0:01

Okay, this next case came up as a situation, um,

0:04

that arises a fair amount

0:05

and the literature bears that out as well.

0:07

This patient was thought to be a high

0:09

risk for coronary disease.

0:10

They had a negative stress test

0:12

and, um, you know, make sure you're sitting down.

0:14

But it turns out stress tests aren't the end all, be all

0:17

of pretest accuracy.

0:19

So what turns out is that, um, there's a fair amount

0:22

of atherosclerosis as soon

0:23

as we start the calcium scoring scan, uh,

0:25

in really all three vessels.

0:27

So it just tells you that there is athero despite the

0:30

negative, uh, test.

0:31

And that's why the cardiologist pursued further imaging.

0:33

Um, and that's actually a pretty good reason

0:35

to do a CTA if you've got a discrepant

0:39

or discordant prior non-invasive test.

0:44

And in this case,

0:45

they just didn't believe the result, which is wise.

0:48

You can see the left main looks pretty good,

0:49

but of course, we're just gonna look at one more view.

0:52

And I, I do agree it's, it,

0:53

there's maybe a touch of disease.

0:54

I'd call it mild, but nothing more.

0:56

Um, but as soon as you get to this LED,

0:59

um, wow, is that scary?

1:00

So first of all, he is a little noisy. That's okay.

1:02

Um, but you have this lipid rich, uh, stenosis here,

1:05

which is pretty long segment

1:07

and it really starts almost at the osteum

1:09

and it just beyond the osteum.

1:12

If I'm reporting this case, I'm gonna tell them

1:13

that it starts about nine millimeters beyond

1:15

that left main bifurcation.

1:17

And then I'm gonna tell them the lesion length,

1:19

which is probably something closer to, um,

1:24

maybe 15 millimeters.

1:26

Uh, it's noncalcified.

1:27

I do believe that if you try to wire that with that degree

1:30

of calcium on the periphery,

1:32

but not the center, it should be an integrated wiring, um,

1:36

is right at the border of the lesions, um, that we see

1:38

that are difficult to suss out severe versus occlusion.

1:42

But I think this is worth a subtotal

1:44

or a severe stenosis, but not an occlusion.

1:47

I think there may be a second lesion in the distal LAD, uh,

1:50

and there are some branches.

1:52

So just clarifying in the report

1:54

that there's a small diagonal branch coming off

1:56

of the distal third of the vessel is helpful.

1:59

Distal third of the stenosis, um,

2:01

also ruling out other stenosis.

2:02

So I'm looking at the circumflex

2:04

and while noisy, it's a non-dominant crc,

2:06

which is not, uh, stenotic.

2:08

And I'm looking at the RCA so far,

2:11

I haven't noticed anything of significance.

2:14

Okay, great. So we've kind of, um, gotten a nice clearance,

2:19

uh, of the other vessels.

2:21

And if this is gonna go forward in invasive angiogram

2:24

to confirm and they're gonna consider therapy, it's helpful

2:27

to give 'em those characteristics.

2:28

So about a 15 millimeter length of vessel.

2:31

Uh, now let's take a look at what the cath showed.

2:34

And that is kind of a long tubular stenosis,

2:36

but you can see it fills without even

2:37

getting a wire across it.

2:39

Uh, and it's a solitary stenosis.

2:42

And there it is In another view, this kind of tubular,

2:45

tubular stenosis can be hard.

2:47

In fact, some, uh,

2:48

different pathologies can look tubular like spontaneous

2:50

dissections as well as ather one.

2:52

It can be hard to tell them apart.

2:54

CT makes that pretty clear though.

2:55

This is atherosclerotic plaque

2:58

And there's, and there's some branches coming off.

3:01

They may end up jailed,

3:02

which means you stent right across the osteum stents are not

3:05

graft stent grafts, they're stents.

3:07

So they have open struts

3:08

and that should allow the contrast through.

3:10

Good look in RCA, just a little bit of a plaque.

3:13

And the decision was made

3:15

to pursue percutaneous coronary intervention.

3:18

Knowing the length of the lesion is helpful

3:20

because you wanna make sure you cover it completely.

3:22

And you can see here they've given a series of stents

3:24

to cover all of the lesion with a successful result.

3:27

So a detailed case in that there's a stenosis, um,

3:32

and we can give a lot of lesion characteristics

3:34

to help plan the percutaneous coronary intervention.