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Evaluation of Anatomy, Variation and Anomalies of the Coronary Arteries with Coronary Computed Tomography Angiography

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Evaluation of Anatomy, Variation and Anomalies of the Coronary Arteries with Coronary Computed Tomography Angiography 154 Review Derleme Evaluation of anatomy, variation and anomalies of the coronary arteries with coronary computed tomography angiography Koroner arterlerin anatomi, varyasyon ve anomalilerinin koroner bilgisayarlı tomografi anjiyografi ile değerlendirilmesi Cengiz Erol, Mustafa Koplay, Yahya Paksoy Department of Radiology, Selçuklu Faculty of Medicine, Selçuk University, Konya-Turkey ABSTRACT Recent technical advances in computed tomography (CT) have improved image quality, diagnostic performance and accuracy of coronary CT angiography (CCTA). Latest dose-reduction strategies reduce radiation dose to an acceptable level even lower than that from conventional coronary angiography. CCTA is a noninvasive imaging modality which can effectively show complex coronary artery anatomy, variations and congenital anomalies of the coronary arteries. Congenital coronary artery anomalies are rare entities, but sometimes have a potential of producing fatal consequences. CCTA is now the primary imaging modality for the evaluation and diagnosis of coronary artery anomalies. Reporters should, there- fore, have knowledge of the normal coronary artery anatomy and variations, and understand the different types of coronary artery anomalies and their respective prognostic implications in order to provide correct diagnosis and to prevent undesirable mistakes during interventional and surgi- cal procedures. (Anadolu Kardiyol Derg 2013; 13: 154-64) Key words: Coronary artery anatomy, variation, anomalies, coronary computed tomography angiography ÖZET Bilgisayarlı tomografi (BT) teknolojisinde yaşanan teknik ilerlemeler koroner BT anjiyografinin görüntü kalitesinde, tanısal performansında ve doğ- ruluğunda iyileşmelere yol açmıştır. Yeni geliştirilen doz düşürmeye yönelik stratejiler sayesinde radyasyon dozu kabul edilebilir düzeylere ve hatta konvansiyonel koroner anjiyografi değerlerinin altına inmiştir. Koroner BT anjiyografi invaziv olmayan bir görüntüleme yöntemi olup koroner arter- lerin kompleks anatomisini, varyasyonlarını ve konjenital anomalilerini etkili bir şekilde göstermektedir. Konjenital koroner arter anomalileri nadir görülen patolojiler olsa da bazen hayatı tehdit edebilen sonuçlar doğurma potansiyeline sahiptir. Koroner BT anjiyografi günümüzde koroner arter anomalilerinin tanısında primer görüntüleme yöntemi olarak kullanılmaktadır. Bu nedenle raporlayıcıların doğru tanı koyabilmeleri ve cerrahi ve girişimsel işlemler sırasında istenmeyen hataları önleyebilmeleri için koroner arter anatomisini, varyasyonlarını ve koroner arter anomalilerinin farklı tiplerini ve bunların prognostik sonuçlarını bilmeleri gereklidir. (Anadolu Kardiyol Derg 2013; 13: 154-64) Anahtar kelimeler: Koroner arter anatomisi, varyasyon, anomali, koroner bilgisayarlı tomografi anjiyografi Introduction the development of new imaging modalities that is noninvasive, fast and effective. Recent technical advances in computed Conventional coronary angiography (CCA) is the gold stan- tomography (CT) have improved image quality, diagnostic perfor- dard imaging modality for the evaluation of coronary artery dis- mance and accuracy of coronary CT angiography (CCTA) (1). ease, which is the leading cause of mortality and disability in The main factors that determine the quality of CCTA are spa- developed countries. CCA has also a risk of morbidity and mor- tial resolution, temporal resolution and volume coverage (2). We tality, and invasive nature of this expensive technique has led to need high spatial resolution to visualize the small diameter coro- Address for Correspondence/Yaz›şma Adresi: Dr. Cengiz Erol, Selçuk Üniversitesi Selçuklu Tıp Fakültesi, Radyoloji Anabilim Dalı, Alaeddin Keykubat Merkez Kampüs, 42250, Selçuklu, Konya-Türkiye Phone: +90 332 241 50 00-41124 Fax:+90 332 241 60 65 E-mail: [email protected] Accepted Date/Kabul Tarihi: 09.07.2012 Available Online Date/Çevrimiçi Yayın Tarihi: 17.12.2012 ©Telif Hakk› 2013 AVES Yay›nc›l›k Ltd. Şti. - Makale metnine www.anakarder.com web sayfas›ndan ulaş›labilir. ©Copyright 2013 by AVES Yay›nc›l›k Ltd. - Available on-line at www.anakarder.com doi:10.5152/akd.2013.041 Anadolu Kardiyol Derg Erol et al. 2013; 13: 154-64 Coronary computed tomography angiography 155 nary arteries and to detect coronary atherosclerosis. Spatial bular junction which demarcates the aortic root from the resolution of new generation CT scanners is about 0.4 mm which ascending aorta. Aortic root has three small dilatations called is inferior from spatial resolution of CCA (0.1 mm). The temporal the coronary sinuses (Fig. 1a). More anteriorly located right resolution of current cardiac CT