J Korean Soc Radiol.  2017 Dec;77(6):353-366. 10.3348/jksr.2017.77.6.353.

The Expanding Role of Computed Tomography Angiography in the Evaluation of Atherosclerotic Coronary Artery Disease

• Yoo SM
• Lee HY
• Kim SM
• Yang DH
• Jung JI
• White CS

• KMID: 2396493
• DOI: http://doi.org/10.3348/jksr.2017.77.6.353

Abstract

Atherosclerotic coronary artery disease (CAD) is a leading cause of morbidity and mortality globally. Because of its remarkable technological advances, a coronary computed tomography angiography (CTA) is now a crucial imaging tool in the evaluation of patients with nonspecific acute and stable chest pain. This review article provides an overview of atherosclerotic CAD, the pros and cons of CTAs as compared to competing imaging modalities, and the potential remedies to overcome drawbacks of CTAs.

MeSH Terms

Angiography*
Atherosclerosis
Chest Pain
Coronary Artery Disease*
Coronary Vessels*
Humans
Mortality

Figure

• 

  Fig. 1 60-year-old male patient with short segment critical stenosis (greater than 70%) in the mid-anterior descending coronary artery. Arrow in (A) on an axial CT image at the level of the left atrium indicates the mild-anterior descending coronary artery. Pinpoint narrowing at the origin of the mid-anterior descending coronary artery (arrow, B) is demonstrated on a consecutive axial CT image next to (A). The diameter of the mid-anterior descending coronary artery (arrow, C) suddenly returns to normal in the consecutive axial CT image adjacent to (B). Such an abrupt diameter change indicates a very short segment coronary stenosis. This lesion was missed on a coronary computed tomography angiography performed one and a half years earlier. Note that the critical stenosis (arrow) is identified on only one (D) of the two invasive coronary angiographic views (D, E) due to the overlapping of the coronary arteries. Thus, radiologists should be careful not to overlook such short segment stenoses by carefully evaluating all axial raw data. CT = computed tomography

• 

  Fig. 2 72-year-old male patient with acute myocardial infarction. This patient presented to the outpatient department with chest pain that developed four days earlier. The attending physician ordered an elective coronary CTA to rule out stable coronary artery disease. However, the coronary CTA was suboptimal due to a high heart rate (71 bpm). Note the significant motion artifact (arrowheads) along the middle right coronary artery on the curved multi-planar reformatted image (A). There is suspicion for a sub-endocardial perfusion defect (arrowheads, B) in the inferior wall of the left ventricle on the axial CT image with a wide field of view at the level of the left ventricle. However, a beam hardening artifact frequently occurs at this location. Thus, an artifact is not reliably excluded in this patient. On the cine images of the mild-portion of the left ventricle (C, D; diastolic and systolic image, respectively), hypokinesia is noted in the territory of the right coronary artery (i.e., interventricular septum, inferior, and inferolateral wall of the left ventricle). Note there is only mild wall thickening (arrowheads, D) in the corresponding segments compared with the normal systolic wall thickening in the antero-lateral wall of the left ventricle (D). This observation indicates the need to evaluate all phases of the axial raw data. On the short segment curved multi-planar reformatted image with the least motion artifact, findings are suspicious for a critical stenosis (arrows, E) at the distal portion of the middle right coronary artery, even though a motion artifact is present. This result was communicated to the attending cardiologist and emergent invasive coronary angiography confirmed the CT findings (arrows, F). This example shows that an analysis of the regional wall motion abnormality on a coronary CTA enhances the identification of acute coronary syndrome in cases involving a motion or blooming artifact. CT = computed tomography, CTA = computed tomography angiography

• 

  Fig. 3 87-year-old male patient with acute myocardial infarction identified on an abdomen CT. The patient was hospitalized for a fracture of the right femoral neck and developed sudden abdominal pain and shock during hospitalization. The attending physician ordered an abdomen CT. Diffuse subendocardial hypoperfusion (arrowheads) is noted on an axial CT image at the level of the left ventricle, which indicated a myocardial infarction due to the obstruction of the left main coronary artery. At follow-up, an electrocardiogram showed an ischemic pattern and the serum troponin increased. The patient ultimately died due to heart failure. CT = computed tomography

• 

  Fig. 4 Napkin ring sign in a 60-year-old male patient on a coronary computed tomography angiography. A typical napkin ring sign is noted in the distal portion of the mid right coronary artery on the axial CT image at the level of the coronary sinus (arrows, A) and on the curved multiplanar reformatted image (arrowheads, B). CT = computed tomography

• 

  Fig. 5 56-year-old male patient with Stanford type B aortic dissection identified on a dedicated coronary CTA. The primary concern of emergency department physician was acute coronary syndrome. Thus, a dedicated coronary CTA was performed. However, the coronary arteries (not shown) were normal. Instead, a Stanford type B aortic dissection (arrowheads) is identified on a sagittal image using a wide field of view. Note the typical z-axis coverage of a dedicated coronary CTA includes only the lower two-thirds of the entire chest. CTA = computed tomography angiography

• 

  Fig. 6 62-year-old female patient with severe coronary calcifications. On the curved multi-planar reformatted images, multiple calcified plaques are noted along the left anterior descending (arrows, A), left circumflex (arrows, B), and right coronary artery (arrow, C). Due to a blooming and/or motion artifact, the presence of 50% or more coronary stenosis is not reliably excluded in this patient. A stress CT perfusion has an important role in this occasion. On a short-axis view of a stress CT perfusion (D), there is a perfusion defect only in the territory of the left anterior descending coronary artery (arrowheads). Thus, calcified plaques in the left circumflex and right coronary artery are not hemodynamically significant (case courtesy by professor Sung Mok Kim, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea). CT = computed tomography

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  Fig. 7 50-year-old male patient with intermediate stenosis (50–70%) in the middle left anterior descending artery. Is revascularization appropriate in this patient? On a curved multi-planar reformatted image, a 50–70% stenosis with noncalcified plaque (arrows, A) is noted in the middle left anterior descending coronary artery. The computed tomography FFR value (B) is 0.69 which indicates hemodynamically significant stenosis. Thus, a percutaneous coronary intervention would be recommended in this patient. In fact, the FFR value on a coronary angiography was 0.7 in this patient (case courtesy by professor Dong Hyun Yang, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea). FFR = fractional flow reserve

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