Computed Tomographic Angiography of the

Coronary Arteries: Techniques and Applications

Thomas C. Gerber, MD, PhD,*,† Jerome F. Breen, MD,‡ Ronald S. Kuzo, MD,†
Birgit Kantor, MD, PhD,§ Eric E. Williamson, MD,‡ Robert E. Safford, MD, PhD,* and
Richard L. Morin, PhD† for the Mayo Foundation for Medical Education and Research

Computed tomographic coronary angiography (CT-CA) is a direct but minimally invasive

method of visualizing coronary arteries. Multidetector-row computed tomography (MDCT)
is currently the CT modality most commonly used for coronary artery imaging. MDCT has
been successfully used to detect stenoses in coronary arteries and coronary artery bypass
grafts and to assess congenital coronary anomalies. Patients should not undergo CT-CA
with MDCT if they have an irregular heart rhythm, a heart rate greater than 70 beats/min,
and contraindications to pharmacologic agents for heart rate control, or if they have severe
coronary artery disease or are likely to require revascularization.
Semin Ultrasound CT MRI 27:42-55 © 2006 Elsevier Inc. All rights reserved.

I maging coronary arteries is challenging because they are

subject to constant (and often rapid) motion. Further-
more, their tortuous shape and relatively small caliber
present additional challenges. Direct but minimally invasive
visualization of coronary arteries was the “holy grail” of car-
diac imaging for many years.1 The first report of magnetic
resonance imaging for minimally invasive coronary angiog-
raphy was in 1993.2 Magnetic resonance coronary angiogra-
phy is described elsewhere in this volume. Computed tomog-
raphy (CT) is another minimally invasive method of
visualizing coronary arteries. In this article, we summarize
current techniques and applications for computed tomo-
graphic coronary angiography (CT-CA).
Technical Issues
CT Scanners
CT-CA was first performed using electron beam computed
tomography (EBCT) in 1995.3 EBCT is uniquely suited for
cardiac imaging; the scanner design uses no mechanical parts
for the acquisition of projection data and allows high tempo-
ral resolution. However, EBCT scanners are not widely avail-
*Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL.
†Department of Radiology, Mayo Clinic, Jacksonville, FL.
‡Department of Radiology, Mayo Clinic, Rochester, MN.
§Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
Address reprint requests to Thomas C. Gerber, MD, PhD, Division of Car-
diovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville,
FL 32224. E-mail: gerber.thomas@mayo.edu.
able, and EBCT coronary angiography (EBCT-CA) is being
studied and used at only a few medical or imaging centers.
In 1999, multidetector-row CT (MDCT) scanners with
gantry-mounted, rapidly rotating x-ray tubes were intro-
duced. When used to image the heart under ideal conditions,
images without motion artifacts could be acquired.4 MDCT
scanners suitable for cardiac imaging are widely used as body
scanners, and MDCT is currently the dominant technique
used for CT-CA.
Differences between these types of CT scanners affect how
CT-CA is performed and the amount of radiation received by
the patient.5 With EBCT scanners, the operator must pro-
spectively decide at which specific time point in the cardiac
cycle to image the heart. Triggered by the R wave of the
electrocardiogram (ECG), planar parallel images are acquired
one at a time, and the patient table makes stepwise advances
relative to the x-ray source and detectors between image ac-
quisitions. Radiation is produced only during projection data
acquisition.
With MDCT scanners, the patient table continuously ad-
vances through the rotating gantry, and radiation is produced
during the entire scan. The table advance is designed to over-
lap gantry rotations, representing each anatomic level along
the z-axis during multiple cardiac cycles. With each gantry
rotation, projection data for several images are acquired si-
multaneously.6 As of August 2005, state-of-the-art MDCT
scanners can capture up to 64 simultaneous images.7 Projec-
tion data are arranged in a helical fashion. Computational
techniques specific to helical CT image reconstruction (eg,
rebinning, z-interpolation) are used to create planar images.

42 0887-2171/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.

