(Circulation. 1998;98:2509-2512.)
© 1998 American Heart Association, Inc.
Brief Rapid Communications |
Intravenous Coronary Angiography by Electron Beam Computed Tomography
A Clinical Evaluation
From the Thoraxcenter (B.J.R., R.J.G., P.O., P.J.F.) and Daniel den Hoed Kliniek (A.B., M.O.), Rotterdam, Netherlands
Correspondence to Benno J. Rensing, MD, Catheterization Laboratory, Thoraxcenter BD416, Dr Molewaterplein 40, 3015 GD Rotterdam, Netherlands. E-mail rensing{at}card.azr.nl
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—Noninvasive detection of coronary stenoses with electron beam CT (EBCT) after intravenous injection of contrast medium has recently emerged. We sought to determine the diagnostic accuracy of EBCT angiography in the clinical setting using conventional coronary angiography as the "gold standard."
Methods and Results—Thirty-seven patients (30 men) were investigated. After intravenous injection of 150 mL of contrast medium, 40 to 60 consecutive transaxial tomograms, covering the proximal and middle parts of the coronary arteries, were obtained with ECG triggering at end diastole during breath-holding. Three-dimensional reconstructions of the proximal and middle parts of the arteries were compared with the conventional angiograms. Of the 259 proximal and middle coronary segments, 211 (81%) were analyzable by EBCT. Of the left anterior descending coronary artery (LAD) segments, 95% were assessable. Right coronary artery (RCA) and left circumflex artery (LCx) segments were assessable in 66% and 76%, respectively. Overall sensitivity and specificity to detect a >50% diameter stenosis were 77% and 94%, respectively. This was 82% and 92% for the LAD, 60% and 97% for the RCA, and 83% and 89% for the LCx (all figures based on assessable lesions).
Conclusions—Intravenous EBCT coronary angiography is a promising coronary imaging technique. The technique is not yet robust enough to be an alternative to conventional coronary angiography. It can detect and rule out significant coronary artery disease of the left main proximal and mid portions of the LAD with good accuracy.
Key Words: angiography • tomography
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Recently, electron beam CT (EBCT) has emerged as an imaging technique that allows visualization of epicardial coronary arteries after intravenous injection of contrast material.1 2 3 4 5 Few data concerning the diagnostic accuracy of EBCT coronary angiography are available at the moment. The latest upgrading of the scanner allows improved resolution in the scanning direction. Slice thickness (collimation) and table feed after each scan can be decreased to 1.5 mm. The purpose of the present study was to compare noninvasive EBCT coronary angiography with conventional coronary angiography in the clinical setting and to determine the diagnostic accuracy of EBCT angiography.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Thirty-seven patients who underwent diagnostic coronary angiography were asked to participate in the study and gave informed consent. The study was approved by the Institutional Review Board. Two patient slots per week for cardiac research were available at the EBCT site. Therefore, our patient population is not strictly consecutive. All patients who met the inclusion criteria were approached until the 2 slots for that week were filled. Exclusion criteria were previous bypass operation or stent implantation, severe lung disease or comorbidity that made breath-holding difficult, renal failure, nonsinus rhythm, and unstable clinical condition.
EBCT Angiography
The EBCT scanner (Siemens Evolution) allows the acquisition of
high-resolution tomograms in 100 ms, which is fast enough to prevent
cardiac motion artifacts. A description of scanner specifications can
be found elsewhere.6 Contrast transit time was determined
by injection of 10 mL of contrast medium (Iopromide, Schering) at a
rate of 4 mL/s through an antecubital vein and visualization of the
passage of the contrast through the ascending aorta by 20 consecutive
tomograms. The time from contrast injection to peak density of the
aorta was considered the transit time. Image acquisition started with
the injection of 150 mL contrast medium at 4 mL/s. At transit time,
tomography commenced just proximal to the takeoff of the left main (LM)
coronary artery after an ECG trigger at 80% of the RR
interval. The table increment after each tomogram was 1.5 mm. A
total of 40 to 60 tomograms were acquired. Because of patient
limitations (maximal breath-hold time) and scanner limitations (1 scan
per heart cycle and 1.5-mm tomogram thickness), only the proximal and
middle parts of the coronary arteries could be visualized
consistently. To decrease breath-holding time, atropine 0.5 to
1.0 mL was administered if heart rate was <60 bpm. Radiation dose was
estimated to be <20 mGy.
