Incremental value of preprocedural coronary computed tomographic angiography to classical coronary angiography for prediction of PCI complexity in left main stenosis

doi:10.4236/wjcd.2013.39090

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World Journal of Cardiovascular Diseases, 2013, 3, 573-580 WJCD

http://dx.doi.org/10.4236/wjcd.2013.39090 Published Online December 2013 (http://www.scirp.org/journal/wjcd/)

Incremental value of preprocedural coronary computed

tomographic angiography to classical coronary

angiography for prediction of PCI complexity

in left main stenosis

Imre Benedek, Monica Chitu, Istvan Kovacs, Bajka Balazs, Theodora Benedek

University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania

Email: [email protected]

Received 24 October 2013; revised 25 November 2013; accepted 6 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: The aim of our study was to assess the

incremental value of Coronary Computed Tomogra-

phy Angiography (CCTA) added to classical coro-

nary angiography, for complex characterization of

coronary lesions and prediction of procedural com-

plexity in patients with significant left main (LM)

stenoses. Material and Methods: Thirty-six patients

with LM disease were enrolled in the study, and each

subject underwent CCTA followed by coronary an-

giography and percutaneous revascularization. Re-

sults: Logistic regression analysis indicated a good

correlation between the angiographic-calculated and

the CCTA-derived Syntax scores for the whole group

(r = 0.87, p < 0.0001) and for the high risk subgroup

(r = 0.86, p < 0.0001), but not for the low and inter-

mediate risk (r = 0.38, p = 0.21 and r = 0.62, p = 0.07

respectively). In cases which required complex PCI

procedures, both angiographic and CCTA Syntax

score were significantly higher than those who did not

require complex revascularization procedures (24.5

+/− 11.5 vs 32.2 +/− 14.6, p = 0.09 for Angio Syntax,

35.3 +/− 11.5 vs 25.2 +/− 11.3, p = 0.01 for CCTA). In

the same time, Ca scoring was significantly higher

and plaque volumes were significantly larger in cases

requiring complex revascularization procedures

(299.5 +/− 359.6 vs 917.3 +/− 495.4, p = 0.04 for cal-

cium score, 79.7 +/− 28.5 vs 108.7 +/− 25.3 mm3, p =

0.002 for plaque volumes). Multivariate analysis iden-

tified the following CCTA parameters as significant

predictors of increased risk for complex intervention

in LM lesions: plaque volume (OR 8.00, p = 0.008),

Ca scoring (OR 6.37, p = 0.02) and CCTA Syntax

score (OR 6.87, p = 0.01). Conclusions: CCTA de-

rived parameters provide incremental information to

classical coronary angiography for preoperative as-

sessment of lesion severity in complex left main steno-

sis. CCTA derived Syntax score significantly corre-

lates with the classical Coronary Angiography Syntax

score and identifies the subgroup of patients who will

be more exposed to procedural complications during

the revascularization interventions.

Keywords: Left Main; Syntax Score; Coronary

Computed Tomographic Angiography

1. INTRODUCTION

The coronary angiography has become nowadays the

gold standard technique for diagnosis of coronary artery

stenoses, including those located in the left main (LM)

coronary artery.

A positive coronary angiography showing severe nar-

rowing of the LM indicates an urgent need for revas-

cularization, which could improve the tolerance to is-

chaemic events in other coronary territories and reduce

the progression of the associated ventricular dysfunction

[1,2]. Percutaneous coronary revascularization has been

recently recognized to represent a viable therapeutic

alternative in patients with severe left main (LM) steno-

sis. Despite of the well-known high risk associated with

complex interventional procedures in unprotected LM

diseases, percutaneous interventions are increasingly

used in the treatment of complex LM lesions [3].

Many studies attempted to reveal the role of interven-

tional revascularization in such cases, as an alternative to

the traditional coronary artery bypass grafting. The SYN-

TAX trial (The Synergy between Percutaneous Coronary

Intervention with TAXUS and Cardiac Surgery) in-

OPEN ACCESS

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580

574

cluded 3.075 patients with left main coronary disease or

three-vessel disease or both, who were randomized to

surgical or percutaneous revascularization [4,5]. The re-

sults of the trial revealed the role of percutaneous reva-

scularization in several subsets of patients, especially

those with isolated left main disease or left main disease

associated with one vessel disease, and led to develop-

ment of the Syntax score.

