Association between coronary artery calcium score and stent expansion in percutaneous coronary intervention

doi:10.1016/j.ijcard.2021.04.021

International Journal of Cardiology

Volume 334, 1 July 2021, Pages 31-36

https://doi.org/10.1016/j.ijcard.2021.04.021 Get rights and content

Highlights

•
The present study showed that high TV-CAC assessed using the multidetector computed tomography is a predictor of stent under-expansion.
•
Stent under-expansion is a mediator of the association between high TV-CAC score and in-stent restenosis.
•
Assessing the TV-CAC score before PCI might be clinically useful to reduce future TLR due to stent under-expansion.

Abstract

Background

Measurement of the coronary artery calcification score using multidetector computed tomography (MDCT) is a useful noninvasive test for the diagnosis of coronary artery disease. However, whether pre-intervention assessment of the target vessel coronary artery calcification (TV-CAC) score is associated with stent expansion failure and future target lesion revascularization (TLR), remains unknown. This study aimed to determine the association between the TV-CAC score measured by MDCT and stent expansion rate in patients who underwent IVUS-guided PCI for stable angina.

Methods

We conducted a retrospective observational study including 135 consecutive patients (186 target lesions) who underwent MDCT and were scheduled for the first PCI. The patients were divided into 2 groups based on the median value of the TV-CAC score. The primary outcome was the stent expansion rate measured by IVUS after stent implantation. The secondary outcome was TLR within 1 year.

Results

Stent expansion rate was associated with the TV-CAC score (p < 0.001). According to the ROC curve analysis, the TV-CAC score had the largest area under the curve (AUC) for the stent expansion area of 0.90 (AUC = 0.893, p < 0.001). The TV-CAC score was a positive predictor for stent expansion rate of <90% (odds ratio: 7.54, p < 0.001). Mediation analysis showed that stent under-expansion was a mediator of the association between high TV-CAC and TLR.

Conclusions

Our study demonstrates that pre-intervention assessment of TV-CAC using MDCT is a predictor of stent expansion. The TV-CAC score might predict the complexity and help in the PCI operative strategy.

Introduction

Coronary artery calcification (CAC) score measured by non-contrast cardiac gated multidetector computed tomography (MDCT) is clinically useful for the diagnosis of coronary artery disease [1]. Severe coronary calcification is a clinical issue in patients undergoing percutaneous coronary intervention (PCI) because previous studies have reported that it is an independent predictor of stent thrombosis (ST) and target lesion revascularization (TLR) [2]. Moreover, studies also showed that in-stent restenosis and ST may present as myocardial infarction (MI), infrequently resulting in mortality [3]. Accumulating evidence on the relationship between CAC and stent expansion suggests that calcified plaques are associated with stent under-expansion [4]. A previous study using intravascular ultrasound (IVUS) also reported that stent under-expansion is one of the leading causes of in-stent restenosis [5].

The CAC score provides an excellent estimation of cardiovascular risk as it is strongly correlated with a coronary atherosclerotic burden. Accordingly, preoperative coronary computed tomography angiogram (CTA) has been used clinically to evaluate the requirement for rotational atherectomy [6]. However, it remains unclear how CAC affects stent dilation. Herein, we investigated the association of per-vessel CAC with stent expansion rate and future TLR in patients with stable angina. We hypothesized that per-vessel CAC score evaluated using MDCT is associated with stent expansion.

Section snippets

Study population

We enrolled 2064 consecutive patients who had been admitted for stable angina pectoris, unstable angina, and acute myocardial infarction at the Miyazaki Prefectural Nobeoka Hospital between January 2013 and July 2019 (Supplemental Fig. 1). Stable angina pectoris, unstable angina, and acute myocardial infarction were diagnosed according to the AHA guidelines [7]. The patients underwent MDCT were referred to an outpatient visit, had acute and chronic chest pain, and were at risk for coronary

