography and coronary CTA require significant contrast, coronary CTA is capable not only to confirm vessel patency, but also may quantify stenosis severity. We found incomplete ICA was especially problematic in patients with aortic valve disease scheduled for AVR. Our findings and the results of other studies assessing the value of coronary CTA prior to non-coronary cardiac surgery and the current appropriateness criteria for coronary CTA use
suggest that CTA may be a reasonable first-choice option in this population especially in patients with sinus rhythm [7, 11, 12].
Limitations The main limitation of our analysis is its retrospective nature. Although it is routine practice in our hospital that patients with incomplete ICA are referred for coronary
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CTA it is possible that the exact number of incomplete ICA may be larger than estimated on the basis of review of indications for coronary CTA.
Conclusions
6.
Incomplete ICA is a significant clinical issue because substantial proportion of subjects requires subsequent revascularization. Therefore, these patients should be further thoroughly investigated, optimally by coronary CTA. Usefulness of coronary CTA in the scenario of incomplete ICA should be reflected in updated appropriateness criteria. Conflict of interest manuscript.
7.
There are no conflicts of interest related to this
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European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J 29(4):531–556 Burgstahler C, Beck T, Kuettner A, Drosch T, Kopp AF, Heuschmid M, Claussen CD, Schroeder S (2006) Non-invasive evaluation of coronary artery bypass grafts using 16-row multislice computed tomography with 188 ms temporal resolution. Int J Cardiol 106:244–249 Hecht HS, Jelnin V, Roubin GS (2008) Indications for multidetector computed tomographic coronary angiography after catheter-based coronary angiography. J Invasive Cardiol. 20:1–6 Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin GD (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/ SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 56(22):1864–1894 Boyle AJ, Chan M, Dib J, Resar J (2006) Catheter-induced coronary artery dissection: risk factors, prevention and management. J Invasive Cardiol. 10:500–503 Karalis DG, Quinn V, Victor MF, Ross JJ, Polansky M, Spratt KA, Chandrasekaran K (1996) Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 131(6):1149–1155 Eggebrecht H, Oldenburg O, Dirsch O, Haude M, Baumgart D, Welge D, Herrmann J, Arnold G, Schmid KW, Erbel R (2000) Potential embolization by atherosclerotic debris dislodged from aortic wall during cardiac catheterization: histological and clinical findings in 7,621 patients. Catheter Cardiovasc Interv 49(4):389–394 Pouleur AC, de Waroux JB, Kefer J, Pasquet A, Coche E, Vanoverschelde JL, Gerber BL (2007) Usefulness of 40-slice multidetector row computed tomography to detect coronary disease in patients prior to cardiac valve surgery. Eur Radiol 17(12):3199–3207 Galas A, Hryniewiecki T, Ke˛pka C, Michałowska I, Abramczuk E, Orłowska Baranowska E, Demkow M, Ru_zyłło W (2012) May dual-source computed tomography angiography replace invasive coronary angiography in the evaluation of patients referred for valvular disease surgery? Kardiol Pol. 70(9):877–882
ORIGINAL PAPER
The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography Jerzy Pregowski • Cezary Kepka • Mariusz Kruk • Gary S. Mintz • Lukasz Kalinczuk • Michal Ciszewski • Lukasz Kochanowski • Rafal Wolny • Zbigniew Chmielak • Jan Jastrze˛bski • Mariusz Klopotowski • Joanna Zalewska Marcin Demkow • Maciej Karcz • Adam Witkowski
•
Received: 30 August 2013 / Accepted: 4 March 2014 / Published online: 13 March 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract To assess the anatomical background and significance of incomplete invasive coronary angiography (ICA) and to evaluate the value of coronary computed tomography angiography (CTA) in this scenario. The current study is an analysis of high volume center experience with prospective registry of coronary CTA and ICA. The target population was identified through a review of the electronic database. We included consecutive patients referred for coronary CTA after ICA, which did not visualize at least one native coronary artery or by-pass graft. Between January 2009 and April 2013, 13,603 diagnostic ICA were performed. There were 45 (0.3 %) patients referred