127~133특집_서준범

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1 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 seojb@amc.seoul.kr J Korean Med ssoc 2007; 50(2): bstract Coronary artery bypass graft surgery (CG) is the standard of care in the treatment of advanced coronary artery disease. Invasive coronary angiography has been used to assess the status of graft. Recently, multidetector computed tomography (MDCT) has emerged as an important diagnostic tool for the evaluation of graft patency. Many studies have shown that MDCT has a high sensitivity and specificity in detecting graft occlusion or highgrade stenosis. However, there are several diagnostic pitfalls in evaluating CG graft patency due to several factors, including technical factors, patient factors, and flow competition. cknowledgment of these pitfalls and remedies to avoid wrong interpretation is essential to improve diagnostic accuracy. In addition, MDCT yields additional information such as plural effusion, pericardial effusion, sternal infection, pneumonia, pulmonary embolism, and so on. The continuing advance in the MDCT technology suggests that MDCT will be a rapid, convenient, and noninvasive tool in evaluating CG patients in the near future. Keywords : Computed tomography; Coronary artery disease; Coronary artery bypass graft 127

) show the patent, contrastfilled internal

2 Seo J C Figure 1. Patent internal mammary artery graft anastomosed to left anterior descending artery. Coronal image and volume rendered image ( and ) show the patent, contrastfilled internal mammary artery (arrows), which is well correlated with conventional angiogram (C) 128

Coronary rtery ypass Graft and MDCT Figure 2. Figure 3.

Patent saphenous vein graft from ascending aorta, anastomosed to

artery is not visualized on MDCT images ( and C).

artery are shown as nodular lesions (arrowhead in C).

3 Coronary rtery ypass Graft and MDCT Figure 2. Figure 3. C Variable coronary artery bypass grafts. Patent saphenous vein graft from ascending aorta, anastomosed to distal right coronary artery (arrow) is shown in both volume rendered MDCT () and conventional angiogram (). Patent radial artery graft to an obtuse marginal branch is also visualized on both images (C and D). The left internal mammary artery graft to left anterior descending artery is not visualized on MDCT images ( and C). Insteads, multiple surgical clips around left anterior descending artery are shown as nodular lesions (arrowhead in C). Catheter angiogram confirmed the graft failure (not shown) Patent right gastroepiploic artery graft anastomosed to posterior descending artery. oth volume rendered MDCT image () and conventional angiogram () show patent graft D 129

Seo J Figure 4. Figure 5. saphenous graft stenosis.

portion of saphenous vein graft (arrow), which is confirmed at

in immediate postoperative period due to acute thrombosis.

4 Seo J Figure 4. Figure 5. saphenous graft stenosis. Volume rendered MDCT images () shows vocal narrowing of distal portion of saphenous vein graft (arrow), which is confirmed at conventional angiogram (arrow in ) Saphenous vein graft occlusion in immediate postoperative period due to acute thrombosis. MDCT image shows saphenous vein graft filled with thrombus with soft tissue density (arrows) 130

Coronary rtery ypass Graft and MDCT Figure 6. Figure 7.

Oblique MDCT image () shows good opacification of left internal mammary artery graft (arrow)

Metallic surgical clips (arrowhead) hamper the detailed evaluation of anastomosis site.

MDCT Vasospasm of graft mimicking significant stenosis.

5 Coronary rtery ypass Graft and MDCT Figure 6. Figure 7. False negative interpretation due to surgical clip at anastomosis site. Oblique MDCT image () shows good opacification of left internal mammary artery graft (arrow) anastomosed to left anterior descending artery. Metallic surgical clips (arrowhead) hamper the detailed evaluation of anastomosis site. Catheter angiogram () shows focal stenosis, resulting in false negative interpretation of MDCT Vasospasm of graft mimicking significant stenosis. Volume rendered MDCT image () obtained 5 days after CG shows multifocal areas of luminal narrowing at radial artery graft (arrows). MDCT image () obtained 6 months later shows patent graft, confirming the vasospasm at early postoperative period 131

6 Seo J Table 1. Results of Studies of the Use of MDCT to Evaluate Occlusion and Highgrade Stenosis of Grafts uthors MDCT No. of Patients No. of Grafts Evaluation possible (%) Sensitivity (%) Specificity (%) Ropers, et al. (11) 4MDCT (135 / 182) 192 (68 / 74) 95 (103 / 108) Nieman, et al. (12) 4MDCT (75 / 86) 192 (24 / 26) 88 (43 / 49) Marano, et al. (13) 4MDCT (92 / 122) 189 (34 / 38) 95 (80 / 84) Kim HJ, et al. (10) 16MDCT (160 / 160) 184 (26 / 31) 95 (123 / 129) Schlosser, et al. (14) 16MDCT (131 / 131) 196 (21 / 22) 95 (104 / 109) Ropers (15) 64MDCT (138 / 138) 100 (54 / 54) 94 (79 / 84) Hightgrade stenosis is defined as 50~99% stenosis 1. ourassa MG, Fisher LD, Campeau L, Gillespie MJ, Mc- Conney M, Lesperance J. Longterm fate of bypass grafts: the coronary artery surgery study (CSS) and Montreal Heart 132