Syntax trial led to development of the Syntax score, a

complex angiographic score based on characterization of

coronary lesions according to specific angiographic para-

meters, such as tortuosity, bifurcation, the presence of a

total occlusion or intracoronary thrombus, calcification,

the dominance, type and number of lesions [6,7].

A Syntax score below 22 classifies the lesion in the

low-risk category, a score between 22 and 32 is associa-

ted with medium risk, while a score above 33 indicates a

high-risk lesion.

This score system became widely accepted in clinical

practice immediately after the Syntax trial and nowadays

many cases of left main disease are referred for surgical

or interventional treatment based on the calculated Syn-

tax score, the general recommendations being in favor of

percutaneous revascularization in cases of low or me-

dium Syntax scores and in favor of surgery in cases with

high Syntax scores [8,9].

However, calculation of Syntax score relies only on

the information provided by coronary angiography. De-

spite the recent widespread use of Coronary Computed

Tomographyc Angiography (CCTA), key information

provided by this technique such as calcium scoring or

plaque volumes is rarely taken into consideration when

establishing the indication for percutaneous coronary in-

tervention (PCI) in LM diseases [10]. However, CCTA

provides incremental value to classical coronary angio-

graphy with regard to complex characterization of coro-

nary lesions. As CCTA offers the unique opportunity for

assessment of atheromatous plaque burden and calcium

content, together with a three-dimensional representation

of the lesion, it could predict a more complex interven-

tional procedure in cases with high calcium burden, large

plaques or difficult anatomy.

The aim of our study was to assess the incremental

value of CCTA on the top of information provided by the

classical coronary angiography, for complex characteri-

zation of left main stenoses and prediction of procedural

complexity in patients with significant LM stenoses.

2. METHODS

2.1. Study Population

This was a single center prospective non-randomized

study to evaluate the incremental value of the informa-

tion provided by CCTA on the top of those obtained by

classical coronary angiography in complex characteri-

zation of coronary lesions in patients with significant left

main disease.

Thirty-six patients with LM disease at the clinical pre-

sentation were enrolled in the study, and each subject

underwent 64 multi-slice CT followed by coronary an-

giography and percutaneous revascularization. All pa-

tients gave written informed consent, and the study pro-

tocol was approved by the ethics committee of the center

where the study was conducted.

The inclusion criteria were age >18 years, documented

significant (>50%) stenosis of the LM coronary artery

and willingness to participate in the study. Patients with

contraindications for the repeated administration of con-

trast agents were excluded from the study.

2.2. CCTA Analysis

All CT acquisitions were made using multi-slice 64 So-

matom Sensation CT (Siemens, Germany) with a 64 ×

0.5 mm detector collimation. During an inspiratory

breath-hold, 60 ml of an iodinated contrast agent (Iopa-

midol, 370 mg I/ml, Bayer Healthcare, Germany) was

infused at a speed of 4.0 ml/sec followed by 20 ml at 2.0

ml/sec. All examinations were preceded by the admini-

stration of a short-acting betablocker to achieve the de-

sired heart rate and were conducted only after achieving

a stable heart rate below 60 beats/min. All acquired

images were transferred to a workstation (Siemens, Ger-

many) for data processing, measurements and inter-

pretation

The following information provided by CCTA have

been used for assessing the severity of the lesions and to

calculate the CCTA-Syntax score: degree of calcification

in the left main lesion, global calcium burden expressed

by calcium score, coronary stenosis severity (in the left

main and in the rest of the coronary tree), length and

diameter of the left main, involvement of the origin of

left anterior descending artery and circumflex artery,

anatomic distribution (type of dominance), extension of

calcification at the origin of the main arteries, involve-

ment of the ostium of the left main, and the plaque

volume. All these information have been evaluated by

Angio CT multislice 64 using multiplanar 3D recon-

structions.

2.3. Coronary Angiography Analysis

Coronary angiography analysis was performed using an

Artis Zee Floor Angiograph (Siemens, Germany), using

repeated injections of 3 - 5 ml contrast material in the left

main coronary lumen and image aquisitions in different

incidences, with different angles and tiltings of the X-ray

tube.

