0:01

All right, next case.

0:01

This is, uh, a high pretest risk patient.

0:04

This patient is 80 years old, um, with symptoms that might,

0:08

uh, suggest coronary atherosclerosis.

0:11

And the decision was made to start with this coronary ct,

0:14

which happens more and more these days.

0:15

Uh, and a fair amount of people

0:17

of this age actually don't have plaque.

0:19

Um, we're gonna ignore the,

0:20

the granulomas disease in the, uh, lymph nodes here.

0:23

But you can see calcium score alone tells you this is a,

0:26

a fairly, uh, atherosclerotic, uh, patient.

0:29

Uh, I will note that there's some valve calcs.

0:31

It's not this course's topic,

0:33

but something to note if you see it,

0:35

the calcium score not gonna be low.

0:38

I'll just, uh, read it out here.

0:41

Came out to 1,522.

0:44

You'll find some older literature that says, stop the scan.

0:47

The likelihood of a non evaluable segment is high.

0:49

We do not find that to be true,

0:50

and we find the yield to be high.

0:52

Um, certainly there's a higher risk of having a vessel.

0:54

You can't, uh, evaluate the same time

0:57

because the yield is higher.

0:59

If there's any positive segment, you have a next step.

1:01

By the way, it passes all image checks,

1:03

no motion artifact, good opacification.

1:05

We like to flush the right heart a little bit

1:07

so we don't get streak artifact.

1:08

And so it's, it's nice to have,

1:10

if you can have a dual phase injector.

1:13

Um, as I trace this RCAI can see ectasia, right?

1:16

It's a bigger vessel, then it's a smaller vessel

1:18

without branching.

1:19

Um, and then I have some atherosclerosis here.

1:23

I think it's mild, possibly bordering moderate, uh,

1:27

in this mid RCA.

1:28

So we did find disease, uh, as is not surprising.

1:31

I don't see any focal severe stenosis.

1:34

So there's that in the RCA.

1:36

It's a dominant, oh, down below here though, I'd think the,

1:39

uh, the RCA has a little bit of a narrowing there.

1:43

Gotta remember that probably it's

1:45

overrepresented when it's just calcified.

1:47

But right around here, it's probably still mild

1:50

'cause it's already branching into the PDA and PLV.

1:52

But, uh, it's a little bit borderline for me.

1:55

Um, second, uh, thing I'll do is go

1:57

and look at the left main,

2:00

although the left main looks fine on this axial view.

2:02

I'll just give myself one other view.

2:03

I like a vertically oriented view. All good.

2:06

Okay, so left main is fine.

2:08

That's very important because that alone should

2:10

drive management decisions.

2:12

And a lot of the trials have shown that just left main.

2:15

Um, if you use that as your prognostic factor, uh,

2:18

that gets you most of the important, uh, disease and events.

2:22

'cause medical management's very good

2:23

for the other, uh, vessels.

2:24

So I don't like what I'm seeing already in the led.

2:27

So there's a lot of disease, uh,

2:29

but nothing significant, maybe mild here, uh, until I get

2:33

to this area right

2:34

around when this diagonal's branching out.

2:36

In fact, this is the, oh, another bridge.

2:38

So, uh, we're really driving the point home.

2:40

70% of people in ct,

2:42

and these are, this one's a kind of an angled bridge,

2:44

not unlike the last one, um, but short and shallow.

2:47

So I'm not even gonna worry about the bridge segment.

2:50

So, um, but I am gonna use that to say that's my LED.

2:54

That means this is already a dag where I'm, uh,

2:56

where my eye was caught, so is not a, uh, small vessel.

3:01

Um, and it has a branch

3:02

or two, by the way, say that I see a touch

3:05

of motion if I'm lucky enough to have an acquisition

3:07

that covers multiple phases, I can just, uh, go

3:10

through in, in time here.

3:11

And so I'm changing my phase just ever so slightly

3:14

that lesion stays.

3:15

And so I'm just gonna move my, uh,

3:16

cardiac cycle phase a bit.

3:18

So there is an, a lesion that doesn't go away

3:21

with changing of phases.

3:23

So worried about the diagonal,

3:24

and it's a fairly proximal with a lot of distal branches.

