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Wk 7, Case 3 - Review

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Patient History

72-year-old male with a history of hyperlipidemia, hypertension and diabetes mellitus type 2, with new onset of chest pain with exertion. Request for CCTA for further risk stratification.

Reports

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: 85mL Isovue 370 injected at 7mL/sec.
QC (signal/noise): Good
Artifacts: None
Complications: None
Heart rate: 53 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 no plaque or stenosis in the left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to two diagonal branches before wrapping the apex. There is a small amount of non calcified plaque with minimal (1-24%) stenosis in the proximal LAD. There is no plaque or stenosis in the remainder of the vessel.

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 minimal (1-24%) stenosis in the proximal LCX. There is a medium amount of non-calcified plaque with a severe (70-99%) stenosis of the distal LCX.

Right coronary artery (RCA):

The right coronary artery is a large caliber, dominant vessel, arising 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 minimal (1-24%) stenosis of the proximal RCA, and mid RCA.

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 and mild calcifications.

Normal mitral valve leaflet thickening.

Pericardium: Normal thickness with no significant effusion or calcium present.

Aorta: The aorta is dilated measuring 3.8 x 3.8 x 4.0 cm at the Sinuses of Valsalva.

There is no aortic rupture, aneurysm, dissection, intramural hematoma.

Pulmonary arteries: Normal in size with multiple filling defects involving the left and right pulmonary arteries consistent with large pulmonary emboli.

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


IMPRESSION:

1. Overall, there is medium amount of non-calcified plaque in a multivessel distribution

2. Obstructive coronary artery disease with severe (70-99%) stenosis of the distal left circumflex. There is minimal (1-24%) stenosis of the proximal LAD, pLCX, proximal RCA, and mid RCA.

3. Bilateral large pulmonary emboli involving the left and right pulmonary arteries.

4. The aorta is dilated at the sinuses of Valsalva.


RECOMMENDATIONS:

CAD-RADS: 4A (70-99% severe stenosis). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider ICA, revascularization should be considered.

Modifier: None

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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