A significant left main stenosis was defined as a >50%

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580 575

narrowing of the LM lumen at coronaty angiography in

at least one incidence.

Angiographic assessment included the following para-

meters which served for calculation of Syntax scores,

according to the algorhythm available on the web

(www.syntaxscore.com): coronary dominance, number

and location of lesions, presence of a total occlusion in

one coronary artery, bifurcation or aorto-ostial lesion,

severe tortuosity, lesion length, presence of calcification

or thrombus. All these parameters were assessed for

every individual lesion, the final Syntax score being re-

presented by the sum of individual scores of all coronary

lesions.

According to their Syntax score, patients were divided

into three groups: low risk (Syntax score <22)—12

patients; intermediate risk (Syntax score between 23 and

32)—8 patients, and high risk (Syntax score above 33)—

16 patients.

2.4. Percutaneous Coronary Intervention

All PCI procedures were performed according to stan-

dard practice and the complexity of PCI was retrospec-

tively assessed immediately after the intervention. A

complex PCI was defined when each of the following

parameters were recorded during the procedure: use of

kissing balloon, use of high-pressure balloons or postdi-

latation, radiation time >25 min or usage of >400 ml

contrast media. Complex PCI was required for 20 pa-

tients, while 16 patients underwent non-complex PCI.

The study objectives were as follows:

1) To demonstrate the correlation between CCTA—

derived Syntax score and coronary angiography-derived

Syntax score in significant LM lesions, in the global

population of the study and in the subsets of patients

with low, medium and high risk lesions.

2) To demonstrate the correlation between Ca scoring

determined by CCTA and Syntax score determined by

CCTA and Coronary Angiography.

3) To identify the significant CCTA and angiogra-

phic-derived predictors of complex PCI procedures in

significant LM stenoses.

2.5. Statistical Analysis

All statistical analyses were performed using the Graph

Pad InStat software, version 3.1, (GraphPad software

Inc., San Diego, California, MA, USA). Categorical va-

riables are expressed as percentages. Fisher’s exact test

was used for comparing the categorical variables. Con-

tinuous values are expressed as the mean and standard

deviation, and statistical significance was determined

using the Mann-Whitney test. Multivariate logistic re-

gression was used to assess the predictors for need of

complex PCI intervention. Statistical significance was

considered for a p value <0.05, and all p values were

2-sided.

3. RESULTS

Baseline characteristics of the 36 patients with LM dis-

eased included in the study are listed in Table 1. We

recorded the predominance of gender male (67.4%) and a

significant presence of risk factors: hypertension in

58.3%, hyperlipidemia in 41.6%, diabetes in 33.33% and

smoking in 36.1% of cases. CCTA characteristics at

baseline indicated an average calcium score of 784.9 +/−

77.6 and a mean LM plaque burden of 96.6 +/− 30.0

mm3.

3.1. Correlation between CCTA—Derived

Syntax Score and Coronary

Angiography-Derived Syntax Score in

Significant LM Lesions

There were no significant differences between the mean

Syntax score calculated by angiography and those calcu-

lated by CCTA.

Angio Syntax score was slightly lower than the one

calculated by CCTA in the global population of the study

(29.1 +/− 13.9 versus 31.6 +/− 12.6, p = 0.4), however

this difference was not statistically significant. We per-

Table 1. Baseline characteristics of study population (n = 36).

Characteristic Values n (%)

Age, years 62.9 +/− 9.5

95% CI 59.7 - 69.2

Gender, male 29 (67.4)

Left Ventricular Ejection Fraction 49.2 +/− 7.2

95% CI 46.7 - 51.7

Cardiovascular risk factors

Hypertension 21 (58.3)

Hyperlipidemia 15 (41.6)

Diabetes 12 (33.3)

Smoker* 13 (36.1)

Obesity (BMS > 25 km/m2) 11 (30.5)

CCTA analysis

Calcium scoring 784.9 +/− 77.6

95% CI 627.1 - 942.7

LM plaque burden 224.3 +/− 45.0

95% CI 132.8 - 315.8

*Past or present; Data are represented as mean+/− standard deviation or as

number (percentage).