scanners ranges from 135 to coronary sinus (RCS) gives rise to the right coronary artery 175 ms, and it is possible now to reach a true temporal resolution (RCA) and the left main coronary artery (LMCA) arises from of 75 ms with dual source imaging. These values are satisfactory more cephaladly located the left coronary sinus (LCS) (Fig. 1b). to image the heart in diastole without motion artifacts related to The posteriorly located aortic sinus normally does not give rise heart beating, nevermore very far away from excellent temporal to a coronary artery and named as the noncoronary sinus (10). resolution of CCA (4-7ms). New CT scanners have 64-320 detec- tor numbers. An anatomic coverage of 16 cm in one rotation is Right coronary artery achieved with 320 detector elements which permit to image the After originated from the RCS, the RCA runs downwards in heart in a single rotation within a single heart beat (2). the right atrioventricular groove to reach the cardiac crux. The Radiation dose concerns regarding associated malignancy first branch of the RCA is the conus artery in most of the cases risk with CCTA have been progressively raised (1). In recent which supply the right ventricular outflow tract (Fig. 2a-c). In a years, the main challenge of CCTA is to reduce radiation dose to small proportion (11.6 to 22%), the conus artery has an origin an acceptable level lower than that from CCA by the dose- directly from the aorta (Fig. 3a) which sometimes causes prob- reduction strategies such as tube current modulation, prospec- lems during ventriculostomy used to treat ventricular septal tively gated sequential scanning, high-pitch dual source spiral defect or pulmonary stenosis (9, 11). The sinoatrial node artery scanning and iterative reconstruction (1, 2). It is now possible to originates from the RCA as the second branch in 55 to 65% of complete a CCTA examination in approximately 1-4 mSv and patients (Fig. 2a) and from the proximal left circumflex artery even lower than 1 mSv (1). For example, in a patient who has (LCx) in 35 to 45% of the population (Fig. 3a) (10, 12, 13). It can heart rates below 65 beats per minute, high-pitch dual source also originate directly from the LCS, RCS, LMCA, (Fig. 3b and 3c) spiral scanning with 256 slice CT allows us to complete a CCTA or from the ascending aorta in a small percentage of patients in a single heart beat with a radiation dose under 1 mSv (2). (0.7%) (13). It courses dorsally towards lateromedial aspect of Document on appropriate use criteria for CCTA, released in the right atrium. The middle RCA gives rise to several right ven- 2010, greatly expands the number of CCTA indications (3). It is tricular branches which supply the anterior free wall of the right very clear that CCTA will gain much a wider application in the ventricle. The largest of them called as the acute marginal field of cardiovascular imaging in the future and supersede CCA branch that runs along the acute margin from base to apex (Fig. as the imaging modality of choice for a broad spectrum of car- 2a). The atrioventricular node artery generally originates from diac pathologies (1, 4, 5). Generally, CCTA is the appropriate the dominant coronary artery (Fig. 2c) (13). In right coronary imaging modality for diagnosis or risk assessment in patients dominancy, the RCA gives off the posterior descending artery with an otherwise low or intermediate risk of coronary artery (PDA) and the posterolateral branch artery (PLB) which perfuse disease, and is usually inappropriate for patients at high risk. the posterior interventricular septum and the inferior left ven- CCA is unable to provide sufficient information about the tricular wall, respectively (Fig. 2c). The RCA is divided into 3 complex anatomy of an anomalous coronary artery because of segments. The proximal segment runs between the ostium and its distinctive two-dimensional feature, and can detect only the right ventricular branch. The middle segment is from this 31-55% of anomalies (6, 7). However, CCTA is better than CCA in point to the acute marginal branch and after, the distal segment showing origin, course and termination of the coronary artery, courses towards the crux of the heart. and its relationship to the great arteries and cardiac structures by using multiplanar reformation, three-dimensional volume- Coronary dominance rendering and maximum intensity projection techniques (4-6). Coronary dominance is determined by observing which cor- CCTA sensitivity in visualization of coronary artery anomalies onary artery passes over the crux of the heart and gives off the (CAA) is 100% (7, 8). Because of this, CCTA has currently PDA. Mainly, the co-dominance is a state where branches from become the method of choice for the diagnosis and preoperative both the distal RCA and the distal LCx supply the posterior inter- evaluation of CAAs (4, 9). However, training in coronary imaging ventricular
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