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Wk 8, Case 4 - Review

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Patient History
68-year-old male with a history of coronary artery disease s/p CABG (LITA to LAD, SVG to RI and SVG to PDA), 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: 125mL 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 short vessel that trifurcates to form a left anterior descending, ramus intermedus, and a left circumflex artery. There is a medium amount of partially calcified plaque with moderate (50-69%) stenosis of the ostial and distal left-main.

Left anterior descending artery (LAD):

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

Ramus Intermedius (RI):

The RI is a medium-sized vessel with a medium amount of calcified plaque with a severe (70-99%) stenosis in the proximal segment. There is a short deep myocardial bridge in the mid-RI but no evidence of plaque or stenosis.

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 medium amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LCX, first, and second OM branches.

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

Grafts:

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

SVG to RI: The ostium of the graft is patent. There is no plaque or stenosis in the body of the graft but the graft appears atretic. The SVG to RI anastomosis is located in the mid RI with no evidence of stenosis at the arteriotomy site.

SVG to PDA: The ostium of the graft is patent. There is no plaque or stenosis in the body of the graft. The SVG to PDA anastomosis is located in 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 with mild calcifications. Normal mitral valve leaflet thickening.

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

Aorta: There is no aortic rupture, aneurysm, dissection, or intramural hematoma. There is a medium amount of partially calcified plaque in the visualized portions of the aorta and its branches.

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. Non-obstructive coronary artery disease with mild (25-49%) stenosis of the distal LAD, PLB, and minimal (1-24%) stenosis of the PDA. Patent LITA-LAD, SVG to PDA, and SVG to RI grafts.

RECOMMENDATIONS:

CAD-RADS: 2 (Mild stenosis- 25-49%). Aggressive risk factor modification and preventive 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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