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580

576

OPEN ACCESS

formed a subgroup analysis of Angio versus CCTA Syn-

tax score in the subgroups with low, intermediate and

high risk. We found that in the low risk subgroup coro-

nary angiography seems to underestimate the severity of

the lesions as compared to CCTA (Angio Syntax score

13.0 +/− 4.8 compared with CCTA Syntax score 18.9

+/− 7.6, p = 0.03). However, we did not find any statisti-

cally significant difference in Angio versus CCTA Syn-

tax scores for the intermediate risk (28.2 +/− 4.1 vs 30.7

+/− 8.1, p = 0.4) and high risk subgroups (42.4 +/− 5.9 vs

43 +/− 8.2, p = 0.8) Table 2.

Similarly with the observation recorded in the global

population of the study, in all the subgroups the Coro-

nary Angiography Syntax score seems to underestimate

the severity of coronary lesions as compared with CCTA

Syntax score.

Similarly, logistic regression analysis indicated a good

correlation between the Angiography-derived and the

CCTA-derived Syntax scores for the whole group (r =

0.87, p < 0.0001) and for the high risk subgrouo (r = 0.86,

p < 0.0001), but not for the low and intermediate risk (r =

0.38, p = 0.21 and r = 0.62, p = 0.07 respectively) Figure

3.2. Correlation between Ca Scoring Determined

by CCTA and Syntax Score Determined by

CCTA and Coronary Angiography

Calcium score is a CCTA-derived parameter useful for

prediction of coronary lesions severity. We found a good

correlation between the calcium score determined by

CCTA and the Syntax scores, either as determined by

Coronary Angiography (r = 0.72, p < 0.0001) or by

CCTA (r = 0.69, p < 0.0001) Figure 2.

CCTA and angiographic-derived predictors of com-

plex PCI procedures in significant LM stenoses.

Another objective of the study was to identify CCTA

and coronary angiography-derived predictors of complex

PCI procedures. In cases which required complex PCI

procedures, both angiographic and CCTA Syntax score

were significantly higher than in those who did not re-

quire complex revascularization procedures (24.5 +/−

11.5 vs 32.2 +/− 14.6, p = 0.09 for Angio Syntax, 35.3

+/− 11.5 vs 25.2 +/− 11.3, p = 0.01 for CCTA Syntax).

In the same time, Ca scoring was significantly higher and

plaque volumes significantly larger in cases requiring

complex revascularization procedures (299.5 +/− 359.6

vs 917.3 +/− 495.4, p = 0.04 for calcium score, 79.7 +/−

28.5 vs 108.7 +/− 25.3 mm3, p = 0.002 for plaque vol-

umes) (Figure 3).

Figure 4 is an exemplification of a significant LM

stenosis with high calcium content and a large volume

atheromatous plaque in the LM, visualized by 3D CCTA

(A), multiplanar reconstruction CCTA (B) and angiogra-

phic aspect before (C) and after PCI (D), the lesion ap-

pearing much more severe in CCTA than in conventional

angiography.

On the other hand, clinical parameters such as ejection

fraction did not show any statistically significant dif-

ference between the subgroup of patients necessitating

complex PCI procedures and those who did not Table 3.

Multivariate analysis identified the following CCTA-

derived parameters as significant predictors of increased

risk for complex intervention in LM lesions: plaque

volume (Odds Ratio 8.00, p = 0.008), Ca scoring (Odds

Ratio 6.37, p = 0.02) and CCTA Syntax score (Odds

Ratio 6.87, p = 0.01). Angiography-derived Syntax score

Table 2. Low CT-attenuation plaques and IVUS-derived markers of vulnerability in culprit lesions.