Three-Dimensional Reconstruction
The 2-dimensional tomograms were transferred to a Silicon
Graphics workstation, where they were stacked and interpolated to form
a 3-dimensional (3D) volume by use of Voxel-View volume-rendering
software. Postprocessing techniques were applied to better visualize
the coronary arteries between the other contrast-enhanced
cardiac structures.7 8 Average postprocessing time was 15
to 20 minutes (Figure 1
). To selectively visualize the coronary
lumen, renderings were made with a lower threshold of 110 Hounsfield
units. Two cardiologists unaware of the results of the selective
coronary angiogram or the EBCT angiograms independently
evaluated either EBCT angiograms (the 3D reconstructions and the
individual tomograms) or the selective coronary angiograms. The
coronary tree was divided into proximal, middle, and distal
segments according to AHA guidelines.9 The proximal and
middle segments were graded as assessable or nonassessable. Then they
were graded as having either no significant disease (<50% diameter
stenosis) or significant disease (
50% diameter
stenosis). In case of disagreement, a third cardiologist
decided.
|
Statistics
The selective angiogram served as the "gold standard" for
determination of the diagnostic value of the noninvasive
EBCT coronary angiogram. The diagnostic accuracy of
EBCT angiography is expressed as sensitivity, specificity, and positive
and negative predictive value.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Thirty-seven patients (30 men) underwent both conventional and EBCT coronary angiography. Mean age was 58±6 years (range, 42 to 82 years). Mean weight was 70±10 kg, and mean height was 171±12 cm. Mean time interval between both examinations was 10±13 days. At conventional angiography, 9 patients had no significant coronary stenosis, 12 had 1-vessel disease, 11 had 2-vessel disease, and 5 had 3-vessel disease. LM disease was present in 1 patient. Mean heart rate during the EBCT angiography was 72±10 bpm (60 to 105 bpm). Mean breath-holding time was 36 seconds. After mild hyperventilation and instruction, all patients were able to hold their breath for
40
tomograms. Atropine 0.5 to 1 mg was administered in 25 patients.
Conventional angiography showed 1 significant LM lesion, 15 right
coronary artery (RCA) lesions, 16 left anterior descending
coronary artery (LAD) lesions, and 8 left circumflex (LCx)
lesions in the proximal and middle portions of the coronary
tree. Of the 259 proximal and middle coronary artery segments,
211 (81%) were assessable by EBCT angiography (Table 1). Five (33%) of the proximal
and middle RCA lesions and 2 (25%) of the proximal and middle LCx
lesions were located in segments deemed not assessable by EBCT
angiography. Table 2 summarizes
diagnostic accuracy parameters of EBCT
angiography. The causes for the inability to assess 46 proximal and
middle coronary segments with EBCT are summarized in Table 3. The causes for false-negatives or
false-positives are given in Table 4. The
major cause of false-positive classification was poor opacification in
small distal coronary arteries. Calcification of the vessel
wall obscuring a luminal narrowing was the major cause of
false-negative classification. The only reported side effect of
atropine was oral dryness in 5 patients. Angina occurred once, with
reversal after oral nitroglycerin.
|
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Others1 2 3 4 5 and we have shown that EBCT coronary angiography is feasible and safe. It allows visualization of the proximal and middle coronary arteries in a majority of patients. With special computer software, the individual tomograms can be stacked and 3D renderings of the coronary arteries constructed.7 8
Limitations of the Technique
The inability to assess coronary anatomy in a
large proportion of mid RCA and LCx lesions requires further
improvement of the technique. Conversely, all but 1 of the LM arteries
and 95% of the proximal and mid LAD segments were assessable by
current EBCT with a good diagnostic accuracy (Table 2
). Breath-holding limitations and single tomogram acquisition
per heart cycle restrict the volume of the heart that can be scanned
during 1 contrast injection. Therefore, distal coronary
arteries are only rarely visualized. Although one could argue whether
stenoses in small distal coronary arteries have
important symptomatic or prognostic meaning per se,
visualization of the posterior descending artery is important and
should be possible. A second contrast injection can visualize the
distal part of the coronary trajectory, but at the expense of
doubling the contrast volume (Figure 2).