doi:10.1053/j.sult.2005.11.005
CT coronary angiography
Because the entire cardiac cycle is represented, the operator
can choose retrospectively to reconstruct images from any
time point in the cycle. Such retrospective, ECG-correlated
gating facilitates image reconstruction at the point of the
cardiac cycle with the least motion artifacts.
Factors Affecting Image
Quality and Interpretation
Scanner Temporal Resolution
and X-Ray Beam Collimation
High temporal resolution is a crucial feature of scanners used
for CT-CA. Otherwise, the perpetual cardiac motion and
high motion velocity of the coronary arteries throughout the
cardiac cycle may result in motion artifacts and image blur-
ring. In EBCT, temporal resolution equals the time required
for the electron beam to sweep across an arc of tungsten
targets (for CT-CA, typically 100 ms).8 In MDCT, temporal
resolution is equal to approximately half the gantry rotation
time (state-of-the-art scanners have a temporal resolution of
approximately 167 ms or less).
X-ray beam collimation dictates the thickness of recon-
structed slices and therefore affects spatial resolution in the
z-axis. The partial volume effects that can interfere with im-
age interpretation can be decreased by using thin recon-
structed slices. For most EBCT scanners, the thinnest colli-
mation slice is 1.5 mm.8 State-of-the-art MDCT scanners
have a beam collimation of 0.6 mm or less.
Patient-Related Factors
The patient’s heart rate and rhythm can create motion and
image reconstruction artifacts that interfere with image inter-
pretation of MDCT coronary angiography (MDCT-CA).9,10 In
general, a scanner with high temporal resolution can accom-
modate a relatively rapid heart rate without compromising
image quality. For example, images acquired with a first-
generation MDCT scanner with a temporal resolution of 250
ms or more show motion artifacts at heart rates exceeding 55
beats/min.11 Conversely, newer MDCT scanners can produce
diagnostic quality images at heart rates of 70 beats/min or
more.9 Because the quality of CT image reconstructions is
best if the heart has nearly the same size and shape at the
same point during successive cardiac cycles, an irregular
heart rhythm from atrial fibrillation or premature beats often
results in nondiagnostic image quality.
The size of anatomic structures containing materials with
high CT density can be exaggerated by partial volume effects.
For example, the lumina of coronary segments that are calci-
fied or arteries containing metallic stents are frequently oblit-
erated by bright, “blooming” representations of calcium or
metal, making assessment of luminal narrowing impossi-
ble.10 Future generations of CT scanners with thinner x-ray
beam collimation or modified algorithms for image recon-
struction may minimize these effects.
No studies have examined the effect of patient body size on
the accuracy of CT-CA. In our experience, CT-CA using stan-
dard scanner settings can exhibit a degree of image noise that
disallows confident image interpretation in patients with a
body mass index of 30 kg/m2 or more.
43
Performance of CT Angiography
The heart rate of an anxious patient before a medical proce-
dure is usually in the range where motion artifacts during
MDCT-CA are likely to occur. Therefore, most centers per-
forming MDCT-CA control the patient’s heart rate pharma-
cologically. ␤-Receptor or calcium channel blocking agents
may be orally or intravenously administered to reduce the
heart rate during the scan.11 The algorithm used at Mayo
Clinic Jacksonville for heart rate control during MDCT-CA
(gantry rotation time, 375 ms) is shown in Fig 1. Pharmaco-
logic heart rate control is usually unnecessary for EBCT-CA.
For CT-CA, the chest is scanned from below the carina to
below the diaphragmatic surface of the heart while the breath
is held. Because the duration of a cardiac EBCT scan increases
as the heart rate decreases, atropine is sometimes adminis-
tered to increase the heart rate and limit the length of time the
breath must be held.8 Sublingual nitroglycerin may also be
administered immediately before the scan to achieve vasodi-
lation.
CT-CA requires intravenous administration of iodinated
contrast medium, but the optimal iodine concentration and
mode of administration have not been studied systematically.
Contrast medium is typically injected at a rate of 2 to 5 mL/s
through a cannula inserted into an antecubital vein. The de-
lay before beginning the scan after the injection of contrast
medium can be determined in several ways: (1) by measuring
circulation time with a test bolus before performing the CT-
CA; (2) by “bolus tracking,” where CT-CA scanning initiates
automatically after enhancement in the aortic root exceeds a
threshold value; and (3) by an empiric estimate from opera-
tor experience. For most patients, a scan delay of 21 to 25 s is
sufficient.12
Contrast enhancement of coronary arteries should be con-
stantly maintained throughout the scan. Thus, the volume of
contrast medium injected depends on the injection rate and
scan duration. For EBCT-CA, scan duration is proportional
to the heart rate. For MDCT-CA, scan duration decreases
with faster gantry rotation time; it also decreases with the
acquisition of a greater number of slices per gantry rotation.
Technical advances in MDCT technology are characterized
by decreased gantry rotation times and increased number of
slices that can be acquired simultaneously. Therefore, the
volume of contrast medium required for MDCT-CA has de-
