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Coronary CT Angiography¹

¹ From the Department of Radiology (U.J.S., P.L.Z., G.S., C.H., J.M.K., P.C.) and Division of Cardiology, Department of Medicine (U.J.S., P.L.Z.), Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425; Department of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy (G.S.); and Department of Radiology, Johann Wolfgang Goethe University, Frankfurt, Germany (C.H.). Received December 30, 2005; revision requested February 24, 2006; revision received March 16; accepted May 2; final version accepted July 6. Address correspondence to U.J.S. (e-mail: schoepf{at}musc.edu).

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 58-year-old man with dizziness at exertion and risk factors for coronary artery disease. Right anterior oblique views of left coronary artery tree are shown. (a) Curved multiplanar reformation (MPR) shows about 60% stenosis (arrow) of the proximal first diagonal branch caused by noncalcified plaque. (b) Conventional coronary angiogram findings confirm the presence of the lesion in a (arrow), which was subsequently treated with stent placement.

View larger version (172K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 58-year-old man with dizziness at exertion and risk factors for coronary artery disease. Right anterior oblique views of left coronary artery tree are shown. (a) Curved multiplanar reformation (MPR) shows about 60% stenosis (arrow) of the proximal first diagonal branch caused by noncalcified plaque. (b) Conventional coronary angiogram findings confirm the presence of the lesion in a (arrow), which was subsequently treated with stent placement.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography of entire thorax in 52-year-old man with smoking history of 25 pack-years who presented to the emergency department with acute chest pain. (a) Maximum intensity projection (MIP) in a left anterior oblique perspective of the left anterior descending (LAD) coronary artery shows atherosclerotic plaque (arrow) in the inferior anteromedial wall. The plaque causes about 50% stenosis and consists of noncalcified tissue adjacent to a calcified nodule. (b) Coronal lung-window reconstructions of the entire chest reveal panlobular emphysema with upper lobe predominance and incidental squamous cell carcinoma (arrow) of the left upper lobe of the lung.

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography of entire thorax in 52-year-old man with smoking history of 25 pack-years who presented to the emergency department with acute chest pain. (a) Maximum intensity projection (MIP) in a left anterior oblique perspective of the left anterior descending (LAD) coronary artery shows atherosclerotic plaque (arrow) in the inferior anteromedial wall. The plaque causes about 50% stenosis and consists of noncalcified tissue adjacent to a calcified nodule. (b) Coronal lung-window reconstructions of the entire chest reveal panlobular emphysema with upper lobe predominance and incidental squamous cell carcinoma (arrow) of the left upper lobe of the lung.

View larger version (62K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiogram (top right panel) and anterior volume-rendered image (top left panel) obtained in 60-year-old man referred for patency evaluation of the left internal mammary arterial (LIMA) bypass graft to the LAD and three saphenous vein grafts (arrows) to the three major coronary territories. A slow and steady heart rate of about 60 beats per minute enables successful use of ECG pulsing for reducing radiation exposure. Full nominal tube current (indicated in red on the ECG [bottom right panel]) is applied only during diastole; the cardiac phase subsequently used for image reconstruction is at 60% R-R, which results in full image quality with a high signal-to-noise ratio (top right panel). During the other cardiac phases, which are not used for image reconstruction, the tube current is lowered to 20% of the nominal output (indicated in blue on the ECG [bottom right panel]).

View larger version (67K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Contrast-enhanced retrospectively ECG-gated 64-section transverse CT angiograms (top right panels) and frontal volume-rendered images (top left panels) obtained in 70-year-old woman referred for equivocal perfusion abnormalities at cardiac single photon emission CT. Owing to her fast and irregular heart rate of approximately 120 beats per minute (bottom right panel), the optimal reconstruction window cannot be predicted reliably and ECG pulsing is not used. (a) Unlike in the patient in Figure 3, in whom the optimal reconstruction window is predictably determined during diastole, in this patient image reconstruction at 60% R-R results in considerable cardiac motion, which blurs the right coronary artery (RCA) on the transverse image (top right panel) and prevents visualization of this vessel on the frontal volume-rendered image (top left panel); the LAD is contorted. However, because the full tube current is maintained throughout scanning (indicated in red on the ECG [bottom right panel]), flexibility is maintained to reconstruct data during any phase of the cardiac cycle. (b) Subsequent reconstruction of the same data set during full systolic contraction at 25% R-R results in a nearly motion-free transverse image (top right panel), which enables clear display of the LAD and RCA on the frontal volume-rendered image (top left panel).

