Using Coronary CTA to Guide Intervention for CTO CRT 2010 Washington, DC Wm Guy Weigold, MD Director, Cardiac CT Washington Hospital Center

Guy Weigold, MD DISCLOSURES Grants/Contracted Research Philips Healthcare

Traditional Approach Diagnosis Intervention No Intervention

Diagnosis Planning Intervention Only Selective Approach No

Decisions Regarding Intervention on CTO Based on Angiographic Variables Discrete lesion / Long lesion Concentric / Eccentric Straight segment / Tortuous segment Ease of access to segment Calcification Side branch presence / location All of these Variables Can Be Visualized and Assessed by 3D Coronary CTA

Limitations of Traditional Coronary Angiography Requires invasive study Projection images (vessel overlap and foreshortening) “Lumenogram” Plaque characterization requires IVUS Multiple injections & runs for optimal viewing angle

Coronary CTA Provides an Alternative Non-invasive 3D Volume of Anatomic Data (No Overlap) Plaque characterization (calcification) Volume Data Can Be Infinitely Manipulated

How Coronary CTA is Interpreted & Utilized Lesion Length Lesion Curvature Lesion Access Side Branch Locations S.B. Origin Angle Distal Vessel Caliber CTO Plaque Character

Value of Preprocedure MSCT to Predict the Outcome of PCI of CTO PCI characteristics Mollet NR, Hoye A, Lemos PA, et al. AJC 2005;95:240-243

Angiographic and MSCT Predictors of Procedural Failure Variable OR (95% CI) P-value Tapered stump (angio) 0.09 (0.02-0.48) <0.01 Occlusion length >15mm (MSCT) 8.77 (1.58-48.76) 0.01 Severe calcification (MSCT) 7.62 (1.33-43.74) 0.02 Mollet NR, Hoye A, Lemos PA, et al. AJC 2005;95:240-243

Dense Calcification Predicts Failure 39 pts with 43 CTO N (%) Successful Revasc 24 (56%) Variable OR (95% CI) Dense calcification (>50% cross sectional area) 0.10 (0.02 – 0.47) Blunt stump 0.24 (0.07-0.86) Non-predictors: CTO duration Presence of side branches Bridging collaterals Absence of microchannels Soon KH, Cox N, Wong A, Chaitowitz I, MacGregor L, Santos PT, et al. CT coronary angiography predicts the outcome of percutaneous coronary intervention of chronic total occlusion. J Int Cardiol 2007;20:359-366

Long, but non-calcified, CTO 50 yo man with angina. Two previous attempts unsuccessful. Ablation of proximal calcium followed by conventional guidewire. Three DES. Six month follow-up. Van Mieghem CAG, van der Ent M, de Feyter PJ. PCI for CTO. Value of preprocedure MSCT guidance. Heart 2007;93:1492

Length, Calcification, Side Br, SB Angle, Distal Vessel

LAD & Diagonal

RCA

LAD & Diagonal

LAD & Diagonal

Angioplasty

100% RCA

Circumflex 100% CX 100% CX

CX after partial wire crossing

Courtesy Shina Systems Initial image Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Plaque location and type Registration result Plaque location and type Lesion length (12.6mm) Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Suggested stent size and positioning Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Courtesy Shina Systems Initial image Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Courtesy Shina Systems Registration result Pathway Composition Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Courtesy Shina Systems Initial image Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Courtesy Shina Systems Planning Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Catheterization result Load and display CT and angiogram data Demonstration of ECG graph and phase Register the displayed CT image to the displayed angiogram image by allowing the user to match points on the Centerline to the angiogram image Load and display Centerline data Display the vessel selected in the straightened view with 3 cursors Sliding along the vessel Assisting in determination of optimal stand size and position Recommendations of X-Ray camera position: providing the cardiologist the best point and angle of view Courtesy Shina Systems

Conclusions Coronary CTA is highly sensitive for the detection of CAD & stenosis Beyond diagnosis, Cor CTA may provide information useful for the planning of PCI Especially in PCI of CTO, the ability to visualize the plaque and the distal vessel will prove useful in planning the intervention The goals: Better patient selection Decreased time / contrast in the lab Decreased complications Better patient outcomes