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CT of Coronary Artery Disease¹

¹ From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (U.J.S., E.K.Y.); Institute of Clinical Radiology, University of Munich, Germany (C.R.B.); and Siemens Medical Solutions, Division CT, Forchheim, Germany (B.M.O.). Received April 29, 2003; revision requested July 10; revision received July 29; accepted August 25; updated September 17. U.J.S. and E.K.Y. supported in part by research grants from Berlex Laboratories, Wayne, NJ. Address correspondence to U.J.S. (e-mail: schoepf@bwh.harvard.edu).

View larger version (67K): [in a new window]   Figure 1. Schematic shows adaptive segmented image reconstruction approach for ECG-gated multi-detector row CT. Dashed lines are z-axis positions of detector rows, which continuously and linearly change position relative to the patient during constant spiral feed. ECG signal is simultaneously recorded during image acquisition and is displayed at bottom of the diagram. At heart rates less than a predefined threshold, one segment of consecutive multisection spiral data is used for image reconstruction. At higher heart rates, two or more subsegments from adjacent heart cycles contribute to the partial scan data segment. In each cardiac cycle, a stack of images is reconstructed at different z-axis positions covering a small subvolume of the heart (dark gray box). The combination of subvolumes from all heart cycles during scanning provides a continuous 3D data set of the entire heart.

View larger version (135K): [in a new window]   Figure 2. Transverse contrast-enhanced 16-detector row CT scan obtained with retrospective ECG gating at the level of the mitral valve. Complete and homogeneous enhancement of left ventricle and coronary arteries can be achieved with a dedicated contrast medium protocol. Contrast medium has passed the right ventricle, and saline flush results in washout of contrast medium from the right ventricle. This reduces or prevents streak artifacts potentially arising from high-attenuating contrast material in the superior vena cava and right atrium, which may interfere with evaluation of the right coronary artery (arrow).

View larger version (125K): [in a new window]   Figure 3a. Maximum intensity projections for routine visualization of large volume multi-detector row CT coronary angiography data sets. (a) Right anterior oblique view along the interventricular groove shows left anterior descending coronary artery (LAD), with mixed atherosclerotic lesion (arrowhead) with calcified components in the proximal course of the vessel. (b) Left anterior oblique view in plane connecting right coronary artery (RCA) and circumflex coronary artery along the atrioventricular groove shows right coronary artery, with calcified nodules (arrowheads) along the course of the vessel. (c) Left anterior oblique "spider" view along long axis of the heart shows course of the left anterior descending coronary artery (LAD) and its diagonal branches, with soft-tissue-attenuation plaque (arrowhead) in the anterior aspect of the left main coronary artery (LM) wall.

View larger version (140K): [in a new window]   Figure 3b. Maximum intensity projections for routine visualization of large volume multi-detector row CT coronary angiography data sets. (a) Right anterior oblique view along the interventricular groove shows left anterior descending coronary artery (LAD), with mixed atherosclerotic lesion (arrowhead) with calcified components in the proximal course of the vessel. (b) Left anterior oblique view in plane connecting right coronary artery (RCA) and circumflex coronary artery along the atrioventricular groove shows right coronary artery, with calcified nodules (arrowheads) along the course of the vessel. (c) Left anterior oblique "spider" view along long axis of the heart shows course of the left anterior descending coronary artery (LAD) and its diagonal branches, with soft-tissue-attenuation plaque (arrowhead) in the anterior aspect of the left main coronary artery (LM) wall.

View larger version (120K): [in a new window]   Figure 3c. Maximum intensity projections for routine visualization of large volume multi-detector row CT coronary angiography data sets. (a) Right anterior oblique view along the interventricular groove shows left anterior descending coronary artery (LAD), with mixed atherosclerotic lesion (arrowhead) with calcified components in the proximal course of the vessel. (b) Left anterior oblique view in plane connecting right coronary artery (RCA) and circumflex coronary artery along the atrioventricular groove shows right coronary artery, with calcified nodules (arrowheads) along the course of the vessel. (c) Left anterior oblique "spider" view along long axis of the heart shows course of the left anterior descending coronary artery (LAD) and its diagonal branches, with soft-tissue-attenuation plaque (arrowhead) in the anterior aspect of the left main coronary artery (LM) wall.

