0:00

Okay, this next case is a 65 year

0:03

old woman with a history of chest pain in shortness of

0:06

breath who's referred for Corner CT and she ends up

0:09

having moderate stenosis. So we'll go through her case next

0:12

so we're gonna start from the top with the axial images

0:15

and you can see the left main here dividing into the LED

0:18

and the circumflex and the left main itself looks

0:21

at least on the axle images free of disease.

0:24

Now we see quite a few branches off of the LED.

0:28

I may not have mentioned this before but the branching

0:31

patterns of the coronaries.

0:33

Are very diverse, I would

0:36

say you can see all sorts of different branching patterns, and it's

0:39

all within the range of normal. So nothing to get concerned about.

0:42

in this case, the patient has a very small first diagonal branch

0:45

and then a

0:46

moderate to large second diagonal Branch here

0:49

And then as we head down further in the LED, you don't

0:52

really see many other branches of any substance.

0:55

if we look at the patient's plaque and the luminal

0:58

patency, it looks like

1:02

you don't really see much in the way of narrowing and throughout

1:05

this proximal segment to the mid segment. There's

1:08

a tiny little dot here on the

1:11

wall of this led right

1:14

here that maybe just the smallest amount

1:17

of calcified black.

1:19

Certainly, the diagonal Branch here looks fine as we

1:22

go more distally you see the origin of

1:25

this septal Branch here. We don't tend to pay a whole lot of

1:28

attention to septal branches.

1:30

Because they don't often.

1:32

Have disease and even if they are diseased, they're

1:35

not really easily treatable.

1:37

As we go down more distally you can see there's

1:40

like this little little blob there of low

1:43

attenuation. That's probably a little bit of non-calify black

1:46

but having said that the lumen

1:49

looks like it's maybe narrowed a bit but not

1:53

not too sphere and as we go down more

1:56

distally, we don't really see any other disease.

1:59

So that's the LED. We'll take another look on the curve

2:02

planar images.

2:04

The circumflex here as we fall down nice really big vessel

2:07

with a big obtuse marginal Branch there and then

2:10

some other smaller branches.

2:12

And those all look three of black.

2:16

And then finally when we go to the RCA.

2:19

This is where we're going to find some significant disease.

2:22

Products more RC looks good with the essay noodle Branch

2:25

here.

2:26

And then when we head down boom we get into this area

2:29

here. We see since stenosis like you see that change in

2:32

caliber from here.

2:34

to there

2:36

So there's significant stenosis there

2:39

that will have to take a look at on the CPR images. And then

2:42

we're back to that that large caliber vessel that

2:45

we saw before and then more narrowing you

2:48

can see that changing caliber there on the excellent engines.

2:51

And then a little bit of calcification as well

2:54

a small acute marginal Branch another acute

2:57

marginal branch and then as we head down distally.

3:01

Again, the RC is really quite large and dominant.

3:05

And you see multiple branches here. There's a PDA Branch

3:08

as well as a posterolateral branch right here

3:11

if we use our myths

3:14

We can get a better look at these postilateral and

3:17

Pa branches.

3:19

And they look like they're free of disease. I find the mips

3:22

are helpful for these vessels that have a tortuous

3:25

sort of a squiggly course.

3:27

They help you just visualize them much

3:30

better than your standard axial slices which are moving in and

3:33

out of the vessel.

3:34

All right, so we know we've got some disease.

3:37

So let's see if we can sort them out on the curve planar

3:40

images.

3:42

Here's the RCA.

3:44

So we can see proximal RCA here. It looks okay, and then

3:47

we get into this area right here. That's that area of caliber

3:50

change where that non calcified plaque was seen if

3:53

we scroll around it all different angles.

3:57

You're gonna see that it's roughly.

4:00

50-ish percent stenosis at all

4:03

angles. And so this is a moderate lesion.

4:06

Nice example of a moderate stenosis here as well.

4:10

We're gonna see that same caliber change sort of a bigger

4:13

vessel here.

4:15

that then Narrows down to the smaller area here so you could even do

4:19

some measurements just to make sure.

4:22

If you want to, you know, feel more confident in

4:25

this case we get you know, roughly.

4:28

Rounding up to roughly eight and rounding up roughly four

4:31

here pixels. So so stenosis right

4:34

around 50% And then the same

4:37

thing goes for this this stenosis here.

4:40

You can do a similar measurement.

4:42

You know right around four versus right around 8

4:45

pixels.

4:46

So it's stenosis of around 50%

4:50

Now we tend to give ranges when we reports stenosis

4:53

in coronary CT because

4:55

To be honest, the technique is not that precise

4:58

that we can give a precise single number. So we

5:01

usually say something like 50 to 60% stenosis

5:04

or

5:06

or even for the amount of plaque we'll just say less than 50% stenosis.

5:10

And that's fine that's acceptable.

5:13

If you go back to that catarat's video remember, we grouped the

5:16

stenosis into different categories in the categories. Have a range.

5:19

And that's all sort of to be expected with

5:22

Corner CT and it really is

5:25

you know more so that the technique is

5:28

not as precise as a single number, but rather

5:31

we should be comfortable with giving ranges

5:34

for the degree of stenosis.

5:36

So having said all that, you know, this patient certainly has

5:39

some moderate disease.

5:41

Somewhere in that 50 or 60% range for

5:44

the right coronary artery.

5:46

Let's take a look at the LED.

5:50

You can see the LED here. We've got a nice.

5:53

Lumen with a little bit of narrowing distally

5:56

from that non-calify plaque right there.

5:59

But if you take a look at it from all different angles, you can

6:02

see that it actually it's fairly mild to see it's maybe on maybe on

6:05

one angle you get a little bit of numerals stenosis and

6:08

other angles. It doesn't look.

6:11

Quite as bad, so that's a less than 50% stenosis there

6:14

and the mid LED from non-calify black.

6:17

So overall at the end of the day this patient

6:20

has moderate disease. And again, this is a bit of a gray area for

6:23

patient management.

6:24

If the symptoms are severe she may go to getting

6:27

some sort of ischemia testing with stress test

6:30

or something like that or where they may just decide

6:33

to medically manage the patient.