0:00

Okay, the next case is a younger patient

0:03

who in their fifties had had a bypass graft

0:05

and had some new symptoms.

0:07

So we're taking a look and we know that there's a cabbage.

0:11

And even without looking at a full field of view,

0:13

you can see that the rema is unused.

0:15

The lima is already off the chest wall.

0:17

Uh, and so it comes down little noisier, um, happens

0:21

with larger patients.

0:22

So you can see that the Lima is patent

0:24

and there's your touchdown.

0:26

The runoff looks okay.

0:27

Um, and then I'll look for the next graft and whoop.

0:31

So this, uh, I'm looking along the aortic wall.

0:34

You can sometimes see cannulation sites. That's fine.

0:37

So clips, but here is a, um, a view of

0:42

what should be a bypass graft,

0:43

but just a little nubbin that's remaining on the aorta.

0:46

And then, um, we are seeing that the vessel's occluded.

0:49

I'm just gonna show you, uh, via long axis, uh,

0:52

what I see pretty well on the axials just to lay it out.

0:55

And so here is a venous bypass graft occlusion.

0:58

The distal vessel is kind of very calcified, um,

1:01

but I don't really see any contrast

1:03

that actually highlights the danger of a mip.

1:05

It looks like it's contrast, but it's just calcium.

1:07

Um, if you look at the volume

1:10

rendered, it kind of corroborates.

1:11

So the lima got cut off by the algorithm here,

1:14

but I'm really more showing you this for the,

1:16

seeing the short OTE segment that's patent.

1:19

And then everything else is occluded in the, uh,

1:22

circumflex venous bypass graft.

1:24

Uh, so occluded graft and then sticking with the left.

1:29

We do see that there as not unexpected,

1:32

but a lot of disease in the left main

1:33

and probably a distal occlusion.

1:35

I'll show you that in another plane just since it's good

1:38

to get familiar with left main disease.

1:41

It's not a surprise here. It clearly was, uh, expected

1:44

or known because we have bypass grafts,

1:47

but this is what a severe left main stenosis looks like.

1:50

Uh, and lots of calcium, lots of noncalcified plaque.

1:54

We find that the native arteries tend to calcify

1:56

after they're bypassed, so it's really not surprising.

1:58

And then just falling the circumflex down,

2:00

you can see why they had to bypass it.

2:02

There was a lot of disease in the native artery.

2:04

Unfortunately that bypass graft went down

2:06

and that's a really good use for ct.

2:08

So very appropriate indication to check bypass grafts.

2:11

Unfortunately, I'm looking at the RCA

2:14

and uh, this lays it out pretty nicely actually,

2:16

and I lose that vessel.

2:18

I don't recall seeing any vi bypass graft,

2:20

so I'm just gonna mip it.

2:21

So you can see it's near osteo occlusion of the RCA

2:25

and um, a lot of disease.

2:27

So I, if I was reading this, I would comment,

2:28

I would comment the length.

2:30

I would note that the distal vessel does appear to be patent

2:32

and does give rise to a PDA and PLV.

2:35

So this dominant right coronary artery

2:37

with a long segment occlusion, probably chronic,

2:39

but we'd need to know history or a prior cath.

2:42

Um, and, uh, really no, um, no grafts

2:46

to the right side that, that I'm identifying right here.

2:49

Uh, the nice option at least you have is rema if you wanna

2:52

do a repeat surgery and things.

2:56

I might also look at, just since I'm here, look at

2:58

The wall thickness so the myocardium is

3:00

all alive and well.

3:02

Um, not saying anything about function,

3:04

but there's at least some myocardium preserved,

3:07

maybe a touch of thinning in places,

3:09

but no reason to think it's a totally, um,

3:11

non-viable myocardium, at least at this point.

3:13

Let's pop over and take a look at the angiographic results.

3:18

There we go. Okay, so the cannulation site is, uh,

3:21

into the Lima graft

3:23

and you can see that the touchdown and runoff are patent.

3:28

Let's see if I can find an injection

3:29

of the left main itself.

3:32

So now the catheter is looped around the, uh,

3:35

vessel into the left main,

3:37

and I guess I'm one frame further than I ought to be.

3:41

I wanna show you the stenting, or at least the wiring.

3:45

So they elected to treat maybe the circumflex.

3:50

So instead of going after the bypass graft,

3:51

we're can see here a wire in the left main into the LAD

3:54

and then a, a stent being deployed in the circumflex.

3:58

We were also worried about the right coronary artery,

4:00

so I'll try to find something there.

4:03

Some of these procedures can be very intensive.

4:05

Let's see how they're doing this far into the case.

4:08

Still stenting. And it looks here like they started

4:13

to deploy some stents into the circumflex with good result.

4:19

And now look how well that's opened up.

4:21

So we know there's a bypass graph to the distal LED, uh,

4:24

or at least the mid LED.

4:25

And then, uh, integrate flow now from the left main into

4:28

that circumflex, which is wired.

4:30

So restored flow.

4:31

Um, I don't see any image of the RCI,

4:34

I think they decided to hold off on that one.

4:35

Um, until a separate per, yeah, they had a second cath.

4:39

So, uh, good result in the end over a couple of sessions.

4:43

Um, but the important thing to remember teaching, um,

4:46

pointwise on this case is, uh,

4:49

make sure you systematically look through, right.

4:51

Look at arterial graft first, then venous grafts.

4:53

Once you see a venous graft that's down, look at the sites.

4:56

And so you're, there's just an oven, a really,

4:59

a long segment and very calcified, uh, graft occlusion.

5:02

So that's not something that would be easy to cross

5:04

for such a long, need a lot of stents to.

5:06

Um, so they decided to go

5:07

and revascularize the totally occluded circumflex branches.