A comparison between dual axis rotational coronary angiography and conventional coronary angiography

Background: Coronary angiography remains the gold standard for the investigation of coronary artery disease, and is carried out in multiple, predefined stationary views, at different angulations around the patient, for both left and right coronary arteries. Dual axis rotational coronary angiography (DARA) is an alternative technique wherein the c‐arm rotates around the patient in a preprogrammed single acquisition, exposing the entire coronary artery at different angulations. The DARA system has been recently installed in the Cardiac Catheterisation Suite at Mater Dei Hospital, Malta, where a monoplane and a biplane machine are available. This study was carried out in order to compare DARA with conventional single and biplane coronary imaging, with respect to radiation dose, contrast loads, and procedure time. Methods: This study was carried out over the period from September to December 2010. Four hundred sixty‐three patients were studied. Patients referred for the investigation of native coronary anatomy, for whatever indication, were consented and included, and randomly assigned to one of four groups depending on which machine and modality was used: monoplane conventional, monoplane DARA, biplane conventional, and biplane DARA. Results: DARA was statistically significantly superior in dose area product, fluoroscopy time, amount of contrast used, and procedure time. These reductions ranged between 12 (contrast used) and 71% (procedure time). Conclusions: The advantages of such systems are obvious to both patient and healthcare provider, and DARA may prove to be an important and useful tool in the refinement of diagnostic coronary angiography by reducing patient contrast and radiation doses and reducing procedure time. © 2012 Wiley Periodicals, Inc.     

Diagnostic accuracy of dual‐source computed tomography angiography for the detection of coronary in‐stent restenosis: A systematic review and meta‐analysis

We sought to perform a meta‐analysis to comprehensively evaluate the diagnostic accuracy of dual‐source computed tomography angiography (DSCTA) in detecting coronary in‐stent restenosis (CISR) when compared to invasive coronary angiography. The stent‐based research studies in which DSCTA was used as diagnostic tool for CISR, as recent as of October 2017, from several reputed scientific libraries (PubMed, Embase, Scopus, The Cochrane Library, and Web of Science) were evaluated. Study inclusion, data extraction, and risk bias assessment were conducted by two researchers independently. Pooled sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under summary receiver operator characteristics (SROC) curve (AUC) were calculated to assess the diagnostic value. In addition, heterogeneity and subgroup analysis were also carried out. A total of 13 studies with a total of 894 patients and 1384 assessable stents were included. The pooled results of DSCTA diagnosing CISR were as follows: SEN 0.92 (95% confidence interval [CI] 0.87–0.96), SPE 0.91 (95% CI 0.87–0.94), PLR 9.83 (95% CI 6.93–13.94), NLR 0.09 (95% CI 0.05–0.15), DOR 114.73 (95% CI 64.12–205.28), and AUC 0.97 (95% CI 0.95–0.98), respectively. The subgroup analysis result suggested that DSTCA performed significantly better in CISR detection when the stent diameter was ≥3 mm compared with the stent diameter <3 mm: (0.98 [0.97–0.99] vs 0.82 [0.79–0.86]) with P < .05. This study revealed that DSCTA has excellent diagnostic performance for detecting CISR and may serve as an alternative for further patient evaluation with CISR, especially for stent diameter ≥3 mm.     

