0:00

Okay, so, um, this next case is a 70 something old patient

0:06

and unique in that they live in a remote site

0:08

where we have a coronary CT program,

0:11

no cath lab, no nuclear lab.

0:13

And so they were thought to have intermediate to high risk

0:17

for coronary disease and this was the first test selected.

0:21

So right off the bat we can at least give a kind

0:24

of a general risk category.

0:26

So they now have, are known to have atherosclerosis.

0:28

So yield is high already.

0:30

Um, but we want to go of course further.

0:33

And uh, the first thing I notice when I look at the RCA,

0:35

there's also a touch of motion on this case.

0:37

So it's worth a discussion.

0:39

Very subtle slab artifact here,

0:40

but you don't wanna get tripped up by these kind of slabs.

0:44

And this one's well above the coronaries.

0:46

In fact, you could argue that that was an unnecessary slab.

0:48

But this one here, it's a subtle breathing

0:51

and there's two ways you can get around that.

0:53

One would be to, um, be very careful

0:57

or the second would be to re-scan.

0:58

And that's what we did. Uh,

1:00

because it's a remote site, we just have the ability

1:02

for the technologist to check in with us,

1:05

still breathe on the second one.

1:06

So we know there's gonna be a difficult road ahead,

1:08

but, uh, we wanna do the best for these patients.

1:11

And this kind of slabs probably not gonna trip you up.

1:14

In fact, I can just look at my sagittal here and say this.

1:17

RCA is small, but it is co-dominant.

1:21

So a nice look here, there's a, it gives rise to A PDA

1:24

that's on the right side of the middle cardiac vein.

1:28

And the circumflex here gives rise to the

1:32

PLV, the posterior left ventricular branch.

1:35

So PLVB.

1:37

So we will focus on the left and left main has some plaque.

1:40

You can see it on this view.

1:42

I'll check it again on this view.

1:44

So plaque but not significant stenosis.

1:47

And then here the ostomy of the LED has kind

1:49

of a little bit of a stenosis.

1:51

There's some calcium

1:54

and uh, I think that'll end up coming out at least moderate.

1:57

I'm gonna turn on it and kind of try to lay that vessel out,

2:00

which is what we always wanna do.

2:03

So we get our best investigation.

2:05

Uh, somebody asked me once from an emergency radiologist

2:08

society, what if we just do, uh, axials?

2:10

'cause we really need that for throughput.

2:12

You will get burned, you'll miss things.

2:14

It's in all the guidelines you have to do npr.

2:16

So not in this day and age,

2:18

but never really the CT is for coronaries,

2:21

always needs a workstation.

2:22

So I totally get that.

2:24

It's an extra step, but it's, you would miss things.

2:27

This is actually to me at least moderate.

2:29

There's some calcium so it might be blooming.

2:31

And then, um, a second lesion there doesn't look as bad.

2:38

Lot of circ disease, but no, uh, significant.

2:41

So what do you do now? This patient's remote.

2:42

Uh, I see a slab, but I don't think

2:44

that's gonna be affecting much.

2:45

I saw the, my worst osis is this moderate LAD.

2:48

Uh, let's see what the official reader said.

2:51

They said moderate

2:54

and they thought it was approximately

2:55

a mid kind of agree there.

2:56

Um, so well you can send

2:58

These off to the, uh, analysis

3:00

and that's pretty reasonable before you move the patient

3:02

and looks pretty positive to me the threshold is 0.75

3:06

and this is very clearly below that

3:08

exactly where we worried.

3:10

Um, RCA is too small to analyze, but we weren't worried.

3:13

Circ is co-dominant. That's fine.

3:15

So we now have a really targeted question, okay,

3:18

to move the patient from their remote location

3:21

where they live and uh, try to get to a catheterization.

3:26

And here's that cath.

3:28

So this is the left circumflex giving rise

3:31

to a co-dominant supplying the inferior wall.

3:33

I think that's the area we wanna look not

3:37

as impressive by cath.

3:41

A couple things about cath too.

3:43

If you're gonna go after something, you have

3:44

to have a lesion to look for.

3:46

So you might say, I need to have a, uh, I-F-R-D-F-R

3:49

or whatever the alphabet soup is without a wire

3:53

placement across a lesion.

3:54

They don't know what they're investigating.

3:56

So in this one

3:59

I can see they didn't go any further other than just some

4:01

careful looks, but that's the only thing I could maybe see

4:05

and it just doesn't pass the sniff test.

4:07

So pretty reasonable to just stop there.

4:11

And, uh, the invasive angiography said they thought it was

4:15

about 30% in those areas

4:18

and they decided to medically manage

4:20

and just carefully treat.

4:21

So pretty reasonable.

4:23

I think it's a, uh, good use of each of these tests here.

4:28

And the FFR is tuned to be a little oversensitive, uh,

4:32

which is what you kind of want just a little bit more

4:34

sensitive than in fr this patient's not a super high risk

4:37

calcium score was 400 and some.

4:39

So a good, uh, example of careful use still ends up with,

4:44

uh, smile discrepancies

4:45

and we're kind of set to be more sensitive than specific.