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Wk 6, Case 5 - Review

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Patient History
69-year-old male with a history of hypertension, mixed hyperlipidemia, and pre-diabetes with new onset of shortness of breath chest tightness with exertion. 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 60-80%

Medications: 100 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 125 mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Good

Artifacts: Increased image noise.

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 vessel that bifurcates to form a left anterior descending, and a left circumflex artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the distal left main.

Left anterior descending artery (LAD):

The LAD is a medium caliber vessel that supplies a diminutive first diagonal and medium caliber second diagonal vessel before terminating as a small vessel near the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LAD and second diagonal branch. There is a short superficial myocardial bridge in the distal LAD.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to three obtuse marginal branches before terminating as a small vessel within the AV groove. There is a small amount of partially calcified plaque with mild (25-49%) stenosis in the 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 small amount of partially calcified plaque with severe (70-69%) stenosis of the proximal RCA, minimal (1-25%) stenosis of the mid RCA, complete (100%) occlusion of the proximal PDA. There is a small amount of non-calcified plaque with positive remodeling and moderate (50-69%) stenosis of the distal RCA, and the PLB.

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 a large amount of calcified, partially calcified and noncalcified plaque in a multivessel distribution.

2. Obstructive coronary artery disease with a complete (100%) occlusion of the PDA, severe (70-99%) stenosis of the proximal RCA and moderate (50-69%) stenosis of the distal RCA, and PLB.

3. Unremarkable extra-coronary findings.

RECOMMENDATIONS:

CAD-RADS: 5 (Total occlusion 100%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider ICA, functional or viability assessment. Revascularization should be considered.

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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