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Wk 8, Case 3 - Review

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Patient History
69-year-old male with a history of coronary artery disease s/p CABG (anatomy is unknown), hypertension, 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: 120mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Good

Artifacts: Mis-alignment artifact

Complications: None

Heart rate: 50 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 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 in the distal left-main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to one large branching diagonal before wrapping the apex. There is a large amount of calcified with a complete (100%) occlusion of the proximal LAD, mid-LAD, and proximal segment of D1. The mid to distal segments of the first diagonal branch has a small amount of non-calcified plaque with minimal (1-24%) stenosis. There is a small amount of non-calcified plaque with minimal (1-24%) stenosis of 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 medium amount of partially calcified plaque with severe (70-99%) stenosis of the proximal LCX and severe (70-99%) stenosis of the proximal segment of the second OM. The is a small amount of non-calcified plaque with minimal (1-24%) stenosis of the mid and distal segments of the second OM and third OM.

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 severe (70-99%) stenosis of the proximal RCA, moderate (50-69%) stenosis of the mid-RCA, mild (25-49%) stenosis of the distal RCA, complete (100%) occlusion of the proximal segment of the PDA, and minimal (1-24%) stenosis of the PLB. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the distal segment of the PDA.

Grafts:

Radial- LAD arterial graft: The origin of the radial graft is patent at the Y anastomosis. There is no plaque or stenosis in the body of the graft. The radial to LAD anastomosis is located in the distal LAD with no evidence of stenosis at the arteriotomy site.

LITA-D1 arterial graft: The origin of the LITA graft is patent. There is no plaque or stenosis in the body of the graft. The LITA to D1 anastomosis is located in the mid-D1 with no evidence of stenosis at the arteriotomy site.

RITA-OM2/OM3 arterial skip graft: The origin of the RITA graft is patent at the Y anastomosis. There is no plaque or stenosis in the body of the graft. The RITA to OM2 and OM3 anastomosis is located in the middle of each vessel, with no evidence of stenosis at the arteriotomy site.

SVG to PDA: The ostium of the graft has moderate (50-69%) stenosis. There is no plaque or stenosis in the body of the graft. The SVG to PDA anastomosis is located in the middle of the PDA 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 sizes 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: The aorta is dilated at the root measuring 4.2 x 3.8 x 3.6 cm. 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 four pulmonary veins, two 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 (50-69%) stenosis of the SVG to PDA graft, and minimal (1-24%) stenosis of the distal LAD, D1, OM2, OM3, PDA, and PLB. Patent RITA-LITA-Radial Y anastomosis and arterial grafts are patent without stenosis.

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

RECOMMENDATIONS:

CAD-RADS 3: (Moderate 50-69%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy is recommended. Consider anti-anginal therapy and functional assessment. Consider ICA if frequent symptoms despite medical therapy.

Modifier: Graft

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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