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For this next case we're going to review a patient who has

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mild calcified black. This case is a

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little trickier than the last one. We looked at because there's quite a

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bit of calcified disease, which I'll show you. We actually

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did a calcium score in the castle score is

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190 in this patient. So we there's a

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fair bit of a calcified plaque but it ends up

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all being mild and severity and to be honest. This is a very common

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pattern that you're going to see if you do a lot of coronary CT. So

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let's start with the axle images. Like I always do we

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start and we see the left main here and there's

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already a hunk of calcium there and left me.

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Just note that for the left mean unlike the

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other coronary arteries a severe stenosis is

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any stenosis 50% or greater? However, in

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this case we can see that this is less than the 50% stenosis.

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As we go down the LED, you'll see multiple additional calcifications.

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There's one there. There's one there

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and several more as we go further along the LED.

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All the way down Beyond this diagonal Branch origin

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here, which is ends up being a

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second Diagon. There's a small first diagonal there and then second diagonal

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there.

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Little flecks of calcium here and there and I'm going to zoom up

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so we can see that a little bit better.

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And then we follow the LED down to the Apex

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and you can see that there's really no more disease.

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now if we go back up to the top

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And we take a look at the circumflex. We can see there's a little dot of

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calcium there.

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another dot of calcium there

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and then the circumflex basically

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gives off this pretty good size obtuse marginal

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and continues as a very tiny vessel.

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And then if we file this obtuse marginal out along the lateral wall

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of the heart. It looks like there's no way I've seen it.

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And then finally the right corner artery.

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comes off here

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There's a little bit of calcification but looks very inferior

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and doesn't seem to have any effect on the patency

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of the origin here. You can

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see that's that sinoatrial nodal Branch here going posteriorly.

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And then as we go down.

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You can see really don't really see any calcifications or

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any other plaque in the right corner area. The PDA in this case

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is quite small and not really well seen.

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Okay. So let's take a closer look at the

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disease in the LED and try to figure out if we think this is significant

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disease or non-obstructive disease. So I

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like to use the curb planer reformats. This is

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a long axis view which really simulates what

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we see in echocardiography.

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And is I think one of the best ways to assess

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the installations?

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So when we look at calcified plaque.

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We basically looked to see if we have a good amount of contrast

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passing by illusion. In this case. You see a nice contrast column.

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You see a nice contrast column here when we

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get distally in the vessel gets smaller. That's one. It's helpful

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to rotate around the vessel.

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And look at all different angles. So in this

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case if I'm taking just this angle here, it looks

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like the plaque is

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occupying quite a bit of the Lumen, but if I look more

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From a different angle. I can actually see this quite a bit of contrast

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getting through same thing for this plaque here.

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Here you can see there's there's a nice column of

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contrast here getting past the vessel.

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Whereas if you look from another Direction may

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be less certain as to whether or not

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there's adequate contrast getting past this lesion.

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So I think the real area where

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CT has trouble in general is with

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calcium. So it's important to keep in mind that any of

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these lesions that we see on CT are generally going to be overestimated

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no matter how wide we window.

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and so

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for that reason if I see usually if I see a

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borderline calcified plaque or not quite completely sure. Maybe

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it's right about 50% I know in my head that

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that lesion is overestimated no matter what and

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so in those cases generally.

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If it's kind of on the borderline, and it looks like it's heavily calcified

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I tend to under call rather than over call.

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Another thing that can help and these are provided with your cases is

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looking at the sharp reconstructions.

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Here's the sharper reconstruction kernel and these actually do

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a nice job of minimizing the size of the calcium blooming

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and so in this case you can see these distillations

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here.

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Look a little bit smaller on these sharp reconstructions than

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they did on the initial soft

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tissue reconstructions, which I'm going to show you on the right hand

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side.

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So another you know helpful kind of

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trick for dealing with these calcified lesions

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is using the sharp reconstructions.

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So overall in this patient, there's mild disease

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certainly less than 50% stenosis with multiple

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calcified plaques. It looks like we have caused by blacks in

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several segments proximal LED mid LED

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Proximal circumflex and so overall you've

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got moderate extent of plaque with only

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mild degree of stenosis.