Angiographic Syntax score CCTA Syntax score p value

Global population of the study

0.4

Mean +/− SD 29.1 +/− 13.9 31.6 +/− 12.6

95% confidence interval 24.4 - 33.8 27.3 - 35.9

Low risk group (Syntax score < 22), n = 12

0.03

Mean +/− SD 13.0 +/− 4.8 18.9 +/− 7.6

95% confidence interval 9.9 - 16.1 14.1 - 23.7

Medium risk group (Syntax score 23 - 32), n = 8

0.4

Mean +/− SD 28.2 +/− 4.1 30.7 +/− 8.1

95% confidence interval 25.1 - 31.4 24.6 - 37.0

High risk group (Syntax score > 33), n = 16

0.8

Mean +/− SD 42.4 +/− 5.9 43 +/− 8.2

95% confidence interval 39.2 - 45.7 38.5 - 47.5

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580 577

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Angio Syntax

CCTASyntax

r = 0.87

p < 0.0001

CCTASyntax

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54

Angio Syntax

r = 0.38

p = 0.21

(A) (B)

24 25 26 27 28 29 30 31 32 33

Angio Syntax

34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

Angio Syntax

CCTASynta

r = 0.62

p = 0.07 r = 0.86

p < 0.0001

CCTASyntax

Figure 1. Correlation between angiography-derived and CCTA-derived Syntax scores in the global population (A) and in the low

risk (B), intermediate risk (C) and high risk (D) lesions. (A) Global population of the study; (B) Low risk; (C) Intermediate risk; (D)

High risk.

10 15 20 25 30 35 40 45 50

Angio Syntax

1900

1800

1700

1600

1500

1400

1300

1200

1100

1000

900

800

700

600

500

400

300

200

100

r = 0.72

p < 0.0001

Ca scoring

r = 0.69

p < 0.0001

10 15 20 25 30 35 40 45 50

CCTA Syntax

1900

1800

1700

1600

1500

1400

1300

1200

1100

1000

900

800

700

600

500

400

300

200

100

Ca scoring

(A) (B)

Figure 2. Correlation between calcium score determined by CCTA and Angio-derived (A) or CCTE-derived (B) Syntax score.

was also associated with a high risk for complex LM

intervention, however with a lower statistical signifi-

cance than the CCTA-derived parameters (Odds Ratio

4.47, p = 0.04) Table 4.

The SYNTAX trial results suggest that CABG remains

the standard of care for patients with complex disease as

expressed by a high Syntax score; however, PCI could

represent a superior alternative for revascularization in

certain subgroup of patients, mainly those with less

complex disease and lower Syntax scores [1,11].

Incorporating the CCTA information into the Syntax

algorythm could provide a more complex set of informa-

tion, thus serving for selection of a more appropriate

therapeutic strategy in complex LM cases. The main ad-

vantage of the CCTA against standard coronary an-

giography is the ability to visualise exactly the extent,

distribution and severity of calcifications at the level of

the lesion, which is of particular importance at the level

of the left main [12]. In the same time, the CCTA tech-

nique provides the unique opportunity of plaque quan-

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580

578

p = 0.09

24.5

32.3

=0.01

35.3

25.2

on complex PCI Complex PCI

(A) (B)

p = 0.04

599.5

917.3

79.7

108.7

p = 0.002

1400

1300

1200

1100

1000

900

800

700

600

500

400

300

200

100

on complex PCI Complex PCI

130

120

110

100

Figure 3. Association between the need for complex PCI procedures and Angio Syntax score (A), CCTE Syntax score (B), CCTA

Ca score (C) and Left Main plaque volume (D). (A) Angio Syntax; (B) CCTA Syntax; (C) CCTA Ca score; (D) LM Plaque volume

(mm3).

Figure 4. Significant LM stenosis with high calcium content

and a large volume atheromatous plaque in the LM, visualized

by 3D CCTA (A), multiplanar reconstruction CCTA (B).

Angiographic aspect before (C) and after PCI (D), showing that

the lesion appeares less severe in conventional angiography

than in CCTA, due to the lack of appropriate calcium visua-

lization by angiography. The severity of the lesion is under-

estimate by angiography.

tification, allowing the determination of plaque volume.

LM plaques are usually large volume plaques which

rupture and embolise frequently during the percutaneous

revascularization procedure, therefore the preoperative

assessment of plaque volume by CCTA and characteris-

tics could help to prevent the procedure-related compli-

cations [13,14].

In this study we demonstrated that use of CCTA Syn-

tax score may better stratify the patients with significant

LM stenosis according to their risk than does the stratifi-

cation based only on angiography-derived Syntax score.

