Impact of Advanced Extravascular Calcified Plaque on the Assessment of Coronary Stenosis Severity.

Toshimitsu Tsugu, Kaoru Tanaka, Mayuko Tsugu, Yuji Nagatomo, Johan De Mey
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Abstract

Coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (FFRCT) provide high diagnostic accuracy for coronary artery disease (CAD), consistent with invasive coronary angiography (ICA), the gold standard diagnostic technique. The presence of calcified components, however, complicates the interpretation of coronary stenosis severity. We present a case where there was a discrepant assessment of coronary stenosis severity between CCTA/FFRCT (indicating significant obstructive CAD) and ICA (showing no apparent obstructive CAD). CCTA/FFRCT revealed that the stenotic lesion, located in the middle segment of the left circumflex artery, was surrounded by plaque components. The proximal and distal portions of the stenotic lesion consisted of 80.9% luminal volume, 0.2% low-attenuation plaque, 13.4% intermediate-attenuation plaque, and 5.5% calcified plaque. In contrast, the stenotic lesion itself contained 50.0% luminal volume, 0.3% low-attenuation plaque, 26.7% intermediate-attenuation plaque, and 22.9% calcified plaque. Invasive coronary angiography showed no apparent obstructive CAD, implying that the lesions appearing as significant obstructive CAD on CCTA/FFRCT were likely overestimated due to the effects of extravascular calcified plaque. Advanced extravascular calcified plaque surrounding the lesion may cause several artifacts (such as blooming and/or beam hardening artifacts) and/or vasodilator dysfunction (either organic and/or functional), potentially leading to an overestimation of the severity of coronary stenosis in CCTA/FFRCT assessments.

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晚期血管外钙化斑块对冠状动脉狭窄严重程度评估的影响
冠状动脉计算机断层扫描血管造影术(CCTA)和由 CT 导出的分数血流储备(FFRCT)对冠状动脉疾病(CAD)的诊断准确率很高,与有创冠状动脉造影术(ICA)这一金标准诊断技术相一致。然而,钙化成分的存在使冠状动脉狭窄严重程度的解释变得复杂。我们介绍了一个病例,在该病例中,CCTA/FFRCT(显示严重阻塞性 CAD)和 ICA(显示无明显阻塞性 CAD)对冠状动脉狭窄严重程度的评估存在差异。CCTA/FFRCT 显示,狭窄病变位于左侧环状动脉中段,周围有斑块成分。狭窄病变的近端和远端由80.9%的管腔容积、0.2%的低衰减斑块、13.4%的中等衰减斑块和5.5%的钙化斑块组成。相比之下,狭窄病变本身包含50.0%的管腔容积、0.3%的低衰减斑块、26.7%的中等衰减斑块和22.9%的钙化斑块。有创冠状动脉造影显示没有明显的阻塞性CAD,这意味着CCTA/FFRCT显示为明显阻塞性CAD的病变很可能是由于血管外钙化斑块的影响而被高估了。病变周围的晚期血管外钙化斑块可能会造成一些伪影(如花斑和/或束流硬化伪影)和/或血管舒张功能障碍(器质性和/或功能性),从而可能导致在 CCTA/FFRCT 评估中高估冠状动脉狭窄的严重程度。
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