0:01

All right. So our next scan in peripheral arterial disease

0:05

is a coral reef appearance and using all the different

0:09

available datasets again to problem solve.

0:12

So we're going to only focus on the vessel of interest in this one.

0:15

There are obviously very many findings in this patient

0:19

that we can go over as well later. But essentially, we have a

0:23

non-contrast series, an arterial series, a pure

0:27

lumen series, which means all of the bones have been materially decomposed

0:31

and you're only seeing the iodine highlighted, and a pure

0:34

calcium series. Now, starting out, out of the bat,

0:39

I want to highlight one thing. I've mentioned before that always make sure you look

0:43

at your source images. So for example, in this pure calcium, even

0:46

though we're looking at the calcium, you can see that because there's dense

0:50

contrast in that right atrium, a lot of

0:54

that contrast did not get removed on the pure calcium image,

0:58

which technically all of that iodine should have been subtracted out of this image,

1:02

but because this is really dense, it still persists,

1:06

just because of its density. So artifacts like this are known, and they do

1:10

occur, so always make sure you double-check everything on your

1:14

source dataset. And you can see here on that non-con,

1:18

there's definitely no calcifications and nothing really in that right

1:22

atrium. So this patient has a lot of atherosclerotic

1:26

disease. They have severe stenosis of their superior mesenteric

1:29

artery, moderate stenosis of their right renal

1:33

artery, severe stenosis of their left renal artery, as

1:37

well as,

1:39

as I'm coning down over here,

1:42

severe stenosis at this ostium of that left inferior mesenteric

1:46

artery. There's this bulky nodular calcified plaque in

1:50

that infrarenal aorta, which if I show you on this

1:54

pure calcium view,

1:56

looks like this nodular

1:59

density within. And then on that

2:03

pure lumen view, which is basically just that iodine only view, you can see

2:07

that as this filling defect right here.

2:10

But really, the vessel that I want to show, you can see there's a stent here and

2:14

we'll cover stents later, and that's why I don't want to go into too much detail in

2:18

more vessels in this patient because we've looked at all the different degrees of

2:21

stenosis and what they look like in all the other arterial branches,

2:25

is the coral reef appearance in an artery.

2:29

So over here, if you look at that left common femoral

2:33

artery again,

2:35

right here, and if I window width and level to get rid of all that

2:39

blooming artifact, you'll notice that one

2:42

might

2:44

consider that all of this is calcified plaque, but there's definitely some amount

2:47

of contrast in here, too.

2:50

All of this bit, like this bit right here is still your calcified

2:54

plaque. This bit obviously is a mushroom-shaped

2:58

calcified plaque, and there's circumferential calcifications right

3:01

here. And I wanted to show this appearance on all the image

3:05

dataset that we have and how we can use it to really problem solve and

3:08

look at and ascertain how much degree of stenosis is it

3:12

really causing. So here is the pure lumen

3:16

view. Again, everything right here is supposed to be iodine, and then here is

3:20

pure calcium view. So again, everything right here is supposed to

3:24

be calcium. And you can see that looking at all of these images,

3:28

it does make it much easier. And if you didn't have the

3:32

non-contrast or a virtual non-contrast or these pure

3:36

calcium imaging, and just looking at this, it would really be

3:39

very easy to just assume that all of this is the contrast bolus

3:43

and assume that this is just a mild stenosis.

3:46

But looking at all these three images, we now know that indeed

3:50

the contrast is only this much

3:54

within this lumen, and there's severe stenosis affecting

3:57

the outflow of this left lower

4:01

extremity artery.

4:04

Other than that, as we scroll down, this person has a lot of

4:07

atherosclerotic disease as well.

4:10

So other than this coral reef aorta, the superficial femoral

4:14

artery in this left lower extremity is okay.

4:19

Right here, it's still only mildly stenosed

4:24

up until the popliteal where it is marred by metal

4:28

artifact reduction. So a good application here would have been to use a

4:32

metal artifact reduction software to get better

4:36

assessment of the popliteal arteries.