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Noninvasive Imaging of Coronary Arteries: Current and Future Role of Multi–Detector Row CT¹

¹ From the Departments of Radiology (P.S., S.S.H., A.E.S., S.A.K., R.D.W.), Cardiovascular Medicine (P.S., S.E.N., E.M.T., R.D.W.), and Thoracic and Cardiovascular Surgery (R.D.W.), Cleveland Clinic Foundation, Desk Hb 6, 9500 Euclid Ave, Cleveland, OH 44195. Received December 30, 2002; revision requested April 11, 2003; revision received April 17; accepted May 1. Supported by an unrestricted training grant from Berlex Laboratories, Pine Brook, NJ. P.S. supported by a postdoctoral fellowship award from the Ohio Valley Regional Affiliate of the American Heart Association. Address correspondence to R.D.W. (e-mail: whiter1@ccf.org) or P.S. (e-mail: schoenp1@ccf.org).

View larger version (128K): [in a new window]   Figure 1. Normal coronary arteries at four-detector row CT. A, Transverse base image, B, transverse curved multiplanar reconstruction, C, oblique transverse thin maximum intensity projection, and D, left anterior oblique volume-rendered surface reconstruction demonstrate normal-appearing LAD coronary artery (black arrows). Proximal segments of right coronary artery (white arrows) and left circumflex coronary artery (arrowhead), which are also free of atherosclerotic changes, are seen.

View larger version (137K): [in a new window]   Figure 2. Coronary artery with complex atherosclerotic plaque at four-detector row CT. A, Transverse base image, B, craniocaudal curved multiplanar reconstruction, C, oblique transverse thin maximum intensity projection, and D, left anterior oblique volume-rendered surface reconstruction demonstrate extensive atherosclerotic changes affecting LAD coronary artery, which contains a long complex plaque with calcified and noncalcified components (brackets) in its proximal segment. Proximal segments of right coronary artery (black arrow) and left circumflex coronary artery (white arrows), which also show irregularity and narrowing from atherosclerosis, are seen.

View larger version (123K): [in a new window]   Figure 3. Coronary artery bypass graft status at four-detector row CT. A-D, Transverse cranial to caudal base images demonstrate occlusion of a dilated aortocoronary venous graft (large arrows) to the left circumflex coronary artery, while another aortocoronary venous graft (small arrows) communicating with the right coronary artery is patent. Left internal mammary artery graft (arrowheads) to the LAD coronary artery is also patent.

View larger version (141K): [in a new window]   Figure 4. Progressing stenosis of coronary artery bypass graft at four-detector row CT. A, Craniocaudal curved multiplanar reconstruction and, B, corresponding 12-month follow-up image demonstrate focal asymmetric narrowing (arrows) of the proximal portion of aortocoronary venous graft to the middle left circumflex coronary artery. Initial 70% narrowing progressed to 90% narrowing and was accompanied by worsening angina.

View larger version (93K): [in a new window]   Figure 5. Coronary artery bypass graft stent patency at four-detector row CT. A, Craniocaudal curved multiplanar reconstruction, B, straight oblique transverse multiplanar reconstruction, C, uncropped anterior reconstruction, and D, cranially cropped volume-rendered surface reconstruction in the same patient as in Figure 4 demonstrate a widely patent stent (arrows) traversing the previously shown stenosis of the proximal portion of aortocoronary venous graft to the middle left circumflex coronary artery.

View larger version (133K): [in a new window]   Figure 6. Coronary artery stent patency at four-detector row CT. Oblique transverse (A, B) and right anterior oblique (C) thin maximum intensity projections and craniocaudal curved multiplanar reconstruction (D) demonstrate short series of sequential stents (large arrows) within the middle LAD coronary artery. Stent patency is supported by prompt flow to distal segments of the artery. At the leading edge of the stent series, stenosis (small arrows) of the artery is noted.

View larger version (67K): [in a new window]   Figure 7. Anomalous coronary arteries at four-detector row CT. Thin oblique transverse maximum intensity projections in two patients with intermittent chest discomfort demonstrate anomalous origin and course of a major coronary artery between aortic root (small circles) and outflow tract of the right ventricle (large circles), resulting in compression and distortion of the artery. A, Anomalous LAD coronary artery (large arrow) has a common origin with the dominant right coronary artery (small arrow) from the right coronary sinus of Valsalva. B, Anomalous right coronary artery (small arrow) originates directly from the left coronary sinus of Valsalva, separately from the left coronary artery system (large arrow).

View larger version (81K): [in a new window]   Figure 8. Coronary myocardial bridge at four-detector row CT. A, Craniocaudal curved multiplanar reconstruction and, B, thin right anterior oblique maximum intensity projection in a symptomatic patient demonstrate intramyocardial course (arrows) of middle portion of the otherwise normal-appearing LAD coronary artery. The overlying myocardium represents the bridge.