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Contrast-enhanced retrospectively ECG-gated 64-section transverse CT angiograms (top right panels) and frontal volume-rendered images (top left panels) obtained in 70-year-old woman referred for equivocal perfusion abnormalities at cardiac single photon emission CT. Owing to her fast and irregular heart rate of approximately 120 beats per minute (bottom right panel), the optimal reconstruction window cannot be predicted reliably and ECG pulsing is not used. (a) Unlike in the patient in Figure 3, in whom the optimal reconstruction window is predictably determined during diastole, in this patient image reconstruction at 60% R-R results in considerable cardiac motion, which blurs the right coronary artery (RCA) on the transverse image (top right panel) and prevents visualization of this vessel on the frontal volume-rendered image (top left panel); the LAD is contorted. However, because the full tube current is maintained throughout scanning (indicated in red on the ECG [bottom right panel]), flexibility is maintained to reconstruct data during any phase of the cardiac cycle. (b) Subsequent reconstruction of the same data set during full systolic contraction at 25% R-R results in a nearly motion-free transverse image (top right panel), which enables clear display of the LAD and RCA on the frontal volume-rendered image (top left panel).

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Contrast-enhanced retrospectively ECG-gated coronary CT angiography performed without saline chasing technique. On (a) transverse section and (b) volume-rendered image seen from left anterior oblique perspective, a streak artifact emanating from high-attenuating contrast material in the right heart (open arrow in a) overlies the RCA and causes artifactual stenosis (solid arrow) of the proximal RCA.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Contrast-enhanced retrospectively ECG-gated coronary CT angiography performed without saline chasing technique. On (a) transverse section and (b) volume-rendered image seen from left anterior oblique perspective, a streak artifact emanating from high-attenuating contrast material in the right heart (open arrow in a) overlies the RCA and causes artifactual stenosis (solid arrow) of the proximal RCA.

View larger version (61K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Contrast-enhanced retrospectively ECG-gated transverse coronary CT angiograms obtained at the level of the right atrium in three patients. Left: Monophasic injection of iodine-based contrast material results in high-attenuating streak artifacts in the right heart. Middle: With biphasic injection of the iodine-based agent performed with a saline chasing technique, residual contrast material is flushed from the right heart and artifacts are avoided; however, the right cardiac chambers can no longer be assessed. Right: With triphasic injection performed by using simultaneous dual flow from two syringes, a mixture of contrast material and saline is administered during the second injection phase. This produces sufficient enhancement for assessment of the right heart, while streak artifacts from high-attenuating contrast material generally are avoided.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 7: Contrast-enhanced retrospectively ECG-gated coronary CT angiograms. A preview function was used to identify the most suitable cardiac phase for image reconstruction. Six representative transverse sections were reconstructed, at the same z-axis position at the level of the aortic valve, from a series of 20 reconstructions at different R-R positions in 5% increments (0%–95% R-R) to encompass the entire cardiac cycle. Image reconstructions performed during full cardiac contraction at end systole (30% R-R) and during full relaxation at end diastole (65% R-R) are suitable to sufficiently suppress cardiac motion and enable clear assessment of the LAD, circumflex artery (Cx), RCA, and sinus node artery (SNA) (second branch of the RCA). These vessels are blurred during the other phases of the cardiac cycle.

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 8a: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 59-year-old man referred for noninvasive assessment of coronary artery stent patency. Reconstructions of the data set with (a, b) a routine coronary CT angiography algorithm and (c, d) a more edge-enhancing algorithm dedicated to assessment of the coronary artery stents and segments with severe calcification are shown. (a, c) Curved MPRs show two coronary artery stents in the distal RCA. (b, d) Oblique MPRs perpendicular to the centerline of the vessel are reconstructed at the level of the distal stent. The proximal stent (open arrow in a and c) can be readily assessed with both reconstruction techniques owing to its filamentous strut structure. The high-attenuating struts of the more distal bare metal stent (solid arrow in a and c) cause excessive streak artifacts at routine reconstruction (a and b) such that patency and areas of intimal hyperplasia, seen as hypoattenuating areas on the inside of the stent (arrow in d), can be appreciated only with use of the dedicated reconstruction algorithm (c and d).