View larger version (138K): [in a new window]   Figure 4. Curved multiplanar reformation in oblique anterior coronal orientation from contrast-enhanced multi-detector row CT coronary angiography study allows visualization of course of the left anterior descending coronary artery in a patient with CAD. Note significant stenosis (arrow) caused by noncalcified coronary artery lesion proximal to a calcified nodule.

View larger version (86K): [in a new window]   Figure 5. Comparison of conventional angiography and contrast-enhanced four-detector row CT coronary angiography in one patient. Left: Anteroposterior cranial projection from conventional selective coronary angiography shows left anterior descending (LAD) and circumflex (Cx) coronary arteries. Right: Volume rendering in anteroposterior cranial projection shows left main coronary artery with its branches, the left anterior descending (LAD) and left circumflex (Cx) coronary arteries.

View larger version (94K): [in a new window]   Figure 6. Comparison of conventional angiography and contrast-enhanced four-detector row CT coronary angiography in one patient. Left: Right anterior oblique projection from conventional selective coronary angiography shows right coronary artery (RCA). Right: CT volume rendering shows right coronary artery (RCA) in 30° right anterior oblique projection.

View larger version (106K): [in a new window]   Figure 7. Contrast-enhanced 16-detector row CT coronary angiography. Colored volume rendering of right coronary artery (RCA) displayed in slightly cranial right anterior oblique perspective. This method of 3D postprocessing provides an intuitive display and conveys information on the often complicated anatomy of tortuous coronary arteries.

View larger version (133K): [in a new window]   Figure 8. Image in left craniolateral perspective was generated by using a dedicated software platform for automated segmentation of the coronary arterial tree from contrast-enhanced CT studies of the heart. On the basis of attenuation thresholds, the course of the left anterior descending coronary artery (LAD, highlighted) and its branches is automatically segmented from volume data.

View larger version (42K): [in a new window]   Figure 9. Image generated from same data set as in Figure 8. Intuitive visualization of left anterior descending coronary artery (LAD) is achieved by displaying curved multiplanar reformation of the segmented vessel along an automatically generated centerline. Note noncalcified soft-tissue-attenuation lesion (arrow) in the wall of the left main coronary artery (LM), causing significant stenosis.

View larger version (80K): [in a new window]   Figure 10. Screenshot shows software platform for detection and quantification of coronary calcification. Lesions exceeding calcium threshold of 130 HU are identified with 3D-based picking and viewing tools and are assigned to left main (LM), left anterior descending (LAD), left circumflex (CX), or right (RCA) coronary arteries. Coronary calcification is quantified by means of Agatston score, calcium volume, and calcium mass. For calculation of calcium mass, calibration factors are established with phantom measurements and are used to adjust for different scan protocols. Quantitative measurements are displayed and reported in table format. Images shown are in a patient with calcifications in left anterior descending (yellow) and circumflex (blue) coronary arteries.

View larger version (120K): [in a new window]   Figure 11. Contrast-enhanced four-detector row CT coronary angiography. Transverse thin-section maximum intensity projection reconstructed at level of the aortic valve (AV) shows coronary artery anomaly, with three coronary arteries arising from the origin of the right coronary artery (arrow) and supplying both left and right vascular territories of the myocardium. Both coronary arteries supplying left side of the heart (arrowheads) are compressed between the left ventricular outflow tract and adjacent cardiac cavities.