To accurately visualize coronary arteries <2 mm (the
major cause of false-positive results and nonassessability), spatial
resolution needs improvement.
|
Technical Improvements
A recently introduced new detector array is expected to improve
in-plane resolution by 30%. This will probably increase assessability
and diagnostic accuracy in small coronary vessels
and might improve discrimination of overlapping contrast-filled
structures. At the moment, the scanner can make only 1 tomogram per
heart cycle. Ideally, the complete heart should be scanned within a few
heartbeats, thereby shortening breath-holding time, decreasing the
deleterious effect of arrhythmias on imaging, and reducing the
total amount of contrast medium necessary for opacification. For this,
the scanner has to be modified to allow acquisition of multiple
simultaneous parallel tomograms and thus become more of a
volume scanner. Finally, to prevent end-diastolic motion
artifacts of the RCA, tomogram acquisition time <100 ms and true
end-diastolic ECG (R wave) triggering are necessary. A
solution to the problem of circular calcification of the vessel wall (a
major source of false-negatives) might be to visualize the
coronary artery from the inside. A postprocessing technique
called "fly-through" tracks the contrast-enhanced lumen of the
artery on the individual tomograms. After stacking and interpolation,
the computer constructs a movie that gives the illusion of traveling
through the artery.
Conclusions
EBCT coronary angiography is a technique under development
and is currently not an alternative to conventional coronary
angiography. At the present time, it can detect and rule out
significant coronary artery disease of the proximal and middle
portions of the LAD with good accuracy and thus may provide us with
important prognostic information.
Received August 18, 1998; revision received October 5, 1998; accepted October 8, 1998.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
-
Moshage WE, Achenbach S, Seese B, Bachmann K,
Kirchgeorg M. Coronary artery stenoses: three
dimensional imaging with electrocardiographically triggered, contrast
enhanced, electron beam CT. Radiology. 1995;196:707–714.
[Abstract/Free Full Text]
-
Schmermund A, Rensing BJ, Sheedy PF, Bell MR,
Rumberger JA. Intravenous electron-beam computed
tomographic coronary angiography for segmental analysis
of coronary artery stenoses. J Am Coll
Cardiol. 1998;31:1547–1554.
[Abstract/Free Full Text]
-
Achenbach S, Moshage W, Bachmann K. Detection of
high-grade restenosis after PTCA using contrast-enhanced
electron beam CT. Circulation. 1997;96:2785–2788.
[Abstract/Free Full Text]
-
Budoff MJ, Oudiz RJ, Zalace CP, Bakshesi H, Goldberg
SL, Rami TG, Brundage BH. Intravenous three-dimensional
coronary angiography using contrast enhanced electron beam
computed tomography. J Am Coll Cardiol. 1997;29:393A.
Abstract.
-
Chernoff DM, Ritchie CJ, Higgins CB. Evaluation
of electron beam CT coronary angiography in healthy subjects.
Am J Radiol. 1997;169:93–99.
[Abstract/Free Full Text]
-
Gould RG. Principles of ultrafast computed tomography:
historical aspects, mechanisms and scanner characteristics. In:
Stanford W, Rumberger JA, eds. Ultrafast Computed Tomography
in Cardiac Imaging: Principles and Practice. Mt Kisco, NY: Futura;
1993:1–16.
-
Van Ooijen PMA, de Feyter PJ, Oudkerk M. An
introduction to three dimensional cardiac image rendering and
processing. Cardiology. 1997;4:312–319.
-
Ney D, Fishman E, Magid D. Volumetric rendering of
computed tomography data: principles and techniques. Comput
Graphics Applications. 1990;10:24–32.
-
American Heart Association Committee Report. A
reporting system on patients evaluated for coronary artery
disease. Circulation. 1975;51:7–34.The
diagnostic accuracy of intravenous electron
beam CT (EBCT) coronary angiography was determined.
Thirty-seven patients underwent both EBCT and conventional
coronary angiography. Of the proximal and middle left anterior
descending coronary artery (LAD) segments, 95% were
assessable. This was 66% for the right coronary artery (RCA)
and 76% for the circumflex artery (LCx). Overall sensitivity and
specificity to detect a >50% diameter stenosis were 77% and
94%. For the LAD, this was 82% and 92%; the RCA, 60% and 97%; and
the LCx, 83% and 89%. EBCT imaging can detect and rule out
significant coronary artery disease of the left main, proximal,
and mid portion of the LAD with good accuracy.
