2024+ASCI共识声明：冠状动脉狭窄和斑块的CT血管造影评估.pdf

331Copyright 2024 The Korean Society of Radiology2024 Consensus Statement on Coronary Stenosis and Plaque Evaluation in CT Angiography From the Asian Society of Cardiovascular Imaging-Practical Tutorial(ASCI-PT)Cherry Kim1*,Chul Hwan Park2*,Bae Young Lee3,Chan Ho Park4,Eun-Ju Kang5,Hyun Jung Koo6,Kakuya Kitagawa7,Min Jae Cha8,Rungroj Krittayaphong9,Sang Il Choi10,Hwan Seok Yong11,Sung Min Ko12,Sung Mok Kim13,Sung Ho Hwang14,Nguyen Ngoc Trang15,Whal Lee16,Young Jin Kim17,Jongmin Lee18,Dong Hyun Yang61Department of Radiology,Korea University Ansan Hospital,Ansan,Republic of Korea 2Department of Radiology and Research Institute of Radiological Science,Gangnam Severance Hospital,Yonsei University College of Medicine,Seoul,Republic of Korea 3Department of Radiology,Eunpyeong St.Marys Hospital,College of Medicine,The Catholic University of Korea,Seoul,Republic of Korea 4Department of Radiology,Soonchunhyang University Cheonan Hospital,Cheonan,Republic of Korea 5Department of Radiology,College of Medicine,Dong-A University,Busan,Republic of Korea 6Department of Radiology and Research Institute of Radiology,Cardiac Imaging Center,Asan Medical Center,University of Ulsan College of Medicine,Seoul,Republic of Korea 7Department of Radiology,Mie University Graduate School of Medicine,Tsu,Japan 8Department of Radiology,Chung-Ang University Hospital,Seoul,Republic of Korea 9Division of Cardiology,Department of Medicine,Siriraj Hospital,Mahidol University,Bangkok,Thailand 10Department of Radiology,Seoul University Bundang Hospital,Seongnam,Republic of Korea 11Department of Radiology,Korea University Guro Hospital,Seoul,Republic of Korea 12Department of Radiology,Yonsei University Wonju College of Medicine,Wonju Severance Christian Hospital,Wonju,Republic of Korea 13Department of Radiology,Samsung Medical Center,Sungkyunkwan University School of Medicine,Seoul,Republic of Korea 14Department of Radiology,Korea University Anam Hospital,Seoul,Republic of Korea 15Center of Radiology,Bachmai University Hospital,Hanoi,Vietnam 16Department of Radiology,Seoul National University Hospital,Seoul,Republic of Korea 17Department of Radiology and Research Institute of Radiological Science,Severance Hospital,Yonsei University College of Medicine,Seoul,Republic of Korea 18Department of Radiology,Kyungpook National University Hospital,Daegu,Republic of KoreaThe Asian Society of Cardiovascular Imaging-Practical Tutorial(ASCI-PT)is an instructional initiative of the ASCI School designed to enhance educational standards.In 2021,the ASCI-PT was convened with the goal of formulating a consensus statement on the assessment of coronary stenosis and coronary plaque using coronary CT angiography(CCTA).Nineteen experts from four countries conducted thorough reviews of current guidelines and deliberated on eight key issues to refine the process and improve the clarity of reporting CCTA findings.The experts engaged in both online and on-site sessions to establish a unified agreement.This document presents a summary of the ASCI-PT 2021 deliberations and offers a comprehensive consensus statement on the evaluation of coronary stenosis and coronary plaque in CCTA.Keywords:Coronary CT angiography;Coronary artery stenosis;Coronary artery plaque;Consensus developmentKorean J Radiol 2024;25(4):331-342eISSN 2005-8330https:/doi.org/10.3348/kjr.2024.0112Recommendation and GuidelineReceived:January 30,2024 Accepted:January 31,2024This article is being published jointly in the Korean Journal of Radiology and Cardiovascular Imaging Asia.*These authors contributed equally to this work.Corresponding author:Dong Hyun Yang,MD,Department of Radiology and Research Institute of Radiology,Cardiac Imaging Center,Asan Medical Center,University of Ulsan College of Medicine,88 Olympic-ro 43-gil,Songpa-gu,Seoul 05505,Republic of Korea E-mail:This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(https:/creativecommons.org/licenses/by-nc/4.0)which permits unrestricted non-commercial use,distribution,and reproduction in any medium,provided the original work is properly cited.332Kim et al.https:/doi.org/10.3348/kjr.2024.0112kjronline.org(Supplementary Table 1).To gauge the panelists experiences and practice patterns and to identify key discussion points for the consensus session,two online pre-meeting surveys were executed.The panel selection,pre-meeting survey preparation,and analysis of results were overseen by the ASCI-PTs director,Dong Hyun Yang,alongside two co-directors,Chul Hwan Park and Cherry Kim.The first survey sought details on the panelists clinical experience,CCTA imaging reconstruction protocols,interpretation methodologies,and reporting protocols(Supplementary Table 2).To accurately reflect current practices,radiological report samples from each participating hospital were collected.The subsequent survey posed queries regarding issues that,despite being partially addressed in existing guidelines,could lead to uncertainties