for coronary CTA after incomplete ICA. Patients were divided into 3 groups: angina symptoms without previous coronary artery by-pass grafting (CABG) (n = 11,212), angina symptoms with previous CABG (n = 986), and patients prior to valvular surgery (n = 925). ICA did not identify by-pass grafts in 21 (2.2 %) patients and in 24 (0.2 %) cases of native arteries. The explanations for an incomplete ICA included: 11 ostium anomalies, 2 left main spasms, 5 access site problems, 5 ascending aorta aneurysms, and 2 tortuous take-off of a subclavian artery. However, in 20 (44 %) patients no specific reason for the incomplete ICA was identified. After coronary CTA revascularization was performed in 11 (24 %) patients: 6 successful repeat ICA and percutaneous J. Pregowski (&) C. Kepka M. Kruk L. Kalinczuk M. Ciszewski L. Kochanowski R. Wolny Z. Chmielak J. Jastrze˛bski M. Klopotowski J. Zalewska M. Demkow M. Karcz A. Witkowski Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland e-mail: [email protected] G. S. Mintz Cardiovascular Research Foundation, New York, NY, USA
intervention and 5 CABG. Incomplete ICA constitutes rare, but a significant clinical problem. Coronary CTA provides adequate clinical information in these patients. Keywords Incomplete coronary angiography Computed tomography Congenital coronary artery anomaly
Introduction Invasive coronary angiography (ICA) is the gold standard in the evaluation of native coronary arteries in patients with suspected coronary artery disease (CAD) or by-pass graft failure after coronary artery by-pass grafting (CABG). However, in very rare cases despite use of dedicated catheters and numerous attempts, it is not possible to visualize the complete coronary anatomy. The clinical significance of incomplete ICA is unknown, and further management in this clinical scenario remains undetermined by known consensus documents. Coronary computed tomography angiography (CTA), is free of several limitations associated with ICA (i.e. inadequate arterial access, anomalous anatomy) and allows visualization of coronary vessels with excellent diagnostic accuracy [1–5]. The aim of our study was to assess the clinical significance of incomplete ICA and to evaluate the value of routine use of coronary CTA in this clinical scenario.
Materials and methods This is a retrospective study performed in a single center with high volume catheterization laboratory and CT departments. All coronary CTA examinations are performed and evaluated by the interventional cardiologists
123
826
(JP, CK, MK) actively working in the local catheterization laboratory. The data on the indications for all coronary CTA examinations are electronically recorded. Since Jan 2009 the patients in whom intended complete diagnostic ICA did not visualize at least one vessel or by-pass graft were routinely referred for coronary CTA. The target population was identified through a computer-assisted review of the electronic database containing indications for coronary CTA. The patients’ characteristics including coronary risk factors, pre-test probability of obstructive coronary artery disease and final decision regarding revascularization following adjunctive coronary CTA examination was then retrieved from patient hospitalization summaries that included complete diagnoses. The prospective coronary CTA registry conducted in our center started in April 2008 and was approved by the local IRB. The ICA was performed with Siemens angiograph (AXIOM ARTIS DFC, Forchheim, Germany). The data on access site, aortography, and amount of contrast and radiation was collected from the procedure reports. The coronary CTA examinations were performed with commercially available scanners: 64 slice Somatom Definition, (Siemens, Forchheim, Germany) or 128 raw Somatom Definition Flash, (Siemens, Forchheim, Germany). Prior to all coronary CTA scans, patients received sublingual nitrates in a dose of 0.8 mg. If the patient’s a heart rate exceeded 65/min intravenous boluses of metoprolol were given (sequential doses of 2.5 mg, maximal dose 10 mg). The reasons for ICA inconclusiveness were established by an experienced ICA and coronary CTA reader (JP) on the basis of the procedure reports and off-line ICA and coronary CTA dataset analyses. Statistics Continuous data are presented as means with standard deviation if normally distributed or as medians with interquartile ranges (IQR). Categorical variables were compared with a Chi square test.