Rotational vs. standard coronary angiography: An image content analysis

Objective : To evaluate the clinical utility of images acquired from rotational coronary angiographic (RA) acquisitions compared to standard “fixed” coronary angiography (SA). Background : RA is a novel angiographic modality that has been enabled by new gantry systems that allow calibrated automatic angiographic rotations and has been shown to reduce radiation and contrast exposure compared to SA. RA provides a dynamic multiple‐angle perspective of the coronaries during a single contrast injection. Methods : The screening adequacy, lesion assessment, and a quantitative coronary analysis (QCA) of both SA and RA were compared by independent blinded review in 100 patients with coronary artery disease (CAD). Results : SA and RA recognize a similar total number of lesions (P = 0.61). The qualitative assessment of lesion characteristics and severity between modalities was comparable and lead to similar clinical decisions. Visualization of several vessel segments (diagonal, distal RCA, postero‐lateral branches and posterior‐descending) was superior with RA when compared to SA (P < 0.05). A QCA comparison (MLD, MLA, LL, % DS) revealed no difference between SA and RA. The volume of contrast (23.5 ± 3.1 mL vs. 39.4 ± 4.1; P = 0.0001), total radiation exposure (27.1 ± 4 vs. 32.1 ± 3.8 Gycm²; P = 0.002) and image acquisition time (54.3 ± 36.8 vs. 77.67 ± 49.64 sec; P = 0.003) all favored RA. Conclusion : Coronary lesion assessment, coronary screening adequacy, and QCA evaluations are comparable in SA and RA acquisition modalities in the diagnosis of CAD however RA decreases contrast volume, image acquisition time, and radiation exposure. © 2009 Wiley‐Liss, Inc.     

Randomized study of the safety and clinical utility of rotational vs. standard coronary angiography using a flat-panel detector.

The purpose of this study was to test the hypothesis that rotational angiography improves patient safety while maintaining diagnostic accuracy for patients undergoing coronary angiography. Despite advances in angiographic technique, patients remain at risk for complications of coronary angiography, including contrast-induced nephropathy and radiation exposure. Technology has been developed to perform coronary angiography with active rotation of the imaging system that may reduce the quantity of contrast and radiation to which the patient is exposed. Fifty patients undergoing diagnostic cardiac catheterization were randomized to either standard vs. rotational angiography of the coronary arteries using a prespecified protocol with a flat-panel single-plane imaging system. We measured the quantity of radiographic contrast utilized and radiation exposure. Using an intention-to-treat analysis, there was a 40% reduction (24 +/- 5 vs. 40 +/- 10 ml; P < 0.0001) in contrast utilization in the rotational group compared to the standard group. Neither radiation exposure (35 +/- 14 vs. 30 +/- 20 Gycm(2); P = 0.35), fluoroscopic time (44 +/- 33 vs. 44 +/- 40 sec; P = 0.99), nor procedure time (249 +/- 137 vs. 214 +/- 79 sec; P = 0.26) differed, although significant intraoperator variability was noted for both standard and rotational angiography. The radiation exposure using this flat-panel system is significantly lower than prior reports that used an image intensifier system. Rotational coronary angiography has the potential to improve patient safety by markedly reducing radiographic contrast exposure while maintaining comparable diagnostic accuracy, radiation exposure, and procedure time compared to standard coronary angiography.     

Randomized study of the safety and clinical utility of rotational angiography versus standard angiography in the diagnosis of coronary artery disease.

This study evaluates the safety and clinical utility of rotational angiography in the diagnosis of coronary artery disease. High-speed rotational angiography is a newly available angiographic modality that gives a dynamic multiple-angle perspective of the coronary tree during a single contrast injection. We prospectively randomized 56 patients referred for diagnostic coronary angiography to either standard or rotational angiography. Contrast and radiation utilization were compared between the two groups. The number of additional cine acquisitions needed was used to determine adequacy of the diagnostic study protocol. Rotational angiography was successfully completed in all subjects. There was a 33% reduction in contrast utilization in the rotational group as compared to the standard group (35.6 +/- 12.6 vs. 52.8 +/- 10.7 ml, respectively; P < 0.0001). Additionally, there was a 28% reduction in total radiation exposure in the rotational group as compared to the standard group (39.0 +/- 18.5 vs. 53.9 +/- 23.4 Gycm(2), respectively; P = 0.01). Total whole-body radiation exposure to the primary operator was 144 mrem with rotational angiography and 170 mrem with standard angiography. Procedure time tended to be shorter for rotational angiography (353.9 +/- 146.7 vs. 396.8 +/- 165.8 s; P = 0.3). Rotational coronary angiography can be rapidly performed in any patient and provides a significant reduction in contrast and radiation utilization while at the same time providing adequate angiographic data to complement or replace standard coronary angiography in the evaluation of coronary artery disease.     

