Expanding the Role of Coronary Computed Tomography Angiography in Interventional Cardiology

HomeCirculationVol. 145, No. 1Expanding the Role of Coronary Computed Tomography Angiography in Interventional Cardiology Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBExpanding the Role of Coronary Computed Tomography Angiography in Interventional Cardiology Luiz F. Ybarra, MD, PhD, MBA and Nicolo Piazza, MD, PhD Luiz F. YbarraLuiz F. Ybarra https://orcid.org/0000-0002-5837-5476 London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada (L.F.Y.). and Nicolo PiazzaNicolo Piazza Correspondence to: Nicolo Piazza, Division of Cardiology, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, 1001 Boul Décarie, Montréal, QC, Canada H4A 3J1. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2809-3408 Department of Medicine, Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.). Originally published29 Dec 2021https://doi.org/10.1161/CIRCULATIONAHA.121.053038Circulation. 2022;145:5–7Coronary computed tomography angiography (CCTA) use has increased in recent years, in part because of increasingly strong outcome and cost-effectiveness data.1 Its use is expected to expand further once cardiologists start to apply the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) results and its main exclusion criteria (significant left main coronary artery disease assessed by CCTA) in their daily practice. Interventional cardiologists should therefore expect to be exposed more frequently to results from this imaging modality. Because data content of CCTA far exceeds that provided by invasive coronary angiography (ICA), interventionalists will also be expected to maximally exploit the CCTA information, similar to what is already done in structural heart interventions. As discussed in the ensuing paragraphs, CCTA can provide a detailed diagnostic and interventional road map before interventionalists embark on interventions within the cardiac catheterization laboratory (Figure).Download figureDownload PowerPointFigure. Coronary computed tomography angiography uses before and during percutaneous coronary intervention. CAD indicates coronary artery disease; CCTA-FFR, coronary computed tomography angiography–derived fractional flow reserve; and CTO, chronic total occlusion.DiagnosisIn the setting of acute coronary syndromes, when collaterals are usually not present, flush ostial side-branch occlusion may go unnoticed during ICA. CCTA can avoid this misdiagnosis by allowing more extensive recognition and understanding of the coronary tree at the potential expense of delaying reperfusion and increasing the risk of acute kidney injury caused by the extra contrast volume (60–80 cm3 contrast typically used for CCTA). The information that can be extracted from CT images, however, goes far beyond the assessment of coronary disease. CCTA-derived fractional flow reserve, virtual histology characterization of plaque, perivascular fat attenuation index, dynamic computed tomography myocardial perfusion, and wall shear stress are some of the established and emerging technologies that can improve risk stratification and provide valuable details about the anatomic and physiological significance of the coronary plaque.2 These may guide decision making on the appropriateness of a subsequent intervention and the mode of revascularization (percutaneous or surgical) and predict its benefits.CCTA can be especially beneficial in patients with previous coronary artery bypass grafts because it can determine the graft type (venous or arterial), the exact location and patency of bypass grafts, the anastomosed coronaries, and the presence of tortuosity and tethering, which may lead to reduced use of contrast and radiation, procedural time, and cost. It may also facilitate detection of coronary anomalies and aortic root aneurysms.Vascular AccessCCTA already plays a critical role in vascular access site selection for structural heart disease interventions, particularly transcatheter aortic valve replacement, and may become of paramount importance for percutaneous coronary intervention (PCI) planning. By extending the tomographic acquisition from the upper extremities to the pelvic area, CCTA can readily provide information on radial and iliofemoral anatomy, including lumen patency, tortuosity, calcification, and previous vascular bypasses. Likewise, the 3-dimensional orientation of brachiocephalic trunk and aorta can be effectively appreciated on multiplanar tomographic reconstruction. These data can guide operators to optimal vascular access, puncture site, choice of access closure method, sheath length, and guide wire stiffness required for guide catheter advancement, depending on the specific planned intervention.Optimal Coronary Fluoroscopic Viewing AnglesFluoroscopy has historically been performed with a limited set of routine viewing angles as a "one-size-fits-all" approach, which is often suboptimal in patients with anatomic variations or disease-specific remodeling. Suboptimal viewing angles are frequently hampered by vessel foreshortening or overlap. These pitfalls may result in geographic stent miss, especially in cases of coronary ostial or bifurcation stenting.Akin to structural heart disease interventions, it is possible to use CCTA volumetric data to simulate fluoroscopic viewing angles that mitigate parallax and foreshortening, precisely tailored for each PCI step, from vessel wiring to stent deployment.3 Preprocedural assessment of the aortic root plane and its relation to the plane of the coronary ostia can provide optimal, nonforeshortened, fluoroscopic views for engagement and, notably, aorto-ostial interventions. This can prove useful in patients with unknown anatomic aberrancies in whom ostial intubation can be challenging even for experienced operators. It may also provide the best view to assess ambiguous proximal caps in acute and chronic occlusions.In a recent publication, CCTA-derived optimal fluoroscopic viewing angles of coronary ostia and bifurcations were measured,3 showing that optimal fluoroscopic viewing angles within practical range were vastly different across bifurcations: left anterior descending/diagonal, 