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Review
. 2021 May-Jun;15(3):192-217.
doi: 10.1016/j.jcct.2020.11.001. Epub 2020 Nov 20.

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Jagat Narula  1 , Y Chandrashekhar  2 , Amir Ahmadi  1 , Suhny Abbara  3 , Daniel S Berman  4 , Ron Blankstein  5 , Jonathon Leipsic  6 , David Newby  7 , Edward D Nicol  8 , Koen Nieman  9 , Leslee Shaw  10 , Todd C Villines  11 , Michelle Williams  7 , Harvey S Hecht  12
Affiliations
Free PMC article
Review

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Jagat Narula et al. J Cardiovasc Comput Tomogr. 2021 May-Jun.
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No abstract available

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Figures

Fig. 1.
Fig. 1.
Central Illustration Role of CTA in chronic CAD. Also please see Table 1.
Fig. 2.
Fig. 2.. CT angiography for detection of high-risk plaques.
(A1) Presence of positive remodeling (yellow arrows) and low attenuation plaques (LAP, red arrow) are the most important determinants of plaque vulnerability. (A2) Stable plaques lack both these features. Major adverse cardiac events by the presence of 1 or both features in a follow up of — patients for 2 years (A3), and 300 patients for up to 10 years. (A4) Patients with HRP had 45 and 10 folds higher likelihood of adverse outcomes, respectively. Presence of significant stenosis over and above HRP features (A5) and interval progression in plaque magnitude (A6) increased the likelihood of adverse events further. Greater number of adverse plaque characteristics were associated with greater of adverse outcomes (A7) and the HRP characteristics were associated with abnormal fractional flow reserve regardless of luminal stenosis (A8). (B) Potential indicators of inflammation by CTA as a complementary feature for identification of plaque vulnerability. It can be detected either by simultaneous PET imaging with F-18 FDG (that targets macrophage infiltration) (A1 & A2), or by fat attenuation index of perivascular fat (that represents lower prevalence of adipocytes consequent to greater cytokines in neointima) (A3 & A4). Modified from Motoyama et al. JACC 2007, Motoyama et al. JACC 2009, Lee et al. JACC 2019 Ahmadi et al. JACC-Imaging 2018, Rogers et al. JACC-Imaging 2010, Antoniades et al. Lancet 2018.
Fig. 2.
Fig. 2.. CT angiography for detection of high-risk plaques.
(A1) Presence of positive remodeling (yellow arrows) and low attenuation plaques (LAP, red arrow) are the most important determinants of plaque vulnerability. (A2) Stable plaques lack both these features. Major adverse cardiac events by the presence of 1 or both features in a follow up of — patients for 2 years (A3), and 300 patients for up to 10 years. (A4) Patients with HRP had 45 and 10 folds higher likelihood of adverse outcomes, respectively. Presence of significant stenosis over and above HRP features (A5) and interval progression in plaque magnitude (A6) increased the likelihood of adverse events further. Greater number of adverse plaque characteristics were associated with greater of adverse outcomes (A7) and the HRP characteristics were associated with abnormal fractional flow reserve regardless of luminal stenosis (A8). (B) Potential indicators of inflammation by CTA as a complementary feature for identification of plaque vulnerability. It can be detected either by simultaneous PET imaging with F-18 FDG (that targets macrophage infiltration) (A1 & A2), or by fat attenuation index of perivascular fat (that represents lower prevalence of adipocytes consequent to greater cytokines in neointima) (A3 & A4). Modified from Motoyama et al. JACC 2007, Motoyama et al. JACC 2009, Lee et al. JACC 2019 Ahmadi et al. JACC-Imaging 2018, Rogers et al. JACC-Imaging 2010, Antoniades et al. Lancet 2018.
Fig. 3.
Fig. 3.
CT-based assessment of FFR in a complex coronary lesion. A 47-year-old male, a smoker with dyslipidemia, presented with ST-elevation myocardial infarction in the left anterior descending artery territory, and was treated by primary PCI. He had a non-culprit lesion in the right coronary artery (RCA). A coronary computed tomography angiography was acquired in the context of the precise PCI plan study (P3 - NCT03782688). The left panel shows a multiplanar reconstruction of an RCA with severe stenosis and high-risk in the proximal segment of the vessel. The cross-section B, C and D show positive remodelling, low attenuation plaque and plaque rupture (white star). The FFRCT model confirmed the hemodynamic significance of the lesion with a pressure gradient across the stenosis of 0.15 FFRCT units and distal FFRCT of 0.80. In the right panel, the results of the FFRCT Planner are shown after the virtual implantation of 18-mm long stent. The results show complete functional revascularization with a predicted FFR post-PCI of 0.92.
Fig. 4.
Fig. 4.
75 y/o man known for hypertension and dyslipidemia, with recent onset of atypical chest pain and abnormal T waves in anterolateral leads. Panels A, B, C, D: Rest coronary CTA shows severe stenosis of mid LAD (Panel A), subtotal occlusion of second diagonal (B), severe stenosis of first obtuse marginal (C) and moderate stenosis of RCA (D). Panels E to J: Dynamic Stress-CTP, short axis view (E to I) and 2-chamber long axis view (J), show reduced MBF of anterior and anterolateral walls. Panel K, L, M: Invasive coronary angiogram shows severe mid LAD stenosis with positive invasive FFR (panel K), severe obtuse marginal stenosis with positive invasive FFR (Panel L), and moderate RCA stenosis with negative invasive FFR (Panel M). CTA: coronary computed tomography angiography; LAD: left anterior descending artery; D2: second diagonal branch; OM: obtuse marginal branch; RCA: right coronary artery; CTP: computed tomography perfusion; MBF: myocardial blood flow; ICA: invasive coronary angiography; FFR: fractional flow reserve. [Courtesy of Dr A. Baggiano and Dr G. Pontone].
Fig. 5.
Fig. 5.
Conceptual diagram outlining the use of CTA in diagnosis, downstream testing and management of chronic stable CAD. Images from the SCCT Statement on CAD-RADS.
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