旋转冠状动脉造影的临床应用和安全性研究

目的:评估旋转冠状动脉造影在冠心病诊断中的临床应用和安全性.方法:入选准备行诊断性冠状动脉造影的患者60例,随机分为标准冠状动脉造影(SA)组与旋转冠状动脉造影(RA)组.比较2组间应用造影剂和射线辐射量.结果:RA组所有患者成功行旋转冠状动脉造影.与标准SA组相比,RA组造影剂应用减少18%[(62.16±15.03):(76.91±20.00)ml,P=0.042],总的射线辐射量,左冠RA与SA相比,射线量减少了23%[(24.4034±8.1150):(31.8861±12.9449)Gycm2,P=0.0188],右冠RA与SA相比,射线量减少了27%[(3.9936±2.089):(5.4869±2.5002)Gycm2,P=0.0263].RA与SA相比,总的手术时间呈缩短趋势[(374.8±136.2):(417.2±183.5)sec;P＝0.2].结论:旋转冠状动脉能够快速完成,安全有效,造影射线量和造影剂明显减少,可以成为评估冠心病的一种补充和/或替代方法.     

Initial clinical experience of selective coronary angiography using one prolonged injection and a 180 degrees rotational trajectory.

OBJECTIVE: Evaluate the safety of prolonged coronary injections during a rotational acquisition covering 180 degrees. BACKGROUND: Rotational angiography has been adapted to coronary angiography and shown to reduce radiation and contrast exposure. Three-dimensional (3D) reconstructions and other advanced applications require imaging over a 180 degrees -arc with a single but longer injection of larger contrast volumes. METHODS: Thirty patients referred for angiography were enrolled. Blood pressure (BP), heart rate (HR), symptoms, and ectopy were recorded before-and-after injections. RESULTS: Pre and post-injection HRs for the LCA/RCA were not statistically different (LCA-pre-injection 63+/-13 bpm vs. LCA-post-injection 62+/-11 bpm, P=0.54 and RCA-pre-injection 65+/-12 bpm vs. RCA-post-injection 65+/-10, P=0.88). Central aortic pressure values were not statistically different for the RCA injections (RCA-systolic-pre-injection 118+/-14 mm Hg vs. RCA-systolic-post-injection 112+/-25 mm Hg, P=0.15, and RCA diastolic-pre-injection 69+/-9 mm Hg vs. RCA-diastolic-post-injection 60+/-10 mm Hg, P=0.88) but were statistically significant for the LCA injections (LCA systolic-pre-injection 122+/-19 mm Hg vs. LCA-systolic-post-injection 116+/-17 mm Hg, P=0.0004, and LCA-diastolic-pre-injection 69+/-10 mm Hg vs. LCA-diastolic-post-injection 65+/-9 mm Hg, P=0.0007). There were no symptoms or electrical events documented during or immediately post-injection. CONCLUSION: This study demonstrates the feasibility and safety of longer coronary injections. There were no significant HR changes, clinically insignificant pressure changes, and no adverse reactions. Additional studies will be needed to assure its safety in a larger and clinically more varied patient population.     

Robotic‐assisted transradial diagnostic coronary angiography

Robotic percutaneous coronary interventions have recently been introduced in the cardiac catheterization laboratory. Robotics offers benefits of greater precision for stent placement and occupational hazard protection for operators and staff. First generation systems were able to advance and retract coronary wires, balloons, and stents, but did not have guide control functions. The second‐generation robotic system (CorPath GRX) has an active guide management function offering the ability to move guide catheters. Expanding utilization of robotics to perform diagnostic coronary angiography would further reduce radiation scatter exposure and other occupational hazards to operators. This approach is particularly appealing in the setting of radial access, as universal radial diagnostic catheters can engage both the right and left coronary arteries without exchange. We describe here, the first two cases of such a procedure with the CorPath GRX robotic system.     