creased with each new generation of MDCT scanners. Use of
a double-head injector to administer a saline flush immedi-
ately after injection of the contrast medium decreases the
amount of contrast medium required and improves contrast
enhancement in the caudad portion of the scanned volume.
Approximately 80 mL of contrast medium are sufficient for
CT-CA with a 64-slice scanner.7
Image Reconstruction and Visualization
To minimize coronary motion artifacts, CT-CA images are
acquired (with EBCT-CA) or reconstructed (with MDCT-CA)
during the point of the cardiac cycle with the slowest coro-
nary motion velocity. Coronary artery motion velocity pro-
files show troughs during ventricular systole, near the end of
44
Figure 1 Mayo Clinic Jacksonville algorithm for pharmacologic heart
rate control. (A) At enrollment. (B) Immediately before scan. BPM,
beats per minute; CI, contraindication. Reprinted from Gerber TC,
Kuzo RS, Lane, et al. J Comput Assist Tomogr 27:62-69, 2003 with
permission of Lippincott, Williams & Wilkins.
isovolumic contraction, and during ventricular diastole, be-
fore atrial contraction begins.13,14 Greater temporal resolu-
tion enhances the systolic and diastolic troughs of the veloc-
ity profiles; thus, the timing of image acquisition, or of the
image reconstruction window, relative to the cardiac cycle
becomes more important as temporal resolution of CT scan-
ners increases.13
Most studies of EBCT-CA have used images acquired dur-
ing diastole, 80% into the R-R interval (between 2 R-waves of
the ECG).5 However, the lowest coronary artery motion ve-
locity usually occurs during ventricular systole. Therefore,
heart rate-dependent image acquisition during systole, ap-
proximately 35% to 50% into the R-R interval, can decrease
the degree of motion artifacts and improve diagnostic accu-
racy of EBCT-CA, particularly in the right coronary artery.8
Most studies of MDCT-CA have used retrospective recon-
struction during diastole, typically with image reconstruction
windows beginning approximately 60% to 65% into the R-R
interval. However, because of the reasons discussed above,
optimal image quality (with the fewest motion artifacts) may
be found during systole when MDCT scanners with higher
T.C. Gerber et al.
temporal resolution are used; some researchers suggest rou-
tine reconstruction of more than 1 image set at different
points of the cardiac cycle.15 Image reconstruction algo-
rithms can decrease the nominal temporal resolution of
MDCT-CA by combining projection data from different car-
diac cycles into 1 image (multisector reconstruction). Such
algorithms are usually applied automatically when the pa-
tient’s heart rate exceeds a preset threshold, but they improve
image quality only when the heart rate is regular.16
Projection data are primarily reconstructed into planar,
transaxial images. A state-of-the-art 64-slice MDCT scanner
generates approximately 300 transaxial images per CT-CA
scan. The number of images recorded per CT-CA scan will
increase with each scanner generation as beam collimation
and individual slice thickness decreases, and individual re-
view of every image may eventually become impractical.
Therefore, visualization techniques that use the 3-dimen-
sional aspect of the CT-CA image data set to allow interactive
examination of individual coronary arteries or the entire cor-
onary artery tree from only a few images (Fig 2), such as
thin-slab maximum-intensity projections or multiplanar ref-
ormations, may become more important in the interpretation
of CT-CA studies.12,17 However, the optimal display combi-
nation for interpreting CT-CA images has not been deter-
mined systematically. Most centers combine at least 2 display
techniques to study and report CT-CA findings.12,17 Visual-
ization techniques with filtering algorithms or numerous
user-defined parameters such as shaded-surface displays can
obscure coronary stenoses or create the appearance of steno-
ses where there are none. Therefore, such displays are typi-
cally used for illustrative purposes only.
Radiation Dose
Because of differences in projection data acquisition, the ra-
diation dose received by the patient from MDCT-CA is typi-
cally higher than the dose from EBCT-CA.18,19 The radiation
dose from MDCT-CA can be decreased by modulating the
current of the x-ray tube. These modulations can be calcu-
lated on the basis of the tube position relative to the longitu-
dinal z-axis of the scan, the patient cross section (x- and
y-axes of the scan), or the time point of the cardiac cycle.
When scanning at a level along the longitudinal axis (eg,
upper vs. lower thorax)20 or from a cross-sectional perspec-
tive (eg, anteroposterior vs. lateral)21,22 where photon atten-
uation is low, radiation output can be reduced without an
increase in image noise. ECG-controlled tube current mod-
ulation23 maintains the highest tube current (and thus the
lowest image noise) during the point of the cardiac cycle
when images will be reconstructed. Importantly, the radia-
tion dose reduction with ECG-controlled tube current mod-
ulation is inversely related to heart rate. The reduction is
approximately 48% at a heart rate of 60 beats/min and ap-
proximately 28% at a heart rate of 70 beats/min.23,24
Published values for 3 parameters of CT-CA radiation do-
simetry are listed in Table 1.18,19,23,25,26 The volume com-
puted tomography dose index27 is useful for comparing the
radiation dose received from different scanning protocols.
CT coronary angiography 45

