0:00

Okay, this next case is a 67 year

0:03

old male who reported to the emergency department

0:06

with chest pain and ended up getting a

0:09

coronary CT.

0:10

And he had severe disease so we'll

0:13

walk through it now.

0:15

Start with the left main here.

0:18

And you can see he has some calcification of the distal left

0:21

main, but it looks mild and severity. There's a nice

0:24

calm of contrast passing through.

0:27

And then as we get into the proximal LED, you can

0:30

see this is the LED coming off a little bit more superiorly and the

0:33

circumflex a little bit more inferiorly as we move

0:36

into the proximal LED. You can see this calcified plaque becomes

0:39

non-calcified and you've got

0:42

it's a large amount of non calcified plaque right here Museum up

0:45

on that.

0:47

This extensive noncosified plaque and

0:50

you really don't see the Lumen very well at all.

0:54

So Lumen here, you've got a little bit of contrast

0:57

here and just probably connecting up right there.

1:00

But certainly it's not nearly

1:03

as much luminal.

1:07

Contrast as you see for the rest of the vessels, so that looks like

1:10

just on the axle images and we'll check the curve planar

1:13

images, of course.

1:15

That sure looks like a bad stenosis.

1:19

Moving forward in the LED. You've got a little bit of calcium

1:22

here some but not significant narrowing. You've

1:25

got a really nice.

1:27

big diagonal Branch coming off here

1:31

another diagonal here. So so moderate to

1:34

large first and second diagonal branches and then you can

1:37

see that the LED continues towards the Apex this blurring

1:40

here. That's a little bit of motion blurring.

1:44

And then down towards the Apex we go and that looks fine.

1:49

So if we take a look at the other vessels.

1:53

You can see he has a large circumflex a tiny bit

1:56

of calcification there without any significant mineral narrowing.

2:00

small obtuse marginal here

2:04

the circumflex then continues gives off another

2:07

small obtuse marginal.

2:09

and then

2:11

a third small obtuse marginal before finally terminating

2:14

and what looks like

2:16

a posterolateral branch here along the back wall

2:19

of the LV and with a couple

2:22

small calcifications. So one there.

2:27

Maybe something right there.

2:29

And another calcification there all least on

2:32

axial Imaging looking mild. Now when you have the

2:35

poster lateral Branch coming off the circumflex and that is a code dominant

2:38

coordinary artery system. So something that

2:41

you can mention so normally in a right dominant system,

2:44

you have the PDA and the poster lateral branch is going from the right.

2:48

And in the left dominant system those branches coming from the circumflex, but

2:51

if you have a situation where the PDA comes from the right?

2:54

And the poster lateral branches come from the left, then

2:57

that's considered a code dominant system.

3:00

Okay. Now finally if we look at the RC in this patient,

3:03

we can see it's a it's a smaller vessel compared to

3:06

the other two vessels.

3:09

And then it gets really quite small actually

3:12

when it heads out into the AV Groove here. You can

3:15

see it's really tiny and then just kind of Peters out.

3:18

So this would suggest that this patient has a left

3:21

dominant system. Although to be honest with you.

3:24

It's hard for me to see the PBA.

3:27

Looking back. It looks like there is actually another branch that

3:30

swings wave posteriorly off the circumflex here.

3:34

Hugging the left atrial wall and then eventually heading

3:37

over into the region of the PDA territory. So

3:40

that's a really small PDA. So this actually is in

3:43

fact the left dominant system.

3:46

Now to do our stenosis assessment, let's look

3:49

at our cprs.

3:53

Here's the LED curve planner image in I think

3:56

right away we can see this is a really severe

3:59

lesion in approximately D. You only

4:02

have just a tiny bit of contrast getting past this stenosis.

4:06

This is a 70% or greater lesion, maybe even 70

4:09

to 90 percent lesion.

4:12

If you're giving reporting a range.

4:15

Certainly, this would fall into the severe category. The rest

4:18

of LED looks looks okay. There is

4:21

this little step off right here and that's

4:24

actually secondary to a little

4:27

bit of motion in this patient.

4:29

And that's not an uncommon place to get that little motion artifact.

4:34

Little bits of calcium here just to leave a no

4:37

significant stenosis.

4:39

Now, let's look at the RCA. You can

4:42

see the RCA here doesn't have much disease. It's

4:45

a small vessel.

4:46

So that kind of goes along with our left dominant.

4:50

Situation and then finally if we look at the Circ

4:53

we can see the Circ has that mild calcification.

4:57

And when we're following out the obtuse marginal

5:00

here we can see.

5:02

That there's not any significant obvious martial disease.

5:06

Now the circuit self you can see beyond the

5:09

obtuse marginal we have some disease

5:12

in this circumflex as it heads over to

5:15

give off the PDA right over here.

5:19

now we're not really at the best angle to look at this with our

5:23

CPR so this is where we may want to do our

5:26

own multiplayer reformat image to get

5:29

a better look at this region so I can review that how we

5:32

would go about that.

5:34

Now you're going to be using ombre, but you're going to set up

5:37

the NPR.

