0:00

It's worth touching a moment on cabbage to that.

0:04

Cabbage, as you know, stands

0:05

for coronary artery bypass grafting

0:07

and, um, one of the few uses in CT

0:11

to use volume rendered images.

0:13

This is a case from the CAD RADS 2.0 guidelines,

0:16

but um, it's a nice illustration of it.

0:19

Uh, arterial graft, so this is a lima

0:22

and you can see it's tortuous,

0:23

but does touch on the LAD as it usually does.

0:25

And then this case also has, uh,

0:28

aortic coronary bypass grafts

0:30

and they can, any vessel can go anywhere.

0:32

These are, um, looking like venous bypass grafts going

0:35

to a diagonal

0:37

and then further to an obtuse marginal,

0:39

they tend not to cross though they can.

0:41

Um, you can use the Lima left internal mammary artery,

0:45

which comes off of the left subclavian,

0:46

or you can use the right internal mammary artery.

0:49

Uh, and sometimes you use both.

0:51

Uh, you probably are aware that many bypass grafts, uh,

0:55

are tenuous and can go down.

0:58

Um, arterial bypass graft such as a Lima arima

1:01

or even a radial artery

1:02

that's transposed from the arm into the chest, uh,

1:06

tend to be more patent.

1:07

You can even use the gastro lipoic artery from the abdomen.

1:10

So if you do have a case where somebody knows they have a,

1:14

uh, abdominal graft, you'd want to extend the scan

1:16

to cover the abdomen as well.

1:18

Uh, when you do these, uh, you're often looking

1:21

through vessels that are occluded.

1:22

So, uh, you may just say the vessels you see

1:26

and the vessels you don't.

1:27

So if there's history of a saphenous graft,

1:28

but you don't find a saphenous graft, probably occluded.

1:31

In fact, 12% of bypass grafts are down by the morning

1:34

after surgery, um, in older studies.

1:37

So we tend not to do as many bypass grafts these days

1:39

and try to focus on arterial grafts when you can, um,

1:43

and give a durable, uh, result.

1:46

You'll also see that there's a lot of, uh,

1:47

clips along this case.

1:49

Those are metallic clips that the enemy of a, uh,

1:51

CT artifacts, uh, or they cause artifacts.

1:54

So sometimes you miss a touch of the anatomy due to streak

1:56

and we just tend to ignore that.

1:58

You wanna look for the origin and the touchdown

2:01

and then look for any stenosis when the graft,

2:02

and we'll look at a lot of cases of,

2:05

uh, graft abnormalities.

2:06

And you're often using this

2:08

to guide the invasive angiography.

2:10

So here's a and matched invasive coronary

2:12

angiogram, sternotomy wire.

2:14

As you can see, this is an arterial graft.

2:16

The same case actually.

2:17

And so this is a very tortuous lima graft,

2:20

but one of your roles as a CT imager is just

2:22

to find the graft anatomy

2:24

because the invasive angiography has to hunt around.

2:27

For instance, if they're looking

2:28

for a saphenous graft in this patient, they'd have

2:30

to know exactly where it arises from the, uh, aorta,

2:34

but the CT imager can find that very clearly.

2:36

In fact, if it's occluded, no need to do an angiogram.

2:39

Uh, so just some, uh, some basic pointers on bypass grafts.

2:43

Uh, and of course you are gonna look at the curve planar

2:46

reformat and the axial images,

2:48

but you, uh, can illustrate this very nicely for surgeons

2:51

and, and interventional cardiologists

2:53

by using volume rendered images.

2:55

And one other note is most sites scan just the

2:58

Heart for a coronary ct.

3:00

If you know there's a bypass graft,

3:01

you wanna extend the scan up to

3:03

above the first ribbon clavicle junction

3:05

because then you'll cover the origin, uh,

3:07

and the entire course of a lima graft

3:09

to the left control mammary.

3:11

And you wanna make sure you clear the inflow from the

3:13

subclavian, which you'll automatically get if you do that.

3:16

One easy rule of thumb

3:17

that we do at our site is we tell our technologist if you

3:20

see a sternotomy scan, the whole chest,

3:22

'cause it has been a cabbage

3:23

or there's another heart surgery

3:24

and a cabbage is potentially addressable.

3:27

So have a sternotomy scan, the whole chest.