Figure 2 Maximum-intensity projection (“unfolded globe” view). This image simultaneously shows all 3 coronary
arteries along center lines. Arrowhead indicates calcium near the ostium of the right coronary artery. Reprinted with
permission from Hoffmann MH, Shi H, Schmitz BL, et al. JAMA 293:2471-2478, 2005.

The dose length product28 represents the integrated radiation
dose received from a specific CT examination. The effective
dose29,30 is a rough estimate of the risk of biological injury
due to exposure to ionizing radiation.
Applications of CT-CA
No indications for the performance of CT-CA have been es-
tablished to date. The diagnostic performance of CT-CA has
been compared to the reference standard of invasive, cathe-
ter-based selective coronary angiography. Most studies were
conducted at medical centers with extensive experience in
CT-CA. Although training standards have recently been pro-
posed,31 little is known about the training requirements,
learning curve, or accuracy of less experienced operators for
performing and interpreting CT-CA.
Potential clinical applications of CT-CA include detection
of coronary artery stenoses, assessment of coronary artery

Table 1 Published Values for 3 Parameters of CT-CA Radiation Dosimetry*

Radiation Dose
Regular Mode ECG-Controlled Tube
(Constant Tube Current) Current Modulation
E, mSv E, mSv
CTDIvol, DLP, mGy ⴛ CTDIvol, DLP, mGy ⴛ
Publication mGy cm M W A mGy cm M W
EBCT (prospectively triggered)
Morin et al, 200319 5.3 63.6 1.1
Hunold et al, 200318 — — 1.5 2
MDCT (retrospectively gated)
Morin et al, 200319 45.6 547 9.3
Hunold et al, 200318‡ — — 10.9 13
Hunold et al, 200318‡ — — 7.6 9.2
Hunold et al, 200318‡ — — 6.7 8.1
Trabold et al, 200325 37.56† 451 8.1 10.9 37.56† 451 4.3 5.6
A, Average effective dose for women and men; CT, computed tomography; CTDIvol, volume computed tomography dose index; DLP, dose length
product; E, effective dose; EBCT, electron beam computed tomography; M, men; MDCT, multidetector-row computed tomography; W, women.
*From Gerber et al.26 Used with permission.
†Reported as “CTDIw.”
‡Measurements performed with 3 different scanner settings.
 46
Table 2 Diagnostic Accuracy of Multidetector-Row Computed Tomographic Coronary Angiography Compared to Selective Coronary Angiography
Gantry Rotation Basis of Excluded†, Sensitivity‡, Specificity‡,
Publication N Collimation* Time, ms Analysis % % % PPV‡, % NPV‡, %
Nieman et al, 200233 59 12 ⴛ 0.75 420 Artery 0 95 (89–98) 86 (83–88) 80 (75–83) 97 (93–99)
Ropers et al, 200334 77 12 ⴛ 0.75 420 Patient 0 85 87 82 81
Martuscelli et al, 200435 64 16 ⴛ 0.625 500 Artery 12 89 98 90 98
Mollet et al, 200436 128 16 ⴛ 0.75 420 Segment 0 92 (88–95) 95 (93–96) 79 (73–88) 98 (97–99)
Kuettner et al, 200437§ 60 12 ⴛ 0.75 420 Segment 0 72 97 72 97
Hoffmann et al, 200438 33 16 ⴛ 0.75 420 Patient 0 86 (72–101) 82 (60–104) 90 75
Schuijf et al, 200439§ 30 4 ⴛ 2.0 or 400–500 Patient 0 91 71 91 71
16 ⴛ 0.5
Morgan-Hughes et al, 200540 58 16 ⴛ 0.625 500 Segment 0 83 97 80 97
Kuettner et al, 200541 72 16 ⴛ 0.75 375 Segment 0 82 98 87 97
Mollet et al, 200542 51 16 ⴛ 0.75 375 Patient 0 100 (88–100) 85 (62–96) 91 (76–97) 100 (80–100)
Schuijf et al, 200543§ 45 16 ⴛ 0.5 400–600 Segment 0 85 89 71 95
Schuijf et al, 200544 31 4 ⴛ 2.0 or 400–600 Segment 12 93 (86–100) 96 (93–99) 88 (80–96) 98 (96–100)
16 ⴛ 0.5
Hoffmann et al, 200545 103 16 ⴛ 0.75 420 Patient 0 97 (88–100) 87 (74–95) 90 (80–96) 95 (84–99)
Kuettner et al, 200546§ 124 16 ⴛ 0.75 370 Patient 0 85 98 91 96
Leber et al, 200547 45 64 ⴛ 0.6 330 Patient 0 88 85 88 85
Leschka et al, 20057 73 64 ⴛ 0.6 370 Segment 0 94 (90–96) 97 (96–98) 87 (84–90) 99 (98–99)
Achenbach et al, 200548 50 16 ⴛ 0.75 375 Patient 4 100 (84–100) 83 (62–92) 100 (80–100) 86 (68–94)
Raff et al, 200549 70 64 ⴛ 0.6 330 Patient 0 95 90 93 93
NPV, negative predictive value; PPV, positive predictive value.
*Number of slices acquired simultaneously with each gantry rotation ⴛ x-ray beam collimation of each slice (mm).
†Percentage of segments, arteries, or patients excluded from analysis (images could not be interpreted).
‡Includes (95% confidence interval) when known.
§Included coronary artery bypass grafts or stented coronary segments or both in analysis.