5:38

Planes, it's very similar to what we see here.

5:41

On this particular workstation, you can ignore the red

5:44

plane that that actually is not contributing to

5:47

the evaluation.

5:49

What we want to do is we want to basically drop

5:52

the crosshairs on the area that we're

5:55

interested in. So in this case, it's this part of the circumflex beyond

5:58

that obtuse marginal.

6:01

Then you ideally want to find the vessel in

6:04

a long axis image and align your plane with

6:07

that vessel. So here it is a long axis and we're going to rotate the plane

6:10

align with it that long axis View.

6:13

And then do the same in the other long axis View and

6:16

then if we do both of those together, we should be

6:19

able to get a decent look at the vessel.

6:23

And be able to tell whether we think these stenosis are

6:26

significant stenosis or molestenosines.

6:29

And sometimes making a MIP can help as well.

6:33

So in this case, I made a thin myth. I'm going to go back to the NPR.

6:38

For this particular station if I double click I can blow up

6:41

on the vessel. And so you can see here comes the column of

6:44

contrast. There's a little bit calcium here, but still quite a

6:47

lot of contrast there. So no significance stenosis.

6:51

And then more distally.

6:53

You can see contrast comes through a little

6:56

bit of calcium here a little bit of calcium there but

6:59

still a good amount of contrast getting through so I'm not

7:02

too concerned that this represents significant disease.

7:05

We can take some other angles though and look

7:08

at the other view the other long axis View and again, you see

7:11

that there is contrast and a little

7:14

bits of calcified plaque.

7:16

One thing I look for is it looks almost like the calcium is sitting

7:19

on top of the lesion rather than sitting in the

7:22

Lumen which tells you that there's positive remodeling

7:25

going on and that there's probably not any significant the

7:28

most stenosis. So that's something that I use when I'm reviewing this

7:31

if you see that the calcium plaque is so just

7:34

Sitting on the top of the vessel rather than within the

7:37

vessel. That's a sign suggesting that it might

7:40

be mild disease.

7:42

Now one of the trick that I use on these nprs

7:45

for assessment is if you put your crosshairs in

7:48

the middle of the lesion and then change your

7:51

plane so that it bisects.

7:54

Through the Lumen and through the

7:57

calcium. Sometimes I can give you a really nice

8:00

visualization of the relationship of lumen

8:03

and calcium, which you see here.

8:06

So again, although you've got a big on a calcium.

8:10

You still have a nice contrast column passing the

8:13

calcium and I know from our previous discussions that whenever

8:16

we see calcium. It's always a little bit overestimated by

8:19

CT.

8:20

So this

8:22

pretty much purely calcify lesion here. It seems

8:25

to be sitting on top of the vessel Lumen I know is probably going

8:28

to be a very mild stenosis if we did a

8:31

subsequent query and geography.

8:34

So this case patient to sum up

8:37

has a left dominant system with a very severe

8:40

proximal LED lesion and what looks like

8:43

mild disease in this circumflex. So this

8:46

patient actually did go to coordinate catheterization and I'm

8:49

going to switch over to a PowerPoint to show you the results.

8:53

Okay. So here's the correlation of the cardiac catheterization on

8:56

the right with the CT on the

8:59

left and you can see there's a really nice match between

9:02

the severe stenosis. We see a coronary CT

9:05

and a Severe stenosis that

9:08

they saw at cardiac catheterization. They didn't end up

9:11

standing this patient.

9:12

Because he was presenting with a cute chest pain. Now.

9:15

Another thing that you can see here is here's

9:18

the left Main.

9:20

Here's the LED and here's the circle. I'm not an expert in

9:23

evaluating cardiac calf, but we can certainly see

9:26

the proximal vessels very nicely and you know,

9:29

I know that this is the circumflex.

9:31

And in this case the circumflex comes down.

9:34

Here's that obtuse marginal that we saw and here's the

9:37

Circ coming down down down and then terminating in

9:40

the PDA. So the PDA we kind of see in profile.

9:43

We don't see very well.

9:45

But if you remember from our coronary CT, this is

9:48

where they saw those little bits of calcium. They look like they were sitting on

9:51

top of the vessel and I think I have that in an image here.

9:55

That's where we saw. This is now that same segment in a

9:58

different view on the calf right here right beyond

10:01

that obtuse, Marshall Branch.

10:04

This segment of the circumflex, which is just beyond this obtuse

10:07

marginal.

10:09

is the area that we were looking at those calcified plaques and

10:12

so I think this is a nice example of how

10:15

calcified plaques on CT which you may wonder if they're substantial.

10:19

Oftentimes are practically invisible.

10:22

On cardiac cath so my kind

10:25

of rule of thumb is if I see the calcium, it looks like it's sitting on the vessel. I

10:28

see a nice calm of contrast going past then for me

10:31

that that's mild disease and that's tends to

10:34

be what we see on cardiac cath as well. So just to sum up

10:37

a nice example of high grades stenosis. In

10:40

this case the cat they call it a 90 to 95% stenosis with

10:43

a good correlation to the CT.