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Wk 8, Case 2 - Review

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Patient History
62-year-old female with a pre-diabetes, hypertension with new onset of chest pain 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: 100 mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Good

Artifacts: None

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

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to two 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 and first 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 medium amount of partially calcified plaque and non-calcified plaque with a with sub-total occlusion (100%) stenosis of the proximal RCA, mild (25-49%) stenosis of the mid RCA, and minimal (1-24%) stenosis of the PDA.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is dilated 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 medium amount of calcified, partially calcified and noncalcified plaque in a multivessel distribution.

2. Obstructive coronary artery disease with a subtotal (100%) occlusion of the proximal RCA, mild (25-49%) stenosis of the mid RCA, minimal (1-24%) stenosis of the distal left main, proximal LAD, proximal LCX, and PDA.

3. Dilated left atrium.

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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