T.C. Gerber et al.

CT coronary angiography 47

Figure 3 Ostial left anterior descending artery (LAD) stenosis more than 70% (arrows). The patient was a 69-year-old
man with typical angina but negative findings after a stress test. (A) Maximum intensity projection approximating
horizontal long-axis orientation, reconstructed from 16-slice MDCT-CA. (B) Selective coronary angiogram, shallow
right anterior oblique view. AO, aorta; RVOT, right ventricular outflow tract.

bypass graft (CABG) status, and evaluation of congenitally
abnormal coronary arteries. Reproducible visualization of the
lumina of coronary artery stents with CT-CA is currently not
possible but may eventually be achieved with future genera-
tions of CT scanners. Perhaps the most exciting CT-CA ap-
plication under development is plaque characterization to
establish a patient’s risk of adverse cardiac events.
Detection of Coronary Artery Stenoses
Most studies of EBCT-CA were conducted before 2000.5,32
With the rapid development of MDCT technology, the ma-
jority of recent studies examining the diagnostic accuracy of
CT-CA for the detection of coronary luminal narrowing have
used MDCT-CA. Results of studies using contemporary
MDCT-CA technology (16 slices or more, gantry rotation
time ⱕ 420 ms) are shown in Table 2.7,33-49 Of note, the
numbers of patients studied were limited, and patients were
often highly selected.
Most studies have used a threshold of 50% luminal nar-
rowing (compared with patient-specific reference diameters)
to define “clinically significant” stenosis. Because coronary
flow reserve typically is not compromised until the lumen is
narrowed by 70% to 75% (Fig 3), sensitivities and positive
predictive values reported in most CT-CA studies do not
identify patients who need revascularization. However, an
oft-stated objective of CT-CA is to replace expensive cardiac
catheterization in patients who do not need coronary revas-
cularization.50 Using CT-CA to identify patients not needing
coronary intervention appears feasible: the negative predic-
tive value of MDCT-CA was uniformly high in all studies,
even when patients had intermediate or high pretest proba-
bility of having clinically significant coronary artery disease
(CAD) or were in a study group where the prevalence of such
CAD was high. The low threshold of 50% luminal narrowing
used to define clinically significant stenoses decreases the
likelihood of failing to identify patients in whom an invasive
diagnostic strategy is warranted. CT-CA may eventually re-
place expensive cardiac catheterizations performed to rule
out clinically significant coronary artery stenoses in patients
with a low likelihood of CAD, such as those having noncoro-
nary cardiac surgery or those with cardiomyopathy of uncer-
tain etiology. However, the cost effectiveness of using CT-CA
to rule out CAD in these situations will be affected by local
disease prevalence and utilization, cost, and expertise in per-
forming CT-CA. Cost-effectiveness studies have not yet been
performed.
Analysis by coronary segment or coronary artery has been
used to evaluate the diagnostic accuracy of CT-CA. These
analyses may improve or worsen diagnostic accuracy
through intraindividual clustering of observations or the in-
ability to assess individual coronary segments. Data from
per-patient analyses best reflect the ability of CT-CA to iden-
tify patients with at least 1 clinically significant coronary
artery stenosis.
The studies of CT-CA to date, performed in patients re-
ceiving referrals to undergo clinically indicated, catheter-
48 T.C. Gerber et al.

Figure 4 Coronary artery bypass grafts. The patient was a 77-year-old woman. Volume rendering was reconstructed
from 16-slice MDCT-CA. The vertical row of vascular clips (asterisk) denotes an occluded left internal mammary artery
graft to the left anterior descending artery. D1-RAG, radial artery graft to first diagonal branch; LV, left ventricle;
OM-SVG, saphenous vein graft to obtuse marginal branch; RCA-SVG, saphenous vein graft to right coronary artery; RV,
right ventricle.

