134~142특집_최병욱

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1 Focused Issue of This Month MDCT young Wook Choi, MD Department of Radiology, Yonsei University College of Medicine bchoi@yumc.yonsei.ac.kr J Korean Med ssoc 2007; 50(2): bstract Multidetector computed tomography (MDCT) has recently been used as a diagnostic tool for the evaluation of coronary artery morphology and stenosis. The accuracy of MDCT has improved as the number of detectors of MDCT has increased. 64MDCT reliably detects significant coronary artery stenosis with a sensitivity and specificity higher than 90%. With its high negative predictive value near 100%, 64MDCT is very practical for excluding significant coronary artery disease and avoiding unnecessary invasive coronary angiography. Furthermore, preprocedural MDCT coronary angiography is useful to provide additional information and predict the procedural outcomes particularly in patients who have chronic total occlusion and those referred for percutaneous coronary intervention. Postprocedural MDCT coronary angiography usually involves evaluation of instent restenosis. Recently, drugeluting stents are widely used and has notably reduced the rate of instent restenosis. However, the rate of instent restenosis of drugeluting stents are still 5 ~10%. Considering the large number of patients who receive coronary artery stents, MDCT would be clinically useful as a noninvasive tool for the reliable detection of instent restenosis. Even with 64MDCT, 30 ~ 40% of stents are not evaluable because the spatial and temporal resolutions are not sufficient for the detection of instent restenosis. With the 64MDCT technology, the accessibility of instent restenosis mainly depends on stent size and severity of metal artifact of stents. lthough the current MDCT does not permit reliable detection of instent restenosis, MDCT can be accepted as a firstline alternative to coronary angiography for the evaluation of stents, especially those with a large diameter such as left main coronary artery stents. Keywords : Multidetector CT (MDCT); Coronary intervention; Coronary artery disease 134

C Figure 1. Total occlusion of left anterior descending artery.

2 C Figure 1. Total occlusion of left anterior descending artery. Coronary angiography shows total occlusion of the proximal left anterior descending artery (). The 3dimensional volume rendered CT image shows calcification along the occluded segments (). The curved multiplanar image excellently shows not only the extent of total occlusion but also occluding mixed plaques with calcification and fibrous components (C) 135

3 Choi W Figure 2. Visualization of patent stent lumen and instent restenosis with coronary MDCT angiography. 64MDCT shows a patent drugeluting stent in the proximal left anterior descending artery (). In a different patient, 64MDCT shows instent restenosis in the distal right coronary artery (). which reveals lowattenuated intraluminal density 136

The total occlusion is passed by a guide wire with

4 C Figure 3. Coronary intervention in chronic total occlusion. total occlusion is noted from the mid to distal left anterior descending artery (). The total occlusion is passed by a guide wire with retrograde fashion through a collateral pathway (). Stenting through the occluded segment is successfully performed (C) 137

Choi W Figure 4. Instent restenosis in distal right coronary artery.

right coronary artery, which was wrongly interpreted as patent ().

The image that is reconstructed with a sharpkernel for evaluation

5 Choi W Figure 4. Instent restenosis in distal right coronary artery. curved multiplanar MDCT angiography shows a stent at the distal right coronary artery, which was wrongly interpreted as patent (). The coronary angiogram shows significant instent restenosis () Figure 5. CT image reconstruction affecting evaluation of coronary stents. The image that is reconstructed with a sharpkernel for evaluation of stents () is superior in evaluation of instent lumen to the image that is reconstructed with a softkernel for angiographic images () 138

The 64 MDCT image shows instent restenosis (arrow) at the distal part

The coronary angiogram confirms instent restenosis ().

6 Figure 6. Figure 7. Instent restenosis and peristent small aneurysms of drugeluting stent. The 64 MDCT image shows instent restenosis (arrow) at the distal part with eccentric neointimal proliferation as a low density (). The coronary angiogram confirms instent restenosis (). Small peristent aneurysms are noted (arrowheads in and ) Stenting of left main artery and bifurcation. The stents in the left main and bifurcation shows low luminal density, which is suggesting significant restenosis (). The coronary angiogram confirms significant restenosis of the stents () 139

$Choi W C Figure 8. Stent fracture.$ In 2year followup, a stent was inserted at the distal right

$In 4year follow up, stent fracture at the proximal segment is$

7 Choi W C Figure 8. Stent fracture. stent was inserted at the proximal right coronary artery. In 2year followup, a stent was inserted at the distal right coronary artery, where significant stenosis was newly developed (). In 4year follow up, stent fracture at the proximal segment is noted, which is well depicted in MDCT (arrow in ) and coronary angiography (arrow in C) 140

