Table Of ContentI
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
III
Contents
M. Oudkerk · M. F. Reiser
(Eds.)
Coronary
Radiology
2nd Revised Edition
With Contributions by
S. Achenbach · M. Ackerman · H. Alkadhi · C. R. Becker · T. Boskamp · A. Broekema
N. Bruining · P. Buszman · P. J. de Feyter · G. J. de Jonge · W. F. A. den Dunnen · S. de Winter
R. Dikkers · R. R. Edelman · R. Erbel · T. G. Flohr · B. Goedhart · M. J. W. Greuter
J. M. Groen · P. Guyon · S. S. Halliburton · R. Hamers · A. Hennemuth · C. Herzog
U. Hoffman · J. P. Janssen · W. A. Kalender · M. T. Keadey · G. Koning · W. Kristanto
C. Kuehnel · A. Lansky · D. Li · G. Ligabue · J. Ligthart · M. J. Lipton · R. Marano
C. H. McCollough · S. Möhlenkamp · B. Ohnesorge · M. Oudkerk · G. L. Raff · P. Raggi
A. Rare · G. P. Reddy · M. R. Rees · J. H. C. Reiber · G. D. Rubin · J. R. T. C. Roelandt
J.-L. Sablayrolles · A. Schmermund · U. J. Schoepf · L. J. Shaw · V. E. Sinitsyn · W. Stanford
A. E. Stillman · A. J. H. Suurmeijer · G. Tarulli · A. J. Taylor · J. C. Tuinenburg
E. J. R. van Beek · P. M. A. van Ooijen · R. Vliegenthart Proença · L. Wexler · C. S. White
J. C. M. Witteman · F. Zijlstra
Foreword by
A. L. Baert
With 267 Figures in 405 Separate Illustrations, 170 in Color and 37 Tables
123
IV
Contents
Matthijs Oudkerk, MD, PhD
Professor of Radiology
University Medical Center Groningen
University of Groningen
Hanzeplain 1
P. O. Box 30.001
9700 RB Groningen
The Netherlands
Maximilian F. Reiser
, MD
Professor and Chairman
Department of Clinical Radiology
University Hospitals – Grosshadern and Innenstadt
Ludwig-Maximilians-University of Munich
Marchioninistrasse 15
81377 Munich
Germany
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN 978-3-540-32983-1 e-ISBN 978-3-540-32984-8
DOI 10.1007 / 978-3-540-32984-8
Medical Radiology · Diagnostic Imaging and Radiation Oncology ISSN 0942-5373
Library of Congress Control Number: 2008921081
(cid:2) 2009, Springer-Verlag Berlin Heidelberg
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V
Contents
Foreword
It is a great privilege to introduce this second, completely revised and updated edition
of the fi rst monograph dealing with both invasive and non-invasive coronary imag-
ing.
This volume offers a comprehensive overview of the latest technological advances in
coronary imaging and of the actual clinical role of this technique.
As in the fi rst edition, the illustrations are numerous, of outstanding technical qual-
ity and selected appropriately to underscore facts and statements.
I am very much indebted to the editors, M. Oudkerk and M. F. Reiser, for their out-
standing engagement and meticulous editing task in order to prepare this second
volume in a record brief period of time, enabling us to include the latest developments
in coronary radiology. They have been supported by a superb group of leading experts
in the fi eld for individual chapters.
This splendid volume should be on the shelves of all radiologists involved in cardiac
radiology. Radiologists in training will fi nd all relevant basic information to help them
better understand and conduct coronary imaging, while the book is equally recom-
mended to cardiologists and cardiac surgeons as a support in their daily clinical man-
agement of patients.
I am convinced that this second edition will meet with the same great success among
readers as the fi rst.
Leuven Albert L. Baert
VII
Contents
Preface
The coronary circulation was fi rst described by Ibn al Nafi s (1213–1288) in the thir-
teenth century. He published Kitab Mujiz - The concise book (1250) in Damascus (Syria)
in which he writes the following: ”the nourishment of the heart is from the blood that
goes through the vessels that permeate the body of the heart”. After the fi rst anatomi-
cal opening of the human body by Mundinus (1270–1326) in Bologna in 1305, it took
almost 250 years before Vesalius (1514–1564) published the fi rst anatomical drawing of
the coronary arteries from observations of the post mortem human body in his famous
De Humani Corporis Fabrica (1543), although Leonardo da Vinci (1452–1519) visual-
ized the coronaries of animals earlier in his famous anatomical sketches. Visualization
of the coronaries in the living human body had to wait for the development of radiology.
