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 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. 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
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
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. 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
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. 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
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