View larger version (183K): [in a new window]   Figure 12a. Patient with superdominant anomalous right coronary artery (AnRCA) supplying the majority of the myocardium. (a) Selective conventional angiographic image and (b) volume-rendered 3D reconstruction (cranial right anterior oblique perspective) from contrast-enhanced 16-detector row CT coronary angiography. Anomalous right coronary artery gives rise to two side branches (arrowheads), which cross over to left anterior surface of the heart, connecting anomalous right coronary artery with left anterior descending (LAD) coronary arterial territory. Native right coronary artery (RCA) is also visualized in its normal anatomic course but is of similar small caliber as left anterior descending artery.

View larger version (128K): [in a new window]   Figure 12b. Patient with superdominant anomalous right coronary artery (AnRCA) supplying the majority of the myocardium. (a) Selective conventional angiographic image and (b) volume-rendered 3D reconstruction (cranial right anterior oblique perspective) from contrast-enhanced 16-detector row CT coronary angiography. Anomalous right coronary artery gives rise to two side branches (arrowheads), which cross over to left anterior surface of the heart, connecting anomalous right coronary artery with left anterior descending (LAD) coronary arterial territory. Native right coronary artery (RCA) is also visualized in its normal anatomic course but is of similar small caliber as left anterior descending artery.

View larger version (145K): [in a new window]   Figure 13a. (a) Selective conventional coronary angiographic image in right anterior oblique projection and (b) volume-rendered 3D depiction (left posterior perspective) from contrast-enhanced four-detector row CT coronary angiography show coronary artery fistula (arrows) arising from left circumflex coronary artery and connecting to right atrium.

View larger version (125K): [in a new window]   Figure 13b. (a) Selective conventional coronary angiographic image in right anterior oblique projection and (b) volume-rendered 3D depiction (left posterior perspective) from contrast-enhanced four-detector row CT coronary angiography show coronary artery fistula (arrows) arising from left circumflex coronary artery and connecting to right atrium.

View larger version (109K): [in a new window]   Figure 14. Colored volume-rendered view from anterior perspective, derived from 16-detector row CT angiography, in a patient with three venous bypass grafts to left anterior descending (VCABG-LAD), circumflex (VCABG-Cx), and right (VCABG-RCA) coronary arterial territories and an additional left internal mammary artery bypass graft (LIMA-BG), also to the left anterior descending coronary artery (LAD).

View larger version (176K): [in a new window]   Figure 15. Colored 3D volume-rendered view from left anterior oblique perspective, derived from 16-detector row CT coronary angiography, enables visualization of native and graft vessels in their relationship to surrounding thoracic anatomy in a patient with left internal mammary artery (LIMA) bypass graft. Anastomosis has been created between left internal mammary artery and left anterior descending coronary artery (LAD) territory. Note extensive atherosclerotic changes in the native vessels.