7%; left main/left anterior descending/circumflex, 39%; right posterior descending/posterolateral, 42%; and circumflex/obtuse marginal, 70%. These findings challenge the ability to correctly visualize and mitigate foreshortening of a bifurcation and should influence the selection of a PCI bifurcation technique (eg, T-and-protusion versus culotte versus double kissing crush).Equipment SelectionThe preprocedural information gathered from CCTA could improve equipment selection during PCI. The size and orientation of the aortic root and the location of coronary anomalies can be evaluated by CCTA and help operators in selecting appropriate guiding catheters for supportive coronary and bypass graft engagement. CCTA can provide information about the severity, eccentricity, calcification, and vessel and lumen dimensions of a diseased coronary segment with high accuracy and thus may eliminate the need for invasive intravascular imaging, allowing precise stent sizing. Pre-PCI demonstration of high calcium burden by CCTA might dictate the need for lesion preparation by rotational/orbital atherectomy or intravascular lithotripsy.PCI StrategyThe impact of CCTA-based planning on selection of PCI technique may be "game changing," particularly in patients with complex or multivessel coronary artery disease. Novel technologies based on 3-dimensional fusion of CCTA and tomographic myocardial perfusion data allow correlation of coronary lesions and corresponding stress-induced myocardial perfusion deficits. Fusion imaging of CCTA and ICA may also decrease contrast use during PCI by allowing noncontrast wiring of the coronaries and device positioning. Preprocedural evaluation of bifurcation geometry and angulations based on 3-dimensional CCTA data sets is more accurate and reproducible compared with that based on ICA.4 Thus, CCTA might guide operators when considering side-branch protection, 1- versus 2-stent strategies, and optimal guide wire bending. Likewise, CCTA may provide crucial information for chronic total occlusion PCI for the segment anatomy, proximal and distal cap location and morphology, occlusion length, calcium burden, presence of disease in the segment distal to the occlusion, and collateral flow. In this context, CCTA-based scores to predict guide wire crossing and success may be superior to the classic angiographic Japan Chronic Total Occlusion score.5In the setting of acute coronary syndromes, preprocedural localization of the culprit lesion, especially in nonstraightforward cases (such as posterior myocardial infarction and multivessel disease), may save precious time and avoid deleterious complications. Such an approach may also allow prompt rule-out of diagnoses other than acute coronary syndrome (acute aortic syndromes, Takotsubo cardiomyopathy, etc).Potential Limitations and Risks of Adding CCTA to the Interventional WorkflowThe addition of a radiation-based, contrast-dependent imaging modality (CCTA) to another one (ICA) likely will increase the risk of radiation and contrast-induced injuries, especially in higher-risk patients and in the assessment of myocardial perfusion. Moreover, the inclusion of an extra layer in the process of coronary artery disease diagnosis and treatment may slow the workflow, delaying care, increasing cost, and perhaps negatively affecting outcomes. The current inability of most interventionalists to interpret and manipulate tomographic images may also hinder CCTA use in daily practice. Its gradual incorporation may provide the opportunity for training to allow both seasoned operators and new trainees to become accustomed to this technology and the information it yields, similar to what has been happening in the cardiac structural space. However, given the large number of coronary interventions performed worldwide, we believe that the widespread use of CCTA in this manner will happen only when deep neural networks (artificial intelligence) become part of the process and are used to consistently provide the interventional information mentioned above for every procedure.ConclusionsAlthough an ever-expanding body of evidence supports its use for diagnostic purposes in coronary artery disease, CCTA is emerging as a key modality for preprocedural planning of interventions in the cardiac catheterization laboratory. By virtue of its 3-dimensional reconstruction of the coronary anatomy, CCTA may allow optimal diagnosis and selection of vascular access, fluoroscopic viewing angles, PCI strategy, and adequate equipment while preventing ICA-associated technical errors and potential sequelae. CCTA has the potential to reduce patient contrast load, radiation exposure, and procedure times and has been demonstrated to be cost-effective when appropriately incorporated into clinical workflows. With the incorporation of artificial intelligence to provide all the necessary information rapidly and reliably for diagnosis and interventional guidance, it is likely that, in the future, patients will undergo a rapid CCTA scanning before arrival at the catheterization laboratory.Article InformationSources of FundingNone.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 7.Correspondence to: Nicolo Piazza, Division of Cardiology, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital, 1001 Boul Décarie, Montréal, QC, Canada H4A 3J1. Email [email protected]comReferences1. 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Accuracy of J-CTO score derived from computed tomography versus angiography to predict successful percutaneous coronary intervention.JACC Cardiovasc Imaging. 2018; 11(2 pt 1):209–217. doi: 10.1016/j.jcmg.2017.01.028CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Khokhar A, Zelias A, Zlahoda‐Huzior A and Dudek D (2022) Complication during robotic‐PCI: Iatrogenic guiding catheter dissection, Catheterization and Cardiovascular Interventions, 10.1002/ccd.30107, 99:5, (1526-1528), Online publication date: 1-Apr-2022. January 4, 2022Vol 145, Issue 1 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.053038PMID: 34965167 Originally publishedDecember 29, 2021 Keywordspercutaneous coronary interventionangiographycomputed tomography angiographyPDF download Advertisement