Results Between January 2009 through April 2013 there were 13,603 diagnostic ICA performed in our center. The major indications for ICA were: suspected CAD in patients without previous CABG in 11,212 patients, suspected disease progression or by-pass graft failure in 986 patients after CABG, assessment of coronary arteries before valvular cardiac surgery in 925 patients, and as part of the diagnosis of heart failure or cardiomyopathy or after heart transplantation in 480 patients. Out of these 13,603 diagnostic ICA 45 (0.3 %) patients were referred for an
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Fig. 1 The flowchart of the study population
additional coronary CTA because ICA did not visualize complete coronary anatomy i.e. at least one native artery or by-pass graft. The flowchart for study population is presented as Fig. 1. There were 33 males, and the mean age was 67.3 ± 12.8 years. Baseline patients’ characteristics are provided in Table 1. Inconclusive non-selective aortography was performed in 6 patients. The radiation dose during ICA was 1,127 ± 877 mGy, dose area product was 9,751 ± 15,397 lGy m2, fluoroscopy time was 16 ± 8 min and contrast volume was 112 ± 68 ml. The radiation dose defined as dose length product during coronary CTA was 1,349 ± 774 mGy cm and the contrast volume was 103 ± 18 ml. The following technical problems during ICA were identified: 11 coronary artery ostium anomalies (most often high take-off of the right coronary artery), 2 cases of suspected left main spasm, 5 cases with peripheral access site problems, 5 cases of ascending aorta or sinus of Valsalva aneurysm, and 2 cases of tortuous take-off of subclavian artery. In 20 (44 %) subjects including 19 patients after CABG, despite careful examination of ICA and CTA images there was no specific reason identified for incomplete ICA. Case examples are provided in Figs. 2, 3, 4, 5, 6. Overall, lack of specific technical difficulties was more common in patients in whom a venous by-pass graft could not be identified (Table 2). After coronary CTA evaluation, further decision to perform revascularization was made in 11 (24 %) patients. In 6 patients repeated ICA was successful guided by information provided by coronary CTA, and percutaneous intervention was performed. In 5 cases CABG (adjunctive to aortic valve replacement in 2 patients) was done solely on the basis of coronary CTA data.
Int J Cardiovasc Imaging (2014) 30:825–832 Table 1 Patients’ demographics and clinical characteristics
827
Patients with angina symptoms without previous CABG, n = 15
Patients prior to valvular surgery, n = 9
Patients with angina symptoms with previous CABG n = 21
P value
Age, (years ± SD)
65.2 ± 13.8
62.6 ± 17.9
70.1 ± 8.6
0.2
Men, n
9
7
17
0.4
Prior myocardial infarction, n
2
0
11
0.004
Congestive heart failure, n
0
8
11
\0.001
Hypertension, n
11
5
16
0.4
Diabetes mellitus, n
4
2
10
0.3
Hypercholesterolemia, n
12
8
21
0.1
Fig. 2 High take-off of the right coronary artery in a patient with aortic stenosis. a Angiography of the left coronary artery. Arrows point at calcifications in the aortic valve and aorta. Right coronary artery could not be visualized. b The CTA reconstruction showing very high take-off of the right coronary artery from the anterior aortic wall (white arrow) and a significant stenosis (red arrow). c ‘‘Angio-like’’ CTA reconstruction of the aortic root and coronary arteries; black arrows point at calcifications in aortic wall and aortic valve. d Curved multi-planar reconstruction of the right coronary artery; red arrow points at a significant stenosis
Incomplete ICA in patients prior to valvular surgery There were 24 patients without previous CABG including 9 patients who were scheduled for aortic valve replacement
(AVR). The indications for AVR were stenosis (8 patients) or regurgitation (1 patient). The reasons for an incomplete ICA were ascending aorta aneurysm in 5 patients, radial artery spasm in 1 patient without alternative femoral
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Fig. 3 Single coronary artery originating from the right sinus of Valsalva. a Angiography of the right coronary artery with visualized anomalous origin of the left circumflex artery (white arrow); left anterior coronary descending artery was not found. b and c CTA reconstructions showing that both left circumflex (white arrow) and left anterior descending artery (red arrow) originate from the proximal part of the right coronary artery. d curved multi-planar
reconstruction showing proximal part of the single coronary artery with left anterior descending artery indicated with red arrow and left circumflex with white arrow. The possible explanation for unsuccessful visualization of the left anterior descending artery is its very proximal origin from anatomical right coronary artery (more proximal than left circumflex) and occlusion of left anterior descending artery ostium with the tip of the right Judkins catheter
access, and a high take-off of the right coronary artery in 3 patients. The coronary CTA identified significant coronary artery lesions requiring revascularization in 2 (22 %) patients who also underwent revascularization during AVR surgery based solely on the coronary CTA data.
