SPC365

Coronary computed tomography angiography before invasive coronary angiography in CABG patients

Session: Comunicações Orais - Sessão 06 - Doença coronária
Speaker: João Baltazar Ferreira

Congress: CPC 2024
Topic: H. Interventional Cardiology and Cardiovascular Surgery
Theme: 12. Coronary Artery Disease (Chronic)
Subtheme: 12.3 Coronary Artery Disease – Diagnostic Methods
Session Type: Comunicações Orais
FP Number: ---
Authors: João Baltazar Ferreira; Inês Pereira de Miranda; Cátia Ribeiro; Pedro Magno; José Loureiro; Miguel Santos; Luis Brízida; João Bicho Augusto; Pedro Farto e Abreu; Sérgio Bravo Baptista

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><strong><span style="font-size:11.0pt">Background</span></strong></span></span></p>

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Invasive coronary angiography (ICA) in patients who have coronary artery bypass grafts (CABG) is often a challenging procedure. Problems&nbsp;may include high exposition to elevated radiation doses, elevated iodine contrast doses, complications associated with ICA, and, ultimately, it may lead to an incomplete assessment of the coronary bypasses. Coronary computed tomography angiography (CCTA) may be useful, allowing a better description of bypass grafts&rsquo; location, type and patency before the invasive procedure.</span></span></span></p>

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><strong><span style="font-size:11.0pt">Objective</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">To evaluate the benefits of CCTA before ICA in patients who had previously&nbsp;underwent CABG.</span></span></span></p>

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><strong><span style="font-size:11.0pt">Methods</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Single-center prospective randomized trial with an experimental arm with CCTA as first-line exam (where&nbsp;ICA was only performed if CCTA was not conclusive or if it showed disease requiring&nbsp;further assessment and/or treatment) and an&nbsp;active comparator arm with ICA as first-line exam (where&nbsp;CCTA was performed&nbsp;if ICA was considered inconclusive)&nbsp;(see figure).&nbsp;</span></span></span><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Patients with prior CABG and a clinical indication for ICA between April 2021 and July 2023 were included. Exclusion criteria were glomerular filtration rate &lt;30 mL/kg/1.73m<sup>2</sup>, CCTA or ICA in the previous 6 months,&nbsp;indication for emergent ICA, previous important adverse reaction to iodine contrast, confirmed or suspected thoracic neoplasia, uncontrolled arrhythmia and pregnancy.</span></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Primary endpoint was the total volume of iodinated contrast. Secondary endpoints included (1) total cumulative radiation exposure, (2) total ICA time and radiation exposure, (3) percentage of patients in whom routine CCTA was enough, (4) percentage of patients in whom routine ICA was not enough and (5) change in creatinine at 48h and at 5 days after the last diagnostic procedure. </span></span></span></p>

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><strong><span style="font-size:11.0pt">Results</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">46 patients were randomized, 50% to each arm. Mean age was 72&plusmn;8 years and 80.4% were male.</span></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Mean total volume of iodinated contrast was significantly less in the intervention group (181 vs 268 mL; p=0.005). </span></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Mean total cumulative radiation dose was similar between the two groups (27.3&nbsp;vs 36.5 mSv; p=0.138). Mean total ICA time and mean total radiation dose in ICA were similar between the experimental and comparator arm ([40.8 vs 40.3 min; p=0.911] and [35.2&nbsp;vs 32.9 </span><span style="font-size:11.0pt">mSv; </span><span style="font-size:11.0pt">p=0.702], respectively). CCTA avoided subsequent ICA in 48% of patients in the intervention group and 21.7% of patients in the control group needed additional CCTA. Changes in creatinine at 48h and 5 days after the last diagnostic procedure did not differ&nbsp;significantly&nbsp;between the two groups (+0.08 vs +0.18 mg/dL; p=0.172 at 48h and +0.07 vs +0.33 mg/dL; p=0.149 after 5 days).</span></span></span></p>

<p><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><strong><span style="font-size:11.0pt">Conclusion</span></strong></span></span></p>

<p style="text-align:justify"><span style="font-family:Arial,Helvetica,sans-serif"><span style="font-size:12pt"><span style="font-size:11.0pt">Performing routine CCTA before ICA, as compared to performing routine ICA, in patients with prior CABG, reduces the total volume of iodinated contrast without a significant increase in total radiation exposure. Routine CCTA avoided subsequent ICA in almost half the patients in the intervention group.</span></span></span></p>