3:27

I'm gonna call this our ramus, intermedius.

3:29

It's disease, but not significant.

3:30

So that's the first diagonal that I see, uh, possible

3:33

to have a tiny diagonal that the CT doesn't see

3:35

that the calf can resolve, but the first large diagonal.

3:39

Um, and then fair amount of disease in my circumflex.

3:42

Nothing's caught my eye too badly here.

3:44

So, uh, again, very similar to last case.

3:47

I'm worried about this diagonal.

3:48

And I think the whole reason that we went

3:50

to a CT first was they were trying

3:52

to avoid a calf in this patient.

3:54

I wanna show you the curved planer reformat

3:57

that we had our 3D lab do of this LED just to show you.

4:00

Really good to get the major vessels.

4:01

And they actually, I think, segmented a branch here.

4:05

But, uh, it's a good way to look at the left main if

4:07

it's done before I get to the case.

4:08

It's nice to have, um,

4:09

sometimes I beat the, the lab to the case.

4:11

Here's the circumflex.

4:13

And same story with the right coronary artery curve.

4:15

Planar reformats are, um, a bit of a double-edged sword

4:19

because if you're off center on the axis,

4:21

you can create the appearance

4:22

of a stenosis where there is none.

4:24

Um, but in this case, uh, I think it, it's helpful

4:27

to illustrate that there's plaque,

4:28

but not at least proximal disease.

4:30

So, um, let's go and send this off to the, uh, C-T-F-F-R.

4:36

Again, we have a fairly, uh, profound, uh,

4:40

drop in the vessel in question.

4:42

So this is that diag.

4:44

Um, a couple of other things that happened.

4:45

The technology is only approved for vessels,

4:47

I think over 1.5 millimeters, maybe two.

4:50

So this actually looks like it's a diag.

4:52

So maybe it's diag, sorry, om.

4:54

Um, but either way, this branch was too small.

4:56

Uh, the one that was very diseased, so they didn't

4:59

evaluate it, they just marked it as gray, too small to model

5:02

or for some other reason, there's an artifact.

5:04

Um, you can see they also only get as far

5:06

as they can in the vessels that they,

5:08

so in the LED it gets small enough here in the distal

5:11

branches, they can't evaluate them.

5:12

But we do have a very focal trans lesional gradient right

5:15

here in this diag.

5:17

Um, and then the other thing is helpful is the RCA,

5:19

just confirmatory and negative.

5:20

We saw some disease, but it

5:21

didn't pick up anything significant.

5:23

So it affirmed what the CT shows.

5:25

These tests aren't a hundred percent.

5:27

But, um, it's helpful here to select

5:29

and say we are okay to, to proceed further with this case.

5:34

Let us look at the angiogram.

5:37

Well, this patient doesn't have

5:39

specifically known coronary disease, uh, ahead of the exam.

5:42

The pretty high risk by the age profile.

5:45

One thing that I should have commented on

5:47

as reviewing is there's a lot

5:48

of tortuosity, uh, in the artery.

5:50

So probably somebody with hypertension.

5:52

Um, but that also makes interpretation of both the CT

5:55

and the angiogram a little harder.

5:56

Things come in and out a plane.

5:58

Uh, so we have to find the vessel in question.

6:01

So this is the LAD hitting the apex.

6:03

There's the, uh, circumflex

6:05

and obtuse marginal branches coming off

6:07

to the left of the image.

6:09

I see that kind of questionable stenosis.

6:12

Here's the RCA injection, just confirming, yes,

6:15

there's lumps and bumps, there's disease, uh,

6:18

but nothing significant.

6:19

And let's see what they ultimately decided to do.

6:23

So they deemed this as an intermediate

6:26

to severe stenosis in the cath lab and decided

6:30

because it's a single vessel to try some medical management.

6:33

First, they actually did do an additional test, the DFR,

6:37

and that they thought

6:38

that it was not hemodynamically significant,

6:40

even though they, um, visually thought it was significant.

6:43

And even with a positive DFR on a single vessel prognostic

6:47

data from large studies shows you could elect

6:49

to try medical management first.

6:50

So I think based on the age of the patient, the risk

6:52

of all the other medications that would come along

6:55

with a stent just to stick with conservative therapy.