open access

Vol 76, No 2 (2017)
ORIGINAL ARTICLES
Published online: 2016-09-28
Submitted: 2016-07-19
Accepted: 2016-08-30
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Anatomic assessment of the left main bifurcation and dynamic bifurcation angles using computed tomography angiography

O. Beton, H. Kaplanoglu, B. Hekimoglu, M. B. Yilmaz
DOI: 10.5603/FM.a2016.0059
·
Pubmed: 27714730
·
Folia Morphol 2017;76(2):197-207.

open access

Vol 76, No 2 (2017)
ORIGINAL ARTICLES
Published online: 2016-09-28
Submitted: 2016-07-19
Accepted: 2016-08-30

Abstract

Background: An understanding of the left main coronary artery (LMCA) anatomy is important for accurate diagnosis and therapy. We aimed to investigate LMCA anatomy via 128-multisliced coronary computed-tomography-angiography (CCTA) in patients with normal LMCA.

Materials and methods: A total of 201 CCTA studies were included in this study. Anatomical features of LMCA including cross-sectional areas of the LMCA ostial, LMCA distal, left anterior descending artery (LAD) ostial and left circumflex artery (LCX) ostial, and degree of tapering and LMCA bifurcation angles (BA) in the form of LMCA-LCX BA, LMCA-LAD BA, LAD-LCX BA at end-diastole and end-systole.

Results: The mean age was 55 ± 11; 55.7% of patients were males. Right coronary artery was dominant in 173 (86.1%) patients. Mean LMCA length was 10.0 ± 4.5 mm. The mean values of LMCA ostial, LMCA distal, LAD ostial and LCX ostial areas were 18.2 ± 5.1 mm2, 13.2 ± 4.0 mm2, 9.0 ± 3.2 mm2 and 7.6 ± ± 2.8 mm2, respectively. LMCA ostial-distal area, LMCA distal-LAD ostial area and LMCA distal-LCX ostial area ratios were ≥ 1.44 – < 1.69 in 47 (23.4%), 53 (26.4%), 47 (23.4%) patients, respectively, and were ≥ 1.69 – < 1.96 in 19 (9.5%), 24 (11.9%), 40 (19.9%) patients respectively. Systolic motion modifies LMCA BAs; systolic motion begets an increment of LMCA-LAD angle in 72.6% of patients and decrement of LAD-LCX angle in 75.6% of patients. Patients with T-shaped LAD-LCX BA was shown to have significantly longer LMCA, larger LAD ostial area, larger LCX ostial area and higher diastolic-to-systolic range (DSR) of LAD-LCX BA compared to patients with Y-shaped LAD-LCX BA.

Conclusions: LMCA with T-shaped distal BA was found to have significantly longer LMCA, larger LAD ostial area, larger LCX ostial area and higher DSR of distal BA compared to patients with Y-shaped distal BA. These findings may provide useful information for LMCA bifurcation stenting or designing dedicated stents for LMCA.

Abstract

Background: An understanding of the left main coronary artery (LMCA) anatomy is important for accurate diagnosis and therapy. We aimed to investigate LMCA anatomy via 128-multisliced coronary computed-tomography-angiography (CCTA) in patients with normal LMCA.

Materials and methods: A total of 201 CCTA studies were included in this study. Anatomical features of LMCA including cross-sectional areas of the LMCA ostial, LMCA distal, left anterior descending artery (LAD) ostial and left circumflex artery (LCX) ostial, and degree of tapering and LMCA bifurcation angles (BA) in the form of LMCA-LCX BA, LMCA-LAD BA, LAD-LCX BA at end-diastole and end-systole.

