eISSN: 1897-4295
ISSN: 1734-9338
Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej
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vol. 18
Original paper

Misclassification of carotid stenosis severity with area stenosis-based evaluation by computed tomography angiography: impact on erroneous indication to revascularization or patient (lesion) migration to a higher guideline recommendation class as per ESC/ESVS/ESO/SVS and CMS-FDA thresholds

Lukasz Tekieli
1, 2, 3
Adam Mazurek
1, 3
Karolina Dzierwa
Justyna Stefaniak
Anna Kablak-Ziembicka
Magdalena Knapik
1, 6
Zbigniew Moczulski
R. Pawel Banys
Malgorzata Urbanczyk-Zawadzka
Wladyslaw Dabrowski
Maciej Krupinski
Piotr Paluszek
3, 8
Ewa Weglarz
Łukasz Wiewiórka
Mariusz Trystula
Tadeusz Przewlocki
1, 2, 8
Piotr Pieniazek
1, 2, 8
Piotr Musialek
1, 3

Department of Cardiac and Vascular Diseases, Jagiellonian University, John Paul II Hospital, Krakow, Poland
Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
Thrombectomy-Capable Stroke Centre, John Paul II Hospital, Krakow, Poland
Cardiovascular Imaging Laboratory, John Paul II Hospital, Krakow, Poland
Department of Bioinformatics and Telemedicine, Jagiellonian University, Krakow, Poland
Department of Radiology, Podhalanski Multispecialty Regional Hospital, Nowy Targ, Poland
Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
Department of Vascular Surgery and Endovascular Interventions, John Paul II Hospital, Krakow, Poland
Adv Interv Cardiol 2022; 18, 4 (70): 500–513
Online publish date: 2023/02/06
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Despite a growing understanding of the role played by plaque morphology, the degree of carotid lumen reduction remains the principle parameter in decisions on revascularization in symptomatic and asymptomatic patients. Computed tomography angiography (CTA) is a widely used guideline-approved imaging modality, with “percent stenosis” commonly calculated as %area reduction (area stenosis – AS).

We evaluated the impact of the non-linear relationship between diameter stenosis (DS) and AS (area = π • (diameter/2)2, so that in concentric lesions 51%AS is 30%DS and 75%AS is 50%DS) on stenosis severity misclassification using calculation of area reduction.

Material and methods:
CTA and catheter quantitative angiography (cQA) were performed in 300 consecutive patients referred to a tertiary vascular centre for potential carotid revascularization (age: 47–83 years, 33.7% symptomatic, 36% female; referral stenosis of ≥ “50%”). CTA-AS was determined by agreement of 2 experienced radiologists; cQA-DS (pivotal trials standard reference, NASCET method) was calculated by agreement of 2 corelab analysts.

For symptomatic lesion thresholds, CTA-AS-based calculation reclassified 76% of “< 50%” cQA-DS measurements to the “50–69%” group, and 58% of “50–69%” measurements to the “≥ 70%” group. For asymptomatic lesion thresholds, 78% of “< 60%” cQA-DS measurements were reclassified to the “60–79%” group, whereas 42% of “60–79%” cQA measurements crossed to the “≥ 80%” class. Overall, employing CTA-AS instead of cQA-DS enlarged the “60–79%” and “≥ 80%” lesion severity classes 1.6- and 5.8-fold, respectively, whereas the “≥ 70%” class increased 4.15-fold.

Replacing the pivotal carotid trials reference standard cQA-DS “%stenosis” measurement with CTA-AS-based “%stenosis” results in a large-scale lesion/patient erroneous gain of an “indication” to revascularization or migration to a higher revascularization indication class. In consequence, unnecessary carotid procedures may be performed in the absence of cQA verification. Until guidelines rectify the “%stenosis” measurement methods with different guideline-approved imaging modalities (and, where needed, re-adjust decision thresholds), CTA-AS measurement should not be used as a basis for carotid revascularization.


carotid stenosis severity, percentage stenosis, computed tomography angiography, catheter angiography, area stenosis, diameter stenosis

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