8 1. Kaneda H, Saito S, Shiono T, Miyashita Y, Takahashi S, Domae H. Sixtyfourslice computed tomographyfacilitated percutaneous coronary intervention for chronic total occlusion. Int J Cardiol 2007;115: Yokoyama N, Yamamoto Y, Suzuki S, Suzuki M, Konno K, Kozuma K, Kaminaga T, Isshiki T. Impact of 16slice computed tomography in percutaneous coronary intervention of chronic total occlusions. Catheter Cardiovasc Interv 2006;68: Mollet NR, Hoye, Lemos P, Cademartiri F, Sianos G, Mc- Fadden EP, Krestin GP, Serruys PW, de Feyter PJ. Value of preprocedure multislice computed tomographic coronary angiography to predict the outcome of percutaneous recanalization of chronic total occlusions. m J Cardiol 2005;95: Van Mieghem C, Cademartiri F, Mollet NR, Malagutti P, Valgimigli M, Meijboom W, Pugliese F, McFadden EP, Ligthart J, Runza G, ruining N, Smits PC, Regar E, van der Giessen WJ, Sianos G, van Domburg R, de Jaegere P, Krestin GP, Serruys PW, de Feyter PJ. Multislice spiral computed tomography for the evaluation of stent patency after left main coronary artery stenting: a comparison with conventional coronary angiography and intravascular ultrasound. Circulation 2006;114: Rixe J, chenbach S, Ropers D, aum U, Kuettner, Ropers U, autz W, Daniel WG, nders K. ssessment of coronary artery stent restenosis by 64slice multidetector computed tomography. Eur Heart J 2006;27: Funabashi N, Maeda F, Nakamura K, Suzuki K, Mita Y, sano M, Narumi H, Kurokawa M, Komuro I. Patency of the left coronary artery by 64slice multislice computed tomography following implantation of sirolimuseluting stent. Int J Cardiol 2006;111: eohar N, Robbins JD, Cavanaugh J, nsari H, Yaghmai V, Carr J, Davidson CJ. Quantitative assessment of instent dimensions: a comparison of 64 and 16 detector multislice computed tomography to intravascular ultrasound. Catheter Cardiovasc Interv 2006;68: Holmes DR Jr, Leon M, Moses JW, Popma JJ, Cutlip D, Fitzgerald PJ, rown C, Fischell T, Wong SC, Midei M, Snead D, Kuntz RE. nalysis of 1year clinical outcomes in the SIRIUS trial: a randomized trial of a sirolimuseluting stent versus a standard stent in patients at high risk for coronary restenosis. Circulation 2004;109: udoff MJ, chenbach S, lumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci D, Lima J, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE. ssessment of coronary artery disease by cardiac computed tomography: a scientific statement from the merican Heart ssociation Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006;114: Hoffmann U, Nagurney JT, Moselewski F, Pena, Ferencik M, Chae CU, Cury RC, utler J, bbara S, rown DF, Manini, Nichols JH, chenbach S, rady TJ. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006;114; Omran H, Schmidt H, Hackenbroch M, Illien S, ernhardt P, von der Recke G, Fimmers R, Flacke S, Layer G, Pohl C, Luderitz, Schild H, Sommer T. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study. Lancet 2003;361: udoff MJ, Georgiou D, rody, gatston S, Kennedy J, Wolfkiel C, Stanford W, Shields P, Lewis RJ, Janowitz WR, Rich S, rundage H. Ultrafast computed tomography as 141

9 Choi W a diagnostic modality in the detection of coronary artery disease: a multicenter study. Circulation 1996;93: Stein PD, eemath, Kayali F, Skaf E, Sanchez J, Olson RE. Multidetector computed tomography for the diagnosis of coronary artery disease: a systematic review. m J Med 2006; 119: Schuijf JD, ax JJ, Shaw LJ, de Roos, Lamb HJ, van der Wall EE, Wijns W. Metaanalysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. m Heart J 2006;151: Gilard M, Cornily JC, Rioufol G, Finet G, Pennec PY, Mansourati J, lanc JJ, oschat J. Noninvasive assessment of left main coronary stent patency with 16slice computed tomography. m J Cardiol 2005;95: Peer Reviewer Commentary 142

127~133특집_서준범

127~133특집_서준범 Focused Issue of This Month ssessment of Coronary rtery ypass Graft Patency Using Multidetector Computed Tomography Joon eom Seo, MD Department of Radiology, University of Ulsan College of Medicine Email