0:01

So this next case is a gentleman who came in

0:04

for preoperative evaluation, uh,

0:07

and was ultimately deemed to have a CT scan

0:12

to reconcile his perioperative risk.

0:16

And, um, I'll just let the images do the talking.

0:22

So clearly had enough risk factors to one,

0:25

and I think he was in his mid to late seventies.

0:27

Um, I'll tell you that his calcium score came out well

0:31

above 3000, almost 4,000.

0:33

Um, so you can see that regardless of

0:35

what risk assessment he has, you know, he has plenty

0:38

of AO sclerosis.

0:39

Um, and so it was probably pretty reasonable

0:42

to look at his risk and, uh, and, and image.

0:45

Um, now we'll ignore the lung findings for now

0:49

and uh, just focus on the fact

0:50

that there's some plaque in the left main,

0:52

so my guard is way up and then extensive atherosclerosis in

0:55

all three of the coronary arteries.

0:57

Um, what's important if you look at a left main is to,

1:02

uh, look at it in more than one plane.

1:03

So we've talked about this in a couple cases

1:06

and so let's do that right now.

1:08

And you can see it's a relatively short left main.

1:12

So I'm just making some oblique NPRs just to show that.

1:15

Um, the hard part about left mains is on an axial view, um,

1:19

it can look pretty reassuring,

1:21

but if it's a wider than tall lesion,

1:23

it might be a very oblique stenosis.

1:26

And so we sort of see that here.

1:27

There's a little bit of an upward, um, angulation

1:30

to the inferior aspect of it.

1:33

And so when I look on the, uh, short axis here,

1:37

I can at least say that there is some mild disease

1:40

and the vessel kind of is a flat like lesion.

1:45

So, uh, a relatively shelf like if you will.

1:48

Um, so my guard is way up.

1:50

And one thing, um, we've learned, uh, from comparing

1:54

to literature and intravascular ultrasound studies is if you

1:58

find that narrowest diameter of the left main, you can kind

2:01

of do a p imagery and you can look at areas.

2:04

Now we know there's some blooming,

2:06

but this is still really the distal left main.

2:08

Where I am here, I'm just kind of giving you my cursor.

2:10

So, uh, there's, it's starting to branch,

2:13

but kind of a ovoid cross section there.

2:18

Um, now the exact numbers, um,

2:20

are always gonna have a little bit of noise in them,

2:23

but you could measure a region of interest

2:27

and look at areas

2:30

and that tends to correlate pretty well

2:31

with intravascular ultrasound.

2:33

Um, depending on who you read the threshold

2:35

for a positive lesion, this one came out

2:37

to be about six millimeters squared, um,

2:39

at this particular location.

2:40

Um, you may wanna also measure it, uh, closer

2:43

or different locations, but that's already on the border.

2:46

Um, 5.8, some say, uh,

2:48

some literature says 4.5 millimeter squared.

2:51

One, one paper correlated with seven we're in that range.

2:55

And a normal would be much higher.

2:56

So, um, if it's something over 10, it's

2:58

Probably not a problem, but we're already getting into the

3:01

abnormal territory before we go, uh, and,

3:03

and worry about the precise quantitation of something.

3:06

We just know we're on the border with the left main alone.

3:09

Um, and it's good to warn the interventionalist

3:11

'cause you can put your catheter right past that lesion.

3:13

And then as I look at this left, uh,

3:15

anterior descending here, just

3:16

'cause it's the next vessel on my search pattern,

3:18

I at least have sort of some mild

3:20

and maybe even moderate disease already in the prox LED.

3:24

Um, and then I kind of have some circumferential lesions

3:26

here and uh,

3:27

I really can't wait till we start getting newer technology

3:30

that has less calcium blooming.

3:32

Um, but in the paradigm of reading for sensitivity,

3:34

not specificity, and this is a pre-op clearance,

3:36

so it's sensitivity all the way.

3:38

Um, I already see what I'm gonna call at least

3:40

moderate stenosis right here.

3:42

Uh, and as I kind of walk my way down the vessel,

3:45

wow, that's a lot of plaques.

3:46

So I see some more circumferential

3:48

or near circumferential plaques.

3:50

We know that's, uh, overrepresented with respect to calcium.

