Research paper|Articles in Press

Mean density of computed tomography for predicting rotational atherectomy during percutaneous coronary intervention

Published:February 10, 2023DOI:



      Multi-slice computed tomography (CT) allows noninvasive evaluation of the severity of coronary calcification. However, there has yet to be a definitive parameter based on the cross-sectional CT image for predicting the need for rotational atherectomy (RA). Therefore, we aimed to investigate the mean density of cross-sectional CT images to predict the need for RA during percutaneous coronary intervention (PCI).


      A total of 154 lesions with moderate to severe calcification detected in coronary angiography were identified in 126 patients who underwent coronary CT prior to PCI for stable angina. PCI with RA was performed for 48 lesions, and the remaining 106 were treated without RA. Multi-slice CT was retrospectively evaluated for its ability to predict the use of RA. We chose the most severely calcified cross-sectional image for each lesion. The mean density within the outer vessel contour, calcium arc quadrant of the cross-sectional CT image, calcium length, calcification remodeling index, and per-lesion coronary artery calcium score was studied.


      Receiver-operator characteristic curve analysis revealed 637 Hounsfield units (HU) (area under the curve ​= ​0.98, 95% confidence interval: 0.97–1.00, p ​< ​0.001) as the best mean density cutoff value for predicting RA. Multivariate logistic regression analysis showed that a mean calcium level >637 HU was a strong independent predictor (odds ratio: 32.8, 95% confidence interval: 7.0–153, p ​< ​0.001) for using RA.


      The mean density of the cross-sectional CT image, a simple quantitative parameter, was the strongest predictor of the need for RA during PCI.



