Korean J Radiol.  2018 Apr;19(2):256-264. 10.3348/kjr.2018.19.2.256.

Natural History of Untreated Coronary Total Occlusions Revealed with Follow-Up Semi-Automated Quantitative Coronary CT Angiography: The Morphological Characteristics of Initial CT Predict Occlusion Shortening

• Wu Q
• Yu M
• Li Y
• Li W
• Lu Z
• Wei M
• Yan J
• Zhang J

• KMID: 2404922
• DOI: http://doi.org/10.3348/kjr.2018.19.2.256

Abstract

OBJECTIVE
To investigate the morphological changes of coronary chronic total occlusion (CTO) as determined by coronary computed tomography angiography (CCTA) follow-up using semi-automated quantitative analysis.
MATERIALS AND METHODS
Thirty patients with 31 CTO lesions confirmed by invasive coronary angiography and baseline/follow-up CCTA were retrospectively included. CTOs were quantitatively analyzed by a semi-automated coronary plaque analysis software (Coronary Plaque Analysis, version 2.0, Siemens) after manually determining the lesion border. Recanalized lumen was defined as the linear-like enhanced opacity traversing the non-opacified occluded segment. Other parameters, such as total occlusion length, total occlusion volume, volume with low attenuation component (< 30 Hounsfield unit [HU]), volume with middle to high attenuation component (30-190 HU) as well as the calcification volume, were also recorded.
RESULTS
Recanalized lumen was found within 48.4% (15/31) occlusions on the follow-up CCTA, compared to 45.2% (14/31) occlusions on the baseline CCTA. Eleven of 14 lesions (78.6%) with CT-visible recanalized lumen within CTOs had a shorter occlusion length on follow-up compared to only 3 of 17 lesions (17.6%) without CT-visible recanalized lumen (odds ratio, 17.1, p < 0.001). The percentage of low attenuation component of occlusions was smaller on follow-up CCTA compared to baseline value (18.1 ± 20.1% vs. 22.6 ± 19.6%, p = 0.033).
CONCLUSION
Coronary computed tomography angiography enables non-invasive characterization of natural progression of untreated CTO lesions. Recanalized lumen within CTOs observed at baseline CCTA was associated with shortening of occlusion length on follow-up. Compared to their earlier stage, occlusions of later stage were presented with higher density of non-calcified components.

Keyword

Chronic total occlusion; Percutaneous coronary intervention; Computed tomography; Coronary angiography

MeSH Terms

Angiography*
Coronary Angiography
Follow-Up Studies*
Humans
Natural History*
Percutaneous Coronary Intervention
Retrospective Studies

Figure

• 

  Fig. 1 Flow chart of inclusion and exclusion.AMI = acute myocardial infarction, CCTA = coronary computed tomography angiography, CTO = chronic total occlusion, ICA = invasive coronary angiography

• 

  Fig. 2 Representative case of CTO in 65-year-old male patient with baseline (A-D) and follow-up (22 months later) (E-H) CCTA.A. 3D-MIP image showed CTO lesion of middle RCA with visible recanalized lumen (arrowhead) on baseline CCTA. B. Occlusion length measured on CPR image was 22.3 mm. C. Color-coded map revealed components with different CT attenuation within occlusion. D. Histogram demonstrated calculated volume of components with different CT attenuation within occlusion. E. 3D-MIP image showed CTO lesion of middle RCA with shorter occlusion length on follow CCTA. Previously scattered recanalized lumen connected to distal end of occlusion (arrowhead). F. Occlusion length measured on CPR image was 15.5 mm. G. Color-coded map revealed components with different CT attenuation within occlusion. H. Histogram demonstrated decreased volume percentage of component with low CT attenuation within occlusion. CPR = curved planar reformation, CT = computed tomography, MIP = maximum intensity projection, RCA = right coronary artery, 3D = three-dimensional

• 

  Fig. 3 Representative case of CTO in 62-year-old male patient with baseline (A-D) and follow-up (12 months later) (E-H) CCTA.A. 3D-MIP image showed CTO lesion of proximal RCA with visible recanalized lumen (arrowhead) on baseline CCTA. B. Occlusion length measured on CPR image was 23.6 mm. C. Color-coded map revealed components with different CT attenuation within occlusion. D. Histogram demonstrated calculated volume of components with different CT attenuation within occlusion. E. 3D-MIP image showed CTO lesion of proximal RCA with shorter occlusion length on follow CCTA. Previously scattered recanalized lumen connected to proximal end of occlusion (arrowhead). F. Occlusion length measured on CPR image was 12.6 mm. G. Color-coded map revealed components with different CT attenuation within occlusion. H. Histogram demonstrated decreased volume percentage of component with low CT attenuation within occlusion.

• 

  Fig. 4 Representative case of CTO in 58-year-old female patient with baseline (A-D) and follow-up (12 months later) (E-H) CCTA.A. 3D-MIP image showed CTO lesion of proximal RCA with visible recanalized lumen (arrowhead) on baseline CCTA. B. Occlusion length measured on CPR image was 11.3 mm. C. Color-coded map revealed components with different CT attenuation within occlusion. D. Histogram demonstrated calculated volume of components with different CT attenuation within occlusion. E. 3D-MIP image showed CTO lesion of proximal RCA with similar morphology on follow CCTA (arrowhead). F. Occlusion length measured on CPR image was 11.2 mm. G. Color-coded map revealed components with different CT attenuation within occlusion. H. Histogram demonstrated similar volume percentage of component with low CT attenuation within occlusion.

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  Fig. 5 Representative case of CTO in 73-year-old male patient with baseline (A, B) and follow-up (32 months later) (C, D) CCTA.A. 3D-MIP image showed CTO lesion of middle RCA with visible recanalized lumen (arrowhead) on baseline CCTA. B. Occlusion length measured on CPR image was 24.1 mm. C. 3D-MIP image showed complete spontaneous recanalization of occlusion on follow CCTA (arrowhead). D. CPR image confirmed complete spontaneous recanalization of occlusion with residual stenosis (arrowhead).

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