This article has been cited by other articles:
 |
|
 |
|
  M. J. Budoff, S. Achenbach, R. S. Blumenthal, J. J. Carr, J. G. Goldin, P. Greenland, A. D. Guerci, J. A.C. Lima, D. J. Rader, G. D. Rubin, et al. Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology Circulation, October 17, 2006; 114(16): 1761 - 1791. [Full Text] [PDF]
|
|
|
|
 |
|
 A S Lowe and C L Kay Recent developments in CT: a review of the clinical applications and advantages of multidetector computed tomography Imaging, June 1, 2006; 18(2): 62 - 67. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. S. Berman, R. Hachamovitch, L. J. Shaw, J. D. Friedman, S. W. Hayes, L. E.J. Thomson, D. S. Fieno, G. Germano, P. Slomka, N. D. Wong, et al. Roles of Nuclear Cardiology, Cardiac Computed Tomography, and Cardiac Magnetic Resonance: Assessment of Patients with Suspected Coronary Artery Disease J. Nucl. Med., January 1, 2006; 47(1): 74 - 82. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A F Kopp, A Kuttner, T Trabold, M Heuschmid, S Schroder, and C D Claussen Multislice CT in cardiac and coronary angiography Br. J. Radiol., December 1, 2004; 77(suppl_1): S87 - S97. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Lu, N. Zhuang, S.-S. Mao, J. Child, S. Carson, and M. J. Budoff Baseline Heart Rate-adjusted Electrocardiographic Triggering for Coronary Artery Electron-Beam CT Angiography Radiology, November 1, 2004; 233(2): 590 - 595. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Schlosser, T. Konorza, P. Hunold, H. Kuhl, A. Schmermund, and J.o. Barkhausen Noninvasive visualization of coronary artery bypass grafts using 16-detector row computed tomography J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1224 - 1229. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Schoenhagen, S. S. Halliburton, A. E. Stillman, S. A. Kuzmiak, S. E. Nissen, E. M. Tuzcu, and R. D. White Noninvasive Imaging of Coronary Arteries: Current and Future Role of Multi-Detector Row CT Radiology, July 1, 2004; 232(1): 7 - 17. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
U. Hoffmann, R. Millea, C. Enzweiler, M. Ferencik, S. Gulick, J. Titus, S. Achenbach, D. Kwait, D. Sosnovik, and T. J. Brady Acute Myocardial Infarction: Contrast-enhanced Multi-Detector Row CT in a Porcine Model Radiology, June 1, 2004; 231(3): 697 - 701. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Desjardins and E. A. Kazerooni ECG-Gated Cardiac CT Am. J. Roentgenol., April 1, 2004; 182(4): 993 - 1010. [Full Text] [PDF]
|
|
|
|
|
|
M. J. Budoff, S. Achenbach, and A. Duerinckx Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1867 - 1878. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Gurevitch, T. Gaspar, B. Orlov, R. Amar, D. Dvir, N. Peled, and D. J. Aravot Noninvasive evaluation of arterial grafts with newly released multidetector computed tomography Ann. Thorac. Surg., November 1, 2003; 76(5): 1523 - 1527. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C R Peebles Non-invasive coronary imaging: computed tomography or magnetic resonance imaging? Heart, June 1, 2003; 89(6): 591 - 594. [Full Text] [PDF]
|
|
|
|
|
|
A W Leber, A Knez, C Becker, A Becker, C White, C Thilo, M Reiser, R Haberl, and G Steinbeck Non-invasive intravenous coronary angiography using electron beam tomography and multislice computed tomography Heart, June 1, 2003; 89(6): 633 - 639. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Barriales-Villa, M. Penas-Lado, C. Moris, P. W.M. Fedak, S. Verma, T. E. David, R. D. Weisel, R. L. Leask, and J. Butany Bicuspid Aortic Valve and Coronary Anomalies * Response Circulation, April 29, 2003; 107 (16): e105 - e105. [Full Text] [PDF]
|
|
|
|
|
|
R. L. Morin, T. C. Gerber, and C. H. McCollough Radiation Dose in Computed Tomography of the Heart Circulation, February 18, 2003; 107(6): 917 - 922. [Full Text] [PDF]
|
|
|
|
|
|