View larger version (124K): [in a new window]   Figure 16a. Contrast-enhanced 16-detector row CT coronary angiography in a patient who has undergone percutaneous transluminal coronary angioplasty with stent placement in right coronary artery (RCA). (a) Colored 3D volume-rendered view from right posterior oblique perspective reveals luminal narrowing (arrowhead) of artery proximal to the stent. (b) Maximum intensity projection and (c) multiplanar reformation in oblique coronal planes show patent stent lumen and mixed atherosclerotic lesion (arrow) with calcified and noncalcified components as the cause of high-grade (70%) stenosis proximal to the stent. (d) Conventional angiographic image in left anterior oblique projection confirms stent patency and presence of stenosis (arrow) but fails to elucidate nature of the lesion causing luminal narrowing. (Case courtesy of C. S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (161K): [in a new window]   Figure 16b. Contrast-enhanced 16-detector row CT coronary angiography in a patient who has undergone percutaneous transluminal coronary angioplasty with stent placement in right coronary artery (RCA). (a) Colored 3D volume-rendered view from right posterior oblique perspective reveals luminal narrowing (arrowhead) of artery proximal to the stent. (b) Maximum intensity projection and (c) multiplanar reformation in oblique coronal planes show patent stent lumen and mixed atherosclerotic lesion (arrow) with calcified and noncalcified components as the cause of high-grade (70%) stenosis proximal to the stent. (d) Conventional angiographic image in left anterior oblique projection confirms stent patency and presence of stenosis (arrow) but fails to elucidate nature of the lesion causing luminal narrowing. (Case courtesy of C. S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (158K): [in a new window]   Figure 16c. Contrast-enhanced 16-detector row CT coronary angiography in a patient who has undergone percutaneous transluminal coronary angioplasty with stent placement in right coronary artery (RCA). (a) Colored 3D volume-rendered view from right posterior oblique perspective reveals luminal narrowing (arrowhead) of artery proximal to the stent. (b) Maximum intensity projection and (c) multiplanar reformation in oblique coronal planes show patent stent lumen and mixed atherosclerotic lesion (arrow) with calcified and noncalcified components as the cause of high-grade (70%) stenosis proximal to the stent. (d) Conventional angiographic image in left anterior oblique projection confirms stent patency and presence of stenosis (arrow) but fails to elucidate nature of the lesion causing luminal narrowing. (Case courtesy of C. S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (136K): [in a new window]   Figure 16d. Contrast-enhanced 16-detector row CT coronary angiography in a patient who has undergone percutaneous transluminal coronary angioplasty with stent placement in right coronary artery (RCA). (a) Colored 3D volume-rendered view from right posterior oblique perspective reveals luminal narrowing (arrowhead) of artery proximal to the stent. (b) Maximum intensity projection and (c) multiplanar reformation in oblique coronal planes show patent stent lumen and mixed atherosclerotic lesion (arrow) with calcified and noncalcified components as the cause of high-grade (70%) stenosis proximal to the stent. (d) Conventional angiographic image in left anterior oblique projection confirms stent patency and presence of stenosis (arrow) but fails to elucidate nature of the lesion causing luminal narrowing. (Case courtesy of C. S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (121K): [in a new window]   Figure 17. Colored volume-rendered view from slightly cranial left anterior oblique perspective, derived from contrast-enhanced four-detector row CT coronary angiography, shows high-grade stenosis (arrow) of proximal left anterior descending coronary artery.

View larger version (134K): [in a new window]   Figure 18a. (a) Conventional selective coronary angiogram and (b) contrast-enhanced four-detector row CT coronary angiographic image, both shown in right anterior oblique projection, show hemodynamically significant stenosis (arrow) of left anterior descending coronary artery.

View larger version (158K): [in a new window]   Figure 18b. (a) Conventional selective coronary angiogram and (b) contrast-enhanced four-detector row CT coronary angiographic image, both shown in right anterior oblique projection, show hemodynamically significant stenosis (arrow) of left anterior descending coronary artery.

View larger version (187K): [in a new window]   Figure 19a. (a) Conventional selective coronary angiogram in right anterior oblique projection and (b) transverse thin-slab maximum intensity projection from 16-detector row coronary CT angiography (view from caudal) in a patient suspected of having CAD. AO = aorta, PA = pulmonary artery. CT coronary angiography (b) demonstrates high-grade (90%) stenosis (lower arrow) in proximal left anterior descending coronary artery close to bifurcation of the first diagonal branch and a second (70%) stenosis (upper arrow) in middle segment of the left anterior descending coronary artery close to bifurcation of the second diagonal branch. Both lesions (arrows) were confirmed on a. (Case courtesy of C.S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (165K): [in a new window]   Figure 19b. (a) Conventional selective coronary angiogram in right anterior oblique projection and (b) transverse thin-slab maximum intensity projection from 16-detector row coronary CT angiography (view from caudal) in a patient suspected of having CAD. AO = aorta, PA = pulmonary artery. CT coronary angiography (b) demonstrates high-grade (90%) stenosis (lower arrow) in proximal left anterior descending coronary artery close to bifurcation of the first diagonal branch and a second (70%) stenosis (upper arrow) in middle segment of the left anterior descending coronary artery close to bifurcation of the second diagonal branch. Both lesions (arrows) were confirmed on a. (Case courtesy of C.S. Soo, MD, HSC Medical Center, Kuala Lumpur, Malaysia.)

