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Wk 2, Case 4 - Review

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Patient History

61-year-old male with recurrent chest pain and an abnormal resting ECG. Request for CCTA for further risk stratification.

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: 200mg Lopressor, 800 mg nitroglycerin

Contrast: 70 mL Visipaque 320 injected at 6 mL/s.

QC (signal/noise): Good

Artifacts: None that are significant with stair-step artifact.

Complications: None

Heart rate: 58 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 bifurcates to form a left anterior descending artery, and a left circumflex artery. There is no plaque or stenosis of 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 minimal (1-24%) stenosis in the proximal LAD, moderate (50-69%) stenosis of the mid LAD and mild (25-49%) stenosis of the distal LAD. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the first and second diagonal branches.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to two obtuse marginal branches before terminating within the AV groove. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal CX and second OM branch.

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel, arising from the right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and posterolateral branch. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal RCA, mid RCA and PDA.

NON-CORONARY CARDIAC FINDINGS:

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

Myocardium: Increased wall thickness, more prominent at the basal septal segments. No outpouching or masses. Moderate mitral annular calcification.

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.

There is a small amount of non-calcified plaque in the descending aorta.

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

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

Impressions
1. Overall, there is a large amount of partially calcified plaque in a multivessel distribution.

2. Obstructive CAD with a moderate (50-69%) stenosis of the mid LAD, mild (25-49%) stenosis of the distal LAD, and minimal (1-24%) stenosis of the proximal LAD, D1, D2, pCX, OM2, pRCA, mRCA and PDA.

3. Increased wall thickness more prominent in the basal septal segments. Recommend cardiac MRI for further evaluation.

RECOMMENDATIONS:

CAD-RADS: 3 (Moderate stenosis 50-69%). Consider functional assessment and aggressive preventive therapy and risk factor modification. Consider anti-anginal therapy

If FFR +, consider ICA, if frequent symptoms despite medical therapy

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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