based coronary angiography, do not conclusively identify
which patients could undergo CT-CA as an initial diagnostic
test. No studies have compared the diagnostic performance
and cost efficiency of CT-CA with conventional stress tests
for initial examinations. In our practice, we typically use
CT-CA as a secondary test for patients who have atypical
symptoms, inconclusive conventional stress test findings, or
both.
The prognostic importance of selective coronary angiogra-
phy findings is well established, but similar studies of CT-CA
have not been performed. For example, it is not known
whether or how aggressive workup and possible revascular-
ization of high grade coronary stenoses identified inciden-
tally on a “screening” MDCT-CA will improve long-term out-
come in an asymptomatic patient.
It is currently not possible to combine CT-CA with percu-
taneous coronary intervention. Therefore, CT-CA is not in-
dicated for patients who are likely to need percutaneous cor-
onary intervention (eg, patients with highly typical angina,
unequivocally abnormal stress tests, or ECG or biochemical
findings suspicious for an acute coronary syndrome).
Coronary Artery Bypass Grafts
CT-CA can be used for generating high quality images of
CABGs (Fig 4) because, compared with coronary arteries,
they do not move very much, have a large caliber, and
often have an axial course. Three-dimensional rendering
of CABG in CT angiograms (eg, volume rendering, shad-
ed-surface displays) can be used to quickly survey graft
anatomy, especially in patients who have undergone mul-
tiple bypass procedures. For the qualitative diagnosis of
CABG occlusion versus patency, MDCT-CA has a sensitiv-
ity of 93% to 100% and specificity of 98% to 100%.51-56
For the quantitative diagnosis of luminal narrowing
greater than 50%, the procedure has 80% to 96% sensitiv-
CT coronary angiography 49

Figure 5 Right coronary artery (RCA) with abnormal origin from the left coronary sinus of Valsalva. The patient was a
58-year-old woman with atypical chest pain; her heart was imaged by using 16-slice MDCT-CA. (A) Proximal course
of the anomalous RCA between the right ventricular outflow tract (RVOT) and the aorta (AO) illustrated in a maximum-
intensity projection that approximates the horizontal long-axis orientation. (B) Potential for compression between the
RVOT and pulmonary artery (PA) (anterior) and the AO (posterior) is illustrated in a maximum-intensity projection
that approximates the vertical long-axis orientation. LA, left atrium; RV, right ventricle. Reprinted with permission from
Deibler AR, Kuzo RS, Vohringer M, et al. Mayo Clin Proc 79:1017-1023, 2004.

ity and 95% to 100% specificity, positive predictive value
between 75% and 81%, and negative predictive value be-
tween 86% and 99%. The diagnostic accuracy of 16-slice
MDCT is superior to that of 4-slice MDCT in the body of a
CABG but not at the distal anastomosis.56
CT angiography of CABGs may not be able to show
distal anastomoses, and its diagnostic accuracy can be in-
fluenced by the type and number of vascular clips. If the
anastomosis between the graft and coronary artery is
nearly parallel to the imaging plane, it will be represented
in only 1 or 2 slices; it is therefore difficult to confidently
exclude stenoses in approximately 25% of anastomosis
sites. Certain types of vascular clips (used to occlude the
side branches of grafts) can create dense image reconstruc-
tion artifacts as the result of beam hardening. These arti-
facts can obscure large portions of CABGs and interfere
with the segmental assessment for stenoses, but qualitative
assessments for patency may still be possible.
Coronary Artery Anomalies
Patients are often referred for CT-CA if coronary angiography
performed for angina, exertional dyspnea, or an abnormal
stress test incidentally identifies coronary anomalies. Clini-
cally, it is important to determine whether the proximal por-
tion of the abnormal coronary artery is in front of the pulmo-
nary artery, behind the aorta, or between the two. This
distinction has prognostic value because coronary arteries
that originate abnormally from the opposite side of their per-
fusion territory and course between the aorta and the pulmo-
nary artery (Fig 5) are associated with an increased risk of
sudden cardiac death.57,58 The putative mechanism for sud-
den cardiac death is myocardial ischemia caused by coronary
artery compression between the aorta and the pulmonary
artery.59 Depending on the clinical scenario, such patients
often undergo CABG surgery.60
During catheterization, a physician can usually engage the
ostium and define the proximal course of abnormal coronary
arteries, but the procedure can be difficult and lengthy, ad-
ditional catheters may be required for spatial reference, and a
large volume of contrast medium may be administered.61
With CT-CA, qualitative assessment of the proximal course
relative to the great vessels is simple,62-69 and quantitative
evaluation is unnecessary because any coronary stenoses will
have been identified during earlier selective coronary angiog-
raphy.
Coronary anomalies are rare, and not all incidentally iden-
tified coronary anomalies require clarification of their proxi-
mal course. For example, circumflex coronary arteries origi-
nating from the right coronary sinus of Valsalva or the
proximal portion of the right coronary artery invariably
course behind the aorta.70
Abnormal coronary arteries have been implicated in the
sudden death of young athletes,58 and echocardiographic
screening for congenital coronary anomalies has been advo-
cated for this group.71 In spite of its efficacy in detecting and
assessing coronary anomalies, CT-CA is unlikely to become a
widely used screening method for this purpose because of the
high cost, radiation exposure, and use of iodinated contrast
medium.
50 T.C. Gerber et al.

