0:00

Okay, so this next case is an example of a

0:03

total occlusion.

0:05

This is a 31 year old male really young guy who

0:08

had a sudden onset of

0:11

chest pain while playing basketball and you'll

0:14

notice when you look at the case that it's a triple Royal

0:17

case and that makes sense in this situation because he's

0:20

a really young guy. You

0:23

wouldn't necessarily expect him to have corn here our disease so they did kind of a more

0:26

broad kind of screening exam

0:29

to look for maybe some some aortic disease or

0:32

pulmonary disease or or coronary disease to account

0:35

for symptoms since he's so young on coronary disease was felt

0:38

to be kind of unlikely. He did actually have elevated cardiac

0:41

enzymes. And so there was

0:44

certainly some concern for him that he could have early onset

0:47

coronary disease and sure enough he did.

0:50

So let's go through the images.

0:52

Young guy really large coronary

0:55

arteries, which sometimes you see with young people which is makes your

0:58

life a lot easier so you can see has a really large left Main

1:01

and led with a diagonal Branch coming off here.

1:04

And then the circumflex.

1:06

there

1:07

and you could really call this a ramus Branch. You

1:10

can see that it left me in comes in LED comes off there this

1:13

Branch here and this Branch here. So this would be a monarch

1:16

to large ramus branch in a small circumflex Branch

1:19

there. If you have lunch sure you can always use the

1:22

nips. Like I mentioned you can see that try application really

1:25

nicely there.

1:27

Let's see. So as we go through the LED you can see this is

1:30

the LED. There's a moderate sized to

1:33

large diagonal Branch there and then as we

1:36

head down the distal LED all the way

1:39

down to the Apex.

1:42

Don't really see any disease.

1:45

And the same goes for this ramus.

1:49

And for this small circumflex.

1:53

They look free of disease now the issue

1:56

is when you get into this RCA. So here's the

1:59

proximal RCA.

2:01

It comes around the bend.

2:05

And then boom contrast is

2:08

gone, right here's contrast.

2:13

And then it disappears right there.

2:16

So that's concerning.

2:18

If you look in this region where

2:21

the contrast disappeared you can see a little dot there

2:24

a little Fleck of calcium a little

2:27

dot there and that there since probably a little bits of calcium

2:30

which would suggest that there was some atherosclerotic disease

2:33

here and this is occlusion related

2:36

to atherosclerosis.

2:38

Other possibilities in a young person would be

2:41

dissection perhaps although use those usually start

2:44

much more proximately than distant.

2:46

We can take a look at the curve planar images, but

2:49

because of that occlusion, sometimes the vessel tracking

2:52

isn't able to track beyond the termination

2:55

that contrast and this doesn't really help you.

2:58

so again

3:00

Here's where we may need to go to our multiplayer reformatted

3:04

images or you can use the short axis reconstructions.

3:07

Here's the short axis free constructions in

3:10

this patient.

3:11

And if we follow the right coronary artery

3:14

out into the AV Groove, you can see it comes around the

3:17

bend here and then boom it's gone.

3:20

nothing

3:23

And again, you've got a little Fleck of calcium there.

3:26

And not really much else maybe a little

3:29

bit right there.

3:30

So for this guy, I mean it's not normal to have an Abrupt termination

3:33

of the right coronary.

3:35

And he had enzymes he had symptoms so there was concern.

3:40

And in this case because of the coronary CT

3:43

read and because the enzymes he did go to cardiac catheterization, which I'm

3:46

going to show you next.

3:47

So here's the cardiac cath in this patient, which correlates

3:50

really nicely with the CT. I made some

3:53

MIP reconstructions of the CT to show you the disease.

3:56

Here's the right coronary injection. It comes

3:59

all the way down and then you hit this.

4:02

Occlusion and you can even see almost like a little meniscus

4:05

of the thrombus in there. And so

4:08

it was a considerative thrombotic occlusion and

4:11

they were able to go in and remove the

4:14

thrombus and stent that area and the

4:17

patient did well, here's the corresponding CT.

4:20

You can see that abrupt occlusion. You

4:23

can see it on this is an axial knit. You can see the

4:26

contrast coming here and then including a

4:29

broccoli and this is where the rcnpa should

4:32

have been if it was normal.

4:34

We have the report from the corner and geography and

4:37

they called it a large dominant vessel 100% thrombotically included

4:40

distally with paint filling via collaterals.

4:43

And then they did successfully perform a PCI

4:46

with suction thrombectomy and

4:49

then they deployed a stent from the distal RCA into

4:52

the proximal PDA. So he did well on

4:55

what was an unexpected and quite traumatic

4:58

case for a young guy.