Three‐dimensional rotational angiography in congenital heart disease: Present status and evolving future

Three‐dimensional rotational angiography (3D‐RA) enables volumetric imaging through rotation of the C‐arm of an angiographic system and real‐time 3D reconstruction during cardiac catheterization procedures. In the field of congenital heart disease (CHD), 3D‐RA has gained considerable traction, owing to its capability for enhanced visualization of spatial relationships in complex cardiac morphologies and real time image guidance in an intricate interventional environment. This review provides an overview of the current applications, strengths, and limitations of 3D‐RA acquisition in the management of CHD and potential future directions. In addition, issues of dosimetry, radiation exposure, and optimization strategies will be reviewed. Further implementation of 3D‐RA will be driven by patient benefits relative to existing 3D imaging capabilities and fusion techniques balanced against radiation exposure.     

Utility of three-dimensional reconstruction of coronary angiography to guide percutaneous coronary intervention.

OBJECTIVE: The goal of this study was to determine whether three-dimensional (3D) reconstruction of traditional coronary angiography could optimize the choice of drug-eluting stent (DES) length and number during percutaneous coronary intervention (PCI). BACKGROUND: Coronary angiography is subject to significant foreshortening artifact that limits the ability of the operator to accurately determine lesion length. METHODS: The angiographic images of the target vessels of consecutive PCI procedures were postprocessed using a 3D reconstruction algorithm. The appropriate length and optimal number of DES to span each target lesion were calculated and compared with the number and length of DES actually chosen by the operator. RESULTS: A total of 42 target vessels were analyzed, and 3D reconstruction was successful in 38/42 (90.5%) of cases. The results of 3D analysis would have changed operator decision making in six cases (16%): in four cases, the stent chosen by the operator was too short requiring an additional DES; in two cases, the chosen DES was too long and exchanged for a shorter one. In each of these six cases, 3D analysis would have determined the correct stent length prior to stent selection. The optimal stent number derived by 3D reconstruction was significantly less than the actual number of stents per lesion used by the operator (1.31 +/- 0.47 versus 1.54 +/- 0.68, P = 0.01), and the optimal stent length trended less than the actual stented length (27.5 +/- 12.8 mm versus 28.7 +/- 14.7 mm, P = 0.23). CONCLUSIONS: 3D reconstruction algorithm of standard coronary angiography is a promising technique to improve DES utilization during PCI.     

Recurrent contrast‐induced encephalopathy following coronary angiography

Contrast‐induced encephalopathy (CIE) is an acute and reversible neurological disturbance associated with the intra‐arterial administration of iodinated contrast medium during cardiac catheterisation. It may manifest with encephalopathy, motor and sensory disturbances; vision disturbances, including cortical blindness, ophthalmoplegia, aphasia; and seizures. Disruption of the blood–brain barrier and direct neuronal toxicity are believed to be implicated in the pathophysiology of the syndrome. Symptoms appear soon after contrast administration and resolve completely within 24–48 h. Risk factors may include hypertension, diabetes mellitus, renal impairment, the administration of large volumes of iodinated contrast, percutaneous coronary intervention or selective angiography of internal mammary grafts and previous adverse reaction to iodinated contrast. On cerebral imaging, CIE may mimic subarachnoid haemorrhage or cerebral ischaemia, but imaging may be normal. Prognosis is excellent with supportive management alone. CIE may recur, but re‐challenge with iodinated contrast without adverse effects has been documented. CIE is a diagnosis of exclusion and is an important clinical entity to consider in the differential diagnosis of stroke following cardiac catheterisation. Physicians should be aware of it and consider it prior to initiating thrombolysis.     