In 1907, an X-ray atlas of the coronary arteries composed of analysis of human cadavers
by Jamin and Merkel was published. In 1933, Rousthoi experimentally performed the
fi rst left ventriculography and coronary visualization. Radner, of Sweden, performed
the fi rst in vivo coronary angiogram by direct sternal puncture of the ascending aorta
in the year 1945. The fi rst selective cine frame coronary arteriogram was recorded by
Mason and Sones, Jr., on October 30, 1958.
Diagnostic coronary angiography was developed through the 1960s and 1970s with
diminishing procedure-related complication and mortality rates. Gruentzig performed
the fi rst percutaneous transluminal coronary angioplasty on September 16, 1977, in
Zurich (Switzerland). In 1972, the fi rst computerized tomographic images of the living
human brain were made by Hounsfi eld and Cormack. Data acquisition took up to
almost 5 min per rotation. In 1988, the fi rst clinical continuously rotating CT systems
were installed, enabling one-second and subsecond scanning. With the introduction
of the multidetector systems from 2000 onwards, rotation times reached levels beyond
350 ms, permitting image time resolution down to 150 ms, which almost equals the
time resolution of the non-mechanical electron beam computed tomography which was
introduced in 1983. Since the coronaries move over a 3- to 5-cm distance per second
and only rest in diastole for no longer than 100 ms, this high performance technology
is absolutely mandatory for non-invasive imaging of the coronary arteries.
With this new CT technology, routine non-invasive examination of the coronary
vessel wall becomes feasible and will provide information that could only be gathered
previously with intra-vascular ultrasound. Initial studies on 4D coronary imaging, vir-
tual coronary angioscopy and thrombus detection within the coronary arteries have
been published, proving the feasibility of a wide range of new diagnostic applications in
the coronaries. Also, new developments in magnetic resonance imaging open up non-
VIII
Preface
invasive coronary vessel wall examination, in particular with recently released
MR contrast agents.
This book covers the full scope of radiological modalities to examine the
coronary arteries and the coronary vessel wall. Today, a complete new era has
emerged in cardiac and coronary imaging in which everyone can be informed
about the condition of his or her coronary arteries non-invasively and in one
simple, short examination. Since every radiologist will visualize many coro-
naries daily during routine CT examinations, including those in asymptomatic
patients, it is of the utmost importance not to neglect this information but to
learn how to interpret and communicate it within the medical community and
to the patient.
Since the release of the fi rst edition, the fi eld of coronary radiology has devel-
oped with turbulent speed. As breaking news is presented in the leading inter-
national media, non-invasive coronary imaging is requested by the patients
themselves before any invasive procedure can be performed. With all these
incentives, the major manufacturers of the radiological equipment involved are
engaging in a real competition for the best image quality within the limitations
of acceptable radiation exposure. Researchers from all over the world are pub-
lishing a vast body of evidence that non-invasive imaging of the coronaries is
indeed a method from which almost every cardiovascular patient can profi t.
It is foreseeable within the near future that not only the coronaries but a
full cardiac examination, including cardiac function, can be assessed within
acceptable radiation dose limits in one study. Furthermore, non-invasive cor-
onary imaging will be mandatory for optimal planning of revascularization
procedures.
This second edition of Coronary Radiology covers the latest developments.
Not only new acquisition technologies, but also the substantial improvements
made by postprocessing software developers, new fi elds of indication for coro-
nary imaging and the latest guidelines on acute chest pain and coronary cal-
cifi cation assessment are discussed. All authors contributing to this edition
are key international authorities in the fi eld endorsed by both the European
Society of Cardiac Radiology as well as the North American Society of Cardiac
Imaging.
Together, they are moving non-invasive coronary imaging in a direction in
which adequate detailed information on the condition of the coronaries will be
available for every patient, not only in the Western world, but worldwide to a
very high degree of standardization and quality.
