Coronary angiography ACC-AHA characteristics of type A, B, and C coronary lesions: Difference between revisions
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==Overview== | ==Overview== | ||
The [[American College of Cardiology]]/[[American Heart Association]] ([[ACC]]/[[AHA]]) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures developed a classification scheme to characterize the complexity of [[Coronary artery stenosis|coronary stenosis]] and the probability of success of a [[percutaneous intervention]]. ACC/AHA lesion complexity system provides short-term prognostic information adjunctive to [[TIMI flow grade|TIMI flow grade (TFG)]] and [[TIMI myocardial perfusion grade|TIMI myocardial perfusion grade (TMPG)]]. | The [[American College of Cardiology]]/[[American Heart Association]] ([[ACC]]/[[AHA]]) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures developed a classification scheme to characterize the complexity of [[Coronary artery stenosis|coronary stenosis]] and the probability of success of a [[percutaneous intervention]]. ACC/AHA lesion complexity system provides short-term prognostic information adjunctive to [[TIMI flow grade|TIMI flow grade (TFG)]] and [[TIMI myocardial perfusion grade|TIMI myocardial perfusion grade (TMPG)]]. | ||
==ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis== | ==ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis== | ||
The lesion-specific classification was proposed by the Subcommittee on Percutaneous Transluminal Coronary Angioplasty to estimate the likelihood of a successful [[Angioplasty#Coronary angioplasty|angioplastic procedure]] (defined as one in which a ≥20% change in luminal diameter is achieved, with the final diameter [[Coronary artery stenosis|stenosis]] <50% and without the occurrence of death, [[acute myocardial infarction]], or the need for emergency [[Coronary artery bypass surgery|bypass operation]]) as well as the likelihood of developing [[abrupt closure|abrupt vessel closure]].<ref>Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB III, Loop FD,Peterson KL, Reeves TJ, Williams DO, Winters WL Jr, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486–502.</ref> | The lesion-specific classification was proposed by the Subcommittee on Percutaneous Transluminal Coronary Angioplasty to estimate the likelihood of a successful [[Angioplasty#Coronary angioplasty|angioplastic procedure]] (defined as one in which a ≥20% change in luminal diameter is achieved, with the final diameter [[Coronary artery stenosis|stenosis]] <50% and without the occurrence of death, [[acute myocardial infarction]], or the need for emergency [[Coronary artery bypass surgery|bypass operation]]) as well as the likelihood of developing [[abrupt closure|abrupt vessel closure]].<ref>Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB III, Loop FD,Peterson KL, Reeves TJ, Williams DO, Winters WL Jr, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486–502.</ref> | ||
===Type A Lesions (High Success, >85%; Low Risk)=== | ===Type A Lesions (High Success, >85%; Low Risk)=== | ||
Type A lesions are associated with an anticipated success procedure rate of ≥85% and a low risk of [[abrupt closure]]. Type A lesions demonstrate all of the following characterisitics: | Type A lesions are associated with an anticipated success procedure rate of ≥85% and a low risk of [[abrupt closure]]. Type A lesions demonstrate all of the following characterisitics: | ||
* Discreteness (<10 mm in length) | * Discreteness (<10 mm in length) | ||
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===Type B Lesions (Moderate Success, 60 to 85%; Moderate Risk*)=== | ===Type B Lesions (Moderate Success, 60 to 85%; Moderate Risk*)=== | ||
Type B lesions are associated with an anticipated success procedure rate ranging from 60 to 85% or a moderate risk of abrupt closure, or both. Type B lesions include all lesions that are neither type A nor type C and are usually identified by, but not limited to, the following characterisitics: | Type B lesions are associated with an anticipated success procedure rate ranging from 60 to 85% or a moderate risk of abrupt closure, or both. Type B lesions include all lesions that are neither type A nor type C and are usually identified by, but not limited to, the following characterisitics: | ||
* Tubular shape (10 to 20 mm in length) | * Tubular shape (10 to 20 mm in length) | ||
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===Type C Lesions (Low Success, <60%; High Risk)=== | ===Type C Lesions (Low Success, <60%; High Risk)=== | ||
Type C lesions are associated with an anticipated success procedure rate of <60% or a high risk of abrupt closure, or both. Type C lesions demonstrate any of the following characterisitics: | Type C lesions are associated with an anticipated success procedure rate of <60% or a high risk of abrupt closure, or both. Type C lesions demonstrate any of the following characterisitics: | ||