Results: The mean age was 55 ± 11; 55.7% of patients were males. Right coronary artery was dominant in 173 (86.1%) patients. Mean LMCA length was 10.0 ± 4.5 mm. The mean values of LMCA ostial, LMCA distal, LAD ostial and LCX ostial areas were 18.2 ± 5.1 mm2, 13.2 ± 4.0 mm2, 9.0 ± 3.2 mm2 and 7.6 ± ± 2.8 mm2, respectively. LMCA ostial-distal area, LMCA distal-LAD ostial area and LMCA distal-LCX ostial area ratios were ≥ 1.44 – < 1.69 in 47 (23.4%), 53 (26.4%), 47 (23.4%) patients, respectively, and were ≥ 1.69 – < 1.96 in 19 (9.5%), 24 (11.9%), 40 (19.9%) patients respectively. Systolic motion modifies LMCA BAs; systolic motion begets an increment of LMCA-LAD angle in 72.6% of patients and decrement of LAD-LCX angle in 75.6% of patients. Patients with T-shaped LAD-LCX BA was shown to have significantly longer LMCA, larger LAD ostial area, larger LCX ostial area and higher diastolic-to-systolic range (DSR) of LAD-LCX BA compared to patients with Y-shaped LAD-LCX BA.

Conclusions: LMCA with T-shaped distal BA was found to have significantly longer LMCA, larger LAD ostial area, larger LCX ostial area and higher DSR of distal BA compared to patients with Y-shaped distal BA. These findings may provide useful information for LMCA bifurcation stenting or designing dedicated stents for LMCA.

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Keywords

coronary computed tomography angiography, left main coronary artery, anatomic dimensions and bifurcations angles

About this article
Title

Anatomic assessment of the left main bifurcation and dynamic bifurcation angles using computed tomography angiography

Journal

Folia Morphologica

Issue

Vol 76, No 2 (2017)

Pages

197-207

Published online

2016-09-28

DOI

10.5603/FM.a2016.0059

Pubmed

27714730

Bibliographic record

Folia Morphol 2017;76(2):197-207.

Keywords

coronary computed tomography angiography
left main coronary artery
anatomic dimensions and bifurcations angles