in practical interpretation.This survey comprised 34 questions that spanned several core topics,including the assignment of coronary segments,assessment of high-risk plaque(HRP)morphologies,and the evaluation of plaque length,composition,and stenosis degree(Supplementary Tables 3-6).Analysis of the initial survey revealed that the experts,on average,possessed 15.1 5.9 years of experience post-board certification.Among the respondents,4(21.1%)interpreted in excess of 500 CCTA scans monthly,6(31.6%)between 200500,and 5(26.3%)between 100200 scans,and 4(21.1%)less than 100 scans.It was noted that 73.7%of the panelists evaluated coronary stenosis using imaging workstations.Examination of the hospital reports showed universal mention of plaque composition,yet only 31.6%specifically identified HRP,and 31.6%reported routinely employing the CAD-RADS.The findings from the second survey were initially processed by the director and co-directors and disclosed at the in-person conference.The two-day meetings schedule is detailed in Supplementary Table 7.Day one involved panelists assessing the results of the pre-meeting surveys,performing literature reviews pertinent to each topic under discussion,and collectively examining cases pertaining to these topics using the available imaging workstations.Following this,eight topics identified as clinically pertinent and exhibiting variability among panel opinions were selected for the final consensus discussion,as listed in Table 1.During the second day,online panelists joined to review the outcomes of the pre-meeting surveys and the preliminary consensus draft.Each point was deliberated in the morning session,with both online and on-site panelists contributing to the voting process.Consensus was defined by the level INTRODUCTIONCoronary CT angiography(CCTA)has emerged as a prominent non-invasive cardiac imaging technique and has rapidly gained widespread acceptance 1,2.The 2021 American Heart Association guidelines for chest pain management now recognize CCTA as a primary diagnostic tool,solidifying its critical role in evaluating potential coronary artery disease(CAD)3.Consequently,its use is anticipated to rise among patients with suspected CAD 3-5.Interpretation of CCTA has largely been guided by the Society of Cardiovascular Computed Tomography(SCCT)guidelines 6,7,and the Coronary Artery Disease Reporting and Data System(CAD-RADS)also offers a detailed framework for interpretation 8-10.However,ambiguities in applying and interpreting these guidelines in real-world CCTA assessments can lead to reader variability and communication challenges in conveying the radiological findings.In 2019,the Asian Society of Cardiovascular Imaging Practical Tutorial(ASCT-PT)convened for the first time,and in 2020,it published a consensus statement addressing contentious issues in cardiac magnetic resonance(CMR)imaging interpretations 11,12.This initiative resulted in improved interobserver reliability and agreement in semi-quantitative scoring of late gadolinium enhancement in the left ventricle for patients with ischemic cardiomyopathy 12.Given the frequent clinical use and importance of grading coronary stenosis and characterizing plaque in CCTA,the ASCT-PT discussions and consensus formation in 2021 regarding these subjects are crucial.This document aims to present the proceedings as follows.We began by clarifying the aspects of the pre-meeting survey that was conducted to pinpoint the contentious topics for the CCTA interpretation consensus session.The results of this survey informed the identification of the primary issues for discussion.Subsequently,we elaborate on the process of achieving consensus through the deliberations of the expert panel and document the consensus outcomes.Pre-Meeting Surveys,Panels,and Consensus MethodsIn preparation for the ASCI-PT consensus session,19 experts from four countries were enlisted.Due to the coronavirus disease pandemic,16 experts from South Korea were able to attend in person,while three panelists from Japan,Thailand,and Vietnam participated online 333Consensus Statement for Evaluation of Coronary Stenosis/Plaque on CCTAhttps:/doi.org/10.3348/kjr.2024.0112kjronline.orgof agreement;items achieving over 75%concordance were classified as having strong agreement,while those with 50%74%concordance were considered to have moderate agreement.Eight Issues Regarding CCTA Semi-Quantitative EvaluationClarification/Consensus on 18-Segment Coronary Artery Model from the SCCT GuidelinesThe ASCI-PT consensus panel endorses and utilizes the 18-segment model of the coronary artery as delineated by the SCCT guidelines for daily interpretations 6,but certain issues have been identified that can cause confusion.To address these ambiguities,the panel has sought to clarify or reach consensus on the following issues through a structured voting process:Issue 1.Distal Margin of the Left Main Artery(LM)Issue:Pinpointing the precise termination point of the