The ability of computed tomography angiography to predict 5-year mortality in the SYNTAX III REVOLUTION trial

The REVOLUTION project: planning and performing surgical revascularization based solely on coronary computed tomography angiography

Coronary computed tomography angiography (CCTA) is a non-invasive diagnostic tool that is increasingly being used as an alternative to invasive coronary angiography (ICA) in patients with suspected coronary artery disease (CAD), providing important information on the extent and severity of CAD. Furthermore, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been recently introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses. ICA has been the preferred diagnostic method to guide the decision-making process between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Recently, two studies have investigated the feasibility of using CCTA rather than ICA to plan CABG. In patients with three-vessel disease and/or left main CAD, the SYNTAX III REVOLUTION trial concluded that clinical decision-making between CABG and PCI using CCTA had a high level of agreement with treatment decisions based on ICA. In the FASTTRACK study, CABG procedures were planned based on CCTA without knowledge of ICA. CABG guided by CCTA showed to be feasible with an acceptable safety profile in a selected population of complex CAD. These intriguing findings should be confirmed in a large randomized trial on the revascularization outcome by comparing patients who underwent a novel non-invasive vs. a traditional invasive roadmap.

Kugel's Artery in Coronary Computed Tomography Angiography in a Patient with Left Main Subtotal Stenosis

The artery of Kugel is defined as a rare anatomical variant of the coronary arteries. It consists of an anastomotic connection between the branches of the right coronary artery (RCA) and the left circumflex artery (LCx). In patients with coronary artery occlusion, the presence of this connection bypassing the area of the occluded vessel may be a factor that prevents significant necrosis of a specific area of the myocardium. Most cases are detected by invasive coronary angiography. We present images from coronary computed tomography angiography (CCTA), which documented the existence of Kugel's artery in a 67-year-old patient with subtotal stenosis of the left main artery. The presented images clearly indicate that CCTA can visualize the existing rescue collateral circulation in patients with significant coronary artery disease.

Coronary bypass surgery guided by computed tomography in a low-risk population

BACKGROUND AND AIMS

In patients with three-vessel disease and/or left main disease, selecting revascularization strategy based on coronary computed tomography angiography (CCTA) has a high level of virtual agreement with treatment decisions based on invasive coronary angiography (ICA).

METHODS

In this study, coronary artery bypass grafting (CABG) procedures were planned based on CCTA without knowledge of ICA. The CABG strategy was recommended by a central core laboratory assessing the anatomy and functionality of the coronary circulation. The primary feasibility endpoint was the percentage of operations performed without access to the ICA. The primary safety endpoint was graft patency on 30-day follow-up CCTA. Secondary endpoints included topographical adequacy of grafting, major adverse cardiac and cerebrovascular (MACCE), and major bleeding events at 30 days. The study was considered positive if the lower boundary of confidence intervals (CI) for feasibility was ≥75% (NCT04142021).

RESULTS

The study enrolled 114 patients with a mean (standard deviation) anatomical SYNTAX score and Society of Thoracic Surgery score of 43.6 (15.3) and 0.81 (0.63), respectively. Unblinding ICA was required in one case yielding a feasibility of 99.1% (95% CI 95.2%-100%). The concordance and agreement in revascularization planning between the ICA- and CCTA-Heart Teams was 82.9% with a moderate kappa of 0.58 (95% CI 0.50-0.66) and between the CCTA-Heart Team and actual treatment was 83.7% with a substantial kappa of 0.61 (95% CI 0.53-0.68). The 30-day follow-up CCTA in 102 patients (91.9%) showed an anastomosis patency rate of 92.6%, whilst MACCE was 7.2% and major bleeding 2.7%.

CONCLUSIONS

CABG guided by CCTA is feasible and has an acceptable safety profile in a selected population of complex coronary artery disease.

Coronary chronic total occlusion on coronary CT angiography: what radiologists should know?

Coronary chronic total occlusion (CTO) often occurs in patients with obstructive coronary artery disease, which remains one of the greatest challenges for interventional cardiologists. Coronary computed tomography angiography (CCTA) with its emerging post-processing techniques can provide a detailed assessment of CTO lesions before percutaneous coronary intervention (PCI), playing an important role in the clinical management of CTO PCI, from early diagnosis, pre-procedural outcome prediction, the crossing algorithm planning, intraprocedural guidance, and finally post-procedural assessment and follow-up. In addition, the feasibility of CT perfusion (CTP) in patients with CTO has been validated. Combined CCTA and CTP have the great potential to be the one-stop-shop imaging modality for assessing both anatomy and function of CTO lesions. This review aims to make radiologists understand the role of CCTA in the diagnosis and assessment of CTO lesions, thus assisting interventionalists in optimizing CTO PCI crossing strategies with the expertise of radiologists.Critical relevance statement The anatomical features of CTO on CCTA can reveal the complexity of CTO lesions and are associated with CTO PCI outcome, thus helping interventionalists optimize CTO PCI crossing strategies.Key points • CTO is the common lesion in invasive coronary angiography, and CTO PCI is technically difficult and its success rate is relatively low.• Length, collaterals, and attenuation-related signs can help distinguish CTO from subtotal occlusion.• The anatomical features of CTO lesions can help grade the difficulty of CTO PCI and predict procedural outcomes and long-term outcomes of CTO PCI.• The real-time fusion of CCTA with fluoroscopic angiography can be applied in highly complicated CTO lesions.• After CTO PCI, CCTA can help guide a second CTO PCI re-entry or follow up stent patency.