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Wk 1, Case 3 - Review

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Patient History
52-year-old female with a history of coronary artery disease s/p CABG (LIMA to LAD, SVG to OM), hypertension, mixed hyperlipidemia and spontaneous coronary artery dissection of the left main to LAD and LCX, with worsening chest pain. Request for CCTA to assess 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 70-75%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 120 mL Isovue 370 injected at 5mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 50 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 a small amount of non-calcified plaque with a severe (70-99%) stenosis in the ostial left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to two small diagonal branches before wrapping the apex. There is a medium amount of non-calcified with a mild (25-49%) stenosis of the proximal LAD, and mid LAD. There is no plaque or stenosis in the distal LAD. The diagonal branches are patent.

Left circumflex artery (LCX):

The circumflex is a small caliber, non-dominant vessel that gives rise to one large branching obtuse marginal before terminating as a diminutive vessel within the AV groove. There is medium amount of non- calcified plaque with a mild (25-49%) stenosis of the proximal LCX. There is no plaque or stenosis in the OM branch.

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 small amount of non- calcified plaque with a minimal (1-24%) stenosis of the proximal RCA.

Grafts:

LIMA- LAD arterial graft: The ostium of the graft is outside the field of view. There is no plaque or stenosis in the body of the graft. The LIMA to LAD anastomosis is located in the mid LAD with no evidence of stenosis at the arteriotomy site.

SVG to OM1: The ostium of the graft has no plaque or stenosis. There is no plaque or stenosis in the body of the graft. The SVG to OM anastomosis is located in proximal segment of OM branch with no evidence of stenosis at the arteriotomy site.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal with no left atrial appendage filling defect. The left and right ventricular cavity size are 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, or 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 a medium amount of non-calcified plaque in a multivessel distribution.

2. Non-obstructive coronary artery disease with a minimal (1-24%) stenosis of the proximal RCA.

3. Patent LIMA to LAD, and SVG to OM grafts, although the ostium of the LIMA graft is outside the field of view, thus cannot rule out obstructive disease in the origin of the LIMA.

RECOMMENDATIONS:

CAD-RADS N (Non-Diagnostic, cannot rule out ≥50% stenosis). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider anti-anginal therapy and functional assessment. Consider repeat test or alternative imaging modality.

Modifier: Graft, non-diagnostic study.

Plaque: P2- Moderate 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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