0:00

Okay, this next patient is a nice example of

0:03

moderate disease. He's a patient who

0:06

has a history of heart failure and came to the Ed with

0:09

chest pain 51 years old and actually had

0:12

a triple rule out examination, which we do

0:15

on occasion. So you'll notice the case actually has in addition

0:18

to the usual coronary CT images. There are some chest images

0:21

as well.

0:22

Obtained as part of the triple lot study.

0:25

So we're going to focus on the corners UT portion of that study, though.

0:28

So if we start from the top

0:31

and scroll down you're going to see here's the left main

0:34

nice big left main with no real disease.

0:37

And then you see that there's a try forcation actually

0:40

into an LED, which is heading right here.

0:44

A ramus which is heading right here pretty decent size vessel which

0:47

and with a little bit of calcium and then a circumflex, which

0:50

is heading downward.

0:52

And if we looked at a myth, you can actually appreciate that maybe a little

0:55

better the traffication there one two, three vessels, right?

0:58

So that's a try application.

1:01

Now let's focus on the LED. We come

1:04

down the LED and boom. We see this non calcified plaque. Now.

1:07

There's also a little tiny bit of calcification there and

1:10

I'm gonna zoom up on that.

1:12

And you could maybe even argue that

1:15

this is a spotty calcification. Remember we talked about those high-risk black

1:18

features earlier.

1:20

Spotty classification is when you have non-calcify black

1:23

with a little bit of calcium centrally.

1:27

And then as we go down further in the LED, you see

1:30

contrast a little bit of calcium here.

1:33

a little Flex of calcium here and there

1:36

a small diagonal branch

1:39

a couple other flecks of calcium

1:43

some more calcium

1:45

a decent size maybe moderate diagonal Branch there and

1:48

then the LED looks

1:52

Fine down towards the Apex you'll find

1:55

if you realize coronary CT the majority of the patients. The disease

1:58

is really

1:59

proximal to Mid vessel for the led the

2:02

Cirque certainly also approximal and

2:05

mid vessels most commonly involved for the RCA adult and

2:08

you'll find pretty much the entire vessel may be involved. So

2:11

in this case now, we're going to look at the ramus on the

2:14

excellent images. We see the ramus comes off here a little Fleck of

2:17

calcium, but nothing that looks really particularly concerning

2:20

there and the circumflex here you

2:23

can see there's a nice hunk of

2:26

calcium here, but next to what you've got quite a

2:29

bit of lumen and if you window really wide that calcium

2:32

Although it looks quite large. There's still quite a

2:35

lot of luma next to it. So I'm not too worried about that being a severe lesion.

2:39

another bit of calcium here, which looks

2:42

Substantial in terms of size but there's quite a

2:45

lot of lumen next to it as well. So I'm not too worried about that either and

2:48

then the obtuse marginal here looks like it's free

2:51

of disease.

2:53

and then finally

2:55

Where the RCA?

2:58

Approximately here right at the origin that looks fine. And then

3:01

soon after the origin though. We get this tapered narrowing

3:04

right there.

3:06

It's hard to tell really on the axial images,

3:09

but I suspect there might be some non-calify plaque in this region

3:12

so out take a look at that on the CPR images.

3:17

And then as we go more distally we see a little

3:20

Fleck of calcium here.

3:22

With maybe some non calcified plaque around

3:25

it, but quite a nice large column of

3:28

contrast next to it. So I'm not to worry about that being a significant stenosis.

3:31

And then when we go down further in

3:34

the RCA can see this kind of caliber change. It's sort

3:37

of

3:38

some irregularities of a lumen

3:41

is how we would usually describe that without any severe stenosis.

3:45

And then the PDA here as a small vessel, but

3:48

looks okay.

3:50

So we know we've got some proximal RCA disease

3:53

and some at least proximal to Mid LED disease

3:56

which looks concerning. I think the Circ disease is probably

3:59

going to be okay, but we'll have to take a look at that as well.

4:02

So we go to our curve planar images.

4:06

Here's our LED.

4:08

And right away, I think it stands out pretty quickly that

4:11

you've got this stenosis here. And so this stenosis

4:14

is one of the it's sort of a classic appearance of

4:17

a moderate stenosis.

4:19

You know somewhere in that 50 to 60% range.

4:22

Got quite a bit of narrowing but you

4:25

still have a decent amount of contrast that's getting through. So this

4:28

would be considered a moderate stenosis.

4:33

Not in that 70 plus category but in that 50

4:36

to 60 percent range.

4:39

Downstream looks like you've got maybe a little bit more mild disease

4:42

from some non-classified black here

4:45

and some maybe a non calcified plaque with a

4:48

spotty calcification here.

4:50

I think these are more mild because I see much sort of more substantial.

4:54

column of contrast going past these lesions

4:58

This one is maybe borderline, but I think probably

5:01

still less than 50% But certainly

5:04

this proximate one is the most severe.

5:07

now if we go on to the circumflex

5:10

And we've always want to window really wide to make

5:13

that calcium small as possible and you'll

5:16

notice that we've got quite a bit disease here along

5:19

the circumflex, but the Lumen looks preserved.

5:23

Right the Lumen from here through here really

5:26

looks fairly preserved without significant little

5:29

narrowing we have disease, but we have positive remodeling

5:32

that results in very little narrowing.

5:35

So I think the circumflex overall.

5:38

Is mild disease may be here distally. It's

5:41

approaching something a little bit more moderate on some views, but

5:44

I think

5:45

the overall impression is that it looks like it's mild disease.

5:48

And then finally the RCA.

5:51

This is a nice example in the RCA of a moderate stenosis

5:54

as well from non-calcified plaque in the

5:57

proximal RCA. So you can see you've got normal looking

6:01

segment of the vessel here and then it tapers down

6:04

to about 50% Maybe, you know,

6:07

approaching 60% stenosis right here at the

6:10

level of this non-calcified plaque.

6:13

So this is an again a nice example of moderate stenosis.

6:17

And then more distally you've got really what looks

6:20

like kind of a classic example of a

6:23

spotty calcification right here. Let

6:26

me zoom up on that which is where you have non calcified

6:29

plaque with a little Central bright Dot from

6:32

calcification. That's that's a body classification.

6:36

But you don't see anything against stenosis.

6:39

And then if we look at the rest of the RCA, we have a pretty continuous.

6:44

Vessel Lumen without much narrowing, maybe a

6:47

little bit of narrowing here just to leave. It's the vessel gets quite

6:50

small. And so I don't think there's a significant at least

6:53

not greater than mild stenosis. They're just

6:57

Putting it all together. We've got mild disease

7:00

in the circumflex and then moderates stenoses

7:03

in the proximal RCA and in

7:06

the proximal LED, so this patient when they fall into

7:09

this moderate category, that's sort of a gray Zone as

7:12

to whether they're, you know symptoms are related to coronary

7:15

disease.

7:16

Most likely two vessels with

7:19

modern disease. You're not going to have any significant. Ischemia, but

7:22

depending on how concerned they are about this patient. They may

7:25

order some sort of stress testing to work

7:28

them up.