0:01

Okay, so this next case is a elderly gentleman

0:05

who had a bypass graft years ago.

0:07

Uh, came in for a CTA to look at some symptoms

0:10

and, uh, let's just solve it as an unknown case.

0:13

So just following the vessels

0:16

and you can now see that the lima is off the chest wall.

0:20

There's rema, a little tortuous.

0:22

Um, this might be a nice example of how it's helpful

0:25

to have a volume rendered CTA

0:27

and you can see the tortuosity of these vessels.

0:29

So I certainly like to use that, uh, to follow these vessels

0:33

and just give an overview.

0:34

Usually snapping a few pictures.

0:35

And there's the lima anastomosis with the LED.

0:37

Again, the most common bypass graft,

0:39

it's the most durable patency with arteries.

0:42

So, and that's the easier one to get to the left side.

0:45

Uh, now if I'm gonna follow the additional bypass grafts,

0:48

you're gonna see that there's

0:49

something coming off the aorta.

0:50

So it's an aortal coronary, probably a, a venous graft.

0:53

It's a little bigger. And then I kinda have some trouble

0:56

following this vessel

0:57

because it's in, oh, there's actually two.

0:59

So here's the first graft coming off of the aorta

1:03

and then there's the second one, a short distance below.

1:06

This is another great use for CTA,

1:08

but uh, you can see already I've cut part

1:10

of the upper graft off, but this one is occluded.

1:12

So the more superior oriented graft is patent

1:16

and the more inferiorly is occluded.

1:19

But you're probably noticing what I'm noticing

1:21

and that there's, uh, something wrong

1:22

with even the patent graft.

1:24

But just to illustrate the use of NPRs for this case,

1:27

it's very easy to confuse one for the other.

1:29

So, um, it's nice to make an image

1:31

and maybe even do a maximal intensity projection image.

1:34

But you can see here there's your patent graft

1:36

and there's your occluded stump of a graft.

1:38

Um, but something about this patent graft does not

1:42

looking normal.

1:44

And so when you follow it, you can see here

1:46

that the vessel looks normal and then it becomes very thick.

1:49

And what you're looking at is a saphenous graft aneurysm.

1:53

And so these are venous aneurysms because the veins are used

1:57

and harvested, they become

1:58

arterialized and a little thicker.

2:00

But what is not normal is the presence of an aneurysm.

2:03

And it's important to think of it just like any

2:06

other aneurysm in the body.

2:07

In fact, we know that invasive angiography will undersize

2:10

these because it won't see the walls,

2:12

whereas you can see the uh, um, aneurysm pretty well here.

2:16

Hard to make a volume rendered

2:18

'cause we're looking at the contrast lumen.

2:19

But you can see that giant aneurysm

2:22

surrounding the venous graft here.

2:23

So I'd make sure I'm centered on it.

2:25

I'd get into perpendicular short axis

2:28

and I can do that with using my alternative planes here.

2:31

And I just wanna make sure that one

2:33

of my views is perpendicular.

2:35

So, uh, this is a nice view to make sure.

2:37

And then I can line the other up.

2:39

So now I've got it perpendicular to both planes

2:42

and I'm just gonna measure it,

2:43

making sure I'm not oblique or exaggerating it.

2:45

And so something that's aneurysmal

2:48

the strictest definition is that anything

2:50

that's 1.5 times the reference segment are larger.

2:53

In this case, there's really not a question.

2:55

This is far beyond that.

2:56

So this is a, you know, eight millimeter vessel, but

2:58

It's a 22 millimeter aneurysm.

3:01

So bypass graft aneurysm,

3:03

and I think we just followed this one.

3:05

They can rupture.

3:06

Uh, it's important to, uh, closely follow them, uh,

3:10

or resect them if you have to.

3:12

Or I suppose you could occlude it

3:13

intentionally shut down the flow.

3:15

Just wanna show you also that there's a, uh,

3:17

nice look at the RCA here.

3:20

And this is an occluded native RCA.

3:22

So if I was gonna talk about this,

3:24

I would talk about the lesion length.

3:25

So it's just on the border of a critical, uh,

3:28

subtotal stenosis versus, uh, severe.

3:30

I think I maybe under measured it there,

3:31

so it's probably a total occlusion likely chronic.

3:34

Uh, and then I'm just gonna real quickly look back

3:37

and make sure I don't, I'm not missing

3:39

that there's a bypass graft.

3:41

So Lima, sorry, REMA unused.

3:43

I'm watching this side of the aorta

3:45

and I'm not finding any, I'm seeing a cannulation site,

3:48

but I'm not seeing any bypass graft.

3:50

So unprotected RCA occlusion and we say unprotected

3:55

because there's not a stent

3:56

or a graft that's supplying the arteries.

4:00

So again, uh, saphenous vein graft aneurysm

4:04

in the circumflex graft

4:06

and then occluded, uh, bypass graft

4:09

and occluded native artery.

4:10

So if we were talking about CAD rads,

4:12

I would give a couple of codes here.

4:14

I would say this is a cadrad G.

4:16

So, um, G is indicative of graft.

4:19

I would say that there is a cadrad five meaning occlusion

4:21

since I have at least a good bypass graft occluded in, um,

4:25

I think a second occlusion in the RCA

4:27

and I might put throw a slash e on there for exceptions.

4:31

'cause an aneurysm doesn't really, uh, care about the degree

4:33

of stenosis, but rather the size.

4:35

So interesting case with a, uh, rare

4:39

but not completely uncommon complication

4:41

of a saphenous graft, which is an aneurysm.