Noncalcified plaque burden quantified from coronary computed tomography angiography improves prediction of side branch occlusion after main vessel stenting in bifurcation lesions: results from the CT-PRECISION registry

Kajetan Grodecki, Sebastien Cadet, Adam D Staruch, Anna M Michalowska, Cezary Kepka, Rafal Wolny, Jerzy Pregowski, Mariusz Kruk, Mariusz Debski, Artur Debski, Ilona Michalowska, Piotr J Slomka, Adam Witkowski, Damini Dey, Maksymilian P Opolski, Kajetan Grodecki, Sebastien Cadet, Adam D Staruch, Anna M Michalowska, Cezary Kepka, Rafal Wolny, Jerzy Pregowski, Mariusz Kruk, Mariusz Debski, Artur Debski, Ilona Michalowska, Piotr J Slomka, Adam Witkowski, Damini Dey, Maksymilian P Opolski

Abstract

Objectives: To assess the incremental value of quantitative plaque features measured from computed tomography angiography (CTA) for predicting side branch (SB) occlusion in coronary bifurcation intervention.

Methods: We included 340 patients with 377 bifurcation lesions in the post hoc analysis of the CT-PRECISION registry. Each bifurcation was divided into three segments: the proximal main vessel (MV), the distal MV, and the SB. Segments with evidence of coronary plaque were analyzed using semi-automated software allowing for quantitative analysis of coronary plaque morphology and stenosis. Coronary plaque measurements included calcified and noncalcified plaque volumes, and corresponding burdens (respective plaque volumes × 100%/vessel volume), remodeling index, and stenosis.

Results: SB occlusion occurred in 28 of 377 bifurcation lesions (7.5%). The presence of visually identified plaque in the SB segment, but not in the proximal and distal MV segments, was the only qualitative parameter that predicted SB occlusion with an area under the curve (AUC) of 0.792. Among quantitative plaque parameters calculated for the SB segment, the addition of noncalcified plaque burden (AUC 0.840, p = 0.003) and low-density plaque burden (AUC 0.836, p = 0.012) yielded significant improvements in predicting SB occlusion. Using receiver operating characteristic curve analysis, optimal cut-offs for noncalcified plaque burden and low-density plaque burden were > 33.6% (86% sensitivity and 78% specificity) and > 0.9% (89% sensitivity and 73% specificity), respectively.

Conclusions: CTA-derived noncalcified plaque burden, when added to the visually identified SB plaque, significantly improves the prediction of SB occlusion in coronary bifurcation intervention.

Trial registration: ClinicalTrials.gov Identifier: NCT03709836 registered on October 17, 2018.

Keywords: Coronary artery disease; Coronary bifurcation; Coronary computed tomography angiography; Percutaneous coronary intervention; Plaque burden.

Conflict of interest statement

Mr. Sebastien Cadet, Dr. Piotr J. Slomka, and Dr. Damini Dey received software royalties from Cedars-Sinai Medical Center. The remaining authors of this manuscript have no conflicts of interest to disclose.

Figures

Fig. 1
Fig. 1
Study flowchart
Fig. 2
Fig. 2
An example of the coronary bifurcation lesion in invasive angiography (a) and its corresponding image in computed tomography angiography (b). Plaque was quantitatively analyzed in the respective bifurcation segments: proximal main vessel (c), distal main vessel (d) and side branch (e). Blue represents lumen, yellow—calcified plaque, and red—noncalcified plaque. In the above lesion, coronary plaque—defined as tissue greater than 1 mm2 associated with the coronary wall—was present only in the proximal segment of the main vessel
Fig. 3
Fig. 3
Comparison of plaque volumes in respective bifurcation segments with and without SB occlusion
Fig. 4
Fig. 4
Comparison of plaque burden in respective bifurcation segments with and without SB occlusion
Fig. 5
Fig. 5
Receiver operative characteristic curves for predicting side branch (SB) occlusion based on visual plaque identification in the SB and addition of noncalcified or low-density plaque burdens

