SHAPE Society

1. Coronary Atherosclerosis with Multislice CT:
What is beyond coronary atherosclerosis
Konstantin Nikolaou
Tobias Jakobs
Bernd Wintersperger
Radiology
Alexander Becker
Andreas Knez
Alexander Leber
Cardiology
Michael Muders
Pathology
Christoph R Becker

2. Calcified & Noncalcified
Plaques

3. CTA Inclusion Criteria
• Asymptomatic
patients
• CV risk factors
• Positive calcium scan
• Symptomatic patients
• No CAD history
• Atypical chest pain
• Inconsistent stress test
< 100 mg CaHA

4. Patient Preparation
82 bpm
• β-blocker
• R/o Contra
indications
• Informed consent
• Metoprolol
• 50 - 100 mg orally
• 30 - 90 min prior
• HR 50 - 60 bpm
65 bpm

5. Coronary CTA Parameters
• Testbolus 20 ml @ 4 ml/sTestbolus 20 ml @ 4 ml/s
• 120 ml (300 mg iodine) @ 3120 ml (300 mg iodine) @ 3
ml/sml/s + NaCl 60 ml+ NaCl 60 ml
@ 3 ml/s@ 3 ml/s
• 500 ms gantry rotation500 ms gantry rotation
• 120 kV, 300 mA120 kV, 300 mA
• 4 x 1 mm collimation4 x 1 mm collimation
• 3 mm/s table feed3 mm/s table feed
• 40 s breath hold40 s breath hold

6. ECG Tube Current Modulation
Pitch
<0,4
250 ms 250 ms250 ms
100%
20%
mAs

7. CTA Radiation Exposure
mSv

8. Left Coronary Artery (RAO)
Coronary Angiography MDCT & VRT

9. LAO 60Coronary Angiography MDCT & VRT
Right Coronary Artery (LAO)

10. Detection of Coronary Stenoses
MDCT Coronary Angiography

11. Coronary Stenoses
CTA & Angiography
Author Journal PPV NPV n.a. n
Niemann Lancet
2001
81% 97% 30% 35
Achenbach Circulation
2001
59% 98% 32% 64
Mean/sum 70% 98% 31% 99

12. CTA Limitations
• Artifacts
• Cardiac motion
• Breathing
• Blooming
• Poor
opacification
• Small vessel

13. Solutions
< Rot. time &
β−blocker
• Cardiac motion
artifacts
< Scan times
• Breathing artifacts
• CM utilization
< Slice thickness
• Small vessels
• Blooming artifact

14. 16 Detector Row CT
Angiography
• 200 ms
• 9 Lp/cm
• 0.8 mm
• 20 s breath hold
• 60 ml CM

15. Coronary Plaque Imaging
MDCT Coronary Angiography

16. Non Calcified Plaque Density

17. Coronary Atherosclerosis
Calcified Nodule
Wall changes Occlusion
ThrombusFibrocalcified
Plaque
Stenoses
Intimal Thickening
Atheroma
Healing Hemorrhage
Rupture/Erosion

18. Atheroma
• 38 YOM
• Non specific complain
• Risk Factors
– Cholesterin
– Smoker
• No calcium
50 HU
50 HU

19. Calcified Nodule
• 62 YOM
• Suspicion of CAD
• 12 mg CaHA

20. Fibrocalcified
Plaque
100 HU

21. Thrombus
• 42 YOM
• Epigastric chest pain
• Risk Factors
– Hypertension
– Smoker
• No calcium
20 HU

22. Thrombus

23. Acute Posterior Wall Infarction

24. Myocardial Infarction Scar
anterior
LAD
lateral
LCx
posterior
RCA

25. CT Plaque Density
Lipid Fibrose50 ± 12 HU 89 ± 31 HU
p = 0.018
Lipid Fibrosis

26. CTA vs IVUS
Schröder Heart 2001;85:576

27. Carotid Atherosclerosis
Estes 1998 J Cardiovasc Surg 39:527

28. Plaque Distribution
Leber 2001 Circulation
Non-
calcifie d
13%
Mixe d
33%
Calcifie d
54%
Myocardial Infarction
n = 12
122 Plaque
Stable Angina
n = 12
135 Plaque
Non-
calcifie d
6%
Mixe d
14%
Calcifie d
80%

29. Summary
• Detection of stenoses
– Calcium
– Small vessels
• Characterization of
plaques
• Identify atheromas
• Follow up under therapy
• Acute coronary event
• Intracoronary thrombus
• Myocardial infarction

30. www.CT2002.org