Patient and lesion demographics

We enrolled 135 patients (186 target lesions) aged 45–92 years. The median age was 71 years (IQR; 65–78), and 71.1% of them were male (Supplemental Table 1). The median score in the high TV-CAC group was 464.5, whereas the median score in the low TV-CAC group was 43.5. The clinical characteristics of the patients enrolled in this study are described in Section 2 of the Supplementary Material, and the lesion/stent characteristics are shown in Table 1. Periprocedural complications during PCI were

Discussion

The major findings of this study were that the TV-CAC score evaluated by MDCT is significantly associated with the stent expansion rate, and is an independent predictor of stent under-expansion and future TLR. To the best of our knowledge, this study is the first to investigate the association of TV-CAC with stent expansion rate measured by IVUS. Our results highlight that TV-CAC score based on a prediction of stent expansion before PCI could help interventionalists to stratify their PCI

Conclusion

The present study showed that high TV-CAC obtained using MDCT is a predictor of stent under-expansion. Because stent under-expansion is a mediator of the association between high TV-CAC score and in-stent restenosis, assessing the TV-CAC score before PCI might be clinically useful to prevent a reduced TLR due to stent under-expansion.

Funding

None.

Disclosures

There are no conflicts of interest.

References (22)

P. Généreux et al.
Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes. Pooled analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) and ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS
J. Am. Coll. Cardiol.
(2014 May 13)
A. Mattesini et al.
Calcium: a predictor of interventional treatment failure across all fields of cardiovascular medicine
Int. J. Cardiol.
(2017 Mar 15)
T. Sekimoto et al.
Regional calcified plaque score evaluated by multidetector computed tomography for predicting the addition of rotational atherectomy during percutaneous coronary intervention
J. Cardiovasc. Comput. Tomogr.
(2016 May-Jun)
S.D. Fihn et al.
2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
J. Am. Coll Cardiol.
(2014 Nov 4)
A.S. Agatston et al.
Quantification of coronary artery calcium using ultrafast computed tomography
J. Am. Coll. Cardiol.
(1990 Mar 15)
J. Zhang et al.
Intravascular ultrasound versus angiography-guided drug-eluting stent implantation: the ULTIMATE trial
J. Am. Coll. Cardiol.
(2018 Dec 18)
M. Kruk et al.
Impact of coronary artery calcium characteristics on accuracy of CT angiography
JACC Cardiovasc. Imaging
(2014 Jan)
S.D. Weisbord et al.
Contrast-associated acute kidney injury and serious adverse outcomes following angiography
J. Am. Coll. Cardiol.
(2020 Mar 24)
G.S. Mintz
Clinical utility of intravascular imaging and physiology in coronary artery disease
J. Am. Coll. Cardiol.
(2014 Jul 15)
K. Fujii et al.
Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study
J. Am. Coll. Cardiol.
(2005 Apr 5)

M.G. Silverman et al.

Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: multi-ethnic study of atherosclerosis

JACC Cardiovasc. Imaging

(2014 May)

Cited by (6)