K Nieman, B J Rensing, R-J M van Geuns, J Vos, P M T Pattynama, G P Krestin, P W Serruys, and P J de Feyter Non-invasive coronary angiography with multislice spiral computed tomography: impact of heart rate Heart, December 1, 2002; 88(5): 470 - 474. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. Y. Kim, P. G. Danias, M. Stuber, S. D. Flamm, S. Plein, E. Nagel, S. E. Langerak, O. M. Weber, E. M. Pedersen, M. Schmidt, et al. Coronary Magnetic Resonance Angiography for the Detection of Coronary Stenoses N. Engl. J. Med., December 27, 2001; 345(26): 1863 - 1869. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Hong, C. R. Becker, A. Huber, U. J. Schoepf, B. Ohnesorge, A. Knez, R. Bruning, and M. F. Reiser ECG-gated Reconstructed Multi-Detector Row CT Coronary Angiography: Effect of Varying Trigger Delay on Image Quality Radiology, September 1, 2001; 220(3): 712 - 717. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Achenbach, T. Giesler, D. Ropers, S. Ulzheimer, H. Derlien, C. Schulte, E. Wenkel, W. Moshage, W. Bautz, W. G. Daniel, et al. Detection of Coronary Artery Stenoses by Contrast-Enhanced, Retrospectively Electrocardiographically-Gated, Multislice Spiral Computed Tomography Circulation, May 29, 2001; 103(21): 2535 - 2538. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. Moshage, S. Achenbach, and W. G. Daniel Novel approaches to the non-invasive diagnosis of coronary-artery disease Nephrol. Dial. Transplant., January 1, 2001; 16(1): 21 - 28. [Full Text] [PDF]
|
|
|
|
|
|
S. Achenbach, S. Ulzheimer, U. Baum, M. Kachelrie{beta}, D. Ropers, T. Giesler, W. Bautz, W. G. Daniel, W. A. Kalender, and W. Moshage Noninvasive Coronary Angiography by Retrospectively ECG-Gated Multislice Spiral CT Circulation, December 5, 2000; 102(23): 2823 - 2828. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S Achenbach, D Ropers, M Regenfus, G Muschiol, W G Daniel, and W Moshage Contrast enhanced electron beam computed tomography to analyse the coronary arteries in patients after acute myocardial infarction Heart, November 1, 2000; 84(5): 489 - 493. [Abstract] [Full Text]
|
|
|
|
|
|
P J de Feyter, K Nieman, P van Ooijen, and M Oudkerk IMAGING TECHNIQUES: Non-invasive coronary artery imaging with electron beam computed tomography and magnetic resonance imaging Heart, October 1, 2000; 84(4): 442 - 448. [Full Text]
|
|
|
|
|
|
S. Achenbach, D. Ropers, J. Holle, G. Muschiol, W. G. Daniel, and W. Moshage In-Plane Coronary Arterial Motion Velocity: Measurement with Electron-Beam CT Radiology, August 1, 2000; 216(2): 457 - 463. [Abstract] [Full Text]
|
|
|
|
|
|
P. M. A. van Ooijen, M. Oudkerk, R. J. M. van Geuns, B. J. Rensing, and P. J. de Feyter Coronary Artery Fly-Through Using Electron Beam Computed Tomography Circulation, July 4, 2000; 102 (1): e6 - e10. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. W. K. Kwok, Y. T. Lim, S. T. Quek, L. K. A. Tan, B. Kwok Wing Kuin, Y. T. Lim, S. T. Quek, and L. Tan Kheng Ann Electron-Beam Computed Tomography for Symptomatic Coronary Disease Asian Cardiovasc Thorac Ann, March 1, 2000; 8(1): 46 - 49. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. R. Margulis and J. H. Sunshine Radiology at the Turn of the Millennium1 Radiology, January 1, 2000; 214(1): 15 - 23. [Abstract] [Full Text]
|
|
|
|
|
|
R J M van Geuns, H G de Bruin, B J W M Rensing, P A Wielopolski, M D Hulshoff, P M A van Ooijen, M Oudkerk, and P J de Feyter Magnetic resonance imaging of the coronary arteries: clinical results from three dimensional evaluation of a respiratory gated technique Heart, October 1, 1999; 82(4): 515 - 519. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B J Rensing, A H H Bongaerts, R J van Geuns, P M A van Ooijen, M Oudkerk, and P J de Feyter In vivo assessment of three dimensional coronary anatomy using electron beam computed tomography after intravenous contrast administration Heart, October 1, 1999; 82(4): 523 - 525. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Noninvasive Coronary Angiography Almost a Reality Journal Watch (General), December 18, 1998; 1998(1218): 2 - 2. [Full Text]
|
|
|
|
|
|
S. E. Langerak, P. Kunz, H. W. Vliegen, J. W. Jukema, A. H. Zwinderman, P. Steendijk, H. J. Lamb, E. E. van der Wall, and A. de Roos MR Flow Mapping in Coronary Artery Bypass Grafts: A Validation Study with Doppler Flow Measurements Radiology, January 1, 2002; 222(1): 127 - 135. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||