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Computed tomography to predict surgical revascularization of a left anterior descending artery occlusion incompletely
Cezary Kepka1, Maksymilian P Opolski, Zbigniew Juraszynski
1Department of Coronary Artery Disease and Structural Heart Diseases, Institute of Cardiology, Warsaw, Poland.
Insights
Computed tomography angiography (CTA) accurately identifies suitable candidates for coronary artery bypass grafting (CABG) in cases of chronic total occlusion (CTO) where conventional coronary angiography (CCA) is unclear. CTA improves procedural success rates for CABG to the left anterior descending artery (LAD).
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Surgical Planning
Background:
- Conventional coronary angiography (CCA) often fails to visualize distal chronic total occlusions (CTOs), potentially limiting surgical revascularization options.
- Despite poor visualization on CCA, successful coronary artery bypass grafting (CABG) is sometimes achievable for CTOs.
- Computed tomography angiography (CTA) offers a noninvasive alternative for assessing coronary anatomy.
Purpose of the Study:
- To evaluate the utility of CTA in guiding CABG to the left anterior descending artery (LAD) when it is incompletely visualized by CCA.
- To determine if CTA can predict procedural success for CABG in patients with CTO of the LAD.
Main Methods:
- Twenty-four patients with symptomatic occluded LAD, deemed unsuitable for revascularization by CCA, underwent preoperative CTA.
- Off-pump CABG to the LAD was attempted based on intraoperative findings.
- Procedural success of CABG to the LAD was the primary outcome measure.
Main Results:
- The overall success rate for CABG to the LAD was 79.2%.
- CTA visualized Rentrop grade 3 in all patients, whereas CCA showed lower grades (0/1 in 25%, 2 in 75%).
- A distal LAD diameter >1.5 mm on CTA predicted CABG availability with 95% sensitivity and 100% specificity. Shorter distal LAD length and intramyocardial course were associated with CABG failure.
Conclusions:
- CTA is superior to CCA in delineating distal coronary CTOs.
- CTA accurately predicts procedural success for CABG in CTOs with challenging distal anatomy.
- CTA serves as a valuable tool for preprocedural coronary mapping and patient selection for CABG.
Purpose:
Previous studies demonstrated that failure to visualize distal chronic total occlusion in conventional coronary angiography (CCA) does not preclude procedural success of coronary artery bypass grafting (CABG). We assessed the utility of computed tomography angiography (CTA) in guiding CABG to the occluded left anterior descending artery (LAD) incompletely visualized by CCA.
Materials And Methods:
Twenty-four symptomatic patients rejected for revascularization of an occluded LAD on the basis of CCA underwent a preoperative CTA before intended transmyocardial laser revascularization. Off-pump CABG to the LAD was attempted in all patients depending on the intraoperative findings. The primary outcome was defined as procedural success of CABG to the LAD.
Results:
The success rate for CABG was 79.2%. By CCA, Rentrop 0/1 was present in 6 patients (25%), whereas Rentrop 2 was present in 18 patients (75%). By CTA, Rentrop 3 was seen in all patients. Compared with the CABG-failure group, the CABG-success group showed a larger mean distal LAD diameter (1.7 ± 0.2 mm vs. 1.3 ± 0.1 mm; P=0.001). By receiver-operating curve analysis, a cutoff value of 1.5 mm for the mean distal LAD diameter predicted CABG availability with 100% specificity and 95% sensitivity. The distal LAD short length and intramyocardial course were other significant correlates of CABG failure compared with CABG success (60% vs. 5.3%, P=0.018; 80% vs. 0%, P<0.001).
Conclusions:
Noninvasive CTA is not only superior to CCA in delineating distal coronary occlusion but also very precisely predicts the procedural success of CABG. CTA represents a robust evaluation tool for coronary mapping of chronic total occlusion with doubtful distal anatomy in CCA.
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