0:01

This next case is an interesting case

0:05

because it started not with a ct, uh,

0:08

but rather with a nuclear scan,

0:11

which is a very common pathway.

0:13

And what happened with a nuclear scan is it was interpreted

0:15

as having inferior ischemia.

0:17

So this stress being a little worse than the rest on this is

0:21

a two chamber or a vertical long axis view.

0:23

And you can see a few less radiotracer counts on the

0:26

inferior wall than it rests.

0:27

So the idea it's possible ischemia, uh,

0:31

and that led to a CT

0:33

because we know that the inferior wall can be

0:35

confounded by gastric activity.

0:36

I don't see that here. Um,

0:38

but also now that we've used that

0:40

as our initial screening test, the patient at higher risk,

0:43

the thought was that, you know, they're,

0:45

they're a little more elderly and the nuclear test, instead

0:47

of taking them right to the, the lab confirmed that

0:50

that's not an artifact.

0:51

Um, so a CT was done

0:53

and here's the calcium scoring just 'cause we always grab that.

0:55

And so not a terribly large amount of calcium,

0:58

but in the right there's some bulky stuff.

1:01

And so inferior wall, we're worried about the right.

1:03

We can already see that's a right dominant case.

1:06

Good image quality, no slabs, uh,

1:09

large left atrium, but no thrombus.

1:12

And I'll follow this RCA

1:15

and well, that's gonna be a tough one to clear, isn't it?

1:17

When you work at a teaching hospital, you can say, oh,

1:20

this would be great for learning,

1:21

and you can make the trainee take their first crack at it.

1:23

But, uh, if you're not lucky enough to work where I do,

1:25

then you might have to just, uh, do it as I'm doing now.

1:28

So, uh, the RCA, that's gonna be a little tough to clear.

1:33

I don't think it's severe, but I'm not sure.

1:36

I'm gonna say it's probably

1:37

moderate and that's what moderate is.

1:38

It's, it's not negative and it's not definitely positive.

1:41

Uh, I will give you that pretty C view just to, uh, dazzle.

1:45

But also this is what it'll look like in the cath lab.

1:47

So you'll have something that's kind of middling,

1:49

but maybe positive here.

1:50

And then another, maybe moderate.

1:52

The other thing I've learned over the years,

1:54

and any interventional cardiologist will tell you is

1:56

that two moderates can be significant

1:58

or even a long mild stenosis.

2:00

So the combination

2:01

of lesions here puts it in the CAD reds three, if

2:04

that's our worst stenosis already.

2:06

Uh, but we didn't even get to the left side,

2:08

so let's take a look at that left main.

2:10

Okay, so I looked at my long axis, really looks good.

2:13

So touch a plaque, but, uh, nothing significant.

2:16

Let's follow our LAD. Uh, oh. All right.

2:19

Immediately my eye goes to this, and this is the LAD proper.

2:22

So some, uh, distance beyond that, uh, first diagonal

2:27

and for the second diagonal, um, I see

2:30

what I'm almost certain is a moderate stenosis already.

2:33

So let's take a look at this. Let's turn on it.

2:36

Always get two views. And here is that, so a large amount

2:39

of plaque, and I think that's gonna be intermediate grade.

2:42

We don't like to put calipers on things and measure them,

2:45

but I will, um, point out that if you consider this

2:47

to be a reference segment, four millimeters,

2:50

anything narrower than two millimeters could be significant.

2:53

And a rule of thumb that a smart,

2:56

very senior interventional cardiologist told me once is

2:59

Any proximal coronary stenosis

3:01

that has a smaller than two millimeter vessel

3:04

has been a heuristic they've used for years.

3:05

And so if it's smaller than two millimeters, just worry.

3:07

But already you're lower than that.

3:09

So it's greater than 50% has stenosis.

3:11

Um, and I know the nuclear test wasn't abnormal in the LED

3:16

territory, but with nuclear you can have, um, confounding

3:20

because you can have balanced ischemia, things like that.

3:22

So, uh, and then I'm looking at the crich

3:24

without even going much further.

3:26

It doesn't look terribly, uh, badly diseased.

3:28

It's non-dominant. Uh, so I think just

3:31

because it was, uh, handy

3:33

and it was a good way to litigate this, uh,

3:35

the test was sent, uh, off to the

3:38

National Core Lab for one of the vendors.

3:40

And here is the F-F-R-C-T.

3:43

Very interesting result

3:44

because I was more worried about the combination

3:47

of RCA lesions,

3:48

but this really gets to only borderline significance, um,

3:51

despite what the nuclear test showed.

