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Wk 9, Case 1 - Review

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Patient History
72-year-old male with a history of coronary artery disease s/p CABG (LIMA to LAD, SVG to OM and SVG to PDA), hypertension, mixed hyperlipidemia with worsening chest pain despite improved medical therapy. 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: 100 mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Increased image noise due to decreased arterial opacification.

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 bifurcates to form a left anterior descending, and a left circumflex artery. There is a small amount of partially calcified plaque with mild (25-49%) stenosis of the distal left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to a two diagonal branches before wrapping the apex. There is a large amount of calcified and partially calcified plaque with a severe (70-99%) stenosis of the proximal LAD and the first diagonal branch, moderate (50-69%) stenosis of the mid LAD shortly after the anastomosis of the LIMA graft and severe (70-99%) stenosis of the distal LAD. There is a short superficial myocardial bridge in the mid 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 large amount of calcified plaque with a total (100%) occlusion of the proximal LCX and distal LCX. There is a small amount of calcified plaque with mild (25-49%) stenosis of the first obtuse marginal branch, a severe (70-99%) stenosis of the second obtuse marginal branch, and mild (25-49%) stenosis of the third obtuse marginal branch.

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 total occlusion (100%) stenosis of the proximal to distal RCA. There is a small amount of non-calcified plaque with minimal (1-24%) stenosis of the PDA and PLB.

Grafts:

LIMA- LAD arterial graft: The ostium of the graft is outside the field of view. The mid portion of the graft is non evaluable due to misalignment artifact. The LIMA to LAD anastomosis is located in the mid LAD before the mid LAD bridge with no evidence of stenosis at the arteriotomy site.

SVG to PDA: proximally occluded (100% stenosis).

SVG to OM3: There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal, and mid segments of the graft, and a severe (70-99%) stenosis in the distal graft prior the OM anastomosis.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal 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: The aorta is at the upper limits of normal measuring 3.9 x 3.9 x 3.8 cm at the sinuses of Valsalva, and dilated at the ascending aorta measuring 4.1 x 3.8 cm. There is no aortic rupture, aneurysm, dissection, intramural hematoma. There is a medium amount of partially calcified plaque in the visualized portions of the aorta.

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 severe (70-99%) stenosis of the distal LAD, D1, OM2, and the SVG-OM3 graft. Occluded SVG to PDA graft with minimal (1-24%) stenosis of the PDA and PLB.

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

RECOMMENDATIONS:

CAD-RADS: 5 (Severe stenosis- 70-99%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider ICA, Revascularization should be considered.

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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