3:54

Uh, but here a heavily diseased vessel.

3:57

Um, lots of potential for over

3:59

and underestimate, um, several moderate stenosis.

4:02

Uh, I'm pretty worried. I'll just show you the LED curve,

4:05

planer reformat that we had our, um, 3D lab, uh, make.

4:09

And so there's already several segments, so it,

4:10

it could be maybe termed serial,

4:13

probably moderate, uh, stenosis.

4:15

And let's look at the circumflex since we're here.

4:20

Um, similar amount of heavy disease burden.

4:23

And right at this segment here, I'm pretty worried.

4:27

Now this just came in as native parts, so we didn't, uh,

4:29

clear any other vessels like the mammary arteries,

4:33

but I'm already seeing two vessel disease plus the potential

4:36

left main that'll need further workup.

4:38

Uh, and then I'm just gonna jump right over to the, um, RCA

4:42

and say that there's probably, um,

4:45

a severe stenosis in the RCA.

4:47

I'm just looking and, and uh, I see

4:49

that there's hypodense plaque in addition

4:51

to the densely calcified plaque.

4:54

My blooming will get worse here with nip,

4:56

but you can see my suspicion is worse in the middle

4:58

of this densely calcified plaque.

5:02

So we're looking at potential three vessel disease

5:04

and it's a right dominant case.

5:06

There could easily be a second lesion in the um, PDA here.

5:10

Uh, and we have some borderline left main disease

5:15

and uh, to top it off some biral enlargement.

5:19

So a lot of reasons not to proceed directly to the or.

5:22

Um, I'll just pull over the cath

5:24

that was done in response to this.

5:26

By the way, this is a, gonna be called CAD cadres four B

5:30

or potential four B, just

5:31

because we probably have at least three vessel stenosis.

5:34

And here we go.

5:36

So, um, here's the, uh, catheter in the pointing left,

5:41

uh, injecting the left main.

5:43

Um, there's already at least some degree of narrowing.

5:45

And then I see multifocal stenosis just read you the,

5:49

uh, cath report.

5:51

The LED was called 40% proximal,

5:55

90% mid vessel and a a distal 90%.

5:58

So let's, let's follow that. LED.

5:59

So here's the LED wrapping around the apex.

6:02

So a 40 somewhere around here.

6:04

And then additional lesions that were thought

6:06

to be closer to 90.

6:08

Maybe there's a better view for that. That's that LED.

6:12

So yeah, something around the range of 40

6:14

and then can see, sort of see it right there.

6:18

Just keep your eye right about here.

6:22

Yeah, there's a pretty tight lesion.

6:24

Um, and then back to this last view

6:26

to look at the circumflex.

6:27

You have something that that, uh,

6:29

looks like the circumflex was called a, um,

6:32

proximal 50% ote, 70% at the om.

6:36

So probably around here,

6:39

let's see if we can find a better view.

6:41

And again, we're looking for, you know,

6:43

per patient sensitivity here.

6:45

So we're already, well on our way, there's that, uh,

6:48

at least intermediate lesion if not tighter.

6:50

Um, and there was, I think this year was the osteo

6:56

70% in that om let's flip over to the right side.

7:00

Oh yeah. And there's something tight there.

7:02

So that right Corona area was called proximal 70

7:04

to 80% stenosis

7:06

and additional views were obtained to look at the left main.

7:10

Uh, ultimately that was, uh, decided to be 40%

7:13

and it was a large caliber left main.

7:16

And so the next um, step was bypass surgery.

7:20

It was, I believe it was a high risk surgery.

7:22

So they decided to revascularize with cabbage.

7:24

When you have three vessel disease, uh, we know

7:27

that the survival benefits are seen

7:29

with complete revascularization.

7:31

And the favored revascularization is cabbage.

7:34

If you have left main disease, um,

7:36

that might alone be enough reason for a cabbage.

7:38

So you sort of had two reasons in this case.

7:41

Uh, and rarely if there's not an option

7:44

to do a cabbage stent can be considered,

7:46

but that's kind of, uh, still pushing the limits.

7:48

So three vessel disease, uh, you would term

7:51

that cataracts four b, uh,

7:53

and pretty good cath correlation there as well.