View larger version (88K): [in a new window]   Figure 20. Conventional selective coronary angiographic image in right anterior oblique projection (A), transverse nonenhanced four-detector row CT image (B), and contrast-enhanced four-detector row CT coronary angiographic image in transverse maximum intensity projection (C) in a patient with hemodynamically significant stenosis of left main coronary artery. With conventional angiography, evaluation is restricted to assessment of the presence and degree of coronary artery stenosis (arrow in A). The cross-sectional nature of high-spatial-resolution multi-detector row CT enables noninvasive evaluation of a soft-tissue-attenuation wall lesion (arrow in C) in posterior circumference of the left main coronary artery and demonstrates absence of macrocalcifications by means of nonenhanced CT (B).

View larger version (136K): [in a new window]   Figure 21a. (a) Selective coronary angiographic image in right anterior oblique projection, (b) transverse contrast-enhanced four-detector row CT coronary angiographic image, and (c) cross-sectional intravascular ultrasonographic (US) image of left anterior descending coronary artery in a patient with coronary atherosclerosis. (a) No hemodynamically significant stenosis can be visualized. (b) Mixed atherosclerotic lesion (arrow) with soft-tissue component can be seen adjacent to a calcified nodule in the anterior wall of the left anterior descending coronary artery. Lesion abuts the vessel lumen but does not cause manifest stenosis. (c) Presence and nature of the lesion (arrow) are confirmed at US, demonstrating soft-tissue-equivalent echogenicity of lesion.

View larger version (63K): [in a new window]   Figure 21b. (a) Selective coronary angiographic image in right anterior oblique projection, (b) transverse contrast-enhanced four-detector row CT coronary angiographic image, and (c) cross-sectional intravascular ultrasonographic (US) image of left anterior descending coronary artery in a patient with coronary atherosclerosis. (a) No hemodynamically significant stenosis can be visualized. (b) Mixed atherosclerotic lesion (arrow) with soft-tissue component can be seen adjacent to a calcified nodule in the anterior wall of the left anterior descending coronary artery. Lesion abuts the vessel lumen but does not cause manifest stenosis. (c) Presence and nature of the lesion (arrow) are confirmed at US, demonstrating soft-tissue-equivalent echogenicity of lesion.

View larger version (140K): [in a new window]   Figure 21c. (a) Selective coronary angiographic image in right anterior oblique projection, (b) transverse contrast-enhanced four-detector row CT coronary angiographic image, and (c) cross-sectional intravascular ultrasonographic (US) image of left anterior descending coronary artery in a patient with coronary atherosclerosis. (a) No hemodynamically significant stenosis can be visualized. (b) Mixed atherosclerotic lesion (arrow) with soft-tissue component can be seen adjacent to a calcified nodule in the anterior wall of the left anterior descending coronary artery. Lesion abuts the vessel lumen but does not cause manifest stenosis. (c) Presence and nature of the lesion (arrow) are confirmed at US, demonstrating soft-tissue-equivalent echogenicity of lesion.

View larger version (164K): [in a new window]   Figure 22a. (a) Prototype of CT system using existing scanner platforms with area-detector (arrow) technology, with detector pixel sizes smaller than 0.5 mm. In the future, such systems may be used to cover the heart in a single gantry rotation with an isotropic resolution of less than 0.3 mm. A beneficial application of increased spatial resolution may be improved depiction of stents and minute coronary artery segments (Fig 23). (b) Anthropomorphic numeric coronary artery phantom used to evaluate the influence of spatial resolution and section width on visualization of coronary artery lumen and coronary artery lesions. Lumen of the simulated contrast-enhanced (250-HU) left coronary artery (LAD) contains plaques with different properties (lipid plaque, 30 HU; fibrous plaque, 80 HU; calcified plaque, 500 HU) and stent with 50% in-stent luminal narrowing caused by 30-HU lesion. (c) Phantom was reconstructed with 1.0- (top), 0.75- (middle), and 0.25-mm (bottom) section widths, and proximal part of phantom artery was displayed with multiplanar reformations. Differentiation of lesions and visualization of stent lumen are possible with section widths of 1.0 mm or less. A 0.25-mm width reduces "blooming" (beam-hardening) artifacts arising from high-attenuating stent struts but does not necessarily provide improved delineation of noncalcified coronary lesions, owing to low signal-to-noise ratio and limited dynamic range for soft-tissue contrast.