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 8b: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 59-year-old man referred for noninvasive assessment of coronary artery stent patency. Reconstructions of the data set with (a, b) a routine coronary CT angiography algorithm and (c, d) a more edge-enhancing algorithm dedicated to assessment of the coronary artery stents and segments with severe calcification are shown. (a, c) Curved MPRs show two coronary artery stents in the distal RCA. (b, d) Oblique MPRs perpendicular to the centerline of the vessel are reconstructed at the level of the distal stent. The proximal stent (open arrow in a and c) can be readily assessed with both reconstruction techniques owing to its filamentous strut structure. The high-attenuating struts of the more distal bare metal stent (solid arrow in a and c) cause excessive streak artifacts at routine reconstruction (a and b) such that patency and areas of intimal hyperplasia, seen as hypoattenuating areas on the inside of the stent (arrow in d), can be appreciated only with use of the dedicated reconstruction algorithm (c and d).

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 8c: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 59-year-old man referred for noninvasive assessment of coronary artery stent patency. Reconstructions of the data set with (a, b) a routine coronary CT angiography algorithm and (c, d) a more edge-enhancing algorithm dedicated to assessment of the coronary artery stents and segments with severe calcification are shown. (a, c) Curved MPRs show two coronary artery stents in the distal RCA. (b, d) Oblique MPRs perpendicular to the centerline of the vessel are reconstructed at the level of the distal stent. The proximal stent (open arrow in a and c) can be readily assessed with both reconstruction techniques owing to its filamentous strut structure. The high-attenuating struts of the more distal bare metal stent (solid arrow in a and c) cause excessive streak artifacts at routine reconstruction (a and b) such that patency and areas of intimal hyperplasia, seen as hypoattenuating areas on the inside of the stent (arrow in d), can be appreciated only with use of the dedicated reconstruction algorithm (c and d).

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 8d: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiography in 59-year-old man referred for noninvasive assessment of coronary artery stent patency. Reconstructions of the data set with (a, b) a routine coronary CT angiography algorithm and (c, d) a more edge-enhancing algorithm dedicated to assessment of the coronary artery stents and segments with severe calcification are shown. (a, c) Curved MPRs show two coronary artery stents in the distal RCA. (b, d) Oblique MPRs perpendicular to the centerline of the vessel are reconstructed at the level of the distal stent. The proximal stent (open arrow in a and c) can be readily assessed with both reconstruction techniques owing to its filamentous strut structure. The high-attenuating struts of the more distal bare metal stent (solid arrow in a and c) cause excessive streak artifacts at routine reconstruction (a and b) such that patency and areas of intimal hyperplasia, seen as hypoattenuating areas on the inside of the stent (arrow in d), can be appreciated only with use of the dedicated reconstruction algorithm (c and d).

View larger version (51K): [in this window] [in a new window] [Download PPT slide]   Figure 9: Contrast-enhanced retrospectively ECG-gated 64-section coronary CT angiograms obtained in 49-year-old man who presented to the emergency department with acute chest pain. Severe calcifications (arrow) are seen in the LAD, and on the transverse section they appear to obliterate the vessel lumen. However, MPRs obtained in the sagittal (middle) and coronal (right) planes enable better appreciation of the eccentric location of the calcified plaque in the anterocranial vessel wall of the LAD. The plaque is causing mild stenosis at this location, but most of the vessel lumen is patent.

