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Wk 7, Case 1 - Review

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Patient History

74-year-old male with a history of coronary artery disease s/p CABG (anatomy is unknown), hypertension, mixed hyperlipidemia 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 60-80%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 100mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Good

Artifacts: Mis-alignment artifact

Complications: None

Heart rate: 52 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 trifurcates to form a left anterior descending, ramus intermedius and a left circumflex artery. There is a large amount of calcified plaque with a moderate (50-69%) stenosis of the mid left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to one small diagonal branch before wrapping the apex. There is a large amount of calcified with complete (100%) occlusion of the mid LAD. The first diagonal branches has a medium amount of calcified plaque and is patent. There is a medium amount of partially calcified plaque with mild (25-49%) stenosis of the distal LAD.

Ramus Intermedius (RI):

The RI is a large branching vessel with a medium amount of calcified plaque with a mild (25-49%) stenosis in the proximal segment. There is a long deep myocardial bridge in the mid RI.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to two small obtuse marginal branches before terminating as a small vessel within the AV groove. There is medium amount of partially calcified plaque with mild (25-49%) stenosis of the proximal LCX, severe (70-99%) stenosis of the distal LCX. The first and second OM branches are patent.

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 and non-calcified plaque with a mild (25-49%) stenosis of the proximal RCA, a complete (100%) occlusion of the mid to distal RCA and the PDA. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the PLB.

Grafts:

LIMA- LAD arterial graft: The ostium of the graft is patent. 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 PDA: The ostium of the graft has a complete (100%) occlusion, as well as a stent within the graft.

SVG to PLB: The ostium of the graft has a small amount of non-calcified plaque with minimal (1-24%) stenosis. There is a medium amount of non-calcified plaque with mild (25-49%) stenosis in the body of the graft. The SVG to PLB anastomosis is located in the middle of the PLB with no evidence of stenosis at the arteriotomy site.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is dilated 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: Two vessel- bovine arch variant with the left common carotid originating from the brachiocephalic artery. The aorta is dilated at the root measuring 4.1 x 3.5 x 3. 7 cm, and the ascending aorta measuring 4.0 x 3.9 cm. There is a large amount of partially calcified, and non-calcified plaque with protruding atheromas in the visualized portions of the aortic arch and descending thoracic 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 five pulmonary veins, three on the right and two on the left.

Impressions
1. Overall, there is an extensive 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, and distal LCFX with mild (25-49%) stenosis of the distal LAD, RI, SVG to PLB graft, and minimal (1-24%) stenosis of the PLB. There is a deep long myocardial bridge in the RI.

3. The aorta is dilated at the root, and the ascending aorta. Recommend serial monitoring.

RECOMMENDATIONS:

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

Modifier: Graft/ Stent.

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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