0:00

So our next case is a 44-year-old, so lower on the end

0:05

of the age spectrum with some risk factors.

0:08

One thing led to another

0:09

and got this CT just showing you that

0:13

he has more calcium than some

0:15

of the elderly patients we've looked at.

0:16

So, um, the, uh, disease doesn't respect textbooks

0:20

or boundaries, but bottom line, the test was selected

0:25

and patient came for this CT angiogram.

0:30

And I'll just jump right to some C views here just

0:33

to show you more than his share of disease, especially

0:36

for age, but with these kinda moderate a series

0:40

of maybe moderate, uh, or moderate and mild lesions.

0:43

And then a distal, uh, RCA stenosis back

0:48

to the left, some disease,

0:51

but not obstructive disease in the left main.

0:54

But I wanna lay that out carefully

0:56

because distal left main can be a pitfall.

0:59

And uh, I do see what looks like very osteo, LAD,

1:05

not the worst, maybe mild, but it's a lot of plaque.

1:08

Uh, and then some really dense calcification here.

1:11

So I'm just gonna reorient.

1:14

So yeah, I'm pretty worried there's a, maybe some

1:17

relatively small vessel sizes there that don't help us any.

1:21

It's very difficult to assess stenosis when you

1:23

don't have a lot of anatomy.

1:25

Um, the circumflex,

1:26

I'm watching it, that's a much bigger vessel.

1:28

Uh, looks pretty good. So I would say that there is osteo

1:32

mild and mid moderate LAD densely calcified plaque,

1:37

and then a series of moderate stenosis in the RCA

1:42

for the record, his calcium score came out to

1:46

1,298.

1:47

So again, I think it's great.

1:49

We proceeded, this is a young patient,

1:50

there's no point in bringing him to the ct.

1:52

And then stopping, uh,

1:53

I'm gonna lay out the LAD for you here.

1:56

It's so bright, it's hard to see that calcium,

1:57

but it's just very diseased.

1:59

And then the RCA just in its, uh, you know, see

2:02

that the distal stuff is what I'm most concerned.

2:05

So moderates and then a distal, we did send it

2:08

for C-T-F-F-R here is that, uh, results.

2:12

So a lot of colors.

2:13

You wanna see blue and green, and now we see lots of red.

2:16

So the LED did pan out to be at least pretty good

2:18

to be positive and the RCA as well.

2:21

So the, the second of the series of lesions is

2:24

where it starts to become significant

2:25

and that distal has another focal trans lesional gradient.

2:28

So, yes, uh, say

2:30

that someone asks you look at this like rainbow of dots.

2:33

Uh, what do you worry about?

2:35

Well, you're gonna look for the focal changes.

2:38

Um, this is just a different view here.

2:39

And so, um, this is just a summary image.

2:42

You can interact in their little workstation,

2:44

but this is done right.

2:45

You rarely need it. Um, this is a

2:48

trans lesional gradient at a site of known disease.

2:51

So that I think that's very clearly, uh, correlates well.

2:55

Um, yeah, you do have a borderline lesion in this

2:57

obtuse marginal, but it's

2:58

Not the worst in its distal.

3:00

So I suspect that that would be ignored, uh,

3:02

by the interventionalist.

3:04

And again, you have borderline

3:07

and then, uh, a second lesion

3:08

that makes it definitively positive.

3:10

So let's see what we saw in geographically.

3:14

There's your RCA already have a wire down,

3:17

so they must have not shown us everything,

3:18

but that proximal lesion, not the worst,

3:22

but the mid segment

3:25

does look exactly like it did on the ct.

3:28

And there may be something significant down

3:30

on the distal edge.

3:32

Looks like they proceeded to, to treat.

3:35

I, I can see in the report that an IFR and it was done first

3:39

and it was positive in the R-C-A-P-T-C-A stands

3:43

for percutaneous transluminal coronary angioplasty.

3:46

So they, they're just putting balloons and,

3:48

and stenting some things and ballooning it open.

3:51

Looks like there was a little bit of a complication

3:52

of a dissection that they recognized.

3:55

And it's expected the more calcium you get.

3:58

So in the end, a good result, very good result.

4:01

Um, and now moving on to the left.

4:03

And you can see this is the circumflex.

4:05

There's a wire down already, but there's that proximal

4:07

or osteo LED lesion.

4:10

We were more worried about the mid segments.

4:14

They just investigated.

4:15

They have a wire in the of tooth marginal territory,

4:19

so pre dilating a stenosis, and that's in the LAD.

4:22

So treating exactly where we thought they would.

4:25

So they did some quantitative angiography, some wiring

4:29

looks like complex case.

4:31

And what the final decision was

4:33

that the LAD was not 75% due to the calcified plaque, uh,

4:38

obtuse marginal, they just a lot of small stuff.

4:41

And they called it subtotal,

4:43

99% occlusion slash stenosis in the distal, uh, RCA.

4:48

So, um, treatments, as you can see,

4:50

was successful in the RCA A and they did an atherectomy.

4:54

That's why there was so many images on the LAD

4:57

and put drug looting stents afterward.

4:59

And that did fix the IFR value. So then it was normalized.

5:02

So a great and very complex case in a fairly young patient.