We found a good correlation between the angiography

derived and CCTA-derived Syntax scores especially for

cases with high Syntax scores. As in the rest of the cases

angiography seems to underestimate the severity of the

lesions, we can conclude that the incremental role of

CCTA to coronary angiography is more obvious espe-

cially in high risk lesions. These are usually heavily cal-

cified lesions, with high atheromatous burden, coronary

calcification and plaque burden being exactly the pa-

rameters easily assessed by the CCTA [15].

This superior value of CCTA relies mainly in provid-

ing incremental information to coronary angiography

I. Benedek et al. / World Journal of Cardiovascular Diseases 3 (2013) 573-580 579

Table 3. Clinical, CCTA and angiographic parameters for pre-

diction of intervention complexity in LM diseases.

Non Complex

PCI n = 20

Complex PCI

N = 16 p value

Ejection Fraction

0.6

Mean +/− SD 50 +/− 7.9 48.6 +/− 7.2

95% confidence interval 45.6 - 54.4 45.4 - 51.9

Angio Syntax score

0.09

Mean +/− SD 24.5 +/− 11.5 32.3 +/− 14.6

95% confidence interval 18.1 - 30.9 25.7 - 38.9

CCTA Syntax score

0.01

Mean +/− SD 25.2 +/− 11.3 35.3 +/− 11.5

95% confidence interval 18.9 - 31.5 30.1 - 40.5

Ca scoring

0.04

Mean +/− SD 599.5 +/− 359.6 917.3 +/− 495.4

95% confidence interval 400.4 - 798.7 691 - 1142.8

LM plaque volume

0.002

Mean +/− SD 79.7 +/− 28.5 108.7 +/− 25.3

95% confidence interval 63.9 - 95.5 97.2 - 120.2

Table 4. Multivariate predictors of intervention complexity in

patients with left main disease.

Odds Ratio (95% CI) p value

Smoker 0.55 (0.14 - 2.17) 0.5

Diabetes 1.36 (0.35 - 5.21) 0.74

Dyslipidemia 1.65 (0.43 - 6.31) 0.51

Left Ventricular

Ejection Fraction 2.43 (0.62 - 9.47) 0.3

Angio Syntax score 4.47 (1.05 - 18.9) 0.04

CCTA Syntax score 6.87 (1.55 - 30.4) 0.01

Ca scoring 6.37 (1.42 - 28.61) 0.02

LM plaque volume 8.00 (1.68 - 37.9) 0.008

with regard to lesion characterization and complex 3D

visualization of coronary plaques in the same time with

plaque quantification and determination of calcium con-

tent within the coronary arteries [15,16].

In this study we found that the most significant pre-

dictors for complex procedures in LM stenoses were the

CCTA derived parameters: Ca score, CCTA Syntax

score and plaque volume, all of them having a prediction

power superior to the conventional angiography-derived

Syntax score. We found that patients with high calcium

content in the coronary arteries, large volumes of LM

coronary plaques or high Syntax scores by CCTA were

more likely to necessitate a complex PCI procedure, ei-

ther lasting longer than usual or necessitating complex

techniques (bifurcation kissing, postdilatation, high pres-

sure balloons, more contrast, longer X-ray exposure, etc.).

This underlines the role of CCTA in providing complex

information necessary for a complex preprocedural eva-

luation in LM lesions.

3.3. Study Limitations

The CT analysis was not able to distinguish between

different low density components of coronary plaques,

which are considered as markers of vulnerability—low

density atheroma, necrotic core or thrombus. However,

identifying a high burden with coronary plaque signifi-

cantly associated with the need of complex revasculari-

zation procedure, irrespective of the differentiation be-

tween thrombus, necrotic core or very low density cho-

lesterol-rich atheroma. A high calcium score could pre-

clude a good quality CT image and this could be re-

flected in Syntax CCTA calculations. Finally, the num-

ber of patients included in the study is not extensive.

4. CONCLUSIONS

CCTA derived parameters provide incremental informa-

tion to classical coronary angiography for preoperative

assessment of lesion severity in complex left main steno-

sis. CCTA derived Syntax score significantly correlates

with the classical Coronary Angiography Syntax score

and identifies the subgroup of patients who will be more

exposed to procedural complications during the revascu-

larization interventions.

Based on these findings, CCTA could represent a new

noninvasive clinical tool, useful for preoperative evalua-

tion of patient risk and for selection of the best therapeu-

tic strategy in these cases.

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