Usefulness of 64-Detector Computed Tomographic Angiography for Diagnosing In-Stent Restenosis in Native Coronary Arteries

doi:10.1016/j.amjcard.2007.09.117

The American Journal of Cardiology

Volume 101, Issue 6, 15 March 2008, Pages 820-824

https://doi.org/10.1016/j.amjcard.2007.09.117 Get rights and content

The purpose of this study was to evaluate the accuracy of detector computed tomographic angiographic qualitative and quantitative analyses for the detection of in-stent restenosis (ISR) Previous studies have used qualitative analyses exclusively and have excluded “unevaluable” stents. Multidetector computed tomographic angiography (MDCT) was performed before quantitative coronary angiography in 67 patients with 132 stents that were evaluated by 2 techniques: (1) qualitative, on the basis of degree of visual hypodensity, and (2) quantitative, comparing in-stent with prestent Hounsfield units. All stents were evaluated, irrespective of image quality. The incidence of ISR was 12.5%. The sensitivity (94%), specificity (74%), and positive predictive value (39%) of the qualitative evaluation were superior to the quantitative technique (82%, 54%, and 21%, respectively); negative predictive values were similar (99% vs 95%). Accuracies were equal in stents located in proximal and distal vessels. In conclusion, ISR can be evaluated qualitatively by 64-slice MDCT with excellent sensitivity and negative predictive accuracy without exclusion of unevaluable stents and with reasonable specificity but low positive predictive value. Quantitative analysis was less accurate.

Section snippets

Methods

The study population consisted of 132 stents implanted in native coronary arteries in 67 consecutive patients who underwent quantitative selective coronary angiography (QCA) preceded by 64-slice MDCT performed within the 30-day period before QCA. All were evaluated for chest pain or shortness of breath; 50% had stent implantation >6 months before the study and were not referred specifically for ISR evaluation. Stent size was available in only 42 of the 132 stents; 21 were 2.5 mm in diameter,

Results

Demographic features are listed in Table 1. Metoprolol was administered to 42% of patients. Distribution of stents is presented in Table 2. ISR was noted in 17 patients (12.9%); 4 (3.0%) with 50% to 75% stenosis, 3 (2.3%) with 75% to 99% stenosis, and 10 (7.6%) with total occlusions. Totally normal stents were noted in 45 (34.1%); there were 56 (42.4%) with <25% stenosis and 18 (13.6%) with 25% to 50% stenosis.

Sensitivity and negative predictive value of the qualitative approach for detection

Discussion

This study was designed to evaluate the accuracy of 64-slice MDCT for the detection of ISR in a typical clinical setting. It differs from previous reports in several major respects. First, all previous 64-slice detector computed tomographic angiographic studies7, 8, 9, 10, 11 have relied entirely on qualitative stent evaluation. To provide a less subjective analysis, a quantitative approach was also applied. Second, all previous studies have presented significantly different analyses with and

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Cited by (31)

