Noncalcified plaque burden quantified from coronary computed tomography angiography improves prediction of side branch occlusion after main vessel stenting in bifurcation lesions: results from the CT-PRECISION registry

Abstract

Objectives: To assess the incremental value of quantitative plaque features measured from computed tomography angiography (CTA) for predicting side branch (SB) occlusion in coronary bifurcation intervention.

Methods: We included 340 patients with 377 bifurcation lesions in the post hoc analysis of the CT-PRECISION registry. Each bifurcation was divided into three segments: the proximal main vessel (MV), the distal MV, and the SB. Segments with evidence of coronary plaque were analyzed using semi-automated software allowing for quantitative analysis of coronary plaque morphology and stenosis. Coronary plaque measurements included calcified and noncalcified plaque volumes, and corresponding burdens (respective plaque volumes × 100%/vessel volume), remodeling index, and stenosis.

Results: SB occlusion occurred in 28 of 377 bifurcation lesions (7.5%). The presence of visually identified plaque in the SB segment, but not in the proximal and distal MV segments, was the only qualitative parameter that predicted SB occlusion with an area under the curve (AUC) of 0.792. Among quantitative plaque parameters calculated for the SB segment, the addition of noncalcified plaque burden (AUC 0.840, p = 0.003) and low-density plaque burden (AUC 0.836, p = 0.012) yielded significant improvements in predicting SB occlusion. Using receiver operating characteristic curve analysis, optimal cut-offs for noncalcified plaque burden and low-density plaque burden were > 33.6% (86% sensitivity and 78% specificity) and > 0.9% (89% sensitivity and 73% specificity), respectively.

Conclusions: CTA-derived noncalcified plaque burden, when added to the visually identified SB plaque, significantly improves the prediction of SB occlusion in coronary bifurcation intervention.

Trial registration: ClinicalTrials.gov Identifier: NCT03709836 registered on October 17, 2018.

Keywords: Coronary artery disease; Coronary bifurcation; Coronary computed tomography angiography; Percutaneous coronary intervention; Plaque burden.

Fig. 1

Study flowchart

Fig. 2

An example of the coronary bifurcation lesion in invasive angiography (a) and its corresponding image in computed tomography angiography (b). Plaque was quantitatively analyzed in the respective bifurcation segments: proximal main vessel (c), distal main vessel (d) and side branch (e). Blue represents lumen, yellow—calcified plaque, and red—noncalcified plaque. In the above lesion, coronary plaque—defined as tissue greater than 1 mm² associated with the coronary wall—was present only in the proximal segment of the main vessel

Fig. 3

Comparison of plaque volumes in respective bifurcation segments with and without SB occlusion

Fig. 4

Comparison of plaque burden in respective bifurcation segments with and without SB occlusion

Fig. 5

Receiver operative characteristic curves for predicting side branch (SB) occlusion based on visual plaque identification in the SB and addition of noncalcified or low-density plaque burdens