Figure 6 Stent in the proximal por-

tion of the right coronary artery
(RCA) of a 42-year-old woman with
atypical chest pain; her heart was
imaged using 64-slice MDCT-CA.
(A) Stent struts protruding into the
aorta (arrowhead, upper left) pre-
vented perfect selective engagement
during coronary catheterization.
Proximal stent lumen is clearly visu-
alized by MDCT-CA in multiple ori-
entations (upper row and lower
left). Contrast medium enhance-
ment in the middle portion of the
right coronary artery confirms pa-
tency of the stent (arrow, lower
right). (B) Corresponding selective
coronary angiogram, left anterior
oblique projection. AO, aorta;
RVOT, right ventricular outflow
tract.

Stents coronary intervention. Recurrent pain is often atypical or differ-

Although drug-eluting stents have decreased the incidence of ent from the angina that originally prompted stent placement.
in-stent restenosis, in-stent restenosis remains a concern in pa- Minimally invasive visualization of the stent lumen by CT-CA
tients who present with recurrent chest pain after percutaneous would be ideal for many of these patients, but beam hardening
CT coronary angiography 51

Figure 7 Plaque imaging. Upper left and middle, MDCT-CA images. Upper right, selective coronary angiography
(SCA) image. Lower row, intracoronary ultrasonographic (ICUS) images. A indicates a proximal left anterior
descending artery segment shown to be free of plaque by all 3 imaging methods. B indicates a proximal left
anterior descending artery segment that shows no plaque in the SCA image but shows plaque in MDCT-CA and
ICUS images. A ⬍⬍ and B ⬍⬍ show cross sections of the artery at the points indicated by A and B. Lower right,
ICUS image demonstrates vascular remodeling to accommodate plaque (gray area). Reprinted with permission
from Schoenhagen P, Tuzcu EM, Stillman AE, et al. Coron Artery Dis 14:459-462, 2003.