left main artery(LM)where it bifurcates into the left anterior descending artery(LAD)and left circumflex artery(LCX),which can occasionally be ambiguous.Clarification/consensus:According to the SCCT guideline,the LM artery extends from its ostium to the bifurcation of the LAD and LCX 6.Lesions occurring within the bifurcation toward the LAD or LCX should be categorized as part of the LM(Fig.1).This interpretation was met with unanimous consent(strong agreement,100%).Issue 2.Proximal vs.Mid-Left Anterior Descending Artery(Proximal LAD vs.Mid-LAD)Issue:When a significant first diagonal artery(D1),greater than 1.5 mm in diameter,originates in close proximity to the LAD ostium,prompting the question of how to classify a very short segment from the LAD ostium to D1 Table 1.Eight issues regarding CCTA semi-quantitative evaluationIssue 1 Distal margin of the left main arteryIssue 2 Proximal vs.mid-left anterior descending arteryIssue 3 Ramus intermedius vs.first obtuse marginal arteryIssue 4 Categorization of coronary plaqueIssue 5 High-risk plaque morphologyIssue 6 Diameter vs.area stenosis and grading systemIssue 7 Determining reference vessels for calculation of percent stenosisIssue 8 Determining diameter on a cross-sectional image of CCTACCTA=coronary CT angiographyFig.1.Definition of left main branch.LM is defined as Ostium of LM to bifurcation of LAD and LCX,and lesions in the bifurcation towards LAD or LCX should be classified under LM.LM=left main artery,LAD=left anterior descending artery,LCX=left circumflex artery,RCC=right coronary cusp,LCC=left coronary cusp,pLAD=proximal LAD,pLCX=proximal LCXPre-meeting questionnaire item:Which structure is this arrow pointing to(diameter of D1 is 1.6 mm)?Pre-meeting responses 1)Proximal LAD:63.2%2)Mid LAD:36.8%Voting results after discussion 1)Proximal LAD:35.3%2)Mid LAD:64.7%Fig.2.Pre-meeting questionnaire item and responses regarding Issue 2.D1=the first diagonal artery,LAD=left anterior descending artery334Kim et al.https:/doi.org/10.3348/kjr.2024.0112kjronline.orgas proximal LAD(pLAD)(Fig.2).Clarification/consensus:The SCCT guideline specifies pLAD as the segment from the end of the LM to the first large septal or D1,whichever is most proximal,with the D1 being greater than 1.5 mm in size 6.Adhering strictly to the SCCT definition,the distal segment near a sizable D1 would be considered mid-LAD(mLAD),which achieved moderate agreement(64.7%).Discussion:A strict interpretation of the SCCT guideline phrase whichever is most proximal would undoubtedly classify the segment indicated in Figure 2 as mLAD.Despite 63.2%of panelists initially favoring pLAD in the pre-meeting survey,there was concern that a very short pLAD segment does not align well with findings from invasive angiography.Proponents of rigorous guideline adherence noted that the presence of a sizable D1 would diminish blood flow in the distal portion,underscoring the need to consider myocardial blood flow when differentiating between pLAD and mLAD.Following thorough deliberations,the final vote favored mLAD(64.7%),a shift from the 36.8%in the pre-meeting survey.Issue 3.Ramus Intermedius(RI)vs.First Obtuse Marginal Artery(OM1)Issue:The classification dilemma arises when determining a significant branch of the LCX(1.5 mm)that branches off near the LM bifurcation(Fig.3).Clarification/consensus:The SCCT guideline characterizes the RI as a vessel that arises from the LM between the LAD and LCX in scenarios involving a trifurcation 6.When interpreting this definition strictly,any LCX branch larger than 1.5 mm that originates near the LM bifurcation and does not result in a trifurcation should be designated as first obtuse marginal artery(OM1)(strong agreement,76.4%).Discussion:In cases where an LCX branch surfaces very close to the LM bifurcation,52.6%of the panelists initially identified it as ramus intermedius(RI)in the pre-meeting survey,adhering to the SCCTs definition of RI in the context of a trifurcation 6.Subsequent discussions among committee members concluded that a stringent interpretation of the definition,particularly concerning trifurcation,would likely decrease interobserver variability.This led to a post-discussion consensus where 76.4%agreed to classify such a branch as OM1.The consensus panel acknowledges that while the SCCTs 18-segment model serves as a solid guideline,detailed discussions and ensuing clarifications are essential for ensuring uniform and precise interpretations among various practitioners.Coronary Plaque CharacterizationIssue 4.Categorization of Coronary PlaqueIssue:The capability of CCTA to assess both coronary stenosis grading and coronary plaque composition is well-established.However,the terminology for classifying coronary plaquessuch as calcified,partially calcified,and noncalcifiedvaries among different studies and across guideline editions.The SCCT 2009 guidelines delineated plaques as calcified,mixed,or noncalcified 13,while the 2011 guidelines introduced the te