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Wk 9, Case 3 - Review

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Patient History

65-year-old female with a history of diabetes, hypertension, and prior coronary artery bypass surgery with new onset of chest pain with exertion. Request for CCTA for further evaluation of graft patency.

Report
PROCEDURE:

1. Cardiac CT Angiography (Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).) (CPT code: 75574)

TECHNIQUE:

Gating: Prospective; data acquisition between 60-80%

Medications: 300 mg oral metoprolol tartrate and 5mg IV lopressor, 0.8mg

sublingual nitroglycerin.

Contrast: 100 mL Visipaque 320 injected at 6ml/sec.

QC (signal/noise): Good

Artifacts: None that are significant

Complications: None

Heart rate : 65 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from their respective normal anatomic ostia.

The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber short vessel that bifurcates to form a left anterior descending, and a left circumflex artery. There is no plaque or stenosis in the left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies three diagonal vessels before wrapping the apex. There is a medium amount of partially calcified plaque with positive remodeling with mild (25-49%) stenosis of the proximal and mid LAD, and minimal (1-24%) stenosis of the distal LAD. There is a large amount of calcified plaque with a likely total occlusion (100%) stenosis of the first small diagonal branch. There is a small amount of partially calcified plaque with mild (25-49%) stenosis of the branching second diagonal branch.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to two obtuse marginal branches before terminating as a small vessel within the AV groove. There is a medium amount of partially calcified plaque with mild (25-49%) stenosis in the proximal LCX and second obtuse marginal branch. The remainder of the vessel and its branches have no evidence of plaque or stenosis.

Right coronary artery (RCA):

The right coronary artery is a large caliber, dominant vessel, arising from the right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and postero-lateral branches. There is a large amount of partially calcified plaque with a non-evaluable stenosis in the proximal RCA due to beam hardening artifact, moderate (50-69%) stenosis of the mid RCA, distal RCA, and mild (25-49%) stenosis of the posterolateral branch.

Arterial/ Venous Grafts:

LIMA-LAD: Partially visualized, atretic vessel with an arteriotomy site in the distal LAD.

SVG-OM: Completely occluded (100%) at the ostium.

SVG-PDA: Completely occluded (100%) at the ostium.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal with no left atrial appendage filling defect. The left and right ventricular cavity size is within normal limits. There are no abnormal filling defects.

Myocardium: Normal thickness. No outpouching or masses.

Valves: Trileaflet aortic valve with normal leaflet thickening. Normal mitral valve leaflet thickening.

Pericardium: Normal thickness with no significant effusion or calcium present.

Aorta: There is no aortic rupture, aneurysm, dissection, intramural hematoma.

Pulmonary arteries: Normal in size without proximal filling defect. Not fully opacified.

Pulmonary veins: Normal pulmonary venous drainage. There are four pulmonary veins, two on the right and two on the left.

Impressions
1. Overall, there is an extensive amount of calcified, and partially calcified in a multivessel distribution.

2. Obstructive coronary artery disease with a total (100%) occlusion of the first diagonal branch, moderate (50-69%) stenosis of the mid RCA, distal RCA, mild (25-49%) stenosis of the proximal LAD, mid LAD, D2, proximal LCX, OM2, PLB and minimal (1-24%) stenosis of the distal LAD.

3. Atresia of the LIMA graft with complete occlusion (100%) of the SVG to the D1, and PDA.

RECOMMENDATIONS:

CAD-RADS: 5 (100% coronary occlusion). Aggressive risk factor modification and preventive medical therapy. Recommend anti-anginal therapy. Consider functional assessment or ICA if symptoms despite medical therapy.

Modifier: Graft (G)/ N (non-evaluable segment)

Plaque: P4- Extensive amount of plaque

Final diagnosis: I25.10 CAD, native

Case Discussion

Faculty

Giovanni E. Lorenz, DO

Cardiothoracic Radiologist

San Antonio Military Health System (SAMHS)

Emilio Fentanes, MD

Director of Cardiac Imaging, Department of Cardiology

Brooke Army Medical Center

Tags

Vascular

Coronary arteries

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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