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Coronary Atherosclerosis with Multislice CT:What is beyond coronary atherosclerosis
Konstantin NikolaouTobias Jakobs
Bernd Wintersperger
Radiology
Alexander Becker
Andreas Knez
Alexander Leber
Cardiology
Michael Muders
Pathology
Christoph R Becker
Calcified & Noncalcified Plaques
CTA Inclusion Criteria
• Asymptomatic patients• CV risk factors• Positive calcium scan
• Symptomatic patients• No CAD history• Atypical chest pain• Inconsistent stress test< 100 mg CaHA
Patient Preparation
82 bpm
• -blocker• R/o Contra
indications• Informed consent• Metoprolol
• 50 - 100 mg orally• 30 - 90 min prior
• HR 50 - 60 bpm
65 bpm
Coronary CTA Parameters
• Testbolus 20 ml @ 4 ml/sTestbolus 20 ml @ 4 ml/s• 120 ml (300 mg iodine) @ 3 ml/s 120 ml (300 mg iodine) @ 3 ml/s
+ NaCl 60 ml @ 3 ml/s + NaCl 60 ml @ 3 ml/s• 500 ms gantry rotation500 ms gantry rotation• 120 kV, 300 mA120 kV, 300 mA• 4 x 1 mm collimation4 x 1 mm collimation• 3 mm/s table feed3 mm/s table feed• 40 s breath hold40 s breath hold
ECG Tube Current Modulation
Pitch<0,4
250 ms 250 ms250 ms
100%
20%
mAs
CTA Radiation Exposure
mSv
Left Coronary Artery (RAO)
Coronary Angiography MDCT & VRT
LAO 60Coronary Angiography MDCT & VRT
Right Coronary Artery (LAO)
Detection of Coronary Stenoses
MDCT Coronary Angiography
Coronary StenosesCTA & Angiography
Author Journal PPV NPV n.a. n
Niemann Lancet2001
81% 97% 30% 35
Achenbach Circulation2001
59% 98% 32% 64
Mean/sum 70% 98% 31% 99
CTA Limitations
• Artifacts• Cardiac motion• Breathing• Blooming
• Poor opacification• Small vessel
Solutions
< Rot. time & blocker • Cardiac motion artifacts
< Scan times• Breathing artifacts• CM utilization
< Slice thickness• Small vessels• Blooming artifact
16 Detector Row CT Angiography
• 200 ms• 9 Lp/cm• 0.8 mm• 20 s breath hold• 60 ml CM
Coronary Plaque Imaging
MDCT Coronary Angiography
Non Calcified Plaque Density
Coronary Atherosclerosis
Calcified Nodule
Wall changes Occlusion
ThrombusFibrocalcified Plaque
Stenoses
Intimal Thickening
Atheroma
Healing Hemorrhage
Rupture/Erosion
Atheroma
• 38 YOM• Non specific complain• Risk Factors
– Cholesterin– Smoker
• No calcium
50 HU
50 HU
Calcified Nodule
• 62 YOM• Suspicion of CAD• 12 mg CaHA
Fibrocalcified Plaque
100 HU
Thrombus
• 42 YOM• Epigastric chest pain• Risk Factors
– Hypertension– Smoker
• No calcium
20 HU
Thrombus
Acute Posterior Wall Infarction
Myocardial Infarction Scar
anteriorLAD
lateralLCx
posteriorRCA
CT Plaque Density
Lipid Fibrose50 ± 12 HU 89 ± 31 HU
p = 0.018
Lipid Fibrosis
CTA vs IVUSSchröder Heart 2001;85:576
Carotid AtherosclerosisEstes 1998 J Cardiovasc Surg 39:527
Plaque DistributionLeber 2001 Circulation
Non-calcified
13%
Mixed33%
Calcified54%
Myocardial Infarctionn = 12
122 Plaque
Stable Anginan = 12
135 PlaqueNon-
calcified6%
Mixed14%
Calcified80%
Summary
• Detection of stenoses– Calcium– Small vessels
• Characterization of plaques• Identify atheromas• Follow up under therapy
• Acute coronary event• Intracoronary thrombus• Myocardial infarction
www.CT2002.org