0:00

Okay, this next case is an example of mild coronary

0:03

artery disease. This is a patient

0:06

a 71 year old woman who was referred for coronary CT

0:09

because she had non-sustained VT and a new cardiomyopathies they're

0:12

interested in whether or not that could be related to

0:16

you know severe coronary disease.

0:19

so we'll go through the

0:21

assessment of the coronaries

0:23

So I always start with the axial images. You can see right away.

0:26

This patient has a really big left atrium.

0:29

So that's certainly would go along with that history of cardiomyopathy.

0:33

And then we get into the left Main and the LEDs

0:36

so you can see here. The left main kind of has this funny angulation as

0:40

it comes off the root, but it looks like it's wide open.

0:43

So I'm not really concerned about any atheroscleric disease there.

0:47

And then you can see there's a bifurcation of LED and circumflex.

0:50

There's this tiny little vessel in

0:53

the middle.

0:54

Probably a very small ramus Branch but doesn't seem to melt

0:57

too much so you could certainly mention that honestly when

1:00

branches are this small it's hard to say a whole lot other than

1:03

it's you know,

1:04

A tiny branch and most likely free of

1:07

disease.

1:08

Now if we follow it on the LED.

1:11

we can see that there's

1:13

a septal Branch coming off right here.

1:17

Going injury so any branches that had this direction or

1:20

Supple branches?

1:22

And we can also see that we get a diagonal Branch

1:25

coming off right here quite small not very substantial so

1:28

not easy to assess and then another small Branch right there.

1:32

And in the LED continues sort of in a tortuous way

1:35

all the way the Apex.

1:38

Now honestly on first pass on these axial images, I

1:41

actually I don't really see a whole lot but the LED

1:44

so that would tell me that there's probably at worst mild

1:47

disease or maybe no disease at all.

1:50

It does look like on some of these images maybe some some fuzziness

1:53

in the fat surrounding the

1:56

coronary which can indicate some soft black.

1:59

And so I find that that can often be

2:02

well seen by the curve planner images and that's

2:05

where the additional reconstructions will help you. So we'll

2:08

take a look at those in a minute.

2:10

Just continuing our search if I go through the circumflex. I

2:13

can see there's a nice big circumflex and this big obtuse marginal

2:16

Branch here which branches out over the lateral wall

2:19

of the left ventricle. And then there's some other

2:22

small not very significant.

2:24

branches distally, which really hardly can see

2:29

the right coronary also a nice size vessel. There's some calcification

2:32

in the aortic root near the origin but doesn't

2:35

seem to be causing any narrowing of the right corner

2:38

origin.

2:39

And then as we follow the right coronary down we can

2:42

see a little acute marginal Branch there.

2:45

And then when we get to the back of the heart, so the

2:48

more posterior aspect of the heart we can see this really squiggly torch

2:51

with PDA which

2:54

heads down the AV Groove.

2:57

And then additional small branches these guys right here gonna be

3:01

better seen with myths.

3:03

You can see there's additional small branches there which are posterolateral ventricular

3:07

branches.

3:09

But so far, I really don't see much in the way of atheroscleric

3:12

disease, but we're going to take a look at the

3:15

Led on the curve planar images.

3:19

so the curved planar images I think are great as an adjunct

3:22

to the axial images because

3:24

it's quite easy to miss.

3:27

Disease that's in the axial plane particularly along sort

3:30

of the posterior wall of the

3:33

vessel as we scroll through. We really don't see that area The Vessel

3:36

very well.

3:37

So here in the LED we can

3:40

see this is the left main. This is the circumflex. This

3:43

is Led coming down and you see right here. We've got

3:46

some non calcified plaque.

3:48

So you see this sort of shoulder of non-classified black

3:51

right here.

3:52

That's resulting in very mild stenosis.

3:56

Of the LED if we were to do.

3:59

A ratio measurement of our normal segments diameter to

4:02

the diameter at the level of narrowing.

4:05

We're certainly well beneath the 50% threshold.

4:09

I don't know if that projects very well, but it's 10 relative

4:12

to 13.

4:15

So certainly well below 50% It's stenosis.

4:19

That tells us we have mild disease now when

4:22

we look at the more distal vessel.

4:25

It looks like there's maybe a little bit of sort of

4:28

fuzziness in this region as well and you can see a little

4:31

bit of narrowing you can see the Lumen changes

4:34

a little bit with some sort of lower attenuation

4:37

stuff right next to the vessel there. So there's probably also some non

4:40

calcified plaque in this area. Just beyond this septal

4:43

branch.

4:44

That's resulting in just some very mild narrowing. So

4:47

if I were to read this case, I would say

4:50

that there's some non-cassified plaque in the proximal and

4:53

the mid LED resulting in

4:56

Miles stenosis and less than 50% severity and

4:59

You know really I'd say this is probably within the 20 to

5:02

30% range. Probably more like 20 really

5:05

in terms of the degree of stenosis.