Abstract
Objectives
Diagnostic accuracy of conventional coronary CT angiography (CCTAconv) may be compromised by blooming artifacts from calcifications or stents. Blooming artifacts may be reduced by subtraction coronary CT angiography (CCTAsub) in which non-contrast and contrast CT data sets are subtracted digitally. We tested whether CCTAsub in patients with severe coronary calcification or stents reduces the number of false-positive stenosis evaluations compared with CCTAconv.
Methods
In this study, 180 symptomatic patients scheduled for invasive coronary angiography (ICA) were prospectively enrolled and CT scanned (2013-2016) at three international centers. CCTAconv, and CCTAsub data sets were reconstructed. Target segments were defined as motion-free coronary segments with a suspected stenosis (> 50% of lumen) potentially due to blooming of either calcium or stents. Target segments were evaluated with respect to misregistration artifacts from the CCTAsub reconstruction process, in which case evaluation was omitted. CCTAsub and CCTAconv were compared with ICA. Primary outcome measure was the frequency of false positives by CCTAconv versus CCTAsub to identify > 50% coronary stenosis by ICA on a per-segment level.
Results
After exclusion of 76 patients, 104 (14% females) with mean age 67 years and median Agatston score 852 were included. There were 136 target segments with misregistration and 121 target segments without. Accuracy calculations in target segments without misregistration showed a reduction of the false positives from 72% [95% confidence interval (CI): 63-80%] in CCTAconv to 33% (CI:25-42%) in CCTAsub, at the expense of 7% (CI:3-14%) false negatives in CCTAsub.
Conclusions
In severely calcified coronary arteries or stents, CCTAsub reduces the false-positive rate in well-aligned, calcified or stent segments suspected of significant stenosis on CCTAconv. Nevertheless, misregistration artifacts are frequent in CCTAsub.
Key Points
• A high calcium-score reduces the diagnostic accuracy in patients scanned with cardiac CT.
• These patients would normally need an invasive angiogram for diagnosis.
• In this prospective, multicenter study, subtraction CT, when evaluable, reduces false-positive stenosis evaluations.
• Subtraction coronary CT angiography may, when evaluable, reduce excessive downstream testing.
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Abbreviations
- AIDR3D:
-
Adaptive iterative dose reduction 3D
- CAD:
-
Coronary artery disease
- CCTA:
-
Coronary computed tomography angiography
- CI:
-
Confidence interval
- CTDSA:
-
Computed tomography digital subtraction angiography
- ICA:
-
Invasive coronary angiography
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Acknowledgements
The authors thank project nurses Christina Møller and Bente Andersen for excellent assistance.
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The scientific guarantor of this publication is tenured senior author: Klaus Fuglsang Kofoed.
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The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.
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Lene Theil Skovgaard, Associate Professor at the Department of Biostatistics, University of Copenhagen, kindly provided statistical advice for this manuscript.
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Methodology
• prospective
• diagnostic or prognostic
• multicentre study
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Fuchs, A., Kühl, J.T., Chen, M.Y. et al. Subtraction CT angiography improves evaluation of significant coronary artery disease in patients with severe calcifications or stents—the C-Sub 320 multicenter trial. Eur Radiol 28, 4077–4085 (2018). https://doi.org/10.1007/s00330-018-5418-y
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DOI: https://doi.org/10.1007/s00330-018-5418-y