View larger version (43K): [in a new window]   Figure 22b. (a) Prototype of CT system using existing scanner platforms with area-detector (arrow) technology, with detector pixel sizes smaller than 0.5 mm. In the future, such systems may be used to cover the heart in a single gantry rotation with an isotropic resolution of less than 0.3 mm. A beneficial application of increased spatial resolution may be improved depiction of stents and minute coronary artery segments (Fig 23). (b) Anthropomorphic numeric coronary artery phantom used to evaluate the influence of spatial resolution and section width on visualization of coronary artery lumen and coronary artery lesions. Lumen of the simulated contrast-enhanced (250-HU) left coronary artery (LAD) contains plaques with different properties (lipid plaque, 30 HU; fibrous plaque, 80 HU; calcified plaque, 500 HU) and stent with 50% in-stent luminal narrowing caused by 30-HU lesion. (c) Phantom was reconstructed with 1.0- (top), 0.75- (middle), and 0.25-mm (bottom) section widths, and proximal part of phantom artery was displayed with multiplanar reformations. Differentiation of lesions and visualization of stent lumen are possible with section widths of 1.0 mm or less. A 0.25-mm width reduces "blooming" (beam-hardening) artifacts arising from high-attenuating stent struts but does not necessarily provide improved delineation of noncalcified coronary lesions, owing to low signal-to-noise ratio and limited dynamic range for soft-tissue contrast.

View larger version (113K): [in a new window]   Figure 22c. (a) Prototype of CT system using existing scanner platforms with area-detector (arrow) technology, with detector pixel sizes smaller than 0.5 mm. In the future, such systems may be used to cover the heart in a single gantry rotation with an isotropic resolution of less than 0.3 mm. A beneficial application of increased spatial resolution may be improved depiction of stents and minute coronary artery segments (Fig 23). (b) Anthropomorphic numeric coronary artery phantom used to evaluate the influence of spatial resolution and section width on visualization of coronary artery lumen and coronary artery lesions. Lumen of the simulated contrast-enhanced (250-HU) left coronary artery (LAD) contains plaques with different properties (lipid plaque, 30 HU; fibrous plaque, 80 HU; calcified plaque, 500 HU) and stent with 50% in-stent luminal narrowing caused by 30-HU lesion. (c) Phantom was reconstructed with 1.0- (top), 0.75- (middle), and 0.25-mm (bottom) section widths, and proximal part of phantom artery was displayed with multiplanar reformations. Differentiation of lesions and visualization of stent lumen are possible with section widths of 1.0 mm or less. A 0.25-mm width reduces "blooming" (beam-hardening) artifacts arising from high-attenuating stent struts but does not necessarily provide improved delineation of noncalcified coronary lesions, owing to low signal-to-noise ratio and limited dynamic range for soft-tissue contrast.

View larger version (106K): [in a new window]   Figure 23. Image from flat-panel CT volume acquisition of stationary human cadaveric heart specimen. Colored volume-rendered view from left anterior oblique perspective shows coronary arteries filled with iodinated contrast material. Image data were acquired during a single rotation around the specimen of the detector panel of the prototype system shown in Figure 22a. Isotropic in-plane and through-plane resolution of 0.25 mm enables visualization of small-caliber marginal branches (arrows) of calcified right coronary artery (RCA) and left anterior descending coronary artery (LAD).