0:01

This next case is, uh, pretty interesting.

0:04

I'll show you the p CT tests, uh, afterward

0:07

and then show you the post CT test as well.

0:10

This is somebody who has a very high risk, uh, CT in

0:15

that they recently had an inferior stemi.

0:17

So STEMI stands for ST elevation mi,

0:21

meaning there was a transmural infarct enough

0:23

that the depolarization manifest on the, uh, ST segments.

0:27

So there was already an mi.

0:29

So no matter what the CT shows

0:32

that it's not gonna be negative

0:33

and it needs to be treated with Kid GLO care.

0:35

This is referred by a, an expert cardiologist.

0:37

They needed help. And I'll explain why

0:39

after we review calcium score is not gonna change anything,

0:43

but it is gonna confirm we have a ton of disease

0:45

and some atic vessels, they said inferior stemi.

0:48

So that should localize to the RCA territory

0:50

'cause we already know he is right dominant.

0:52

So, um, if you saw anything on just this first axial review,

0:56

you saw the findings, but let's go back and do it slowly.

0:59

So, right coronary artery, osteo patent, lots of disease,

1:03

lots of disease, looks like an occluded

1:05

or a severely stenotic segment.

1:07

And then coming down here, it's getting really tight,

1:10

probably occluded, and it's a very long segment.

1:13

So I don't know how else

1:14

to explain such a long segment other than it's

1:17

an occluded artery.

1:19

And then I'll just quickly go through the left main plaque,

1:22

but not real stenosis,

1:23

maybe some mild borderline moderate LED.

1:27

There's a bridge. Those aren't any crime.

1:29

Uh, it's not the worst bridge, but it's long.

1:31

And how about this?

1:32

So the circumflex, non-dominant, decent vessel.

1:36

So this patient, by the way,

1:38

should have some revealing functional information.

1:42

So we just saw with our own eyes

1:45

and heard with history that there was an mi uh,

1:47

that affected the inferior wall.

1:49

Not that impressive of, of a wall thickness, though.

1:52

I'm, I'm actually surprised at how

1:55

it's not completely an aneurysm

1:57

and it's, there's still some myocardium left.

1:59

So there must be lots of robust collaterals.

2:01

And remember, this is a resting ct,

2:03

but let's just look at the function.

2:04

So, um, beautiful example of inferior wall hypokinesis,

2:08

which matches the territory.

2:10

So we've tipped all the way down the ischemic cascade.

2:12

This is a resting wall motion abnormality.

2:14

So it's more than likely an MI myocardial infarction.

2:17

It's probably a sub endocardial myocardial infarction.

2:20

Now, the month

2:22

before the ct, there was an outside angiogram, uh,

2:25

and I don't seem to be able to retrieve that.

2:27

Uh, but this patient is now, um, stable,

2:32

comes in as an outpatient.

2:33

And let's look at the C-T-F-F-R.

2:35

So the goal of this would be, just to clarify,

2:37

is there any second lesion in the left

2:40

that might warrant treatment?

2:41

If they're gonna go after the, uh, RCA, now

2:46

this vendor is, um, FDA approved

2:49

to look at stenosis but not occlusion.

2:51

And you can see there's an RCA occlusion.

2:53

So they don't model that they thought it was artifact.

2:55

It's just occlusion. But what we have here is the LED.

2:59

And there is kind of a gradual transition.

3:01

So while this does get into the positive range,

3:04

I don't see a focal lesion.

3:05

So if I were doing this catheterization, I would expect

3:08

to not find a focal disease

3:10

and probably not needing to be treating the, uh,

3:13

left side at all these distal small things, uh,

3:15

without a focal, even in the circumflex branches.

3:18

No big deal. So let's move on

3:20

and look at the invasive angiogram if we can find it.

3:24

I think the history actually said on the ct they were unable

3:27

to successfully cannulate the right coronary artery at the

3:30

outside hospital, or at least they couldn't get

3:32

a wire down and stented.

3:34

So they wanted to know the clinical targeted question

3:37

of the CT was, is the vessel patent?

3:39

And our answer is no.

3:40

Um, you know, we did a little talking about, um,

3:43

CTO planning.

3:45

This is just one view.

3:46

I, I won't, uh, go too crazy with it,

3:48

but you can see this long.

3:49

So there's some stenosis

3:50

and then there's a long segment of a occlusion.

3:52

There's some calcium, right? So there's a lot of bending.

3:55

Uh, there's a long segment

3:57

and there is probably, maybe a better way to show it.

4:01

We'll just go back to the source.

4:03

Um, if I look at the entry point, it's tapered.

4:07

It's not abrupt. So that's a good sign.

4:11

The tortuosity a bad sign.

4:13

The length I think is longer than it's a long segment.

4:16

Uh, really all the way down into the distal, um,

4:21

branches into the PLV and the PDA.

4:23

So bad long segment, bad rim calcification, uh,

4:27

bad tortuosity, good that it's not calcified in the center.

4:31

Good that it's got a tapered lesion.

4:33

So I probably think you could wire this,

4:35

but it'll maybe take a, uh, intermediate amount of time.

4:38

So here's our cardiac catheterization.

4:41

Um, and I'll, I'll point out actually

4:42

before I even get to the cath.

4:44

The, they start these procedures knowing there's a chronic

4:47

total occlusion, they often cannulate both the left

4:49

and the right coronary artery.

4:50

So that's why you have two, this is kind

4:52

of animating quickly, but, um, bilateral cath simultaneously

4:55

because you have to pacify left

4:57

and right to find the, get the collateral flow.

5:00

Um, and so what you see is what we saw on the CTA, which is

5:04

that there's a long, um, patent but tortuous segment

5:09

and then it kind of becomes an occlusion.

5:11

Um, and without getting, um, these things can take all day

5:14

to get tough cases.

5:16

Uh, but you'll see, um, that they were able

5:19

to get some contrast through the, uh,

5:22

acute marginal branches of the right ventricle.

5:24

They injected the left.

5:26

Um, so here's a wire into the, uh, RCA stenosis

5:29

and here's the LAD.

5:30

So no focal things, very tortuous, lot of careful wiring

5:35

and, um, high skill level cath.

5:39

I'm just gonna go right

5:40

and you can see it really was a lot of work

5:42

to get across this, but there's a stent deployed in

5:45

that distal SCA and look at that beautiful result.

5:48

But these things amaze me

5:49

because sometimes I, I look at the CT

5:51

and think, how could anyone push a six foot wire

5:54

and carefully do that? But here's

5:56

Your final result.

5:57

Um, a lot of forward flow.

6:00

Uh, and on this last one, you see the stent is patent

6:03

and there's your PDA and your PLV, uh, so amazing.

6:06

Uh, they were able to restore flow

6:08

and not an unreasonable thing to do.

6:11

There was an mi but there was still viable tissue.

6:13

Uh, we were able

6:14

to spare the patient a I don't even know if you could do a

6:17

bypass surgery 'cause there wouldn't be great targets,

6:20

uh, and flow restored.

6:21

So hopefully the ischemic symptoms resolve.

6:24

But, uh, a nice example of a total occlusion.

6:28

I don't believe that this could be considered a chronic

6:31

total occlusion based on the timeframe, but it

6:33

nonetheless, a, a total occlusion with a, uh, very difficult

6:37

but successful revascularization.