Matthijs Oudkerk
Groningen
Munich Maximilian F. Reiser
IX
Contents
Contents
1 Coronary Anatomy
Gonda J. de Jonge, Peter M. A. van Ooijen, Jean-Louis Sablayrolles,
Guido Ligabue, and Felix Zijlstra . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Invasive Coronary Imaging
2.1 Conventional Catheterisation
Michael R. Rees and Felix Zijlstra . . . . . . . . . . . . . . . . . . . . . . 25
2.2 Quantitative Coronary Arteriography
Johan H. C. Reiber, Joan C. Tuinenburg, Gerhard Koning,
Johannes P. Janssen, Andrei Rareş, Alexandra J. Lansky, and
Bob Goedhart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.3 Clinical Intracoronary Ultrasound
Jurgen Ligthart and Pim J. de Feyter . . . . . . . . . . . . . . . . . . . . . 67
2.4 Quantitative Coronary Ultrasound (QCU)
Nico Bruining, Ronald Hamers, Sebastiaan de Winter, and
Jos R. T. C. Roelandt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
3 Non-Invasive Coronary Imaging
3.1 Multi-Detector Row Computed Tomography – Technical Principles,
New System Concepts, and Clinical Applications
Thomas Flohr and Bernd Ohnesorge . . . . . . . . . . . . . . . . . . . . . 99
3.2 Developments in MR Coronary Angiography
Robert R. Edelman and Debiao Li . . . . . . . . . . . . . . . . . . . . . . . 135
3.3 Clinical Implementation of Coronary Imaging
Hatem Alkadhi, Riksta Dikkers, Christoph R. Becker,
Stephan Achenbach, and Valentin E. Sinitsyn. . . . . . . . . . . . . . . 149
3.4 MDCT in Acute Coronary Syndrome
Hatem Alkadhi, Riksta Dikkers, Christoph R. Becker,
Charles White, and Udo Hoffman. . . . . . . . . . . . . . . . . . . . . . . 165
3.5 Coronary CT Angiography Guidance for
Percutaneous Transluminal Angioplasty
Jean-Louis Sablayrolles and Philippe Guyon. . . . . . . . . . . . . . . . 175
X
Contents
3.6 Use of Multidetector Computed Tomography for the Assessment of
Acute Chest Pain: Guidelines of the North American Society of
Cardiac Imaging and the European Society of Cardiac Radiology
Arthur E. Stillman, Matthijs Oudkerk, Margaret Ackerman,
Christoph R. Becker, Pawel E. Buszman, Pim J. de Feyter,
Udo Hoffmann, Matthew T. Keadey, Riccardo Marano,
Martin J. Lipton, Gilbert L. Raff, Gautham P. Reddy,
Michael R. Rees, Geoffrey D. Rubin, U. Joseph Schoepf,
Giuseppe Tarulli, Edwin J. R. van Beek, Lewis Wexler, and
Charles S. White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4 Non-Invasive Measurement of Coronary Atherosclerosis
4.1 Pathophysiology of Coronary Atherosclerosis and Calcifi cation
Wilfred F. A. den Dunnen and Albert J. H. Suurmeijer . . . . . . . . . 205
4.2 Detection and Quantifi cation of Coronary Calcifi cation
Rozemarijn Vliegenthart Proença and Christopher Herzog. . . . . 211
4.3 Measuring Coronary Calcium
Jaap M. Groen, Marcel J. W. Greuter, and Matthijs Oudkerk . . . . . 223
4.4 Coronary Calcium as an Indicator of Coronary Artery Disease
Axel Schmermund, Stefan Möhlenkamp, and Raimund Erbel . . . . . 235
4.5 Epidemiology of Coronary Calcifi cation
Rozemarijn Vliegenthart Proença and Jacqueline C. M. Witteman. . . 247
4.6 Coronary Artery Calcium Screening: Current Status and
Recommendations from the European Society of Cardiac Radiology
and North American Society for Cardiovascular Imaging
Matthijs Oudkerk, Arthur E. Stillman, Sandra S. Halliburton,
Willi A. Kalender, Stefan Möhlenkamp, Cynthia H. McCollough,
Rozemarijn Vliegenthart Proença, Leslee J. Shaw,
William Stanford, Allen J. Taylor, Peter M. A. van Ooijen,
Lewis Wexler, and Paolo Raggi. . . . . . . . . . . . . . . . . . . . . . . . . 267
5 Multi-Dimensional Computed Cardiac Visualization
Peter M. A. van Ooijen, Wisnu Kristanto, Gonda J. de Jonge,
Caroline Kuehnel, Anja Hennemuth, Tobias Boskamp,
Jaap M. Groen, and André Broekema . . . . . . . . . . . . . . . . . . . . . . . . . 297
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
List of Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
1
Coronary Anatomy
1
Coronary Anatomy
Gonda J. de Jonge, Peter M. A. van Ooijen, Jean-Louis Sablayrolles,
Guido Ligabue, and Felix Zijlstra
CONTENTS
1.1
Introduction
1.1 Introduction 1
1.2 Physiological and Anatomical Bases 2
Knowledge of the physiology, normal and variant
1.3 Normal Coronary Anatomy 5 anatomy and anomalies of coronary circulation is
1.3.1 Left Coronary Anatomy 6
essential for the assessment of coronary disease.
