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Correlation between Intravascular Ultrasound
and Multi-Detector Computed Tomography in Assessment of Coronary Lesion in Patients with
Ischemic Heart Disease
Khaled Emad elrabbat1, Ali Ibrahim Attia1, Hany Hassan Ebaid1* and Ehab Khairy Abdelshakour2
1Department of Cardiology, Benha University, Egypt
2Department of Cardiology, Military Production Hospital, Egypt
Submission: April 01, 2019; Published: April 18, 2019
*Corresponding author: Hany Hassan Ebaid, Department of Cardiology, Benha University, Benha, 5 kamel hegazy street, kafr shukr kalubia, Egypt
How to cite this article:Khaled E e, Ali I A, Hany H E, Ehab K A. Correlation between Intravascular Ultrasound and Multi-Detector Computed Tomography in
Assessment of Coronary Lesion in Patients with Ischemic Heart Disease. J Cardiol & Cardiovasc Ther. 2019; 13(5): 555871. DOI: 10.19080/JOCCT.2019.13.555871
Objectives: To correlate multi-detector computed tomography (MDCT) with intra vascular ultrasound (IVUS) for assessment of coronary circulation.
Patients and Methods: This prospective comparative study was held in the cardiovascular department of Benha University Hospital and Military Production Hospital in the period between May 2016 and May 2018. Fifty patients with ischemic heart disease were included in this study and planned for coronary angiography. MDCT and IVUS were performed within 72 hours before coronary angiography. Coronary dimensions were obtained by both techniques. All measurements were collected and compared at the level of patient, vessel and segment.
Results:Impaired level profile was the most prevalent risk factor (62%). At all levels, using both IVUS and MDCT, minimal luminal area, minimal luminal diameter and plaque burden were highly correlated, and this correlation was statistically significant (P<0.001).
Conclusion:MDCT shows significant correlation with IVUS for the assessment of coronary lumens’ dimensions regardless to plaque burden even (>40%) or (<40%).
Undoubtedly, ischemic heart disease (IHD) causes major morbidities and represents 53% of all death worldwide . Its clinical presentation is highly variable. Patients may complaint of chronic stable angina, unstable angina, prinzemtal angina or acute myocardial infarction. However, it may be asymptomatic (silent ischemia) or complicated with heart failure, cardiac arrhythmia or sudden cardiac death .
The degree of coronary luminal narrowing is universally used to aid in the diagnosis as well as designing the therapeutic interventions . Intravascular ultrasonography (IVUS) is the invasive gold standard method for anatomical assessment of coronary lesion. It allows visualization of the cross-sectional image of coronary artery and this modality helps to quantify plaque burden, artery size and luminal stenosis .
Various non- invasive methods for coronary lumen assessment and atherosclerotic plaque detection had been used. Multi-detector computed tomography (MDCT) is one of them. It
gives excellent image quality and high diagnostic accuracy when compared with other methods . CT image does not provide only coronary luminography, as it also adds more information about plaque morphology, plaque burden and the plaque remodeling degree .
Different authors had previously compared MDCT with IVUS, indicating a good agreement between these two methods [7,8]. Data showed that both techniques appeared to be highly accurate for estimating luminal area, plaque volume, plaque burden as well as detecting plaque morphology . It was crucial to evaluate the accordance between MDCT and IVUS in a detailed manner according to local settings and practice. Thus, our study aimed
to comprehensively investigate quantitative measurements of
coronary lumen dimensions using MDCT and IVUS.
The study was conducted on IHD patients of both sexes
and any age at cardiovascular department of Benha University
Hospital and Military Production Hospital in the period between
May 2016 and May 2018 after approval from the local research
ethics committee. All patients planned for coronary angiography
were explained the criteria of enrollment in the study as well as
the description of the two tested interventions. Out of 72 patients
who met our inclusion criteria, 55 patients agreed to be enrolled
in the study. Eligible participants signed a written informed
consent form before the beginning of the trial. Five patients, who
developed allergy during intervention, were excluded.
We excluded patients who had one of the following criteria:
acute myocardial infarction, previous stenting, documented
allergy of intravenous contrast medium and renal insufficiency
(creatinine >1.5 mg/dl) that contraindicated its administration.
Patients with findings suggestive of suspected pregnancy, heart
rate (>80bpm) or arrhythmias, contraindication to coronary
angiography such as high risk of bleeding, heavy calcification (Ca
score >600) and patients having obstacles in undergoing the CT,
like improper breath holders were also excluded.