7 Coronary rtery ypass Graft and MDCT Institute experiences. Circulation 1985;72:V runy JE. Complications of coronary arteriography. In: aum S, ed. brams' angiography: vascular and interventional radiology, 4th ed. oston: Little, rown and Company, 1997: de ono DP, Samani NJ, Spyt TJ, Hartshorne T, Thrush J, Evans DH. Transcutaneous ultrasound measurement of blood flow in internal mammary artery to coronary artery grafts. Lancet 1992;339: Gomes S, Lois JF, Drinkwater DC Jr, Corday SR. Coronary artery bypass grafts: visualization with MR imaging. Radiology 1987;162: Langerak SE, Vliegen HW, de Roos, Zwinderman H, Jukema JW, Kunz P, Lamb HJ, van Der Wall EE. Detection of vein graft disease using highresolution magnetic resonance angiography. Circulation 2002;105: Ha JW, Cho SY, Shim WH, Chung N, Jang Y, Lee HM, Choe KO, Chung WJ, Choi SH, Yoo KJ, Kang MS. Noninvasive evaluation of coronary artery bypass graft patency using threedimensional angiography obtained with contrast enhanced electron beam CT. m J Roentgenol 1999;172: chenbach S, Moshage W, Ropers D, Nossen J, achmann K. Noninvasive, threedimensional visualization of coronary artery bypass grafts by electron beam tomography. m J Cardiol 1997;79: Ueyama K, Ohashi H, Tsutsumi Y, Kawai T, Ueda T, Ohnaka M. Evaluation of coronary artery bypass grafts using helical scan computed tomography. Catheter Cardiovasc Interv 1999;46: Hong C, ecker CR, Huber, Schoepf UJ, Ohnesorge, Knez, runing R, Reiser MF. ECGgated reconstructed multidetector row CT coronary angiography: effect of varying trigger delay on image quality. Radiology 2001;220: Kim HJ, Seo J, Lee YK, Do KH, Heo JN, et al. ECGgated CT angiography for the assessment of coronary bypass graft patency: the influence of heart rate, type of bypass graft, target vessel and surgical technique on the diagnostic accuracy. J Korean Radiol Soc 2006;54: Ropers D, Ulzheimer S, Wenkel E, aum U, Giesler T, Derlien H, Moshage W, autz W, Daniel WG, Kalender W, chenbach S. Investigation of aortocoronary artery bypass grafts by multislice spiral computed tomography with electrocardiographicgated image reconstruction. m J Cardiol 2001; 88: Nieman K, Pattynama PMT, Rensing J, van Geuns RJM, de Feyter PJ. Evaluation of patients after coronary artery bypass surgery: CT angiographic assessment of grafts and coronary arteries. Radiology 2003;229: Marano R, Storto ML, Maddestra N, onomo L. Noninvasive assessment of coronary artery bypass graft with retrospectively ECGgated fourrow multidetector spiral computed tomography. Eur Radiol 2004;14: Schlosser T, Konorza T, Hunold P, Kuhl H, Schmermund, arkhausen J. Noninvasive visualization of coronary artery bypass grafts using 16detector row computed tomography. J m Coll Cardiol 2004;44: Ropers D, Pohle FK, Kuettner, Pflederer T, nders K, Daniel WG, autz W, aum U, chenbach S. Diagnostic accuracy of noninvasive coronary angiography in patients after bypass surgery using 64slice spiral computed tomography with 330 ms gantry rotation. Circulation 2006;114: Frazier, Qureshi F, Read KM, Gilkeson RC, Poston RS, White CS. Coronary artery bypass grafts: assessment with multidector CT in the early and late postoperative settings. RadioGraphics 2005;25: Rossi R, Chiurlia E, Ratti C, Ligabue G, Romagnoli R, Modena MG. Noninvasive assessment of coronary artery bypass graft patency by multislice computed tomography. Ital Heart J 2004;5:36-41 Peer Reviewer Commentary 133

134~142특집_최병욱

134~142특집_최병욱 Focused Issue of This Month MDCT young Wook Choi, MD Department of Radiology, Yonsei University College of Medicine Email : bchoi@yumc.yonsei.ac.kr J Korean Med ssoc 2007; 50(2): 134-142 bstract Multidetector