0:01

Okay, this is an interesting case on several counts.

0:03

Number one, we already had a coronary angiogram from an

0:08

outside hospital when we did this case.

0:10

So why did we do a CT scan?

0:12

Well, this is the situation where, uh, it was understood

0:15

to be a complex lesion.

0:17

You can see all the calcium. That alone

0:18

is a feature of complexity.

0:20

Uh, but importantly, we, um, were asked

0:24

by the interventional cardiologist to help plan this.

0:27

And so, um, I won't belabor it other than to say we knew

0:31

that, um, one of the areas

0:33

that needed thoughtful treatment was the LAD.

0:36

And one thing that's very difficult

0:38

to see on an invasive angiogram is calcium.

0:41

And so just warning them

0:43

that this is a very densely calcified lesion,

0:47

adds a feature of complexity.

0:49

And then also noting that there are branches coming off.

0:52

So here's the circumflex,

0:53

which has the calcified plaque going into it diagonal.

0:57

So we're gonna cross over two pretty significant major

1:00

branches on the way to this bridged segment here,

1:03

which is a very long segment bridge of the LED.

1:06

And then if you want to go

1:07

after the RCA, you're also gonna have similar problems.

1:10

Um, rather than spend a ton of time on it, I just wanted

1:13

to show you some cool things you can do with reforms.

1:16

Uh, so these are straight, uh,

1:18

multiplanar reformatted images.

1:20

You can also do curve planar reformatted images.

1:23

And this is just a way to stretch the vessel out.

1:25

So the only thing that's reliable on A CPR

1:27

or a curve planer reformat is the center line on the image.

1:30

So the periphery of the image can be very distorted

1:33

and it's very contingent upon a proper placement

1:35

of your data seed points within your, uh, vessel.

1:38

So this one happened to trace down into that, uh,

1:40

large diagonal that's calcified.

1:43

Um, you can also, you can do the R-C-A-R-C-A is much more

1:46

curved vessel, but you can see here we've, uh, followed that

1:49

and you can see multiple lesions,

1:51

but also knowing how long the calcium is.

1:53

Very helpful. Uh,

1:54

another thing you can do is reformat in the, the, uh, manner

1:58

that in which a cath shows you.

2:00

So you can segment out just one side

2:02

of the heart, and that's what we've done here.

2:03

So left main LAD with a bridge, large diagonal circumflex,

2:08

and you just inverted the threshold away, everything else,

2:11

and then inverted the image.

2:13

So black is white, white is black.

2:15

Uh, and that can be very helpful

2:16

to match up to the cath lab views.

2:19

So when they have a blind stick

2:21

or when there's an occlusion, they see

2:22

where the catheter should be going,

2:23

kind of what angle it should follow.

2:25

Um, there are softwares that can do this in real time,

2:27

but generally not the most important thing.

2:29

Let's see how it looked in the cath lab.

2:31

I'll just show you the invasive angiogram done

2:34

after that, uh, planning scan.

2:37

And here you have it. So now

2:38

they've deployed two different catheters.

2:40

One heading left, one heading right, injecting the RCA.

2:43

You can see the vessel fill.

2:44

They're looking for some collaterals

2:45

to fill up the distal LAD territory.

2:49

Uh, and I won't show you the entire,

2:51

these can be very long procedures,

2:52

but you can see that stenosis going into the

2:55

bridged LED proper.

2:56

And then there's the occluded, uh, diagonal. So

2:58

You can see here, um, that maybe

3:00

with some late images you'll have some filling,

3:03

but that's a, a much more complex case.

3:06

It might even warrant going through a transseptal.

3:08

Well-developed collateral to get to the distal LED.

3:11

Uh, and you can see there's a ton of views

3:13

and, um, pretty nice, uh, eventual crossing with a wire.

3:17

And once the wires crossed, then you can start,

3:19

uh, opening up with stents.

3:20

So complex, uh, percutaneous coronary intervention planning.

3:24

Things to warn the operator about are dense calcium lengths

3:28

of lesions, crossing of bifurcations and angulations.