oronary artery disease (CAD) and its thrombotic complications are the leading cause of morbidity and mortality in the industrialized countries. Over the past 30 years, invasive coronary angiography (ICAG) has been the gold standard method for the visualization and detection of coronary stenosis. Recently, efforts have been made to develop reliable noninvasive diagnostic methods that would allow a broader use, as well as decreasing the risks linked to an invasive examination.Multislice computed tomography (MSCT), which started with a 4-slice scanner in 1998, was the beginning of visualizing the coronary arteries noninvasively, 1-9 and with the development of 16-slice MSCT, this desire has been realized to some extent. To date, many investigators have evaluated the accuracy of MSCT for detecting significant coronary stenosis and in most of the published studies the sensitivity is approximately 80% and the specificity approximately 90%. [10][11][12][13][14][15][16][17][18][19] The results appear promising, but those studies did not consist of consecutive patients, including those with unsatisfactory images for interpretation. Besides, cases with severe calcification, high heart rates (>70 beats/min), or previous revascularization, were excluded from most of the studies.In daily practice, however, we often encounter patients with advanced CAD, having severely calcified arteries, or patients who are post percutaneous coronary intervention (PCI) using different treatment modalities such as stenting, plain old balloon dilatation, or debulking.The new 64-slice MSCT (64-MSCT), which provides a 0.4 mm isotropic resolution and less than 165 ms temporal resolution, has the potential to overcome image-degrading artifacts related to motion, pixel noise, calcification or coronary stents to some extent. 20,21 The aim of our study was to evaluate the diagnostic accuracy of 64-MSCT in various types of patients, including those with severely calcified arteries or post-PCI, as Background Multislice computed tomography (MSCT) is a promising noninvasive method of detecting coronary artery disease (CAD). However, most data have been obtained in selected series of patients. The purpose of the present study was to investigate the accuracy of 64-slice MSCT (64 MSCT) in daily practice, without any patient selection. Methods and ResultsUsing 64-slice MSCT coronary angiography (CTA), 69 consecutive patients, 39 (57%) of whom had previously undergone stent implantation, were evaluated. The mean heart rate during scan was 72 beats/min, scan time 13.6 s and the amount of contrast media 72 mL. The mean time span between invasive coronary angiography (ICAG) and CTA was 6 days. Significant stenosis was defined as a diameter reduction of >50%. Of 966 segments, 884 (92%) were assessable. Compared with ICAG, the sensitivity of CTA to diagnose significant stenosis was 90%, specificity 94%, positive predictive value (PPV) 89% and negative predictive value (NPV) 95%. With regard to 58 stented lesions, the sensitivity, specificity, PPV and NPV were 93...

ObjectivesThis study sought to evaluate the diagnostic accuracy of coronary binary in-stent restenosis (ISR) with angiography using 64-slice multislice computed tomography coronary angiography (CTCA) compared with invasive coronary angiography (ICA).

uidewire crossing is the most important component of a successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Several special guidewires, such as the Magnum wire, [1][2][3] Laser wire 4-6 and hydrophilic wire, 7 have been developed and favorable results have been reported. Other than these guidewires, some Japanese products, such as the Athlete, Miracle, and Conquest wires (Asahi Intecc, Seto, Japan), 8 are used in some countries and constitute a range of stiff products. In particular, the Conquest wire is a tapered spring coil wire with a very stiff tip (9 g) that gives good torque control and penetrating ability even in hard fibrous plaque. This type of guidewire may be the last choice for uncrossable, very old CTOs. 8 Although the Athlete wires will advance into a false lumen at the end of the procedure in unsuccessful cases, we can also use them to penetrate the flap to re-enter the true lumen as a second step.Coronary angiography is limited as a guide for guidewire crossing in PCI for CTOs. On the other hand, by showing the cross-sectional anatomy of the coronary vessels, intravascular ultrasound (IVUS) can provide information on the plaque morphology and distribution, 9 and the exact location of the guidewires within a coronary artery, discriminating a false lumen from the true lumen before guidewire crossing. We report here a novel application of IVUS for very old and hard CTOs (abrupt occlusion with a side branch in case 1 and bending occlusion with severe calcification in case 2) in which the use of very stiff guidewires caused dissections, decreasing the collateral flow. Case Reports Case 1: Side Branch MethodA 68-year-old Japanese man had experienced chest oppression on effort since May 2000. He visited hospital in July 2000, and coronary angiography revealed a CTO in the proximal segment of the large left circumflex coronary artery (LCX). There was no significant stenosis in the left anterior descending coronary artery (LAD) or the right coronary artery (RCA). His coronary arteries were left dominant. He had not had any episodes suggestive of acute myocardial infarction. Cardiac catheterization revealed left ventricular dysfunction and moderate mitral regurgitation. PCI for the CTO was unsuccessful at that time. He was treated medically and his condition improved. However, he complained of chest oppression on effort again in October 2001. We attempted to re-open the CTO of the LCX. The age of this CTO was unknown, but was thought to be more than 18 months, based on the angiographic record. We obtained the consent of the patient after fully explaining the efficacy and risks associated with our new technique using IVUS before the PCI.The occlusion was severely calcified and flush with the orifice of the vessel, tapering nicely into a large obtuse marginal artery (Fig 1a). A 10Fr JCL 4.0 with a side hole (Bright Chip, Cordis, Miami, FL, USA) was used in order to prepare for the possible use of a rotablator with a 2.5-mm burr. A 2.9Fr IVUS catheter (Ultracross, Boston Sci...

SUMMARYWe evaluated the influence of diabetes on plaque volume and vessel size at a reference segment in diabetic patients undergoing percutaneous coronary intervention using both angiograms and quantitative intravascular ultrasound. A total of 344 patients with 449 de novo coronary lesions including 97 diabetics (133 lesions) who underwent elective percutaneous coronary intervention under intravascular ultrasound guidance were included in this study. Eleven diabetic patients (19 lesions) received insulin and 52 patients (77 lesions) oral hypoglycemic drugs. The other 34 patients (37 lesions) received diet/exercise therapy alone. We measured vessel area (VA) and lumen area (LA) at proximal and distal reference segments by intravascular ultrasound, which were averaged. Plaque area (VA-LA) and % plaque area (100 × plaque area/VA) were subsequently calculated. Although VA was similar between diabetic and non-diabetic patients (13.46 ± 4.49 mm 2 in diabetics versus 14.11 ± 5.24 mm 2 in non-diabetics, P = 0.214), LA was smaller (6.51 ± 2.63 mm 2 versus 7.38 ± 3.08 mm 2 , P = 0.004) and % PA was larger (50.4 ± 11.7 versus 46.5 ± 11.3, P < 0.001) in diabetic patients, especially the group receiving a hypoglycemic drug or insulin. VA, LA, and % PA were similar between patients with and without insulin treatment. These results potentially might cause undersized device selection without intravascular ultrasound guidance. (Jpn Heart J 2004; 45: 573-580)

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