Korean J Radiol.  2019 Apr;20(4):621-630. 10.3348/kjr.2018.0399.

Prevalence of Decreased Myocardial Blood Flow in Symptomatic Patients with Patent Coronary Stents: Insights from Low-Dose Dynamic CT Myocardial Perfusion Imaging

• Li Y
• Yuan M
• Yu M
• Lu Z
• Shen C
• Wang Y
• Lu B
• Zhang J

• KMID: 2440485
• DOI: http://doi.org/10.3348/kjr.2018.0399

Abstract

OBJECTIVE
To study the prevalence and clinical characteristics of decreased myocardial blood flow (MBF) quantified by dynamic computed tomography (CT) myocardial perfusion imaging (MPI) in symptomatic patients without in-stent restenosis.
MATERIALS AND METHODS
Thirty-seven (mean age, 71.3 ± 10 years; age range, 48-88 years; 31 males, 6 females) consecutive symptomatic patients with patent coronary stents and without obstructive de novo lesions were prospectively enrolled to undergo dynamic CT-MPI using a third-generation dual-source CT scanner. The shuttle-mode acquisition technique was used to image the complete left ventricle. A bolus of contrast media (50 mL; iopromide, 370 mg iodine/mL) was injected into the antecubital vein at a rate of 6 mL/s, followed by a 40-mL saline flush. The mean MBF value and other quantitative parameters were measured for each segment of both stented-vessel territories and reference territories. The MBFratio was defined as the ratio of the mean MBF value of the whole stent-vessel territory to that of the whole reference territory. An MBFratio of 0.85 was used as the cut-off value to distinguish hypoperfused from non-hypoperfused segments.
RESULTS
A total of 629 segments of 37 patients were ultimately included for analysis. The mean effective dose of dynamic CT-MPI was 3.1 ± 1.2 mSv (range, 1.7-6.3 mSv). The mean MBF of stent-vessel territories was decreased in 19 lesions and 81 segments. Compared to stent-vessel territories without hypoperfusion, the mean MBF and myocardial blood volume were markedly lower in hypoperfused stent-vessel territories (77.5 ± 16.6 mL/100 mL/min vs. 140.4 ± 24.1 mL/100 mL/min [p < 0.001] and 6.4 ± 3.7 mL/100 mL vs. 11.5 ± 4 mL/100 mL [p < 0.001, respectively]). Myocardial hypoperfusion in stent-vessel territories was present in 48.6% (18/37) of patients. None of clinical parameters differed statistically significantly between hypoperfusion and non-hypoperfusion subgroups.
CONCLUSION
Decreased MBF is commonly present in patients who are symptomatic after percutaneous coronary intervention, despite patent stents and can be detected by dynamic CT-MPI using a low radiation dose.

Keyword

Coronary artery disease; Multidetector computed tomography; Angiography; Stents; Percutaneous coronary intervention

MeSH Terms

Angiography
Blood Volume
Contrast Media
Coronary Artery Disease
Heart Ventricles
Humans
Male
Multidetector Computed Tomography
Myocardial Perfusion Imaging*
Percutaneous Coronary Intervention
Prevalence*
Prospective Studies
Stents*
Veins
Contrast Media

Figure

• 

  Fig. 1 Flowchart illustrating inclusion and exclusion criteria.CCTA = coronary CT angiography, CT = computed tomography, ICA = invasive coronary angiography, ISR = in-stent restenosis, MI = myocardial infarction, MPI = myocardial perfusion imaging, PCI = percutaneous coronary intervention

• 

  Fig. 2 Representative case of post-PCI patient with patent stent and reduced myocardial perfusion.A. 3D-MIP image showed stent implantation of first diagonal branch (arrow). B. CPR image confirmed stent patency (arrow). C. Short-axis view of MBF fusion image revealing decreased MBF in apical lateral segment (arrows), corresponding to first diagonal branch territory. D. Long-axis view of MBF fusion image demonstrating decreased MBF in apical lateral segment (arrows); mean MBF was 90.5 mL/100 mL/min. CPR = curved planar reformation, MBF = myocardial blood flow, MIP = maximum intensity projection, 3D = three-dimensional

• 

  Fig. 3 Representative case of post-PCI patient with patent stent and normal myocardial perfusion.A. 3D-MIP image showing stent implantation of proximal LAD (arrow). B. CPR image confirming stent patency (arrow). C. Short-axis view of MBF fusion image revealing normal MBF throughout left ventricle. Mean MBF of LAD territory was 150.9 mL/100 mL/min. LAD = left anterior descending

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  Fig. 4 Box plot of MBF for stent-vessel territories and reference territories.A. Mean MBF of stent-vessel territories with hypoperfusion was significantly lower than that of reference territories. B. Mean MBF of stent-vessel territories with hypoperfusion was similar to that of that reference territories.

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