Korean J Radiol.  2017 Oct;18(5):753-762. 10.3348/kjr.2017.18.5.753.

Calcification Remodeling Index Characterized by Cardiac CT as a Novel Parameter to Predict the Use of Rotational Atherectomy for Coronary Intervention of Lesions with Moderate to Severe Calcification

• Yu M
• Li Y
• Li W
• Lu Z
• Wei M
• Zhang J

• KMID: 2427212
• DOI: http://doi.org/10.3348/kjr.2017.18.5.753

Abstract

OBJECTIVE
To assess the feasibility of calcification characterization by coronary computed tomography angiography (CCTA) to predict the use of rotational atherectomy (RA) for coronary intervention of lesions with moderate to severe calcification.
MATERIALS AND METHODS
Patients with calcified lesions treated by percutaneous coronary intervention (PCI) who underwent both CCTA and invasive coronary angiography were retrospectively included in this study. Calcification remodeling index was calculated as the ratio of the smallest vessel cross-sectional area of the lesion to the proximal reference luminal area. Other parameters such as calcium volume, regional Agatston score, calcification length, and involved calcium arc quadrant were also recorded.
RESULTS
A total of 223 patients with 241 calcified lesions were finally included. Lesions with RA tended to have larger calcium volume, higher regional Agatston score, more involved calcium arc quadrants, and significantly smaller calcification remodeling index than lesions without RA. Receiver operating characteristic curve analysis revealed that the best cutoff value of calcification remodeling index was 0.84 (area under curve = 0.847, p < 0.001). Calcification remodeling index ≤ 0.84 was the strongest independent predictor (odds ratio: 251.47, p < 0.001) for using RA.
CONCLUSION
Calcification remodeling index was significantly correlated with the incidence of using RA to aid PCI. Calcification remodeling index ≤ 0.84 was the strongest independent predictor for using RA prior to stent implantation.

Keyword

Calcification; Rotational atherectomy; Computed tomography; Angiography; Percutaneous coronary intervention; Coronary calcium

MeSH Terms

Adult
Aged
Aged, 80 and over
Area Under Curve
Atherectomy, Coronary
Computed Tomography Angiography
Female
Humans
Male
Middle Aged
Multivariate Analysis
Odds Ratio
Percutaneous Coronary Intervention
ROC Curve
Retrospective Studies
Severity of Illness Index
Vascular Calcification/diagnostic imaging/*pathology/surgery

Figure

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  Fig. 1 Flow chart of patient inclusion and exclusion.CCTA = coronary computed tomography angiography, ICA = invasive coronary angiography, PCI = percutaneous coronary intervention

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  Fig. 2 Illustration of calculation of calcification remodeling index.Index was defined as ratio of lumen area (with inclusion of calcium) of most severely calcified site versus lumen area of proximal reference.

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  Fig. 3 Representative case of calcified coronary stenosis treated with RA and PCI.A. 3D-MIP image of left coronary artery showing calcified lesion located at LM and proximal LAD (white arrow). B. Calcification length measured on CPR image (white arrow) was 12.2 mm. Calcium volume and focal Agatston score were 191.8 mm3 and 256.3, respectively. Calcification remodeling index of this lesion was calculated to be 0.47. Involved calcium arc quadrant was 3 as identified on cross-sectional images. C. Fluoroscopy of left coronary artery revealing calcification of proximal LAD (white arrow). D. ICA of left coronary artery showing severe stenosis of proximal LAD (white arrow). E. Lesion was modified with RA (white arrow) prior to stent deployment. F. Lesion was successfully treated after stent implantation as confirmed by ICA (white arrow). CPR = curved planar reformation, LAD = left anterior descending, LM = left main, MIP = maximum intensity projection, RA = rotational atherectomy

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  Fig. 4 Representative case of calcified coronary stenosis treated with PCI but without RA.A. 3D-MIP image of left coronary artery showing long diffusely calcified lesion located at proximal to middle LAD (white arrows). B. Calcification length measured on CPR image (white arrow) was 38.2 mm. Calcium volume and focal Agatston score were 782.9 mm3 and 977.6, respectively. Calcification remodeling index of this lesion was calculated to be 0.91. Involved calcium arc quadrant was 2 as identified on cross-sectional images. C. Fluoroscopy of left coronary artery revealing calcification of proximal to middle LAD (white arrows). D. ICA of left coronary artery showing severe stenosis of proximal LAD (white arrow). E. Lesion was successfully treated after stent implantation without use of RA (white arrow).

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  Fig. 5 ROC curve analysis of various parameters for identifying calcified lesions treated with RA.Calcification remodeling index showing largest AUC and best diagnostic performance over other parameters. AUC = area under curve, CI = confidence interval, ROC = receiver operating characteristic.Calcification remodeling index showing largest AUC and best diagnostic performance over other parameters.

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