      CAC (coronary artery calcium), CT (computed tomography), HU (Hounsfield unit), IVUS (intravascular ultrasound), MLA (minimum lumen area), MSA (minimum stent area), OCT (optical coherence tomography), PCI (percutaneous coronary intervention), QCA (quantitative coronary angiography), RA (rotational atherectomy), ROC (receiver operator characteristic), WL/WW (window level/window width)
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        • Bourantas C.V.
        • Zhang Y.J.
        • Garg S.
        • et al.
        Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention: a patient-level pooled analysis of 7 contemporary stent trials.
        Heart. 2014; 100: 1158-1164
        • Généreux P.
        • Madhavan M.V.
        • Mintz G.S.
        • et al.
        Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes: pooled analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) and ACUITY (acute catheterization.
        J Am Coll Cardiol. 2014; 63: 1845-1854
        • Kastrati A.
        • Schömig A.
        • Elezi S.
        • et al.
        Predictive factors of restenosis after coronary stent placement.
        J Am Coll Cardiol. 1997; 30: 1428-1436
        • Fujii K.
        • Carlier S.G.
        • Mintz G.S.
        • et al.
        Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study.
        J Am Coll Cardiol. 2005; 45: 995-998
        • Kawamoto H.
        • Latib A.
        • Ruparelia N.
        • et al.
        In-hospital and midterm clinical outcomes of rotational atherectomy followed by stent implantation: the ROTATE multicentre registry.
        EuroIntervention. 2016; 12: 1448-1456
        • Iannaccone M.
        • Piazza F.
        • Boccuzzi G.G.
        • et al.
        RoTational AThErectomy in acute coronary syndrome: early and midterm outcomes from a multicentre registry.
        EuroIntervention. 2016; 12: 1457-1464
        • Voros S.
        • Rinehart S.
        • Qian Z.
        • et al.
        Coronary atherosclerosis imaging by coronary CT angiography: current status, correlation with intravascular interrogation and meta-analysis.
        JACC Cardiovasc Imaging. 2011; 4: 537-548
        • Agatston A.S.
        • Janowitz W.R.
        • Hildner F.J.
        • Zusmer N.R.
        • Viamonte M.
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiol. 1990; 15: 827-832
        • Suzuki Y.
        • Matsumoto N.
        • Nagumo S.
        • et al.
        Incremental predictive value of coronary calcium score in risk stratification of coronary revascularization in patients with normal or mild ischemia using nuclear myocardial perfusion single photon emission computed tomography.
        Circ J. 2021; 85: 877-882
        • Yasuyuki S.
        • Naoya M.
        • Shunichi Y.
        • Yasuo A.
        • Yasuo O.
        Coronary artery calcium score: current status of clinical application and how to handle the results.
        J Cardiol. 2022; 79: 567-571
        • Sadamatsu K.
        • Okutsu M.
        • Sumitsuji S.
        • et al.
        Practical utilization of cardiac computed tomography for the success in complex coronary intervention.
        Cardiovasc Interv Ther. 2021; 36: 178-189
        • Fujino A.
        • Mintz G.
        • Matsumura M.
        • et al.
        TCT-28 A new optical coherence tomography-based calcium scoring system to predict stent underexpansion.
        EuroIntervention. 2018; 70: B12-B13
        • Rochitte C.E.
        • Dewey M.
        • Niinuma H.
        • Clouse M.E.
        Patterns of coronary arterial lesion calcification.
        Int J Cardiovasc Imag. 2014; 29 (PATTERNS): 1619-1627
        • Maejima N.
        • Hibi K.
        • Saka K.
        • et al.
        Relationship between thickness of calcium on optical coherence tomography and crack formation after balloon dilatation in calcified plaque requiring rotational atherectomy.
        Circ J. 2016; 80: 1413-1419
        • Saito Yuichi
        • Kobayashi Yoshio
        • Fujii Kenichi
        • et al.
        Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics.
        Cardiovasc Interv Ther. 2020; 35: 1-12
        • Fujii K.
        • Kubo T.
        • Otake H.
        • et al.
        Expert consensus statement for quantitative measurement and morphological assessment of optical coherence tomography.
        Cardiovasc Interv Ther. 2020; 35: 13-18
        • Zhang M.
        • Matsumura M.
        • Usui E.
        • et al.
        Intravascular ultrasound-derived calcium score to predict stent expansion in severely calcified lesions.
        Circ Cardiovasc Interv. 2021; 14e010296
        • Sekimoto T.
        • Akutsu Y.
        • Hamazaki Y.
        • et al.
        Regional calcified plaque score evaluated by multidetector computed tomography for predicting the addition of rotational atherectomy during percutaneous coronary intervention.
        J Cardiovasc Comput Tomogr. 2016; 10: 221-228
        • Yu M.
        • Li Y.
        • Li W.
        • Lu Z.
        • Wei M.
        • Zhang J.
        Calcification remodeling index characterized by cardiac CT as a novel parameter to predict the use of rotational atherectomy for coronary intervention of lesions with moderate to severe calcification.
        Korean J Radiol. 2017; 18: 753-762
        • Qi L.
        • Tang L.J.
        • Xu Y.
        • et al.
        The diagnostic performance of coronary CT angiography for the assessment of coronary stenosis in calcified plaque.
        PLoS One. 2016; 11e0154852
        • Yu C.W.
        • Lee H.J.
        • Suh J.
        • et al.
        Coronary computed tomography angiography predicts guidewire crossing and success of percutaneous intervention for chronic total occlusion.
        Circ Cardiovasc Imaging. 2017; 10: 1-11
        • Kurogi K.
        • Ishii M.
        • Yamamoto N.
        • Yamanaga K.
        • Tsujita K.
        Optical coherence tomography - guided percutaneous coronary intervention: a review of current clinical applications.
        Cardiovasc Interv Ther. 2021; (0123456789): 12928
        • Mehanna E.
        • Bezerra H.G.
        • Prabhu D.
        • et al.
        Volumetric characterization of human coronary calcification by frequency-domain optical coherence tomography.
        Circ J. 2013; 77: 2334-2340
        • Kume T.
        • Okura H.
        • Kawamoto T.
        • et al.
        Assessment of the coronary calcification by optical coherence tomography.
        EuroIntervention. 2011; 6: 768-772
        • Takahashi Y.
        • Toba T.
        • Otake H.
        • et al.
        Feasibility of morphological assessment of coronary artery calcification with electrocardiography-gated non-contrast computed tomography: a comparative study with optical coherence tomography.
        Int J Cardiovasc Imag. 2021; 37: 1445-1453
        • Monizzi G.
        • Sonck J.
        • Nagumo S.
        • et al.
        Quantification of calcium burden by coronary CT angiography compared to optical coherence tomography.
        Int J Cardiovasc Imag. 2020; 36: 2393-2402
        • Sandfort V.
        • Bluemke D.A.
        CT calcium scoring. History, current status and outlook.
        Diagn Interv Imaging. 2017; 98: 3-10