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

2. Guy Weigold, MD DISCLOSURES Grants/Contracted Research
Philips Healthcare

3. Traditional Approach
Diagnosis
Intervention No
Intervention

4. Diagnosis Planning Intervention Only Selective Approach No

5. 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

6. 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

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

9. 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

10. 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:

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

12. 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 ( )
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:

13. 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

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

19. LAD & Diagonal

20. RCA

21. LAD & Diagonal

22. LAD & Diagonal

23. Angioplasty

29. 100% RCA

30. Circumflex
100% CX
100% CX

31. CX after partial wire crossing

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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