Characterization of Complex Coronary Artery Stenosis Morphology by Coronary Computed Tomographic Angiography
Brett M. Wertman, MD*,
Victor Y. Cheng, MD*, ,
Saibal Kar, MD*,
Heidi Gransar, MS*,,
Ryan A. Berg, MD*,
Hursh Naik, MD*,
Rajendra Makkar, MD*,
John D. Friedman, MD*,, ,
Jay N. Schapira, MD*,
Daniel S. Berman, MD*,,,*
* Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California
Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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Figure 1 Examples of  70% Diameter Stenoses by Visual Inspection on CTA
Images were displayed using Vitrea 2 software (Minnetonka, Minnesota). Determination of stenosis severity was based on at least 2 longitudinal views (top and bottom panels in each column). Yellow arrows indicate sites of severe stenosis. Left panels (A1, A2) show severe, noncalcified focal stenosis of a proximal left circumflex artery. Middle panels (B1, B2) show severe, predominantly calcified stenosis of the distal left main coronary artery. This lesion seemed to involve ostia of both the left anterior descending and left circumflex arteries. Right panels (C1, C2) show a severe, noncalcified focal stenosis of the mid right coronary artery. CTA = computed tomographic angiography.
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Figure 2 Determining Stenosis Length on CTA
Stenosis length was obtained by measuring plaque dimension in the long-axis oblique multiplanar reconstruction image that best showed the entirety of the plaque. (A1, A2) Longitudinal views of severe stenosis from a noncalcified plaque in the proximal left circumflex artery. The plaque measured 11.4 mm in length (A1). (B1, B2) Longitudinal views of a severe stenosis in the proximal left anterior artery from a complex plaque with calcified and noncalcified components. Length of this plaque is 30.2 mm, classifying the stenosis as type C. CTA = computed tomographic angiography.
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Figure 3 Representative Type C Lesions Identified by CTA and ICA
The CTA images are on the left; the ICA images are on the right. (A1, A2) Ostial involvement: yellow arrows indicate ostial stenosis of the left anterior descending artery. (B1, B2) Total occlusion: a long, predominantly noncalcified plaque in the mid right coronary artery is accompanied by absence of luminal contrast, indicating a total occlusion (yellow arrows), confirmed on ICA. (C1, C2) Long lesion (also shown in Fig. 2): a long region in the proximal left anterior descending artery appeared severely stenotic from calcified and noncalcified plaque on CTA. Length of this region measured >20 mm on ICA (yellow arrowheads), meeting type C criterion. (D1, D2) Major branch involvement: a large, predominantly noncalcified plaque extending from the left main artery into the left anterior descending artery causes severe stenosis in both vessels while crossing the left circumflex artery. Branch involvement and >20 mm lesion length were confirmed on ICA (yellow arrowheads). CTA = computed tomographic angiography; ICA = invasive coronary angiography.
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