All patients were subjected to history taking (including
age, gender and major contributing factors for Coronary artery
disease (CAD) e; HTN, DM, Smoking, and dyslipidemia), clinical
examination (vital signs, general examination and local cardiac
examination) and routine laboratory test including (CBC, renal
function and lipid profile).
All patients were referred to do MDCT and IVUS within 72 hour
before coronary angiography. Measurements including minimal
luminal area, minimal luminal diameter and plaque burden were
obtained by both techniques and compared at patient, vessel and
Before the procedure, patients with heart rate (>65bpm)
received beta-blocker before the acquisition of MDCT image,
unless contraindicated due to specific clinical situation. All
patients were instructed that how to hold breath, as it is crucial for
the exam, told and reassured about the side effects of the contrast
as warm sensation in the body after injection. Intravenous
injection of contrast agent, lopromide (Ultravist 370/ml solution
for injection@ Bayer limited, Germany) and when a threshold of
180 Hounsfield units (HU) was reached, at descending aorta, the
helical scan for MDCT was obtained.
The following parameters were assessed:
• Coronary calcium score: It allowed quantification of
coronary calcium using dedicated software.
• Minimal luminal area and stenosis grading: At the
site of the maximum narrowing of the coronary segment, it
was studied using double-oblique short axis and luminal
cross sectional area measurements were obtained, then the
percentage of luminal stenosis was also calculated by (MLA/
corresponding reference lumen area) x100 and classified to
mild stenosis <50%, moderate stenosis>50<75% and severe
• Plaque volume: It was measured using the equation
of multiplying the total plaque areas of the studied crosssections
by their thickness. Small side branches were ruled
out to avoid small non measurable plaques (beyond the CT
• Plaque burden quantification: was calculated by (Plaque
volume X100/vessel volume). Plaque burden were calculated
It was conducted with meticulous adherence to the standard
protocol. After the vascular access was achieved through the
femoral artery by “Seldinger technique” using 7f sheath, IVUS
examination was started using a dedicated IVUS console (Volcano
Corporation). Intracoronary nitrate was administrated then IVUS
catheter was adjusted to a suitable position at distal coronary
segment and was pulled back toward the ostium of coronary
artery at continuous speed 0.5mm/s and assessment of all the
following: Luminal and external elastic lamina, Athermanous
area, Minimal luminal area and Plaque burden.
Statistical analysis was performed on a personal computer
using IBM SPSS Statistics version 21 (IBM Corp., Armonk, NY).
The data was test for the normality of distribution of numerical
data by Kolmogorov–Smirnov goodness. The normally distributed
numerical data were presented as mean ± SD, while the paired
samples student t test was used to test the in-between groups’
differences. Also, the categorical data were presented as number
and percentage. Parameters were compared by “Wilcoxon
signed ranks test” and correlated using “Pearson’s and spearman
coefficients”. Two-tailed P values < 0.05 were considered
The study population consisted of 50 patients who had
coronary artery disease with different presentations and planned
for coronary angiography. 72% of study participants were men
and the mean age was 56.3 years. Dyslipidemia was the most
prevalent risk factor followed by hypertension and smoking.
Chronic stable angina and unstable angina were the two main
presentations. After MDCT and coronary angiography were
performed, single vessel disease was the commonest finding
and multi-vessel involvement was the least encountered one.
73 vessels (1.4 vessels per patient) were visualized and the left
anterior descending vessel was the most viewed one as shown in
(Table 1). Also, 73 plaques were detected by using IVUS (63 with
plaque burden more than 40% with remaining 10 with plaque
burden less than 40%).
The revealed data at the patient and vessel levels, the
measurement of reference luminal area, reference luminal
diameter, minimal luminal area, minimal luminal diameter and
plaque burden showed high statistically significant correlation
between IVUS and MDCT (P<.001) as shown in (Table 2). The
parameters’ differences between both techniques with 95% limits
of agreement were calculated for evaluation of their concordance
as presented in (Figure 1).
(Figure 2) revealed that, regardless plaque burden (>40%
or <40%), MDCT and IVUS were significantly correlated at the
segment level with (P<0.001) though the high mean absolute
differences that were detected among segments with plaque
CAD is the commonest heart disease that causes death due to
heart attacks. It is caused mainly by developing a plaque along the
interiors of the coronaries, which narrows the arteries’ lumens
and reduces their blood flow. It is a prevalent cause of hospital
admissions and deaths worldwide .