problem in 4 patients. In a single patient there was no obvious reason for an incomplete ICA. In 4 (27 %) patients coronary CTA identified a significant stenoses in arteries not visualized by ICA. All 4 subjects had clinical indications for revascularization: 2 presented with non- ST segment elevation myocardial infarction and 2 with typical symptoms of stable angina pectoris. Three patients were treated with CABG because of multi-vessel disease, and 1 right coronary artery with a high take-off was successfully stented using the coronary CTA data for procedure planning.
Incomplete ICA in patients with angina without previous CABG Out of 15 patients without previous CABG in whom ICA was incomplete there were 13 subjects with high and 2 subjects with intermediate pre-test probability of obstructive coronary artery disease. In 14 cases we identified 8 coronary ostia anomalies (4 high right coronary artery take-off, 1 right coronary artery originating from the left sinus, 1 single coronary artery, and 2 origination of left coronary artery from the right sinus of Valsalva); 2 cases of left main coronary artery spasm; and vascular access
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Incomplete ICA in patients with previous CABG There were 21 (2.2 %) patients with an incomplete ICA after previous CABG (graft age 9.2 ± 5.0 years) in whom a saphenous vein graft or left internal mammary artery (LIMA) could not be identified. In two cases the LIMA
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Fig. 4 Significant stenosis in a saphenous vein graft to the marginal branch. Upper panels Initial coronary angiography. a Proximal occlusion of the vein graft to the right coronary artery. b Patent graft to the left anterior descending artery (black arrow). During coronary angiography no other grafts were found. Middle panels Clinically driven (recurrent angina symptoms) CTA performed after coronary angiography. c Patent graft to the left anterior descending artery (black arrow) and stenotic graft to the marginal branch (red arrow points at stenosis site). d Occluded graft to the right coronary artery (white arrow). Lower panel. e Curved multi-planar reconstruction of the vein graft to the marginal branch (red arrow points at stenosis site). f During repeated catheterization driven by CTA, results the stenotic graft was identified (red arrow points at stenosis site) and subsequently treated with stent implantation
could not be visualized because of tortuous course of the left subclavian artery while in 19 cases there was no specific reason for lack of the venous graft visualization. The coronary CTA examination showed a patent LIMA in 2 patients, a highly stenotic venous graft in 2 patients, at least 1 occluded venous graft in 7 patients, and widely patent venous grafts in 10 patients. Based on the coronary CTA
data and clear clinical indications (non-ST segment elevation myocardial infarction in 2 subjects and recurrence of stable angina symptoms in 3 subjects) additional ICA with subsequent stent implantation into 2 venous grafts and 3 native coronary arteries supplied by occluded grafts was performed using the coronary CTA data with regards to the graft origin prior to the procedure.