Authors

O. Beton
H. Kaplanoglu
B. Hekimoglu
M. B. Yilmaz

References (31)
  1. Aliabadi D, Tilli FV, Bowers TR, et al. Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting. Am J Cardiol. 1997; 80(8): 994–997.
  2. AL-Mangour B, Mongrain R, Yue S. Coronary stents fracture: An engineering approach (review). Materials Sciences and Applications. 2013; 04(10): 606–621.
  3. Athappan G, Patvardhan E, Tuzcu ME, et al. Left main coronary artery stenosis: a meta-analysis of drug-eluting stents versus coronary artery bypass grafting. JACC Cardiovasc Interv. 2013; 6(12): 1219–1230.
  4. Campos CM, van Klaveren D, Farooq V, et al. EXCEL Trial Investigators. Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. Eur Heart J. 2015; 36(20): 1231–1241.
  5. Chen HY, Hermiller J, Sinha AK, et al. Effects of stent sizing on endothelial and vessel wall stress: potential mechanisms for in-stent restenosis. J Appl Physiol (1985). 2009; 106(5): 1686–1691.
  6. De Caterina AR, Cuculi F, Banning AP. Incidence, predictors and management of left main coronary artery stent restenosis: a comprehensive review in the era of drug-eluting stents. EuroIntervention. 2013; 8(11): 1326–1334.
  7. Doi H, Maehara A, Mintz GS, et al. Classification and potential mechanisms of intravascular ultrasound patterns of stent fracture. Am J Cardiol. 2009; 103(6): 818–823.
  8. Dou K, Zhang D, Xu Bo, et al. An angiographic tool for risk prediction of side branch occlusion in coronary bifurcation intervention: The RESOLVE score system (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion). JACC Cardiovasc Interv. 2015; 8(1 Pt A): 39–46.
  9. Foin N, Sen S, Allegria E, et al. Maximal expansion capacity with current DES platforms: A critical factor for stent selection in the treatment of left main bifurcations? EuroIntervention. 2013; 8(11): 1315–1325.
  10. Fujii K, Carlier SG, Mintz GS, 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; 45(7): 995–998.
  11. Girasis C, Farooq V, Diletti R, et al. Impact of 3-dimensional bifurcation angle on 5-year outcome of patients after percutaneous coronary intervention for left main coronary artery disease: a substudy of the SYNTAX trial (synergy between percutaneous coronary intervention with taxus and cardiac surgery). JACC Cardiovasc Interv. 2013; 6(12): 1250–1260.
  12. Girasis C, Serruys PW, Onuma Y, et al. 3-Dimensional bifurcation angle analysis in patients with left main disease: A substudy of the SYNTAX trial (SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery). JACC Cardiovasc Interv. 2010; 3(1): 41–48.
  13. Hahn JY, Chun WJ, Kim JH, et al. Predictors and outcomes of side branch occlusion after main vessel stenting in coronary bifurcation lesions: results from the COBIS II Registry (COronary BIfurcation Stenting). J Am Coll Cardiol. 2013; 62(18): 1654–1659.
  14. Handran CB, Garberich RF, Lesser JR, et al. The left main bifurcation angle and changes throughout the cardiac cycle: Quantitative implications for left main bifurcation stenting and stents. J Invasive Cardiol. 2015; 27(9): 401–404.
  15. Ho DS, Liu MW, Iyer S, et al. Sizing the Gianturco-Roubin coronary flexible coil stent. Cathet Cardiovasc Diagn. 1994; 32(3): 242–248.
  16. Javier SP, Mintz GS, Popma JJ, et al. Intravascular ultrasound assessment of the magnitude and mechanism of coronary artery and lumen tapering. Am J Cardiol. 1995; 75(2): 177–180.
  17. Kang SJ, Ahn JM, Song H, et al. Comprehensive intravascular ultrasound assessment of stent area and its impact on restenosis and adverse cardiac events in 403 patients with unprotected left main disease. Circ Cardiovasc Interv. 2011; 4(6): 562–569.
  18. Kawasaki T, Koga H, Serikawa T, et al. The bifurcation study using 64 multislice computed tomography. Catheter Cardiovasc Interv. 2009; 73(5): 653–658.
  19. Lassen JF, Holm NR, Banning A, et al. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club. EuroIntervention. 2016; 12(1): 38–46.
  20. Lassen JF, Holm NR, Stankovic G, et al. Percutaneous coronary intervention for coronary bifurcation disease: Consensus from the first 10 years of the European Bifurcation Club meetings. EuroIntervention. 2014; 10(5): 545–560.
  21. Marrey RV, Burgermeister R, Grishaber RB, et al. Fatigue and life prediction for cobalt-chromium stents: A fracture mechanics analysis. Biomaterials. 2006; 27(9): 1988–2000.
  22. Naganuma T, Chieffo A, Meliga E, et al. Long-term clinical outcomes after percutaneous coronary intervention for ostial/mid-shaft lesions versus distal bifurcation lesions in unprotected left main coronary artery: the DELTA Registry (drug-eluting stent for left main coronary artery disease): a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment. JACC Cardiovasc Interv. 2013; 6(12): 1242–1249.
  23. Park SJ, Ahn JM, Foin N, et al. When and how to perform the provisional approach for distal LM stenting. EuroIntervention. 2015; 11(Suppl V): V120–V124.
  24. Pflederer T, Ludwig J, Ropers D, et al. Measurement of coronary artery bifurcation angles by multidetector computed tomography. Invest Radiol. 2006; 41(11): 793–798.
  25. Ragosta M, Dee S, Sarembock IJ, et al. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv. 2006; 68(3): 357–362.
  26. Rizik DG, Klassen KJ, Burke RF, et al. Interventional management of unprotected left main coronary artery disease: Patient selection and technique optimization. J Interv Cardiol. 2015; 28(4): 326–338.
  27. Russo RJ, Silva PD, Yeager M. Coronary artery overexpansion increases neointimal hyperplasia after stent placement in a porcine model. Heart. 2007; 93(12): 1609–1615.
  28. Sianos G, Morel MA, Kappetein AP, et al. The SYNTAX Score: An angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005; 1(2): 219–227.
  29. Stankovic G, Lefèvre T, Chieffo A, et al. European Bifurcation Club. Consensus from the 7th European Bifurcation Club meeting. EuroIntervention. 2013; 9(1): 36–45.
  30. Timmins LH, Meyer CA, Moreno MR, et al. Mechanical modeling of stents deployed in tapered arteries. Ann Biomed Eng. 2008; 36(12): 2042–2050.
  31. Windecker S, Kolh P, Alfonso F, et al. Authors/Task Force members. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014; 35(37): 2541–2619.

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