View larger version (105K): [in a new window]   Figure 9. Coronary artery aneurysm (Kawasaki disease) at four-detector row CT. A, Oblique transverse thin maximum intensity projection, B, C, craniocaudal curved multiplanar reconstructions, and D, left anterior oblique volume-rendered surface reconstruction demonstrate calcified fusiform aneurysm (arrows) of the proximal middle LAD coronary artery containing thrombus (circles).

View larger version (19K): [in a new window]   Figure 10. Coronary calcification scoring. A, Left lateral and, B, left anterior oblique projections of the distribution of plaques detected (numbered) during scoring of atherosclerotic coronary calcification with nonenhanced four-detector row CT. Because of the extent of coronary calcification, outlines of LAD, left circumflex (LCx), and dominant right (RCA) coronary arteries are formed.

View larger version (142K): [in a new window]   Figure 11. Soft, noncalcified, atherosclerotic plaque at four-detector row CT. A, B, Oblique transverse thin maximum intensity projections, C, craniocaudal curved multiplanar reconstruction, and D, left anterior oblique volume-rendered surface reconstruction demonstrate multiple noncalcified atherosclerotic plaques within the LAD coronary artery system, which result in focal arterial wall thickening with mild narrowing of the coronary lumen. Best example is noted in proximal portion of a major diagonal branch, where a prominent soft plaque (black arrows), followed by a small nodular collection of calcification (white arrows), is seen.

View larger version (107K): [in a new window]   Figure 12. Correlative atherosclerotic plaque characterization. Comparison between, A, four-detector row CT, B, intravascular US, and C, left anterior oblique selective conventional angiography for atherosclerotic plaque formation in proximal middle LAD coronary artery. A, Oblique transverse thin maximum intensity projection shows coronary arterial wall calcification at two plaque sites (large arrows), most notably at site 1, with interposed positive remodeling (small arrow). Center image is an enlargement of boxed area in A. Reliable assessment of luminal dimension at sites of calcification is not possible because of the "blooming" artifact. In contrast, C confirms absence of significant stenosis but provides poor definition of arterial wall changes (arrows). B, Intravascular cross-sectional native (left) and illustrated (right) US images at sites 1 (top) and 2 (bottom) demonstrate calcified plaque without significant narrowing. Illustrations demonstrate the catheter (light gray) in the center of the lumen (black), which is surrounded by the vessel wall (dark gray). Calcified plaque in the vessel wall causes a characteristic signal void termed calcium shadow.

View larger version (149K): [in a new window]   Figure 13. Positive coronary artery remodeling at four-detector row CT. A, B, Oblique transverse thin maximum intensity projections and, C, craniocaudal and, D, transverse curved multiplanar reconstructions demonstrate ectasia (black arrows) of the proximal LAD coronary artery, with irregularity of arterial wall due to early atherosclerotic plaque formation. The segment is followed by a densely calcified segment (white arrows) with luminal narrowing.

View larger version (49K): [in a new window]   Figure 14. Thrombotic coronary occlusion at the site of positive remodeling at four-detector row CT. A, B, Oblique transverse thin maximum intensity projections and, C, craniocaudal curved multiplanar reconstruction demonstrate complete filling with thrombus of the ectatic lumen (arrows) of mildly calcified proximal LAD coronary artery.

View larger version (109K): [in a new window]   Figure 15. Comparison of calcified and noncalcified coronary atherosclerotic plaque. Individual cross-sectional intravascular US images (A-C) and a corresponding oblique transverse thin maximum intensity projection from 16-detector row CT angiography data set (right) demonstrate atherosclerotic plaque just proximal to a segment with stent in the proximal LAD. A, B, Calcified and, C, noncalcified components of the plaque are depicted; native (left) and illustrated (right) images at different sites in the vessel segment are shown. Illustrations demonstrate catheter (light gray) in the center of lumen (black), which is surrounded by vessel wall.

View larger version (155K): [in a new window]   Figure 16. Correlation between patterns of coronary atherosclerosis and resulting myocardial necrosis. A, Oblique transverse thin maximum intensity projection, B, transverse curved multiplanar reconstruction, and C, left anterior oblique volume-rendered surface reconstruction at four-detector row CT in a patient with non-ST segment-elevation myocardial infarction demonstrate a potentially unstable combination of focal soft atherosclerotic plaque with a calcified nodule (arrows) within the middle LAD coronary artery. D, Two-chamber vertical long-axis delayed-enhancement 1.5-T MR image shows corresponding hyperintense region in the middle to apical left ventricular myocardium, which indicates subendocardial myocardial necrosis (arrow), despite distal patency of LAD coronary artery following thrombolytic therapy.