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Wk 9, Case 5 - Review

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Patient History

68-year-old male with a history of obesity, hyperlipidemia, hypertension, and diabetes mellitus type 2, coronary artery disease with prior PCI to the LAD and LCX with new onset of chest pain with exertion. Request for CCTA for further risk stratification.

Report

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: 51 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from their respective normal anatomic ostia.

The coronary circulation is co-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 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 patent stent in the proximal to mid-LAD. There is large amount of non-calcified plaque with severe (70-99%) of the first and second diagonal branches, with minimal (1-24%) stenosis of the distal LAD.

Left circumflex artery (LCX):

The circumflex is a large caliber, co-dominant vessel that gives rise to two obtuse marginal branches before terminating as a left posterolateral branch. There is a patent stent in the proximal LCX. There is a medium amount of non-calcified plaque in the second obtuse marginal branch, but the segment is non-evaluable due to stairstep artifact with mild (25-49%) stenosis of the distal LCX and LPLB.

Right coronary artery (RCA):

The right coronary artery is a large caliber, co-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 large amount of non-calcified plaque with a total (100%) occlusion of the proximal 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: There is no aortic rupture, aneurysm, dissection, intramural hematoma.

Pulmonary arteries: Dilated in size (34 mm) 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 large amount of non-calcified plaque in a multivessel distribution

2. Obstructive coronary artery disease with a total (100%) occlusion of the proximal RCA and severe (70-99%) stenosis of the first and second diagonal branches. The stents in the proximal to mid-LAD and proximal LCX are patent. There is mild (25-49%) stenosis of the distal LCX and LPLB.

3. Dilated pulmonary artery, recommend further evaluation with an echocardiogram to assess for pulmonary hypertension

RECOMMENDATIONS:

CAD-RADS: 5 (100% total occlusion). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy is recommended. Consider ICA, revascularization should be considered.

Modifier: Stent (S)/ N (non-diagnostic segment)

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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