0:01

Okay, this is a very spry octogenarian

0:06

who came to the CT

0:08

after an invasive coronary angiogram, which was done

0:11

for very targeted reasons.

0:13

And it's two reasons.

0:14

Number one, to plan some, uh, coronary imaging

0:18

to clarify a degree of stenosis

0:20

and calcium at the site of an occlusion.

0:22

And also to look at the peripheral access.

0:26

So when they do a situation like this

0:29

where it would be considered a high risk

0:31

PCI percutaneous coronary intervention, um,

0:34

just like in the other cases we talked about, it's helpful

0:37

to know how calcified things are.

0:39

Uh, they already know that there's gonna be some severe

0:42

stenosis in the LED.

0:43

So it's more about describing the lesion, seeing how much

0:46

of it is calcified, how long the segment of occlusion is,

0:49

if there's an occlusion, uh, and giving a roadmap.

0:52

Uh, and that's certainly easy enough to do.

0:54

In a way it's the easiest job

0:57

because we already have the prior angiogram.

0:59

In fact, the angiogram in this case was done, um,

1:03

just the month before.

1:05

And before I show you that, uh, I just wanted

1:08

to show you the importance of getting a proper CT angiogram

1:11

of the, uh, chest avenue and pelvis.

1:15

And what you're really looking for in this case,

1:17

they also want to do, uh, balloon, uh, pump support

1:21

or, um, they might be thinking of doing something called,

1:26

um, a device, um,

1:27

which is basically like a left ventricular assist device,

1:30

but via a catheter.

1:32

But the, um, the blood is sucked out of the left ventricle

1:37

through a rotating tubular, uh, pump

1:41

and then out into the aorta.

1:43

So what you can do there then is cross the aortic valve,

1:45

offload the left ventricle

1:47

by doing, managing the forward flow.

1:49

And that, um, relaxes the demand for blood so

1:52

that if you do inflate a balloon and occlude the left main

1:55

or the LAD something proximal, you don't stress the heart

1:58

because they're, the heart's not

1:59

working to pump blood forward.

2:00

Just the opposite. You've rested the heart.

2:02

So, um, for one of these reasons, they've done that.

2:05

And you can also just happen to see a little bit

2:06

of fatty metaplasia and the seven endocardial

2:08

interceptive wall here.

2:09

So an old mi uh, certainly not a surprise.

2:12

Uh, and if you're gonna do this, uh, planning to look

2:14

for the, um, the device,

2:16

the device is about five millimeters, so you wanna make sure

2:18

that there's no segment throughout the, um, chest, abdomen,

2:22

or pelvis into the iliac access

2:25

that is smaller than five millimeters.

2:26

And you also wanna warn them about really acute

2:29

angulation or tortuosity.

2:30

Nothing terrible here.

2:31

Um, so nothing that I see,

2:33

and I'm not gonna measure it in front of you,

2:34

but you could certainly get your calipers out.

2:36

And we do, when we read these, make sure

2:38

that if there is a stenosis that looks tight, just

2:40

to make sure it's not less than five millimeters so

2:42

that the catheter can go from the groin up into the heart.

2:45

So that part looks widely successful.

2:47

Um, and then of course,

2:49

you can do your mapping views like we did before.

2:51

So there's that tight LED stenosis.

2:53

Um, and we can look at the lesion characteristics.

2:55

There's, uh, some calcium before and after it, and

2:59

Then we can look at the invasive angiogram.

3:02

Okay, so here's the invasive angiogram.

3:04

Loading up and remembering that this happened

3:07

before the CT angiogram.

3:09

It's actually kind of an occlusion of the LEDI see, uh,

3:12

collateral vessels.

3:14

I see the circumflex,

3:15

but I, the LED ought to be right around here.

3:18

Let's take another look. You can see it's just kinda absent.

3:21

That looks like a large, uh, septal perforator to me.

3:25

So really kinda absent LED.

3:27

So what on the CT is difficult

3:30

to distinguish from stenosis, from occlusion?

3:33

Uh, we can tell by that forward flow in the catheterization

3:35

that there's a, a total occlusion.

3:39

Now, one thing that can help us clarify that is, uh, knowing

3:42

what the anatomy looks like normally.

3:44

And so in this view, this is the lateral wall.

3:46

This is, um, septal perforators.

3:48

The LED should be coming down straight at us.

3:50

Um, another thing that can help you is if you look late in

3:52

the runs on the contralateral injection, in this case,

3:56

you're looking at the RCA injected

3:57

and late filling in retrograde.

4:00

From right to left collaterals is the filling

4:02

of the distal LED,

4:03

which I didn't see on the integrated injection.

4:06

So a really nice example of a chronic total occlusion,

4:09

partly supplied by collaterals

4:11

and the complementary role of CT

4:14

and, uh, catheter angiography.

4:16

In this case, we can augment the confidence

4:21

that this is a calcified stenosis,

4:22

so it's gonna be a difficult, uh,

4:25

antegrade wiring of this vessel.

4:27

And of course, we would measure the angulation,

4:29

show the number of branches, uh, talk about the,

4:31

the stump approximately

4:33

and how much calcium, how many bends,

4:37

and, uh, any other features that we wanna note for risk.

4:40

And we also talked about the use of,

4:42

looks like not an issue in this case,

4:44

but when they go to the intervention, just make sure

4:46

that every vessel segment between the heart

4:48

and the groin have at least five millimeters of diameter.