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 10a: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (30K): [in this window] [in a new window] [Download PPT slide]   Figure 10b: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 10c: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 10d: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (59K): [in this window] [in a new window] [Download PPT slide]   Figure 10e: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 10f: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 55-year-old man with atypical chest pain and risk factors for coronary artery disease. The work flow of coronary CT angiographic analysis with dedicated visualization platforms is shown. (a–c) CT angiograms reveal moderate stenosis (arrow) of the proximal LAD due to a mixed, partially noncalcified plaque. (a) Postprocessing consists of automated sculpting of the chest wall to enable an unobstructed view of the heart, which is depicted as a volume rendering from the right anterior oblique–cranial perspective. (b) After placement of a seed point, extraction of the coronary arteries from the contrast-enhanced data set is performed. (c) The extracted coronary artery is depicted on an automatically generated MPR, which facilitates intuitive visualization of the entire vessel. (d) Defining the centerline of the LAD enables reconstruction of cross sections in planes orthogonal to the vessel axis, which facilitates assessment of the location and morphology of the noncalcified plaque component (arrow) (e) Automated assessment of stenosis severity (bottom left panel) on the same images (b [bottom right panel]), c [top right panel], and d [top left panel]) at the level of the noncalcified plaque relative to nonstenotic proximal (1a) and distal (1b) vessel portions adjacent to the site of stenosis (1) reveals 55% luminal obstruction. (f) Findings on conventional angiogram later confirm the site and severity of the LAD lesion (arrow)

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 11a: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 63-year-old man with atypical chest pain and risk factors for coronary artery disease. (a, b) Volume-rendered images from right anterior oblique–cranial perspective obtained after automated extraction of the heart from the thoracic anatomy (a) and after selection of the coronary artery tree (b), as well as (c) automatically generated MPR, reveal extensive atherosclerotic changes throughout the coronary artery tree, with particularly severe calcifications (arrow) in the proximal LAD. (c) Only automated unraveling of the tortuous course of the diseased vessel on the curved MPR enables reliable identification of a short-segment stenosis in the calcified proximal LAD. (d) Findings on the conventional catheter angiogram confirm the presence of the stenosis (arrow). Other segments of the LAD are largely patent.

View larger version (32K): [in this window] [in a new window] [Download PPT slide]   Figure 11b: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 63-year-old man with atypical chest pain and risk factors for coronary artery disease. (a, b) Volume-rendered images from right anterior oblique–cranial perspective obtained after automated extraction of the heart from the thoracic anatomy (a) and after selection of the coronary artery tree (b), as well as (c) automatically generated MPR, reveal extensive atherosclerotic changes throughout the coronary artery tree, with particularly severe calcifications (arrow) in the proximal LAD. (c) Only automated unraveling of the tortuous course of the diseased vessel on the curved MPR enables reliable identification of a short-segment stenosis in the calcified proximal LAD. (d) Findings on the conventional catheter angiogram confirm the presence of the stenosis (arrow). Other segments of the LAD are largely patent.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 11c: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 63-year-old man with atypical chest pain and risk factors for coronary artery disease. (a, b) Volume-rendered images from right anterior oblique–cranial perspective obtained after automated extraction of the heart from the thoracic anatomy (a) and after selection of the coronary artery tree (b), as well as (c) automatically generated MPR, reveal extensive atherosclerotic changes throughout the coronary artery tree, with particularly severe calcifications (arrow) in the proximal LAD. (c) Only automated unraveling of the tortuous course of the diseased vessel on the curved MPR enables reliable identification of a short-segment stenosis in the calcified proximal LAD. (d) Findings on the conventional catheter angiogram confirm the presence of the stenosis (arrow). Other segments of the LAD are largely patent.

View larger version (49K): [in this window] [in a new window] [Download PPT slide]   Figure 11d: Contrast-enhanced retrospectively ECG-gated 64-section CT angiography in 63-year-old man with atypical chest pain and risk factors for coronary artery disease. (a, b) Volume-rendered images from right anterior oblique–cranial perspective obtained after automated extraction of the heart from the thoracic anatomy (a) and after selection of the coronary artery tree (b), as well as (c) automatically generated MPR, reveal extensive atherosclerotic changes throughout the coronary artery tree, with particularly severe calcifications (arrow) in the proximal LAD. (c) Only automated unraveling of the tortuous course of the diseased vessel on the curved MPR enables reliable identification of a short-segment stenosis in the calcified proximal LAD. (d) Findings on the conventional catheter angiogram confirm the presence of the stenosis (arrow). Other segments of the LAD are largely patent.