1.3.1.1 Left Main Coronary Artery 6
1.3.1.2 Left Anterior Descending Coronary disease accounts for a high morbidity
Coronary Artery 6 and mortality, therefore, proper evaluation is nec-
1.3.1.3 The Circumfl ex Artery 7 essary.
1.3.2 Right Coronary Anatomy 7
Traditionally, the coronary arteries were evalu-
1.3.2.1 Right Coronary Artery 7
ated using conventional catheter coronary angiog-
1.3.2.2 Determination of Dominance 8
raphy. This technique, however, has some major
1.4 Visualization of the
disadvantages: The exact course of the coronary
Normal Coronary Artery Tree 8
arteries may be diffi cult to assess, because of their
1.4.1 Anatomy on
Catheter Coronary Angiography 8 complex three-dimensional anatomy which is dis-
1.4.2 Anatomy on Multi-detector CT 8 played in two dimensions. This is a major problem,
1.5 Anomalies of the Coronary Artery Tree 18 especially in the diagnosis of coronary artery anom-
1.5.1.1 Coronary Artery Fistula 18 alies. A misdiagnosis of the course of an anomalous
1.5.1.2 Anomalous Origin of a Coronary Artery coronary artery is reported to occur in up to 50%
from the Pulmonary Trunk 19 of cases (Schmid et al. 2006). Furthermore, catheter
1.5.1.3 Myocardial Bridging 20
coronary angiography only provides information on
1.5.2 Vessels Originating from the Contralateral
Side, With an Interarterial Course 20 the coronary artery lumen and not on the vessel wall,
1.5.2.1 Right-Sided Left Coronary Artery 20 and it is an invasive procedure with a morbidity and
1.5.2.2 Left-Sided Right Coronary Artery 20 mortality of 1.7% and 0.1%, respectively (Dikkers
1.5.2.3 Congenital Coronary Anomalies Not
et al. 2006). Therefore, a non-invasive alternative
Causing Myocardial Ischemia 23
was greatly desired.
References 24
In 1998, multi-detector computed tomography
(MDCT) was introduced and since then, cardiac CT
has played a major role in the evaluation of the cor-
G. J. de Jonge, MD; P. M. A. van Ooijen, PhD
onary arteries. Before the introduction of this new
Department of Radiology, University Medical Center
Groningen, University of Groningen, Hanzeplein 1, technique, electron beam computed tomography
P.O. Box 30.001, 9700 RB Groningen, The Netherlands (EBCT) had already been used to evaluate the heart,
J.-L. Sablayrolles, MD
but because of the inferior spatial resolution com-
Centre Cardiologique du Nord, 32–36 Rue de Moulins
pared with MDCT and the fact that it is not widely
Gémeaux, 93200 Saint Denis, France
G. Ligabue, MD available, EBCT does not play a major role in car-
Cattedra e Servizio di Radiologia, Policlinico di Modena, diac imaging today (Wintersperger and Nikolau
Via del Pozzo 71, 41100 Modena, Italy 2005).
F. Zijlstra, MD, PhD
With the advent of newer generations of CT scan-
Professor, Thorax-Center, Department of Cardiology,
ners, the 64-slice MDCT, and more recently, the
University Hospital Groningen, P.O. Box 30.001,
9700 RB Groningen, The Netherlands dual-source CT (DSCT), temporal and spatial reso-