3:53

Uh, and this LAD, I'll just lay it out on this view,

3:57

has a very clear trans lesional gradient,

3:59

right where we worried, right?

4:00

Maybe we said the first diagon before that large second one.

4:03

So, and maybe there's even a DIA

4:04

or that might be a septal perforator.

4:06

So we do have a trans lesional gradient,

4:07

which takes us into the positive zone

4:09

and then it just gets worse from there.

4:11

So, um, a gradual decline to a 0.6 wouldn't bother me

4:15

as much as a focal decline.

4:16

So I would call this as CAD reds.

4:19

Three on the anatomy,

4:21

I would've separately reported this coronary CT as

4:25

I would add CAD reds three plus whatever

4:28

p plaque designation.

4:29

There's a fair amount. Uh, I plus,

4:32

because this has ischemia potentially in this vessel,

4:36

but I would also dictate that the RCA

4:38

by FFR looks not definitively positive, I should phrase it.

4:42

Um, so here we have a patient where we've got a couple

4:44

of tests now and we'd like to, um, go further.

4:48

And so we're gonna grab that angiogram.

4:53

Okay, so here's the invasive coronary angiogram.

4:55

So the catheter's pointing left.

4:57

Uh, I see that there is a lot of irregularity in the vessels

5:02

and circumflex stays in the AV groove.

5:04

So there it is with some obtuse marginal branches.

5:07

And the LAD is coming kind of at us in the main plane here.

5:11

So we wanna lay that out so we can look,

5:14

remember we had a question about the LAD itself.

5:15

So we want it to be, uh,

5:17

in long axis if we can project it that way.

5:20

This is more of a spider view. I do see a stenosis already.

5:23

Uh, a spider view is good for looking at the left main

5:25

and the, if you have it a ramus.

5:28

So it looks like they saw something they

5:31

thought needed treating as well.

5:32

Let's go back and just re-look at it again.

5:34

And I'm just gonna pause these.

5:36

Invasive angiograms can be tough, especially

5:38

for radiologists that are used to static images.

5:40

Um, so I'll just kind of try to trap it,

5:42

but I don't like what I'm seeing there.

5:43

And that's where we were between the diags.

5:45

Um, let's lay that out one other way.

5:48

And you can see some irregularity there.

5:52

Here, a wire's been placed,

5:53

so you can see where this is gonna go.

5:55

So it was deemed treatment

5:56

Worthy. There's a stent in

5:57

place

5:58

and we can kind of cut to the chase.

6:02

Looks like they were ballooning,

6:04

hopefully have a nice result.

6:05

Looks like several stents were placed to cover all lesions,

6:08

some more ballooning, so it was a successful stenting.

6:11

Um, I do wanna show you the right coronary artery.

6:14

There is a stenosis there,

6:15

and it was actually the proximal lesion,

6:16

as our gestalt initially told us,

6:18

the distal doesn't look so bad.

6:20

So here's one. I think the FFR off the CT was reassuring,

6:23

whereas this is visually very positive.

6:26

Um, and this correlates

6:28

with the nuclear studies profusion territory abnormality.

6:30

I'm gonna jump to the end of the case where you have a

6:33

restoration of flow via stent.

6:35

So that looks a lot better. So nice angiographic result.

6:38

Uh, patient got better.

6:40

So, um, a good case in that complex disease.

6:43

And you can have this, so a nuclear showed us part

6:46

of the story, but not all of the story.

6:47

Uh, C-T-F-F-R underrepresented part of that story.

6:51

But because the CT angiogram was positive for two vessels

6:55

and the catheter angiogram was positive for two,

6:57

and the nuclear and the FFR each were positive

7:00

for another vessel, uh, one of each,

7:02

that was a pretty good reason to, uh, treat.

7:05

And it's hard to know which one

7:06

would be causing the symptoms.

7:07

So decision was made to treat, uh, both

7:09

of these in this pretty complex situation.

7:12

Uh, and I'll mention if you're talking about pretest risk,

7:15

this patient had a calcium score of 453,

7:20

so, uh, not as high as the others, but, um, difficult

7:23

and very focal calcium made some

7:25

of those lesions a little bit hard to see through.

7:27

So the fity of the, uh, disease is probably a,

7:30

a bigger driver than the total calcium score.

7:33

So this LED, um, not as bad,

7:35

but the RCA kind of bulky, uh, calcium.

7:38

And you're not gonna get tripped up by this artifact here,

7:40

but really a nice correlation.

7:42

That was what we first got our eyes drawn to,

7:43

and that's what the, uh, angiogram first saw as well.