and partial volume effects from metallic stent material often
entirely obscure the lumen during CT-CA.
Most early studies of stent EBCT-CA used flow measurements
of contrast enhancement patterns in coronary segments distal to
the stent as an indirect indicator of stent patency.72 However, a
recent study of stent EBCT-CA compared flow measurements
and visualization of the stent lumen as predictors of stent reste-
nosis in 117 patients.73 Delayed enhancement of the coronary
lumen distal to the stent predicted only subtotal occlusion
(⬎90%) but not the less severe yet clinically significant in-stent
stenoses (⬎75% occlusion). Assessment of the stent lumen did
not predict the severity of luminal compromise.
In vitro studies of stent MDCT-CA showed improved im-
aging of the stent lumen with thinner slice collimation and
image reconstruction algorithms designed to decrease
“blooming” (sharp instead of standard kernels). However,
lumen narrowing caused by metal-related image reconstruc-
tion artifacts could resemble up to 100% occlusion.74,75
Up to 40% of stent lumina cannot be imaged with diag-
nostic quality in vivo.76,77 The main determinants of visu-
alizing the stent lumen are stent caliber (ⱖ3.5 mm) and
stent location (left main coronary artery, the proximal seg-
ment of the left anterior descending artery, or saphenous
vein CABGs).76,77 Using 16-slice MDCT-CA in patients
with a high prevalence of large-caliber stents78,79 yielded
diagnostic quality images of stent lumina for approxi-
mately 75% of patients (Fig 6). For assessable segments
only, detection of luminal narrowing (at least 50%) had a
sensitivity of 78% to 100% and a specificity of 92% to
100%. Specificity decreased to approximately 75% when
all coronary segments were included in the analysis.
Plaque Imaging
Most acute coronary syndromes are the result of rupture or
erosion of an “unstable” plaque, followed by coronary throm-
bosis.80 Although instability is probably a biological (not me-
chanical) feature, morphologic characteristics of rupture-
52
prone plaques have been described.81 These plaques typically
contain a soft, lipid-rich core and are covered by a thin,
fibrous cap. Although the cap is too thin to be imaged, it may
be possible to determine the main constituents of the plaque
core with CT.
The appearance of atherosclerotic plaques in MDCT-CA
(Fig 7) has been compared to intracoronary ultrasonographic
images82-90 and histologic specimens.91-93 The degree of cor-
onary remodeling (a vessel enlargement process that occurs
in early atherosclerosis and may increase the likelihood of
plaque rupture) can be characterized qualitatively82 and
quantitatively83 by 16-slice MDCT-CA. On the basis of
MDCT-CA findings, accurate qualitative observations can be
made about plaque morphology (concentric vs. eccentric)
and composition (noncalcified, calcified, mixed).82,84
Plaques characterized with intracoronary ultrasonography
are classified as “soft” (presumably lipid rich), “intermediate”
(presumably fibrous), and “calcified.” The plaque types have
different degrees of x-ray attenuation and thus can be differ-
entiated by MDCT-CA.85-87 However, when quantifying the
volume of noncalcified plaque, the image quality of 16-slice
MDCT-CA is not sufficient compared with intracoronary ul-
trasonography.88,89 Therefore, MDCT-CA imaging of noncal-
cified plaques does not yet allow serial assessment of progres-
sion or regression of atherosclerosis. Qualitative assessment
of plaque components and quantitative measurements of CT
attenuation in ex vivo studies showed that MDCT-CA could
differentiate between plaque types IV, V, and VII of the his-
tologic classification of atherosclerotic lesions proposed by
the American Heart Association.94,95 However, early (type III)
lesions were recognized with low sensitivity and could not be
distinguished from type IV lesions on the basis of attenua-
tion.91-93
Qualitative, descriptive assessment by MDCT-CA of 85
patients with stable angina identified plaques on average in 6
of 16 coronary segments per patient.96 A third of the plaques
were “large” (⬎50% luminal narrowing), and 76% were cal-
cified or mixed (calcified and noncalcified). Of 68 patients
with unfavorable coronary risk factor profiles, noncalcified
plaques were found in 45% of patients with coronary calci-
fications and 10% of patients without coronary calcifica-
tions.97 A study of 8 patients with ECG changes suggestive of
myocardial damage but without appreciable CAD (demon-
strated by selective coronary angiography) showed noncalci-
fied plaques (identified by MDCT-CA) were more prevalent
in patients with recent myocardial infarction than in patients
with myocarditis.90 A comparison of 40 patients with acute
myocardial infarction to 19 patients with stable angina pec-
toris showed the ratio of noncalcified plaques to calcified
plaques identified by MDCT-CA was higher in patients with
myocardial infarction.98 These findings suggest that noncal-
cified plaques have a role in the pathogenesis of acute coro-
nary syndromes. However, the precise role of CT-CA identi-
fication of noncalcified plaques in the prognosis of patients
with high risk for adverse cardiac events requires further
study.
T.C. Gerber et al.
Table 3 Selection Criteria for Computed Tomographic Coro-
nary Angiography (CT-CA)
Potential indications for CT-CA
Coronary risk factors and atypical symptoms, and/or
nondiagnostic stress test
Unable to undergo stress testing
Coronary artery bypass grafts
Congenital coronary anomalies
Symptoms or abnormal stress test findings (patient
refuses to undergo selective coronary angiography)
Contraindications for CT-CA
Atrial fibrillation or other heart arrhythmia
Coronary artery disease other than coronary artery
bypass graft (patient can undergo selective coronary
angiography)
Stent patency or stenosis (except stents < 3.5 mm in
diameter)
Highly typical symptoms or unequivocal stress test
findings
Acute coronary syndrome with electrocardiogram or
enzymatic evidence of myocardial compromise
Summary
MDCT is currently the predominant mode of performing
CT-CA. MDCT scanners used for CT-CA should have a gan-
try rotation time of 420 ms or less and a beam collimation of
0.75 mm or less. The effective radiation dose received from
MDCT-CA (about 8-10 mSv) is higher than that received
from EBCT-CA (1-2 mSv).
Further clinical studies are needed to define the role of
CT-CA in the contemporary practice of cardiology. Emerging
clinical applications of CT-CA include assessment of patients
with atypical presentation or nondiagnostic stress test find-
ings, examination of CABGs for patency and stenoses, and
clarification of the course of congenitally abnormal coronary
arteries. CT-CA may also be considered for patients sus-
pected of having CAD who cannot undergo stress testing or
selective coronary angiography.
Patients should be selected carefully (Table 3). To mini-
mize coronary motion artifacts that limit the diagnostic value
of CT-CA, pharmacologic heart rate control can be applied to
slow the heart rate to 60 to 65 beats/min during the scan.
Patients with atrial fibrillation or other types of irregular heart
rhythms and patients with high resting heart rates who have
contraindications to the pharmacologic agents are not good
candidates for CT-CA.
Patients with severe CAD are unsuitable for CT-CA be-
cause their arteries are likely to have considerable coronary
calcification. Selective coronary angiography is preferred
over CT-CA for the serial assessment of patients known to
have CAD, especially for evaluating the subtle progression of
coronary artery stenoses and for patients likely to require
revascularization. Similarly, CT-CA cannot reliably produce
images of stent lumina (for assessment of in-stent restenosis)
because of partial volume effects and beam hardening. Future
CT technology may eliminate the need for pharmacologic
CT coronary angiography
heart rate control and decrease the negative effects of calcium
and metallic stents on CT-CA image quality.
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