Three Technologies That Will Guide Revascularization of Chronic Coronary Syndrome Patients into the 21st Century: A Review

Abstract

Although medical therapy is the preferred first-line treatment for patients with chronic coronary syndrome (CCS), revascularization remains an important consideration. We present a review that identifies the three diagnostic technologies most important to guiding the decision to revascularize patients with CCS: (1) cardiac computed tomography, (2) intracoronary imaging, and (3) lesion-specific physiological guidance.

Keywords: cardiac computed tomography; chronic coronary syndrome; fractional flow reserve; instantaneous wave-free ratio; intravascular ultrasound; medical therapy; optical coherence tomography; revascularization.

Fig. 1

Cardiac computed tomography (CT) of a mild-to-moderate coronary artery stenosis with computed tomography fractional flow reserve (CT-FFR) and angiographic correlation. ( A, B ) Curved planar reformats of the left anterior descending artery showing a large focal plaque. ( C, D ) Closeup of double oblique multiplanar reformatted images with lumen measurements at the site of greatest stenosis and at the distal normal lumen. ( E ) CT-FFR with a value distal to the left anterior descending lesion of 0.87. ( F ) Angiographic image. White arrow = lesion.

Fig. 2

Intravascular ultrasound (IVUS) of pre- and post-percutaneous coronary intervention. ( A ) An IVUS image of a diseased coronary artery. ( B ) The same coronary artery segment after percutaneous coronary intervention. After intervention, the lumen area is much larger compared with preintervention. The white star indicates the IVUS catheter lumen. The red star indicates the atherosclerotic plaque.

Fig. 3

Optical coherence tomography image of a culprit lesion. The image at the top is a cross-sectional view of the culprit lesion in a coronary artery. A calcified plaque and a lipid plaque can be identified. The image at the bottom is a longitudinal view of the same coronary artery segment. This longitudinal view gives an accurate assessment of the length of the lesion, which can be used to optimize percutaneous coronary intervention. Image courtesy of Dr. Mark Rabbat M.D. from Loyola University Medical Center.

Fig. 4

Optical coherence tomography illustrating intracoronary and stent thrombus. ( A ) De novo intracoronary thrombus. ( B ) Stent thrombosis. The white star indicates the thrombi. The intracoronary and stent lumen is outlined by the dotted line in both images.

Fig. 5

Fractional flow reserve (FFR) in an angiographically moderate coronary artery stenosis. ( A ) A coronary angiogram of the left coronary system in a right anterior oblique cranial projection. The mid left anterior descending coronary artery has an angiographically moderate stenosis of 50 to 60% (white arrow). ( B ) The FFR assessment of this stenosis, which is positive with a value of 0.76 (<0.80 is considered positive). ( C ) The same segment after percutaneous coronary intervention with placement of a drug-eluting stent (red arrow).

Fig. 6

Instantaneous wave-free ratio (iFR) in an angiographically moderate coronary artery stenosis. ( A ) A coronary angiogram of the left coronary system in an anteroposterior caudal projection. The obtuse marginal-1 vessel has a long 50 to 70% stenosis (white arrow). An iFR wire can be seen in the obtuse marginal-1 branch (red arrow). ( B ) The iFR pressure tracings with a final value of 0.97. As seen in the image, multiple runs were performed, and all iFR values were negative (>0.89).