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Stent Size Selection Using 64-Detector Coronary Computed Tomography Angiography

Posted Jun 30, 2008 Updated Apr 7, 2023
By Troy LaBounty MD , Baskaran Sundaram MBBS , Stanley Chetcuti MD , Cyril Ruwende MD , Ella A. Kazerooni MD MS , Hitinder S. Gurm MBBS
6 min read

Rationale and Objectives

Compare stent size selection using coronary computed tomography angiography (CCTA) to invasive coronary angiography (ICA). CCTA is increasingly performed before cardiac catheterization; however, the utility of incorporating these data into coronary interventions is unknown.

Methods

Retrospective study of 18 consecutive patients with 24 coronary artery lesions evaluated with 64-detector CCTA followed by ICA and resulting stent placement. Two blinded interventional cardiologists independently reviewed designated arterial segments on both CCTA and ICA during different reading sessions and determined anticipated stent length and nominal diameter, maximum stenosis, the need for postdilation of either stent margin, and final proximal and distal stent diameters.

Results

There was strong correlation between CCTA and ICA in the anticipated stent length ( r = 0.85, P < .001) and final stent diameter (proximal end r = 0.74, P < .001; distal end r = 0.63, P = .001). Anticipated stent length was longer with CCTA compared to ICA (27.0 ± 16.0 vs. 21.8 ± 13.3 mm; P = .006). The final stent diameters were larger with CCTA compared to ICA, both at the proximal end (3.6 ± 0.5 vs. 3.1 ± 0.5 mm; P < .001) and distal end (3.2 ± 0.6 vs. 2.9 ± 0.4 mm; P = .004).

Conclusions

Using 64-detector CCTA, interventional cardiologists select longer stents with larger final stent diameters than with ICA. Further studies are needed to determine the clinical utility of incorporating CCTA, when available, in defining interventional strategy.

Cardiovascular disease is the leading cause of death in the United States, with coronary artery disease (CAD) diagnosed in more than 13 million American adults. Invasive coronary angiography (ICA) is the reference standard for the diagnosis of CAD, and in 2003 there were more than 1.4 million diagnostic coronary angiograms and 664,000 percutaneous coronary interventions (PCI) performed in the United States ( ). Coronary computed tomography angiography (CCTA) provides noninvasive imaging of the coronary arteries, is rapidly growing in use, and now has established appropriateness indications ( ). As its use increases, more patients undergoing PCI will have had prior CCTA.

In patients who have CCTA and subsequent ICA with PCI, the added utility of incorporating CCTA data into the interventional strategy has not been evaluated. ICA has major limitations given its two-dimensional view of a three-dimensional structure ( ). CCTA is able to visualize the lumen in any dimension and can characterize plaque and the coronary artery wall morphology. It may provide a more accurate estimation of the vessel wall diameter and lesion length, potentially allowing for more accurate stent size selection. This could result in less size mismatch between the stent and vessel wall and allow optimal placement of the stent margins in relatively disease-free segments. Although intravascular ultrasound (IVUS) can also provide some of this information, it is associated with increased cost, a small increased risk of adverse events ( ), and longer procedural time, all of which limit its routine clinical use.

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Materials and methods

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CCTA Technique and Image Analysis

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ICA Technique and Image Analysis

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Statistical Analysis

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Results

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Figure 1, ( a ) Stent length with coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). ( b ) Bland-Altman plot of stent length with CCTA and ICA. The mean anticipated stent length was 5.1 mm longer with CCTA compared with ICA ( P = .006). SD: standard deviation.

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Figure 2, ( a ) Proximal final stent diameter with coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). ( b ) Bland-Altman plot of proximal final stent diameter with CCTA and ICA. The mean proximal final stent diameter was 0.44 mm longer with CCTA compared to ICA ( P < .001). SD: standard deviation.

Figure 3, ( a ) Final distal stent diameter with coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). ( b ) Bland-Altman plot of distal final stent diameter with CCTA and ICA. The mean distal final stent diameter was 0.28 mm longer with CCTA compared to ICA ( P = .004). SD, standard deviation.

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Discussion

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Figure 4, ( a ) A 55-year-old male with an abnormal electrocardiographic treadmill test and subsequent coronary computed tomography angiography (CCTA). Based on the lesion detected by CCTA ( a , large arrow ), the patient was referred for invasive coronary angiography (ICA), which confirmed the lesion ( b , large arrow ). The patient then had a stent placed in the right coronary artery. For this lesion, the mean anticipated stent length was 28.0 mm based on CCTA and 18.0 mm based on ICA, with a mean final proximal stent diameter of 2.8 mm based on CCTA and 2.6 mm based on ICA. The lesion appears to extend more proximally and distally based on CCTA ( a , small arrows ), which may explain the longer stent anticipated with CCTA.

Figure 5, ( a ) A 64-year-old male with progressive exertional angina and significant stenosis in the left anterior descending artery detected with coronary computed tomography angiography (CCTA) ( a , large arrow ). The patient then had a cardiac catheterization that confirmed this finding ( b , large arrow ), and this lesion was treated with a stent. For this lesion, the mean anticipated stent length was 25.5 mm based on CCTA and 17.0 mm based on invasive coronary angiography (ICA), with a mean final proximal stent diameter of 4.3 mm based on CCTA and 3.0 mm based on ICA. This lesion appears to extend more distally based on CCTA ( a , small arrow ), which may explain the longer stent anticipated with CCTA.

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Academic Radiology, Volume 15, Issue 7
Journals General Radiology
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