Research paper
Coronary CT angiography-derived quantitative markers for predicting in-stent restenosis

https://doi.org/10.1016/j.jcct.2016.07.005Get rights and content

Abstract

Objective

To evaluate quantitative markers derived from coronary CT angiography (coronary CTA) performed prior to percutaneous coronary intervention (PCI) with stent placement for predicting in-stent restenosis (ISR) as defined by quantitative coronary angiography (QCA).

Materials and methods

We retrospectively analyzed the data of 74 patients (60 ± 12 years, 72% male) who had undergone dual-source coronary CTA within 3 months prior to a PCI procedure that included stent placement. Quantitative markers of the target vessel were derived from coronary CTA: Total plaque volume (TPV), calcified and non-calcified plaque volumes (CPV and NCPV), plaque burden (PB in %), remodeling index (RI), and lesion length (LL). Marker performance for predicting ISR, as defined by QCA at follow-up, was assessed.

Results

Twenty-one of 74 stented lesions showed ISR on follow-up (mean 616 ± 447 days). When comparing stent length and LL in patients with ISR, a trend towards less complete stent coverage of the target lesion was observed in cases with ISR (17/21 vs. 4/53 cases, p = 0.07). In multivariate analysis (corrected for dyslipidemia), the following markers showed predictive value for ISR (odds ratio [OR]): NCPV (OR 1.08, p = 0.045), LL (OR 1.38, p = 0.0024), and RI (OR 1.13, p = 0.0019). Sensitivity and specificity for ISR were: NCPV 65% and 80%, LL 74% and 74%, and RI 71% and 78%. At receiver-operating characteristics analysis, NCPV (0.72, p = 0.001), LL (0.77, p < 0.0001), and RI (0.79, p < 0.0001) showed discriminatory power for predicting ISR. A combination of these markers showed incremental predictive value (AUC 0.89, p < 0.0001) with sensitivity and specificity of 90% and 84%, respectively.

Conclusion

Coronary CTA-derived NCPV, LL, and RI portend predictive value for ISR with incremental predictive value when combining these parameters.

Introduction

Percutaneous coronary intervention (PCI) with stent placement is a standard therapy for myocardial revascularization of hemodynamically significant coronary artery disease (CAD).1 However, in-stent restenosis (ISR) after stent placement is possible and clinically relevant. Newer generation drug-eluting stents (DES) have decreased the incidence of ISR as compared to bare metal stents (BMS), with ISR rates of up to 5% and 30%, respectively.2, 3, 4, 5 The development of ISR can be attributed to procedural factors, lesion-related characteristics, and patient factors.6, 7 Previous studies using pre-interventional angiographic and intravascular ultrasound (IVUS) measurements during invasive coronary angiography (ICA) have shown that lesion-related markers such as lesion length, plaque burden, plaque composition, and positive remodeling were independent predictors of ISR.8, 9, 10

Recent studies using coronary CT angiography (CTA) for plaque quantification have proposed that quantitative morphological and functional markers derived from coronary CTA for coronary artery stenosis characterization may enhance the performance of coronary CTA for predicting hemodynamically significant stenosis, acute coronary syndrome, and future cardiac events.11, 12, 13, 14, 15 However, the potential role of coronary CTA-derived lesion-specific markers to predict ISR has been insufficiently investigated to date.

Thus, we sought to evaluate the performance of coronary CTA-derived quantitative morphological and functional markers for predicting ISR as defined by quantitative catheter angiography (QCA).

Section snippets

Study population

This study was approved by the local Institutional Review Board with a waiver of informed consent. We retrospectively analyzed the data of a patient cohort with suspected or known CAD who had undergone dual-source coronary CTA within 3 months prior to a PCI procedure that included stent placement between March 2007 and May 2012. Another inclusion criterion was the availability of ICA follow-up for the evaluation of ISR. Patients were excluded if they had a prior percutaneous coronary stent

Patient characteristics

In this single-center retrospective study, a total of 74 stents in 74 patients (60 ± 12 years, 72% male) who had undergone dual-source coronary CTA within 3 months prior to PCI with stent placement were included. Clinical indications for initial ICA/QCA and follow up catheterization included abnormal exercise or nuclear stress test results, recurring chest pain, and/or routine follow-up. A flow diagram of the study is shown in Fig. 1. Further patient demographics and baseline characteristics

Discussion

This study evaluated coronary lesion characteristics derived from coronary CTA regarding their ability to predict restenosis after treatment by stent placement.

Our results show that non-calcified plaque volume (NCPV) portends predictive value for ISR, resulting in an AUC value of 0.72 (p = 0.001) and a corresponding sensitivity and specificity of 65% and 80%, respectively. RI and LL as markers also showed predictive power with AUC values of 0.79 (p < 0.0001) and 0.77 (p < 0.0001). Sensitivity

Disclosures

Dr. Schoepf is a consultant for and/or receives research support from Astellas, Bayer, Bracco, GE, Guerbet, Medrad, and Siemens. Drs. De Cecco and Varga-Szemes are consultants for Guerbet. All other authors have no conflicts of interest to disclose.

Christian Tesche is an exchange visiting scholar supported by a grant from the Fulbright Visiting Scholar Program of the U.S. Department of State, Bureau of Educational and Cultural Affairs (ECA).

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