References

    1. Ford TJ, McCartney P, Corcoran D, et al. Single- versus 2-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up. J Am Heart Assoc. 2018;7(11):1–10. doi: 10.1161/JAHA.118.008730.
    1. Hahn JY, Chun WJ, Kim JH, et al. Predictors and outcomes of side branch occlusion after main vessel stenting in coronary bifurcation lesions: results from the COBIS II registry (COronary BIfurcation Stenting) J Am Coll Cardiol. 2013;62(18):1654–1659. doi: 10.1016/j.jacc.2013.07.041.
    1. He Y, Zhang D, Yin D, et al. Development and validation of a risk scoring system based on baseline angiographic results by visual estimation for risk prEdiction of side-branch OccLusion in coronary bifurcation InterVEntion: The baseline V-RESOLVE score. Catheter Cardiovasc Interv. 2019;93(S1):810–817. doi: 10.1002/ccd.28068.
    1. Opolski MP, Grodecki K, Staruch AD, et al. Accuracy of RESOLVE score derived from coronary computed tomography versus visual angiography to predict side branch occlusion in percutaneous bifurcation intervention. J Cardiovasc Comput Tomogr. 2019 doi: 10.1016/j.jcct.2019.11.007.
    1. Neumann JT, Goßling A, Sörensen NA, Blankenberg S, Magnussen C, Westermann D. Temporal trends in incidence and outcome of acute coronary syndrome. Clin Res Cardiol. 2020 doi: 10.1007/s00392-020-01612-1.
    1. Koo BK, Waseda K, Kang HJ, et al. Anatomic and functional evaluation of bifurcation lesions undergoing percutaneous coronary intervention. Circ Cardiovasc Interv. 2010;3(2):113–119. doi: 10.1161/CIRCINTERVENTIONS.109.887406.
    1. Suárez de Lezo J, Medina A, Martín P, et al. Predictors of ostial side branch damage during provisional stenting of coronary bifurcation lesions not involving the side branch origin: an ultrasonographic study. EuroIntervention. 2012;7(10):1147–1154. doi: 10.4244/EIJV7I10A185.
    1. Xu J, Hahn JY, Song YB, et al. Carina shift versus plaque shift for aggravation of side branch ostial stenosis in bifurcation lesions: volumetric intravascular ultrasound analysis of both branches. Circ Cardiovasc Interv. 2012;5(5):657–662. doi: 10.1161/CIRCINTERVENTIONS.112.969089.
    1. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2019 doi: 10.1093/eurheartj/ehz425.
    1. Moss AJ, Williams MC, Newby DE, Nicol ED. The updated NICE guidelines: cardiac CT as the first-line test for coronary artery disease. Curr Cardiovasc Imaging Rep. 2017;10(5):15. doi: 10.1007/s12410-017-9412-6.
    1. Opolski MP. Cardiac computed tomography for planning revascularization procedures. J Thorac Imaging. 2018;33(1):35–54. doi: 10.1097/RTI.0000000000000262.
    1. Achenbach S. Coronary CTA and percutaneous coronary intervention: a symbiosis waiting to happen. J Cardiovasc Comput Tomogr. 2016;10(5):384–385. doi: 10.1016/j.jcct.2016.07.017.
    1. Schmermund A, Eckert J, Schmidt M, Magedanz A, Voigtländer T. Coronary computed tomography angiography: a method coming of age. Clin Res Cardiol. 2018;107(2):40–48. doi: 10.1007/s00392-018-1320-5.
    1. Werner N, Nickenig G, Sinning JM. Complex PCI procedures: challenges for the interventional cardiologist. Clin Res Cardiol. 2018;107(2):64–73. doi: 10.1007/s00392-018-1316-1.
    1. Dou K, Zhang D, Xu B, et al. An angiographic tool for risk prediction of side branch occlusion in coronary bifurcation intervention: the RESOLVE score system (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) JACC Cardiovasc Interv. 2015;8:39–46. doi: 10.1016/j.jcin.2014.08.011.
    1. Lassen JF, Holm NR, Banning A, et al. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European bifurcation club. EuroIntervention. 2016;12(1):38–46. doi: 10.4244/EIJV12I1A7.
    1. Kini AS, Yoshimura T, Vengrenyuk Y, et al. Plaque morphology predictors of side branch occlusion after main vessel stenting in coronary bifurcation lesions: optical coherence tomography imaging study. JACC Cardiovasc Interv. 2016;9(8):862–865. doi: 10.1016/j.jcin.2016.02.022.
    1. Ihdayhid AR, Goeller M, Dey D, et al. Comparison of coronary atherosclerotic plaque burden and composition as assessed on coronary computed tomography angiography in East Asian and European-origin Caucasians. Am J Cardiol. 2019;124(7):1012–1019. doi: 10.1016/j.amjcard.2019.06.020.
