Multidetector Computed Tomography Angiography (MD-CTA) of Coronary Artery Bypass Grafts – Update 2017

Abstract

Background Coronary artery bypass grafting (CABG) is still an important therapeutic approach in the treatment especially of advanced coronary artery disease. In this study, we elucidate the current role of multidetector computed tomography angiography (MD-CTA) in imaging patients after CABG surgery.

Method This study is based on recent reports in the literature (2007 – 2016) on imaging of CABG using 64-slice MD-CT scanners and beyond. We included 13 reports that compared ECG-gated MD-CTA with conventional invasive coronary angiography (ICA) as the reference standard for the assessment of graft patency and for the detection of > 50 % stenoses. These studies had to provide absolute values for true-positive, true-negative, false-positive and false-negative results or at least allow calculation of these numbers. In total, 1002 patients with 2521 bypass grafts were the basis for this review.

Results and Conclusion The sensitivity and specificity for the assessment of graft patency or the detection of > 50 % graft stenosis were 97.2 % and 97.5 %, respectively. The negative and positive predictive values were 93.6 % and 99 %, respectively. By using prospective ECG-gating and an increasing pitch factor, the radiation dose exposure declined to 2.4 mSv in the latest reports. ECG-gated MD-CTA provides a fast and reliable, noninvasive method for assessing patients after CABG. The most substantial benefit of the newest CT scanner generations is a remarkable reduction of radiation dose exposure while maintaining a still excellent diagnostic accuracy during recent years.

Key Points 

• MD-CTA using 64-slice MDCT scanners and beyond is a reliable, noninvasive method for evaluating CABGs.

• Technical advances such as prospective ECG-gating, iterative reconstruction algorithms and high-pitch scanning lead to a remarkable drop-down in radiation dose exposures as low as 2.4 mSv.

• Despite significant dose reductions, MD-CTA could maintain a high diagnostic accuracy in evaluating CABGs in recent years.

Citation Format

• Jungmann F, Emrich T, Mildenberger P et al. Multidetector Computed Tomography Angiography (MD-CTA) of Coronary Artery Bypass Grafts – Update 2017. Fortschr Röntgenstr 2018; 190: 237 – 249

Zusammenfassung

Hintergrund Die aortokoronare Bypassoperation stellt unverändert einen wichtigen Bestandteil in der Behandlung der koronaren Herzerkrankung insbesondere in fortgeschrittenen Krankheitsstadien dar. In der vorliegenden Arbeit soll der aktuelle Stellenwert der Multidetektor-CT-Angiografie (MD-CTA) bei Patienten nach stattgehabter aortokoronarer Bypassoperation (ACVB) dargelegt werden.

Methode Die vorliegende Übersichtsarbeit basiert auf Publikationen aus den Jahren 2007 – 2016 zur nicht-invasiven Bildgebung von Patienten nach ACVB-Operation, die an MD-CT-Geräten mit mindestens 64 Zeilen untersucht wurden. Voraussetzung für eine Berücksichtigung in der Analyse waren Angaben zu den absoluten Vorhersagewerten (richtig-positiv, richtig-negativ, falsch-positiv und falsch-negativ) bzw. ihre Berechnung musste möglich sein. Insgesamt konnten 13 Publikationen berücksichtigt werden, bei denen die EKG-getriggerte CT-Angiografie mit der konventionellen Koronarangiografie als Referenzstandard hinsichtlich Bypassoffenheit bzw. der Detektion von > 50 % Bypassstenosen verglichen wurde. Insgesamt wurden 1002 Patienten mit 2521 Bypässen in die Arbeit eingeschlossen.

Ergebnisse und Schlussfolgerung Die gepoolte Sensitivität und Spezifität in der Evaluation der Bypassoffenheit bzw. der Detektion von > 50 % Bypassstenosen betrugen 97,2 % und 97,5 %. Der gemittelte positiv prädiktive Wert und der gemittelte negativ prädiktive Wert erreichte 93,6 % bzw. 99 %. Durch prospektive EKG-Triggerung und einer Erhöhung des Pitch-Faktors konnte die Strahlenexposition in den neuesten Publikationen auf bis zu 2,4 mSv gesenkt werden. Die EKG-getriggerte MD-CTA ist eine schnelle und zuverlässige Methode zur Untersuchung von Patienten nach ACVB-Operation. Der größte Fortschritt der neueren CT-Scanner-Generationen ist eine signifikante Reduktion der Strahlenexposition bei einer unverändert hohen diagnostischen Genauigkeit in der Bypassbeurteilung in den vergangenen Jahren.

Kernaussagen 

• Die MD-CTA ist eine zuverlässige, nicht-invasive Methode zur Beurteilung aortokoronarer Bypässe.

• Technische Weiterentwicklungen wie prospektive EKG-Triggerung, iterative Rekonstruktionsalgorithmen und high-pitch Technik führen zu einer deutlichen Reduktion der Strahlenexposition auf bis zu 2,4 mSv.

• In den vergangenen Jahren konnte die diagnostische Genauigkeit der MD-CTA auf konstant hohem Niveau gehalten werden, mit weiterhin ausgezeichneten Sensitivitäten und negativ prädiktiven Werten in Bezug auf Bypassoffenheit bzw. der Detektion relevanter Bypassstenosen.

Key words

coronary artery bypass grafting - multidetector computed tomography - cardiac-gated imaging techniques - vascular patency - radiation monitoring

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