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Wk 2, Case 3 - Review

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Patient History
68-year-old male with a history of recurrent chest pain with an equivocal stress test with ST-T wave changes suggestive of ischemia at peak exercise but no evidence of ischemia on SPECT imaging.

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: 100mg Lopressor, 800 mg nitroglycerin

Contrast: 100mL Visipaque 320 injected at 6 mL/s.

QC (signal/noise): Fair, delayed bolus timing

Artifacts: Calcified plaque

Complications: None

Heart rate: 53 bpm sinus rhythm.

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 vessel that trifurcates to form a left anterior descending, a ramus intermediate, and a left circumflex artery. There is a large amount of partially calcified and calcified plaque with a moderate (50-69%) at the ostium of the left main, as well as a mild (25-49%) stenosis in the distal left-main.

Left anterior descending artery (LAD):

The LAD is a medium-caliber vessel that supplies one diagonal vessel before terminating as a diminutive vessel near the apex. There is a medium amount of partially calcified plaque with moderate (50-69%) stenosis of the proximal LAD and minimal (1-24%) stenosis in the mid-LAD.

Ramus intermedius (RI):

The ramus is a medium-caliber vessel that supplies part of the anterior wall. There is a small amount of partially calcified plaque with mild (25-49%) stenosis.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to three obtuse marginal branches before terminating within the AV groove. There is a small amount of partially calcified plaque with mild (25-49%) stenosis in the proximal LCX and minimal (1-24%) stenosis in the distal LCX and obtuse marginal branches.

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 positive remodeling and spotty calcification with mild (25-49%) stenosis of the proximal RCA. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the mid-RCA and distal RCA.

NON-CORONARY CARDIAC FINDINGS:

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

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, with a small amount of partially calcified plaque in the visualized thoracic aorta.

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

Pulmonary veins: Normal pulmonary venous drainage. There were five noted pulmonary veins, three on the right and two on the left.

Impressions
1. Overall, there is a large amount of partially calcified and non-calcified plaque with vulnerable plaque characteristics in a multivessel distribution.

2. Obstructive coronary artery disease with a moderate (50-69%) stenosis of the ostial LM and proximal LAD. Mild (25-49%) stenosis of the distal LM, proximal LCX, RI, and proximal RCA. Minimal (1-24%) stenosis of the mid-LAD, dLCX, mid-RCA, and distal RCA.

3. The right ventricle is dilated.

RECOMMENDATIONS:

CAD-RADS: 4B (Left main ≥50%) Invasive coronary angiography is recommended. Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy is recommended. Revascularization should be considered.

CAD-RADS Modifier: High-risk plaque features

Plaque: P3- Severe 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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