Invasive and non-invasive imaging analysis for calcified coronary artery lesions
2022, Annales de Cardiologie et d'Angeiologie
Les calcifications coronaires sont fréquemment identifiées au sein des lésions coronaires et leur incidence augmente avec l’âge et les facteurs de risque cardiovasculaires. Leur localisation peut être superficielle ou profonde, correspondant à des physiopathologies différentes. Dans tous les cas, la présence de calcifications au sein de la paroi vasculaire est un facteur de mauvais pronostic clinique et d’évolution défavorable après revascularisation percutanée. Les calcifications coronaires peuvent être analysées par angiographie, scanner ou imagerie endocoronaire (IVUS ou OCT) avec des performances variables. L'angiographie est la méthode la plus utilisée mais est peu sensible (sensibilité proche de 50 %) et insuffisante pour leur quantification précise. Le scanner est une méthode non invasive plus efficace permettant une bonne analyse de la lésion avant coronarographie. L'IVUS et l'OCT sont, grâce à leur résolution spatiale, les méthodes les plus sensibles pour l'identification des calcifications (présents dans près de 75–80 % des lésions) et leur quantification. Ces deux dernières techniques offrent des perspectives intéressantes pour l'identification des lésions les plus à risque de mauvais pronostic post revascularisation, la planification des procédures d'angioplastie (dont le choix des outils de préparation de plaque), le monitorage de leur exécution et l’évaluation du résultat post-stenting immédiat.
Coronary calcifications are frequently identified within coronary lesions as their incidence increases with age and cardiovascular risk factors. Their location can be superficial or deep, according to different pathological process. In all cases, the presence of calcifications within the vascular wall predicts poor clinical prognosis and unfavorable evolution after percutaneous revascularization. Coronary calcifications can be analyzed by angiography, CT or intracoronary imaging (IVUS or OCT) with variable accuracies. Angiography is the most frequently used method but is not very sensitive (sensitivity close to 50%) and insufficient for their precise quantification. The CT scan is a more effective non-invasive method leading to an accurate analysis of the lesion before coronary angiography. IVUS and OCT have an excellent spatial resolution and are the most sensitive methods for the identification (present in nearly 75–80% of lesions) and quantification of calcifications. These intracoronary imaging techniques offer interesting perspectives for identification of the highest-risk lesions, PCI procedures planning (including the choice of an optimal dedicated plaque preparation devices), the monitoring of their execution and the evaluation of the immediate post-stenting results.
Mid-term outcome of de novo lesions vs. in stent restenosis treated by intravascular lithotripsy procedures: Insights from the French Shock Initiative
2022, International Journal of Cardiology
Citation Excerpt :
2) The immediate and one-year outcome of IVL treatment appears comparable between ISR and DNL. The presence of underlying coronary calcification negatively impacts prognosis and procedural complications rates in PCI [1,2,13,15]. New tools to improve the safety and effectiveness of PCI are thus urgently needed [1].
Intravascular lithotripsy (IVL) is a promising new technology for disrupting de-novo calcified coronary lesions (DNL) before percutaneous coronary intervention (PCI). We assessed 12-month outcomes of IVL in patients undergoing PCI for DNL or intra stent restenosis (ISR) lesions related to device underexpansion.
Prospective analysis of patients in the multicentre all-comers French Shock Initiative IVL registry. The primary safety endpoints in this analysis were in-hospital and 12-month major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). The primary effectiveness endpoint was procedural success, defined as <30% residual stenosis without severe angiographic complications. Event rates were analysed for the cohort and for DNL and ISR procedures separately.
A total of 220 lesions were treated (76.7% DNL and 23.3% ISR) in 202 patients. Procedural success was achieved in 95.5% of patients (DNL group: 96.5%; ISR group: 92.0%). In-hospital MACE occurred in 6.4% of cases, mainly driven by periprocedural infarctions. The rate of MACE-free survival at 1 year was 86.6% in the overall cohort. Rates of target vessel (TVR) and lesion (TLR) revascularisation were 6.4% and 2.5%, respectively. The 1-year MACE rate was 91.5% in DNL group and 83.8% in ISR group.
In this large all-comers IVL cohort, rates of in-hospital and 1-year MACE were moderate. The safety and efficiency of IVL was comparable in DNL and ISR lesions. A comparative study of the impact of IVL on outcomes appears warranted.
Contribution of the Optical Coherence Tomography in Calcified Lesions
2023, Reviews in Cardiovascular Medicine
Role of coronary computed tomography angiography to optimise percutaneous coronary intervention outcomes
2023, Heart
Efficacy and safety of drug-coated balloon in the treatment of acute myocardial infarction: a meta-analysis of randomized controlled trials
2022, Scientific Reports
Effectiveness of spherical tip noncompliant balloon for stent postdilatation: the REPIC02-RECONQUISTHA study
2022, REC: Interventional Cardiology

View full text

Association between coronary artery calcium score and stent expansion in percutaneous coronary intervention

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Patient and lesion demographics

Discussion

Conclusion

Funding

Disclosures

J. Am. Coll. Cardiol.

Int. J. Cardiol.

J. Cardiovasc. Comput. Tomogr.

J. Am. Coll Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

JACC Cardiovasc. Imaging

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

JACC Cardiovasc. Imaging