64层CT冠状动脉成像技术和冠状动脉造影对冠状动脉疾病诊断的对照研究

目的比较64层计算机断层摄影扫描冠状动脉成像技术(64-slice computed tomography coronaryangiography,64-SCTCA)和冠状动脉造影(coronary artery angiography,CAG)在冠状动脉粥样硬化性心脏病(冠心病)诊断中的价值。方法回顾性分析126例疑似冠心病的患者64-SCTCA和CAG检查资料,并对两组资料进行对比分析。结果 64-SCTCA和CAG检查结果中可用于评价的病变血管段支数比较,差异无统计学意义(P0.05)。CAG共发现≥50%狭窄节段242个,64-SCTCA共发现≥50%狭窄节段199个,两种检查方法对病变狭窄的显示情况比较,差异无统计学意义(P0.05)。全部126例冠心病患者中有91%通过64-SCTCA发现(110/121)。64-SCTCA诊断冠状动脉病变血管的敏感性、特异性、阳性预测值、阴性预测值分别为81.6%、98.8%、79.5%、99%。结论 64-SCTCA可作为冠心病无创、便捷、可靠的检查方法。     

Strategies for drug‐eluting stent treatment of bifurcation coronary artery disease in the United States: Insights from the e‐Cypher S.T.L.L.R.Trial

Objectives: Our goal is to report the first large multicenter data for percutaneous coronary intervention (PCI) of bifurcation disease with drug‐eluting stents (DES) in the United States. Background: Bifurcation PCI remains a challenge to this date. There are limited data on outcomes of patients treated with bifurcation DES implantation, particularly in the United States. Methods: There were 161 patients with bifurcation disease [side branch (SB) ≥2‐mm] treated with ≥1 sirolimus‐eluting stents at 41 centers participating in the Stent deployment Techniques on cLinicaL outcomes of patients treated with the cypheR?stent (STLLR) trial. There was no protocol mandated strategy for bifurcation PCI. One‐year outcome data were collected. Angiographic and clinical data were adjudicated independently. Results: There were 147 patients (91.3%) treated with single stent strategy. Only 14 (8.7%) patients received sirolimus‐eluting stents implantation in both branches. Among patients with single stent strategy, double wire strategy (DW) was selected in 27 (18.4%) patients whereas single wire strategy (SW) was selected in 120 (81.6%) patients. There were 48 (32.7%) Medina 1,1,1 bifurcations treated with SW (n = 34; 70.8%) and DW (n = 14; 29.2%). There were 26 procedures started with SW which had SB dilatation during the procedure, one as a bailout (TIMI‐1 grade flow in the SB). Overall 1‐year death, myocardial infarction, and target lesion revascularization occurred in 2.4, 4.0, and 5.6%, respectively. There was no significant difference in clinical outcomes between SW and DW. SB dilatation was associated with a high rate of stent thrombosis (8.6%). Conclusions: Main branch stenting without SB protection is the most common approach utilized in the STLLR study, which may reflect contemporary DES bifurcation strategies in the Unite States. This strategy was associated with an acceptable low incidence of adverse outcomes at 1‐year. © 2009 Wiley‐Liss, Inc.     

Rotational X-ray coronary angiography.

We designed and implemented a digital flat-panel-based rotational X-ray coronary angiography technique hypothesizing that luminal disease could be identified with less radiation exposure and contrast usage compared to conventional angiography. Individuals scheduled for diagnostic coronary angiography were prospectively enrolled. In addition to conventional acquisitions in standard planes, subjects underwent one additional left coronary artery (LCA) or right coronary artery (RCA) rotational (spin) acquisition using a predefined trajectory. Radiation exposure and contrast volume were recorded for each run. Seventy-five subjects were enrolled. When compared with standard five-view cine acquisition, LCA spin angiography with one cranial and one caudal run resulted in 34.38% +/- 13.65% less radiation, 18.98% +/- 4.97% less contrast, and comparable assessment of stenosis severity. One spin acquisition compared with three standard cine acquisitions for RCA angiography resulted in 59.31% +/- 29.07% lower radiation, no significant change in contrast, and comparable assessment of stenosis severity. Rotational X-ray coronary angiography provides comparable visualization of coronary anatomy compared with traditional nonrotational coronary angiography with significantly less radiation exposure and contrast volume.