Hendrik's Chronic Coronary Artery Disease Journey

Coronary artery disease (CAD) is the number one cause of death worldwide

claiming over nine million lives each year.¹ CAD, sometimes also called coronary heart disease or ischemic heart disease is a chronic inflammatory disease of the coronary arteries and the most common type of heart disease. It involves heart problems caused by narrowed coronary arteries that supply blood oxygen and nutrients to the heart muscle.^2,3

The therapy goal for CAD is to restore the blood flow in the coronary arteries to maintain a healthy heart. 12.9 million invasive procedures are performed annually worldwide, of which 5.3 million are PCI and 7.6 million are diagnostic only. ⁴

78-year-old man with an active lifestyle presents with stable angina, preserved LV function, and optimal medical therapy.

The first step is to perform an ECG, confirming Hendrik's atrial fibrillation and ruling out ST elevation, a sign for acute myocardial infarction.

If Hendrik’s ECG had shown signs of acute myocardial infarction, high-sensitivity troponin testing could have been carried out at the point of care with Atellica VTLI, delivering results in just 8 minutes.

To obtain more information regarding the patient's coronary arteries and the source of his angina, the decision is made to transfer him to the cardiology department for a coronary angiography. Let‘s take a look at his angiograms …

The diagnostic angiography performed reveals that Hendrik is suffering from multivessel disease:

The images show an intermediate to severe lesion in the mid part of the right coronary artery (RCA) and an intermediate lesion of the circumflex artery (LCX) on the left side of his heart.

These findings are supported by excellent image quality even under difficult circumstances:

The new CNR regulation (OPTIQ) offers constant image quality in all angulations and has the potential to save up to 70% dose.^5,6

(for Doro: OPTIQ uses a database of 300mio entries and evaluates up to 15.000 parameter combinations in real-time to find the optimal settings for the required image quality, automatically, situation-independent and completely unleashed regarding the parameter combination possibilities) The required image quality level based on CNR can be adjusted according to individual needs.

Additionally, Structure Scout, our material specific imaging technique as part of OPTIQ, optimizes the visibility of different devices and materials, such as iodine and iron, based on the individual dose absorption properties.

To determine the hemodynamic relevance of the LCX lesion and to support in therapy decision-making, vFFR, an angio-derived FFR measurement, is now used.

Although the lesion seemed angiographically rather insignificant, it showed a vFFR value of 0.61, indicating treatment (borderline vFFR: 0.8).

Quantweb vFFR obtains coronary physiology information with just a few clicks. Two angiograms clearly visualizing the target coronary artery and the aortic root pressure serve as input for vFFR. A 3D reconstruction of the vessel, the pressure drop, and the vFFR value are then calculated.

Looking at the RCA stenosis, a value of 0.73 is calculated.

Key messages in literature for angio-derived FFR⁷

The FAST II study confirms that vFFR is a powerful diagnostic alternative to invasive pressure wire-based physiological lesion assessment, showing good correlation between vFFR and pressure wire-based FFR and high diagnostic accuracy⁸

As well as the significance of the lesion determined via vFFR, the decision on how to treat Hendriks stenoses is also based on intravascular imaging to determine the morphology of the lesion and the perfect landing zone for the stent.

The stenosis in the LCX shows acoustic shadowing, illustrative of calcium, and a plaque burden of 81%. Learnings from this IVUS pullback are now that the lesion needs preparation in terms of predilatation with a noncompliant balloon.

To avoid landing in an area with over 50% plaque burden, the target lesion is analysed by IVUS and stent sizing and placement in a healthy reference area can be carried out accordingly.

The stenosis of the RCA shows fibro fatty plaque without calcification but plaque burden of 82%, thus a direct stenting approach without pre-dilatation is considered.

To avoid landing in an area with over 50% plaque burden, the target lesion is analyzed by IVUS and stent sizing and placement in a healthy reference area can be carried out accordingly.

An alternative device from the portfolio of Siemens Healthineers that could have been used to help stage the disease and guide treatment decisions in Hendrik's case is photon-counting CT. Thanks to high spatial resolution and Dual Source technology, NAEOTOM Alpha¹⁰ can provide detailed visualization on the lesion and plaque morphology to support therapy decision-making.

According to a recent study, NAEOTOM Alpha¹⁰ and Quantum HD Cardiac could have helped to reduce the need of invasive coronary angiography for 54% of patients in the detection of coronary artery disease in a high-risk population.⁹

Thanks to this comprehensive lesion characterization, Henrik's lesions can now be treated accordingly. Let‘s take a look…

First, the intermediate lesion in the LCX with an vFFR value of 0.61 is treated. Due to the high plaque burden, a predilatation with a noncompliant balloon is conducted, followed by a repeat IVUS, showing the disrupted calcium shell. After choosing a stent that fits the distal lumen of 2.5 mm, the proximal part is postdilated to 3.5 mm.

ClearStent is used during post dilatation to get the balloon positioned clearly visible within the stent to avoid missing the edges and generating edge dissections.

ClearStent is a stent enhancement tool improving stent visibility even under difficult conditions, for example with thinner stent struts, which are less radiopaque and therefore less visible. 

After treatment of the LCX, the RCA lesion is directly stented with a drug-eluting stent and the procedure continued with balloon postdilatation, increasing the final minimal stent area.

As seen on the clinical image, the ClearStent technique shows the correctly positioned balloon clearly visible within the stent.

The use of ClearStent guidance during PCI may improve patient outcomes: Results from a study published in the European Heart Journal indicate that major adverse cardiac events (MACE rate) were significantly reduced in patients who underwent ClearStent-guided PCI compared to patients without ClearStent guidance.¹¹

In order to verify the results, we proceed to the post-PCI check and follow-up.

For the LCX,
IVUS is repeated to check stent edges and expansion:

LCX post-PCI IVUS shows a stent expansion above 100%, with no edge dissections, distal and proximal, and good values for the minimal stent area.

IVUS is performed again to check stent edges and expansion:

RCA post-PCI confirms plaque burden at edges of below 50%, no edge dissections, distal and proximal, and good values for the minimal stent area (MSA).

As a final step of the procedure, an angiogram is performed, showing a superb result in terms of restoring the lumen of the vessels and regular blood flow.

With excellent results in both stenoses, we can happily send Hendrik home, in the knowledge he is on the road to recovery.

Thank you for accompanying Hendrik on his coronary artery disease journey!