IVUS was considered the best, but invasive method in
evaluating and assessment of coronary lumen and athermanous
plaque . It provides valuable data regarding stenosis
severity, lumen and vessel morphology, lesion length and plaque
characteristics . On the other hand, MDCT has been used
in diagnosis of coronary artery disease as it improved spatial
resolution and temporal resolution of the images. Thus, MDCT
proved to be a reliable alternative to invasive method with high
diagnostic accuracy [13,14].
Our study which was carried on 50 patients known to
suffer from coronary artery disease and planned for coronary
angiography (imaged vessels 73). All measurement obtained by
MDCT and IVUS including (MLA, MLD and plaque burden) were
compared at patient and vessel levels. Our study reported that,
there is a high correlation between MDCT and IVUS (p<0.001) for
assessment of coronary lumen. Also, with any given plaque burden
(>40% or <40%), MDCT and IVUS were statistically correlated
with high significance (P<0.00) at segment level.
With the rising involvement of MDCT in management of CAD,
it is critical to overview its relationship with IVUS as well their
diagnostic accuracy to obtain minimal luminal diameter, minimal
luminal area and plaque burden. It was agreed that MDCT could
provide useful data in managing for patients with CAD [15,16].
Different reports regarding the diversity of MDCT and IVUS
parameters had been published. Mostly, the variation originated
from changes of lesion criteria, lesion intensity, methodological
designs and different sample sizes [17-23].
Our study was supported and in agreement with those
reported by Alexander et al.  who studied 59 patients. Their
study showed that, measurements of coronary lumen by MDCT
correlated well with IVUS [MLA correlation r=0.81 (p<0.001), MLD
correlation r=0.78 (p<0.001) and plaque area r=0.72 (p<.001)].
Also, Caussin et al.  who 54 imaged vessels with 30%
to 70% stenosis in a major coronary vessel, showed that there
was a good correlation between MDCT and IVUS in assessment
of coronary lumens including MLD, MLA and atherosclerotic
plaque burden [(r=0.88, 0.846 and 0.806 respectively (P<0.001)].
Moreover, Papadopoulou et al.  showed that there was
excellent agreement between MDCT and IVUS for measurement
of MLA and atherosclerotic plaque burden [r=0.87 and r=0.79
respectively with (p<0.001)].
Some results pointed the MDCT potential to determine
coronary atherosclerotic plaque in cases without significant
coronary stenosis, but with further advancements in image
quality that would be necessary to reach more reliable
assessment, especially of non-calcified plaque throughout the
coronary circulation . Others stated that although the density
measurements were highly dependent on slice width as well as
the enhancement of contrast medium, the results indicated that
more methodology standardization was required till the CT
non-invasive detection of coronary plaque morphology could be
announced as a primary screening tool for coronary plaques in
any clinical setting .
However, the MDCT measurements, apart from being
significantly correlated with IVUS, slightly gave relatively vast margin of error through lower measurements of both lumen
area and minimal lumen diameter . Cademartiri et al. 
showed that plaque attenuation was significantly affected by the
lumen attenuation measured by CT. It was a direct proportionate
relationship more lumen attenuation meant more plaque
attenuation detected. On the other hand, both calcium and
surrounding fat attenuation were not significantly affected.
Basically, tracing coronary lumen and plaque borders by the
use of a semiautomatic tool, using aortic lumen attenuation, could
underrate plaque affected segments’ luminal area and therefore
decrease the CT specificity to detect the non-significantly affected
segments by the use of IVUS. To sum up, MDCT gave acceptable
alternative that provided good overall predictive accuracy in
detecting markers of the limited flow in coronary lesions as
luminal area < 4.0 mm² or MLA < 1.8 mm .
In conclusion, the newly advanced state of art MSCT, being
significantly correlated with IVUS with or without significant
plaques, can identify mildly stenotic coronary lesions and aid the
assessment of its morphology and remodeling management.
Of course, our study had some limitations. Increasing motions
artifacts, in patients with heart rate more than 70 bpm during MDCT,
limited the study even with the use of beta blockers. Our study
population had a high prevalence of risk factors, which limited the
generalizability of the study results to multiple clinical scenarios.
Also, the correlation between MDCT and IVUS measurements
could be altered by excluding patients with coronary calcium
score >600. Conducting multi-center comprehensive trial with
bigger sample size to confirm our results is recommended.