    1. Dey D, Schepis T, Marwan M, Slomka PJ, Berman DS, Achenbach S. Automated three-dimensional quantification of noncalcified coronary plaque from coronary CT angiography: comparison with intra-vascular US. Radiology. 2010;257(2):516–522. doi: 10.1148/radiol.10100681.
    1. Goeller M, Achenbach S, Cadet S, et al. Pericoronary adipose tissue computed tomography attenuation and high-risk plaque characteristics in acute coronary syndrome compared with stable coronary artery disease. JAMA Cardiol. 2018;3(9):858–863. doi: 10.1001/jamacardio.2018.1997.
    1. Cheng V, Gutstein A, Wolak A, et al. Moving beyond binary grading of coronary arterial stenoses on coronary computed tomographic angiography: insights for the imager and referring clinician. JACC Cardiovasc Imaging. 2008;1(4):460–471. doi: 10.1016/j.jcmg.2008.05.006.
    1. Achenbach S, Ropers D, Hoffmann U, et al. Assessment of coronary remodeling in stenotic and nonstenotic coronary atherosclerotic lesions by multidetector spiral computed tomography. J Am Coll Cardiol. 2004;43(5):842–847. doi: 10.1016/j.jacc.2003.09.053.
    1. Hell MM, Dey D, Marwan M, Achenbach S, Schmid J, Schuhbaeck A. Non-invasive prediction of hemodynamically significant coronary artery stenoses by contrast density difference in coronary CT angiography. Eur J Radiol. 2015;84(8):1502–1508. doi: 10.1016/j.ejrad.2015.04.024.
    1. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometr. 1988;44(3):837–845. doi: 10.2307/2531595.
    1. Diaz-Zamudio M, Fuchs TA, Slomka P, et al. Quantitative plaque features from coronary computed tomography angiography to identify regional ischemia by myocardial perfusion imaging. Eur Heart J Cardiovasc Imaging. 2017;18(5):499–507. doi: 10.1093/ehjci/jew274.
    1. Voros S, Rinehart S, Qian Z, et al. Prospective validation of standardized, 3-dimensional, quantitative coronary computed tomographic plaque measurements using radiofrequency backscatter intravascular ultrasound as reference standard in intermediate coronary arterial lesions: results from the ATLANTA I study. JACC Cardiovasc Intervent. 2011;4(2):198–208. doi: 10.1016/j.jcin.2010.10.008.
    1. Matsumoto H, Watanabe S, Kyo E, et al. Improved evaluation of lipid-rich plaque at coronary CT angiography: head-to-head comparison with intravascular US. Radiol Cardiothorac Imaging. 2019;1(5):e190069. doi: 10.1148/ryct.2019190069.
    1. Kini AS, Vengrenyuk Y, Pena J, et al. Plaque morphology predictors of side branch occlusion after provisional stenting in coronary bifurcation lesion: Results of optical coherence tomography bifurcation study (ORBID) Catheter Cardiovasc Interv. 2017;89(2):259–268. doi: 10.1002/ccd.26524.
    1. Kang SJ, Kim WJ, Lee JY, et al. Hemodynamic impact of changes in bifurcation geometry after single-stent cross-over technique assessed by intravascular ultrasound and fractional flow reserve. Catheter Cardiovasc Interv. 2013;82(7):1075–1082. doi: 10.1002/ccd.24956.
    1. Gwon HC, Song YB, Pan M. The story of plaque shift and carina shift. EuroIntervention. 2015;11(V):V75–V77. doi: 10.4244/EIJV11SVA16.
    1. Park JJ, Chun EJ, Cho YS, et al. Potential predictors of side-branch occlusion in bifurcation lesions after percutaneous coronary intervention: a coronary CT angiography study. Radiology. 2014;271(3):711–720. doi: 10.1148/radiol.14131959.
    1. Lee SH, Lee JM, Song YB, et al. Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion. EuroIntervention. 2019;15(9):e788–e795. doi: 10.4244/EIJ-D-18-00113.
    1. Dalager MG, Bøttcher M, Dalager S, et al. Imaging atherosclerotic plaques by cardiac computed tomography in vitro: impact of contrast type and acquisition protocol. Invest Radiol. 2011;46(12):790–795. doi: 10.1097/RLI.0b013e31822b122e.
    1. Grodecki K, Opolski MP, Staruch AD, et al. Comparison of computed tomography angiography versus invasive angiography to assess medina classification in coronary bifurcations. Am J Cardiol. 2020 doi: 10.1016/j.amjcard.2020.02.026.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel