One researcher calls the practice “no-brainer,” but acknowledges that not everyone will have access to CT.
BOSTON, MA – Adjunctive coronary CT angiography (CCTA) prior to invasive coronary angiography in patients with prior CABG reduces procedure time, improves patient satisfaction, and reduces rates of contrast-induced nephropathy (CIN), procedural complications, and MACE at 12 months , according to new randomized data.
“If it’s logistically feasible, a CT makes a lot of sense,” said Daniel Jones, MD, PhD (Queen Mary University of London, England), who presented the results during a landmark clinical science session at TCT 2022. said TCTMD. He acknowledged that not all centers may have access to CT, particularly for patients with ACS on the same day, but called the practice “a no-brainer” when the equipment is available.
The results are somewhat in contrast to those of the GREECE study, which, as reported by TCTMDshowed that CCTA before invasive coronary angiography actually increased the amount of contrast agent used, although it did not increase the amount of CIN.
“The main difference is in essence [that GREECE] was a very small study [with approximately] 80 patients in each arm and it wasn’t run for any endpoint other than contrast,” Jones said. “We turned our study off of the consequences of the contrast agent, i.e. the contrast agent-induced nephropathy, and the duration and satisfaction of the procedure. . . . They also used older generation CT scans and admitted it at the time.”
Ori Ben-Yehuda, MD (Cardiovascular Research Foundation, New York) called this a “really nice study” in a press conference. He said, “That’s my practice, but it’s always better to have real data.”
Process improvements with CCTA
For the study, Jones and colleagues randomized 688 patients (mean age 70 years; 84% male) with prior CABG to invasive coronary angiography alone (n=344) or prior CCTA (n=344). Approximately 45% of patients overall presented with ACS and there was a high burden of comorbidities, with 85% of patients having hypertension, 48% with prior PCI, and 68% with prior MI. The average number of bypass grafts in both arms was approximately 1.2.
Compared with patients who received only invasive coronary angiography, those who underwent adjunctive CCTA had a shorter procedure duration (mean 17.4 vs. 39.5 min; OR -22.12; 95% CI -24.68 to -19.56), less CIN (3.2% vs. 27.9%; P <0.0001) and 40% higher patient satisfaction on a questionnaire with a 5-point scale where 1 is satisfied and 5 is dissatisfied (1.49 vs. 2.54).
In patients who underwent CCTA prior to their procedure, significantly less contrast was used (mean 77.4 vs 173 mL) and the radial approach was used more frequently (76.85% vs 56.73%; P < 0.001 for both). While only a single patient in the CCTA arm had at least one graft not examined because it could not be located or was assumed to be occluded, 24.27% of patients without CCTA fell into this category.
There was also an 80% reduction in procedural complications with adjunctive CCTA (2.4% vs. 10.8%; P <0.001), with significant reductions in both periprocedural myocardial infarctions (0.58% vs. 6.43%; P = 0.001) and vascular access complications (0.58% vs. 4.39%; P =0.007).
At 12 months, MACE was lower in those who underwent CCTA (16.28% vs. 29.36%; adjusted OR 0.44; 95% CI 0.30-0.64), indicating significantly lower rates non-fatal MI (9.59% vs. 18.60%; adjusted OR 0.44; 95% CI 0.28-0.70). Cardiovascular mortality (1.74% vs. 3.78%; P = 0.079) and unscheduled revascularization (5.81% vs. 9.30%; P = 0.092) also trended down with preprocedural CCTA.
“Amazing” AKI rate
In the discussion following the presentation, Jeffrey Moses, MD (New York-Presbyterian/Columbia University Irving Medical Center, New York, NY) described the rate of acute kidney injury in the non-CCTA arm as “amazing.” He questioned whether this contributed to the “sharp split in MACE” in the long run.
“We were surprised by the AKI rate in the control group,” Jones replied. “I think that despite their initial renal dysfunction, the patient groups were at relatively high risk. There are high rates of diabetes, there was a high proportion of elderly patients in the group, and 27% is not disproportionate to the published literature of similar high-risk patient groups, although I admit it is on the higher end. ”
He added that the study was not designed to show a difference in MACE, but said: “I think there was a lot of evidence that a reduction in MACE over 12 months might not be surprising. We had a reduced rate of procedural complications, less vascular access, less contrast-induced nephropathy, greater completeness of diagnostic information, which may indicate complete revascularization. So I think there’s enough signal to suggest that CT might result in a benefit, but I think we probably need more studies to confirm that.”
If it is logistically feasible, a CT makes perfect sense. Daniel Jones
Panelist J. Dawn Abbott, MD (Brown University, Providence, RI) asked whether the pre-procedure timing of CCTA “could be an issue for hospitalized patients, although the venous contrast agent may not be as kidney toxic.”
Jones said stable patients typically had their scans 1-2 weeks in advance “because we had time to schedule it.” In contrast, in ACS patients, “CT was performed either the day before the angiography or on the day of the angiography.” He added that while they have not yet performed an analysis to see if there is an interaction between same-day CCTA and acute kidney injury, “but we haven’t found rates of AKI [with] the elective CT and the angiogram.”
The study protocol “does not prescribe how operators use the information from the CT,” but suggests that occluded grafts are not reinserted, Jones explained. “There were different procedures as to whether a continuous graft was imaged in the angiography. My personal practice is that in invasive angiography I would only select a vein graft if it was diseased on CT or if the native conduit provides retrograde certainty for CTO, for example.
There was a “large proportion” of patients in the CCTA group who did not have grafts invasively imaged, he continued, “which I think explains why there was such an impressive difference in procedure time, contrast levels and outcomes. But that was not logged as part of the study.”
Panelist Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center) commented, “A lot of us have been in this situation where we don’t know how many grafts there are, we don’t know where they’re being delivered, and we look for catheter reports and OP reports and the like. In many ways, this is a nice proof of concept in that regard,” he said.
Kirtane agreed that the CIN risk “appears much more striking and warrants further explanation.” However, he noted: “From a practical point of view, we sometimes get CTs after the fact. So maybe it makes a lot of sense to do this in advance, especially in less clear cases.”
Panelist Davide Capodanno, MD, PhD (University of Catania, Italy) commended the researchers for using a patient-reported outcome measure as the primary endpoint. “This is a trend we’re seeing more and more in experimental design,” he said. “Obviously I feel like patients are happier when you do more diagnostics because of course they feel like they’re being guided well in a way.”
He questioned whether a pre-trial CCTA would be cost effective. “I suspect this strategy would be beneficial because you need to spend fewer days in the hospital because you have contrast-induced nephropathy,” Capodanno said. “But was that considered cost-effective? Because with two diagnoses, the costs for the hospital stay would of course increase.
While he doesn’t have cost-effectiveness data yet, Jones said it will be interesting to look at “because I think we may have extended some of the in-patient stay in the ACS group,” he said. “So if someone had a CT the next day and then an angiogram, that would have added 24 hours. I suspect it would be cost effective but there will be some patients who will have extended their stay.”
#CCTA #patients #previous #CABG #incision #complications #invasive #angio #BYPASSCTCA
Leave a Comment