High-definition computed tomography for coronary artery stents imaging: Initial evaluation of the optimal reconstruction algorithm
2015, European Journal of Radiology
The aim of this study was to evaluate the in vivo performance of four image reconstruction algorithms in a high-definition CT (HDCT) scanner with improved spatial resolution for the evaluation of coronary artery stents and intrastent lumina.
Thirty-nine consecutive patients with a total of 71 implanted coronary stents underwent coronary CT angiography (CCTA) on a HDCT (Discovery CT 750 HD; GE Healthcare) with the high-resolution scanning mode. Four different reconstruction algorithms (HD-stand, HD-detail; HD-stand-plus; HD-detail-plus) were applied to reconstruct the stented coronary arteries. Image quality for stent characterization was assessed. Image noise and intrastent luminal diameter were measured. The relationship between the measurement of inner stent diameter (ISD) and the true stent diameter (TSD) and stent type were analysed.
The stent-dedicated kernel (HD-detail) offered the highest percentage (53.5%) of good image quality for stent characterization and the highest ratio (68.0 ± 8.4%) of visible stent lumen/true stent lumen for luminal diameter measurement at the expense of an increased overall image noise. The Pearson correlation coefficient between the ISD and TSD measurement and spearman correlation coefficient between the ISD measurement and stent type were 0.83 and 0.48, respectively.
Compared with standard reconstruction algorithms, high-definition CT imaging technique with dedicated high-resolution reconstruction algorithm provides more accurate stent characterization and intrastent luminal diameter measurement.
In vitro evaluation of 56 coronary artery stents by 256-slice multi-detector coronary CT
2011, European Journal of Radiology
We sought to investigate stent lumen visibility of 56 coronary stents with the newest 256-multi-slice-CT (256-MDCT) technology for different reconstruction algorithms in an in vitro model.
Early identification of in-stent restenosis (ISR) is important to avoid recurrent ischemia and prevent acute myocardial infarction (AMI). Since angiography has the disadvantage of high costs and its invasiveness, MDCT could be a convenient and safe non-invasive alternative for detection of ISR.
Percentages of in-stent lumen diameter and in-stent signal attenuation (measured as contrast-to-noise ratio (CNR)) of 56 coronary stents (group A ≤2.5 mm; group B = 2.75–3.0 mm; group C = 3.5–4.0 mm) were evaluated in a coronary vessel in vitro phantom (iodine-filled plastic tubes) employing four different reconstruction algorithms (XCD, CC, CD, XCB) on a novel 256-MDCT (Philips-iCT, collimation = 128 mm × 0.625 mm; rotation time = 270 ms; tube current = 800 mA s with 120 kV). Analysis was conducted with the semi-automatical full-width-at-half-maximum (FWHM) method. P-values <0.05 were regarded statistically significant.
In-stent lumen diameter >60% for group C stents was significantly larger and CNR was significantly lower (both p < 0.05) for sharp kernels (CD; XCD) when compared to groups A/B. The FWHM-method showed significantly smaller in-stent lumen diameter (p < 0.05) when compared to the manual method.
256-MDCT could potentially be employed for clinical assessment of stent patency in stents >3.0 mm when analysed with cardio-dedicated sharp kernels, although clinical studies corroborating this claim should be performed. However, stents ≤3.0 mm reconstructed by soft kernels revealed insufficient in-stent lumen visualisation and should not be used in clinical practice.
Further improvements in spatial and temporal image resolution as well as reductions of radiation exposure and image noise have to be accomplished for the ambitious goal of characterising both CT coronary artery anatomy and in-stent lumen.
Multidetector Computed Tomography Coronary Angiography for the Assessment of Coronary In-Stent Restenosis
2010, American Journal of Cardiology
Citation Excerpt :
A progressive increase in the number of slices from 4 up to 40 allowed a contemporaneous increase in spatial resolution from 1.25 to 0.5 mm, providing promising results in ISR detection.2,12–16 The temporal resolution of old-generation scanners was further improved in the mid-2000s with the introduction of 64-slice multidetector computed tomographic scanners and DSCT.5–8,17–30 Moreover, in addition to detector improvements, these scanners were equipped with much faster gantries, resulting in effective temporal resolution up to 83 ms.24,25,30
The investigators conducted a review to evaluate the diagnostic performance of multidetector computed tomography (MDCT) for coronary stent evaluation. The prespecified inclusion criteria selected prospective or retrospective human studies published in English. Studies that did not report raw numbers of diagnostic accuracy for the detection of in-stent restenosis were excluded. The data from 24 studies are reported, 6 performed with old-generation scanners (4-, 16-, and 40-slice MDCT) and 18 performed with 64-slice MDCT or dual-source MDCT. With old-generation MDCT, up to 18% of coronary stents were missed, the rate of nonevaluable stents ranged from 2.6% to 23.5%, and the overall feasibility and diagnostic accuracy were 90.4% and 90%, respectively. With 64-slice MDCT, no stent was missed, and the overall feasibility and diagnostic accuracy were 90.4% and 91.9%, respectively. Advancements in MDCT and stent technologies may further reduce the number of nonassessable stents and improve diagnostic performance.
Diagnostic accuracy of 64 multislice CT angiography in the assessment of coronary in-stent restenosis: A meta-analysis
2010, European Journal of Radiology
The aim of this study was to perform a meta-analysis of the diagnostic accuracy of 64-slice CT angiography for the detection of coronary in-stent restenosis in patients treated with coronary stents when compared to conventional coronary angiography.
A search of PUBMED/MEDLINE, ProQuest and Cochrane library databases for English literature was performed. Only studies comparing 64-slice CT angiography with conventional coronary angiography for the detection of coronary in-stent restenosis (more than 50% stenosis) were included for analysis. Sensitivity and specificity estimates pooled across studies were tested using a fixed effects model.
Fourteen studies met selection criteria for inclusion in the analysis. The mean value of assessable stents was 89%. Prevalence of in-stent restenosis following coronary stenting was 20% among these studies. Pooled estimates of the sensitivity and specificity of overall 64-slice CT angiography for the detection of coronary in-stent restenosis was 90% (95% CI: 86%, 94%) and 91% (95% CI: 90%, 93%), respectively, based on the evaluation of assessable stents. Diagnostic value of 64-slice CT angiography was found to decrease significantly when the analysis was performed with inclusion of nonassessable segments in five studies, with pooled sensitivity and specificity being 79% (95% CI: 68%, 88%) and 81% (95% CI: 77%, 84%). Stent diameter is the main factor affecting the diagnostic value of 64-slice CT angiography.
Our results showed that 64-slice CT angiography has high diagnostic value (both sensitivity and specificity) for detection of coronary in-stent restenosis based on assessable segments when compared to conventional coronary angiography.
The challenge of coronary stent imaging
2010, Journal of Cardiovascular Computed Tomography
Stent Gap by 64-Detector Computed Tomographic Angiography. Relationship to In-Stent Restenosis, Fracture, and Overlap Failure
2009, Journal of the American College of Cardiology
The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF).
SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR.
A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents.
Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter ≥3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis.
Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with ≥3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.

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: This study was supported by a grant from Philips Medical Systems, Cleveland, Ohio.

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Coronary artery diseaseUsefulness of 64-Detector Computed Tomographic Angiography for Diagnosing In-Stent Restenosis in Native Coronary Arteries

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Int J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Acad Radiol

J Am Coll Cardiol

J Am Coll Cardiol

Coronary artery disease
Usefulness of 64-Detector Computed Tomographic Angiography for Diagnosing In-Stent Restenosis in Native Coronary Arteries