* Diffuseness (>20 mm in length) | * Diffuseness (>20 mm in length) | ||
* Excessive tortuosity of proximal segments | * Excessive tortuosity of proximal segments | ||
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==Modified ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis== | ==Modified ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis== | ||
The standard ACC/AHA classification of the primary target stenosis is prospectively modified to subdivide type B stenoses into '''B1 (one adverse characteristic)''' and '''B2 (≥ two adverse characteristics)''' on the basis of previous studies suggesting the cumulative significance of mutiple adverse lesion characteristics.<ref name="Ellis- | |||
The standard ACC/AHA classification of the primary target stenosis is prospectively modified to subdivide type B stenoses into '''B1 (one adverse characteristic)''' and '''B2 (≥ two adverse characteristics)''' on the basis of previous studies suggesting the cumulative significance of mutiple adverse lesion characteristics.<ref name="Ellis-1990">{{Cite journal | last1 = Ellis | first1 = SG. | last2 = Vandormael | first2 = MG. | last3 = Cowley | first3 = MJ. | last4 = DiSciascio | first4 = G. | last5 = Deligonul | first5 = U. | last6 = Topol | first6 = EJ. | last7 = Bulle | first7 = TM. | title = Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group. | journal = Circulation | volume = 82 | issue = 4 | pages = 1193-202 | month = Oct | year = 1990 | doi = | PMID = 2401060 }}</ref> | |||
==Clinical Significance== | ==Clinical Significance== | ||
* | |||
* A greater ACC/AHA lesion complexity at 60 to 90 minutes after [[fibrinolytic]] administration was shown to be associated with poorer [[TIMI flow grade|epicardial flow]] and [[TIMI myocardial perfusion grade|myocardial perfusion]] as well as a higher risk of [[pulmonary edema]], [[shock]], and mortality within 30 days. However, increased lesion complexity was not associated with a higher risk of recurrent [[myocardial infarction]].<ref name="pmid15219518">{{cite journal| author=Gibson CM, Bigelow B, James D, Tepper MR, Murphy SA, Kirtane AJ et al.| title=Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction. |journal=Am J Cardiol | year= 2004 | volume= 94 | issue= 1 | pages= 108-11 | pmid=15219518 | doi=10.1016/j.amjcard.2004.03.038 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15219518 }} </ref> | |||
* Independent of [[left anterior descending coronary artery]] infarct location, [[TIMI flow grade 3|TIMI grade 3 flow]], age, performance of rescue or adjunctive [[PCI]], pulse, and [[systolic blood pressure]] on admission, type C lesion complexity was associated with an increased short-term mortality rate at 30 days.<ref name="pmid15219518">{{cite journal| author=Gibson CM, Bigelow B, James D, Tepper MR, Murphy SA, Kirtane AJ et al.| title=Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction. |journal=Am J Cardiol | year= 2004 | volume= 94 | issue= 1 | pages= 108-11 | pmid=15219518 | doi=10.1016/j.amjcard.2004.03.038 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15219518 }} </ref> | * Independent of [[left anterior descending coronary artery]] infarct location, [[TIMI flow grade 3|TIMI grade 3 flow]], age, performance of rescue or adjunctive [[PCI]], pulse, and [[systolic blood pressure]] on admission, type C lesion complexity was associated with an increased short-term mortality rate at 30 days.<ref name="pmid15219518">{{cite journal| author=Gibson CM, Bigelow B, James D, Tepper MR, Murphy SA, Kirtane AJ et al.| title=Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction. |journal=Am J Cardiol | year= 2004 | volume= 94 | issue= 1 | pages= 108-11 | pmid=15219518 | doi=10.1016/j.amjcard.2004.03.038 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15219518 }} </ref> | ||
==References== | ==References== | ||
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{{Coronary Angiography}} | {{Coronary Angiography}} |
Latest revision as of 18:36, 6 April 2014
Coronary Angiography | |
General Principles | |
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Anatomy & Projection Angles | |
Normal Anatomy | |
Anatomic Variants | |
Projection Angles | |
Epicardial Flow & Myocardial Perfusion | |
Epicardial Flow | |
Myocardial Perfusion | |
Lesion Complexity | |
ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis | |
Lesion Morphology | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Vanessa Cherniauskas, M.D. [3]
Overview
The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures developed a classification scheme to characterize the complexity of coronary stenosis and the probability of success of a percutaneous intervention. ACC/AHA lesion complexity system provides short-term prognostic information adjunctive to TIMI flow grade (TFG) and TIMI myocardial perfusion grade (TMPG).
ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis
The lesion-specific classification was proposed by the Subcommittee on Percutaneous Transluminal Coronary Angioplasty to estimate the likelihood of a successful angioplastic procedure (defined as one in which a ≥20% change in luminal diameter is achieved, with the final diameter stenosis <50% and without the occurrence of death, acute myocardial infarction, or the need for emergency bypass operation) as well as the likelihood of developing abrupt vessel closure.[1]
Type A Lesions (High Success, >85%; Low Risk)
Type A lesions are associated with an anticipated success procedure rate of ≥85% and a low risk of abrupt closure. Type A lesions demonstrate all of the following characterisitics:
- Discreteness (<10 mm in length)
- Concentricity
- Ready accessibility
- Location in a nonangulated segment (<45°)
- Smoothness of contour
- Little or no calcification
- Absence of total occlusion
- Nonostial location
- Absence of major branch involvement
- Absence of thrombus
Type B Lesions (Moderate Success, 60 to 85%; Moderate Risk*)
Type B lesions are associated with an anticipated success procedure rate ranging from 60 to 85% or a moderate risk of abrupt closure, or both. Type B lesions include all lesions that are neither type A nor type C and are usually identified by, but not limited to, the following characterisitics:
- Tubular shape (10 to 20 mm in length)
- Eccentricity
- Accessibility influenced by moderate tortuosity of proximal segment
- Location in a moderately angulated segment (>45°, <90°)
- Irregularity of contour
- Moderate or severe calcification
- Presence of thrombus
- Ostial location
- Bifurcation lesions requiring double guide wires
- Total occlusions <3 months old
* Although the risk of abrupt vessel closure is moderate, in certain circumstances the likelihood of a major complication may be low as in dilation of total occlusions <3 months old or when abundant collateral channels supply the distal vessel.
Type C Lesions (Low Success, <60%; High Risk)
Type C lesions are associated with an anticipated success procedure rate of <60% or a high risk of abrupt closure, or both. Type C lesions demonstrate any of the following characterisitics:
- Diffuseness (>20 mm in length)
- Excessive tortuosity of proximal segments
- Location in an extremely angulated segment (>90°)
- Total occlusion >3 months old
- Inability to protect major side branches
- Degeneration of older vein grafts with friable lesions
Modified ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis
The standard ACC/AHA classification of the primary target stenosis is prospectively modified to subdivide type B stenoses into B1 (one adverse characteristic) and B2 (≥ two adverse characteristics) on the basis of previous studies suggesting the cumulative significance of mutiple adverse lesion characteristics.[2]
Clinical Significance
- A greater ACC/AHA lesion complexity at 60 to 90 minutes after fibrinolytic administration was shown to be associated with poorer epicardial flow and myocardial perfusion as well as a higher risk of pulmonary edema, shock, and mortality within 30 days. However, increased lesion complexity was not associated with a higher risk of recurrent myocardial infarction.[3]
- Independent of left anterior descending coronary artery infarct location, TIMI grade 3 flow, age, performance of rescue or adjunctive PCI, pulse, and systolic blood pressure on admission, type C lesion complexity was associated with an increased short-term mortality rate at 30 days.[3]
References
- ↑ Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB III, Loop FD,Peterson KL, Reeves TJ, Williams DO, Winters WL Jr, et al. Guidelines for percutaneous transluminal coronary angioplasty. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988;78:486–502.
- ↑ Ellis, SG.; Vandormael, MG.; Cowley, MJ.; DiSciascio, G.; Deligonul, U.; Topol, EJ.; Bulle, TM. (1990). "Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group". Circulation. 82 (4): 1193–202. PMID 2401060. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 Gibson CM, Bigelow B, James D, Tepper MR, Murphy SA, Kirtane AJ; et al. (2004). "Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction". Am J Cardiol. 94 (1): 108–11. doi:10.1016/j.amjcard.2004.03.038. PMID 15219518.