Original Article
Diagnostic accuracy of 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: A meta-analysis

https://doi.org/10.1007/s12350-010-9218-2Get rights and content

Abstract

Background

We sought to evaluate the diagnostic accuracy of 64-slice multi-detector row computed tomography (MDCT) compared with invasive coronary angiography for in-stent restenosis (ISR) detection.

Methods

MEDLINE, Cochrane library, and BioMed Central database searches were performed until April 2009 for original articles. Inclusion criteria were (1) 64-MDCT was used as a diagnostic test for ISR, with >50% diameter stenosis selected as the cut-off criterion for significant ISR, using invasive coronary angiography and quantitative coronary angiography as the standard of reference; (2) absolute numbers of true positive, false positive, true negative, and false negative results could be derived. Standard meta-analytic methods were applied.

Results

Nine studies with a total of 598 patients with 978 stents included were considered eligible. On average, 9% of stents were unassessable (range 0-42%). Accuracy tests with 95% confidence intervals (CIs) comparing 64-MDCT vs invasive coronary angiography showed that pooled sensitivity, specificity, positive and negative likelihood ratio (random effect model) values were: 86% (95% CI 80-91%), 93% (95% CI 91-95%), 12.32 (95% CI 7.26-20.92), 0.18 (95% CI 0.12-0.28) for binary ISR detection. The symmetric area under the curve value was 0.94, indicating good agreement between 64-MDCT and invasive coronary angiography.

Conclusions

64-MDCT has a good diagnostic accuracy for ISR detection with a particularly high negative predictive value. However, still a relatively large proportion of stents remains uninterpretable. Accordingly, only in selected patients, 64-MDCT may serve as a potential alternative noninvasive method to rule out ISR.

Introduction

Coronary stent implantation is increasingly performed in the treatment of significant coronary artery disease and has significantly reduced the occurrence of restenosis as compared with balloon angioplasty.1,2 Moreover, with the recent introduction of drug-eluting-stents (DES), the occurrence of in-stent restenosis (ISR) has further decreased.3,4 Nonetheless, even after DES implantation, excessive neo-intimal hyperplasia resulting in partial or complete ISR may still occur. Accordingly, in patients presenting with recurrent chest pain following DES implantation, invasive coronary angiography remains frequently indicated to evaluate the presence of ISR. However, considering the fact that a substantial number of these invasive coronary angiograms are not followed by intervention, the need for a noninvasive alternative approach for ISR detection is evident. To this end, stress tests may be used to assess patients with suspicion of ISR. However, the diagnostic accuracy of stress tests for ISR detection is moderate,5 and direct stent visualization would be preferred. With previous 4- and 16-slice multi-detector row computed tomography (MDCT) systems, MDCT was of limited value in the assessment and follow-up of patients with coronary stents, due to the frequent occurrence of motion and blooming artefacts.6,7 With the introduction of 64-slice systems, some of these limitations have been partially overcome due to increased temporal resolution (due to increased gantry rotation speed), increased spatial resolution and enhanced craniocaudal coverage. Although initial data obtained with 64-MDCT appear promising, more robust data are needed to confirm that this technique may become a potential alternative to invasive coronary angiography for ISR detection in daily clinical practice. The most important features of a clinical test are few false negative and false positive results (affecting sensitivity and specificity, respectively). Additionally, when restenosis rate is low, as it is currently the case for simple lesions treated with DES, a high negative predictive value (NPV) allows exclude ISR in the majority of patients. Subsequently, only in a limited number of patients, invasive coronary angiography would be required to confirm and potentially treat ISR.

In order to determine the current diagnostic accuracy of 64-MDCT, we performed a meta-analysis of all available studies comparing 64-MDCT with invasive coronary angiography for the diagnosis of ISR.

Section snippets

Search Strategy

Database searches for English articles published until April 2009 were performed in MEDLINE, Cochrane library, and BioMed Central databases. We combined the medical subject headings for computed tomography, multi-detector computed tomography, and coronary angiography, with the exploded terms stent and restenosis and scanned references in retrieved articles and reviews. The retrieved studies were carefully examined to exclude potential duplicates or overlapping data. Meeting abstracts were

Search Results

The search resulted in detection of 211 hits. After the exclusion of nonrelevant articles by title and abstract, 37 articles were retrieved for full text evaluation, and of these 10 studies fulfilled all inclusion criteria. One study was excluded because it was performed using a dual-source 64-slice MDCT system.14

From the study by Rist et al15 the data on proximal, distal, and in-stent restenosis were combined to a single result. Despite using a 40-MDCT system, the study by Gaspar et al16 was

Discussion

In this meta-analysis, we focused on the diagnostic performance of the 64-MDCT generation of MDCT as a potential alternative, noninvasive method for ISR detection. We observed an average weighted sensitivity of 86% and specificity of 93% for 64-MDCT in the detection of ISR as compared to invasive coronary angiography. These observations are not substantially different from the meta-analysis by Hamon et al, who included both 16- and 64-MDCT systems.24 While in fact the majority of data were

Conclusions

The results of the current meta-analysis demonstrate that 64-MDCT has a good diagnostic accuracy for ISR detection with a particularly high NPV. However, still a relatively large proportion of stents, although improved as compared to previous reports, remains uninterpretable. Accordingly, only in selected patients, 64-MDCT may serve as a potential alternative noninvasive method to rule out ISR.

Acknowledgments

We are grateful to Annibale Biggeri, from the Biostatistics Unit, Cancer Prevention and Research Institute ISPO, Florence, for his assistance with the statistical analyses performed for this research.

Disclosures

Dr de Graaf is co-supported by the Dutch Technology Foundation STW (Utrecht, the Netherlands), Applied Science Division of NWO and the Technology Program of the Ministry of Economic Affairs, Grant No. 10084. Dr Bax has research grants from Medtronic, Boston Scientific, BMS Medical Imaging, St. Jude

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