0:01

Okay, next case is a little nuanced.

0:03

It's a 60 something year old patient with a known stent.

0:06

So you already have a very high pretest risk just based on

0:09

them having a prior stent.

0:10

And I'm gonna show you that on the calcium score

0:13

that's CRCA stent.

0:14

So even if you don't get great history,

0:16

which can happen occasionally, um, you're gonna know that

0:19

that's the different type of interpretation for the RCA.

0:22

And then you can see some scattered

0:23

calcified plaque through the left.

0:25

Um, now symptoms can recur in these patients

0:28

or it can occur in new vessels.

0:30

So first things first, let's try to find that RCA.

0:33

Um, and there's your stent.

0:35

So far I didn't see much at all,

0:36

but um, the volume rendered kind of highlights it,

0:39

but I just wanna lay it out for you and let's see.

0:44

Yeah, not all that impressive.

0:45

Bit of a slab touch of respiratory artifact.

0:47

Uh, not the worst though. Um, okay.

0:50

And you can see the distal vessel.

0:52

While it does have a little bit of artifact, um,

0:55

you can kind of clear that up.

0:56

Looking at multiple phases and looks pretty good to me.

1:00

I'm gonna now say we're gonna put that one to rest

1:03

and we'll go look at the left main.

1:04

Uh, a little bit of plaque but no stenosis.

1:06

LAD, little more

1:09

and fair amount

1:10

of calcium there looks a almost circumferential.

1:14

Um, very wary now

1:15

because I know that can be a cause

1:16

of false negative angiography also can be a cause

1:19

of false positive.

1:21

So it's just that that's the hard task

1:23

that we get sometimes with ct.

1:26

I'm changing my phases to be as careful as I can to freeze,

1:29

oh, that looks like a good phase.

1:30

I feel more comfortable here. Um,

1:32

but then right around here I feel less comfortable in

1:35

that I do see what looks like real calcified plaque.

1:40

And another thing

1:41

that really almost keeps me up at night is when I have this

1:44

calcium that's similar to the density of the contrast bolus.

1:47

It's a known phenomenon.

1:48

One of my colleagues, Veit Bian actually

1:50

who first wrote it up, the idea

1:52

that you can miss calcified plaque on a

1:55

CTA if you're not careful.

1:56

But we're not gonna miss that.

1:57

But also it's hard not to say that's at least moderate.

2:01

Not sure it's a severe.

2:03

Um, now this is a not a great phase for the circumflex.

2:07

Let's sharpen that up.

2:08

And okay, right here, little bit of a

2:12

lipid rich plaque in addition to the calcified plaque.

2:15

So the non stented vessels are the ones I have

2:17

concerns about in this case.

2:19

And you have a couple of, uh, segments here.

2:21

If this all turns out to be nothing in

2:23

the circum, I'm not shocked.

2:24

But the LED hard to ignore that, you know, that kind

2:27

of pitfall lesion and you can see a bit of abnormality.

2:30

So before you go any further, um,

2:32

you might wanna do A-C-T-F-F-R.

2:35

Important to note that the stented lesion, um,

2:38

with the some vendors is not allowed by the FDA.

2:42

So we know they will by law have to decline the RCA.

2:46

But my questions are on

2:47

the left, so I think it's reasonable.

2:48

So with that in mind, we did that, of course,

2:50

they said metallic stent, no go.

2:53

Um, in the LED, right

2:56

where I was worried. So it's these two areas.

2:58

There's not a focal trans lesional gradient

3:00

that meets significance.

3:02

It's only gets to, you know, in the border.

3:04

And then it gradually goes down to abnormal.

3:07

So these tend not to correlate with angiographic

3:10

or physiologically invasively evaluated, um, severe stenosis

3:14

or significant stenosis.

3:15

Same story on the circumflex. So, um, this is comforting.

3:19

We already know we're medically managing maximally

3:21

'cause we're on a stent and we might even ramp that a bit.

3:24

But, uh, low yield calf.

3:26

Um, so that was decided not to go further.

3:28

So again, you wanna look for a trans

3:29

lesional gradient that's positive.

3:31

And this one's only borderline.

3:32

So very reasonable to just continue with medical management,

3:35

especially knowing stent's fine,

3:37

the native vessels around the stent are fine.

3:39

And, um, there's no new severe stenosis.