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Fig. 5 Non-coronary sinus aneurysm in a patient with aortic regurgitation. a Angiogram of the left coronary artery; white arrows point at calcifications in the sinus wall. b Unsuccessful attempt to intubate the right coronary artery; white arrow point at calcifications in the sinus wall. c CTA reconstruction showing the aneurysm of the non-coronary sinus; red arrow points at origin of the right coronary
artery. d ‘‘Angio-like’’ CTA reconstruction showing heavy calcifications in the sinus of Valsalva (white arrow) and origin of the right coronary artery (red arrow). e CTA reconstruction of the aortic root with origin of the right coronary artery indicated with red arrow. f Curved multi-planar reconstruction or the right coronary artery with significant stenoses indicated with green arrows
Discussion
However, these criteria do not refer to the specific clinical scenario of the incomplete coronary angiography. Difficult intubation of a coronary artery or by-pass graft ostium and hazardous maneuvers with the diagnostic catheter are risk factors for ostium and aortic dissection [8]. In patients with extensive atherosclerosis in the ascending aorta, this may also result in stroke, transient ischemic attack, or peripheral embolization [9, 10]. We observed a transient ischemic attack in one of our patients. Moreover, high contrast volume used during numerous attempts of ostium intubation may increase risk of renal failure especially in patients after CABG who are often older with numerous comorbidities. The results of our study suggest that in case of increasing difficulties during the invasive diagnostic process it may be prudent to stop the procedure and refer the patient for coronary CTA examination. In three quarters of patients this approach resulted in further medical treatment alone as no significant lesion was found; and in 24 % of patients, an obstructive lesion was identified that led to a coronary CTA-guided revascularization. The alternative approach could be non-selective aortic root angiography. Prior to the introduction of coronary CTA into clinical practice, it was the only option when ICA was incomplete. However, non-selective aortography has several limitations: (1) it may confirm vessel patency, but not exclude presence of significant stenosis and (2) the
The unique findings of our study are: (1) nearly one quarter of patients with incomplete ICA may eventually require coronary revascularization (2) coronary CTA is a reliable and valuable tool for deciding on, and planning revascularization strategy after incomplete ICA. The usefulness of coronary CTA after inconclusive ICA was suggested by Hecht et al. based on the results obtained in a small group of 14 patients examined in a single CT lab [6]. However, the group described by Hecht et al. comprised patients selected for coronary CTA after incomplete ICA based on the unknown criteria which could result in selection bias (i.e. more symptomatic patients could be included). Our study enrolled unselected, consecutive patients routinely referred for coronary CTA after incomplete ICA out of over 13,600 cases. Moreover, due to the three times larger study sample we could evaluate more clinical scenarios in which ICA was incomplete and assess in more details the specific coronary anomalies responsible for ICA incompleteness. As to our knowledge, no other previous reports exist that described the causes and proposed further management in cases of incomplete coronary angiography. Current appropriateness criteria for utilization of coronary CTA support its use for the assessment of coronary anomalies and saphenous vein graft patency [7].
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Fig. 6 High right coronary artery take-off from the left sinus of Valsalva. a The angiogram of the left coronary artery with short significant stenoses indicated with white arrows. b Aortography showing origin of the right coronary artery (white arrow); following aortography despite use of several catheters the right coronary artery was not intubated. c and e CTA reconstructions showing anomalous
high take-off of the right coronary artery from the left sinus of Valsalva. d Curved multi-planar reconstruction of the right coronary artery originating from the aorta with course of the proximal segment between aorta and pulmonary trunk (red arrow). f The cross-section of the right coronary artery at the minimal lumen area site (MLA = 3 mm2). The patient was referred for triple by-pass surgery
Table 2 Reasons for incomplete coronary angiography according to patients’ subgroup Patients with angina symptoms without previous CABG, n = 15
Patients prior to valvular surgery, n=9
Patients with angina symptoms with previous CABG, n = 21
Coronary ostium anomaly, n
8
3
0
Vascular access problems, n
4
1
0
Subclavian artery tortuosity, n Coronary ostium spasm, n
0 2
0 0
2 0
Ascending aorta aneurysm, n
0
5
0
No specific reason for Incomplete CA, n
1
0
19
P value
\0.0001
CABG coronary artery by-pass grafting, CA coronary angiography
anatomical information from single plane aortography is less detailed than from CTA. While both aortography and coronary CTA require significant contrast, coronary CTA is capable not only to confirm vessel patency, but also may quantify stenosis severity. We found incomplete ICA was especially problematic in patients with aortic valve disease scheduled for AVR. Our findings and the results of other studies assessing the value of coronary CTA prior to non-coronary cardiac surgery and the current appropriateness criteria for coronary CTA use
suggest that CTA may be a reasonable first-choice option in this population especially in patients with sinus rhythm [7, 11, 12].
Limitations The main limitation of our analysis is its retrospective nature. Although it is routine practice in our hospital that patients with incomplete ICA are referred for coronary
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CTA it is possible that the exact number of incomplete ICA may be larger than estimated on the basis of review of indications for coronary CTA.
Conclusions
6.
Incomplete ICA is a significant clinical issue because substantial proportion of subjects requires subsequent revascularization. Therefore, these patients should be further thoroughly investigated, optimally by coronary CTA. Usefulness of coronary CTA in the scenario of incomplete ICA should be reflected in updated appropriateness criteria. Conflict of interest manuscript.
7.
There are no conflicts of interest related to this
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