0:00

Okay, so this next one is an 80 something year old woman

0:04

who presented, uh, with biomarkers

0:07

and ECGs consistent with an acute coronary syndrome.

0:11

But there was comorbidities preventing, uh, an angiogram.

0:16

So the right thing to do in the setting of a known MI

0:20

that's acute would be go right to the cath lab,

0:22

don't stop at ct.

0:23

This person had some GI bleeding

0:25

and there was really high risk

0:26

and they didn't want to anticoagulate.

0:28

So the situation would be,

0:29

as such, you need to know the anatomy.

0:31

You can't take the risk of a cath, uh,

0:33

without making it sure it's really high risk, uh, and uh,

0:36

and high yield calcium score doesn't

0:39

matter, but you see their disease.

0:40

So we've confirmed that, uh,

0:42

this patient does have atherosclerosis.

0:44

You can see there's a lot going on in the lungs.

0:46

I won't, uh, hone in on that.

0:48

I'm just gonna look at the RCA here

0:50

and just really quickly with just an axial set

0:52

of images, looks pretty good to me.

0:54

Um, if you wanted that C view, again, you would click here,

0:58

um, maybe turn on your mip, twist on it,

1:01

and then just, uh, angulate your image

1:05

and maybe thicken your MIP so you can get

1:08

what the catheterize will see.

1:09

So no need to cath the

1:11

RCA, at least there's something there.

1:12

Uh, but let's now, um, go on

1:16

and look at this LED and already I don't like what I see.

1:20

So the left main, um,

1:22

certainly looks patent really wide, big vessel.

1:25

Uh, but now that the circumflex has already exited the

1:28

picture, I'm looking down this LED

1:30

and I'm seeing lots of other sclerosis.

1:32

Uh, and here's a lesion.

1:34

This is a, maybe a too thick of a mip,

1:36

but, um, so mild, maybe moderate,

1:40

and a lot of lipid rich plaque there.

1:42

So the type that tends to be more, uh, active plaque,

1:45

uh, a big bridge.

1:47

I'm just showing you that here. Uh,

1:48

but the, the MIP kind of shows me

1:50

that there's stenosis in the, uh,

1:53

I guess it's a diagonal branch.

1:55

And another important teaching point if you are gonna

1:58

scan a high risk patient like this.

1:59

And I, you know, was a carefully considered

2:01

CT angiogram, that's for sure.

2:03

Um, we need to remember that our limitations could be

2:06

that we Ms. Small stuff and

2:08

that can be the cause of troponin leak.

2:09

So, uh, also just knowing that a negative CT a

2:12

with a positive, uh, biomarkers

2:14

or ECG means that it's an mi

2:16

doesn't mean that you're exonerated.

2:18

But we've also rolled out high risk disease, no RCA,

2:20

no proximal left main.

2:22

So now we're into the mid LAD and some diagonals.

2:25

Um, now it becomes a clinical judgment whether

2:28

to pursue further and local an angiogram,

2:29

but already a tubular stenosis, so moderate.

2:32

And then the other thing, you wanna see the whole vessel

2:35

and looks like another lesion down here.

2:37

I'm gonna lay that out for you a little differently,

2:39

but I'm also gonna give you a volume rendered.

2:42

And I just make that point

2:44

because now the heat is on

2:46

that you probably will get a calf, um, a high risk calf,

2:49

but you have a chance to be a second guess.

2:52

So you want to put your a game on.

2:54

Um, and what I really don't like about this

2:57

patient when I look at

2:58

Her coronaries is it had a dis ectasia.

3:01

So that's gonna accentuate the appearance of stenosis.

3:05

And I'm gonna turn on my MIP

3:07

and I'm just gonna show you that.

3:09

So a small vessel, whether this is a dual LA

3:12

or a dag, it's gotta almost like an

3:14

aneurysmal segment there.

3:16

And another way to lay that out would just be to bend this

3:19

and kind of lay along the vessel that works well

3:22

for the distal LED territory.

3:24

Um, and so I'm just giving some MIP

3:26

and I'm kind of putting my, uh, I know I'm the auto segment,

3:29

kind of cut off some things and there's a bone right there,

3:32

the, the rib,

3:33

but this looks like it's gonna be a second

3:35

severe stenosis in the same vessel.

3:37

So you got the tubular thing proximally,

3:39

and then a, uh, severe

3:41

and you can sort of see it here,

3:43

maybe not the most perfect image.

3:45

Um, the other place that it's good to do that kind

3:48

of technique to look at vessels would be along the,

3:51

uh, marginal branches.

3:52

So I'm just gonna take my vessel, uh, plane here

3:56

and then just kind

3:57

of tilt along the lateral aspect of the heart.

4:00

No, I've only been looking at one phase here,

4:02

so I can always sharpen it up by changing phases,

4:04

um, becomes academic.

4:05

This person's probably, if they're having any kind

4:08

of a significant mi gonna go to the lab.

4:10

I also see a couple of lesions here.

4:11

This is in a two marginal branch.

4:13

It's outta the AV groove, a branch of the circumflex.

4:16

And that's actually a moderate lesion.

4:18

So it's a complex disease, a second stenosis too.

4:21

So I really do think that with two vessels

4:25

and serial lesions, uh, knowing that the series

4:27

of lesions could be significant, next step is a calf, um,

4:31

in the setting of an mi uh, C-T-F-F-R is not, uh,

4:35

FDA approved in the US

4:36

and I think, I wouldn't care what it shows,

4:39

it wouldn't be defensible not

4:41

to at least explain why you didn't do an angiogram.

4:43

The other thing is you kind of have a moderate prox, LED,

4:45

so, uh, and you just look and it's lipid rich.

4:47

So, uh, probably not.

4:49

But that combo of LED plus the second branch slash diag in a

4:53

series, uh, as well as just

4:56

that open question on the circumflex, uh,

4:59

next step in my mind is clear.

5:01

And I think it was to the team by the way.

5:03

Two days passed between these, uh, exams, uh, makes sense

5:07

because they probably had to turn off the anticoagulants

5:10

or figure out the GI bleeding

5:11

or whatever else clinically needed done.

5:14

Look how tortuous these arteries are.

5:15

We saw that in the CT as well.

5:17

It's gonna be very hard to find the, um, the stenosis,

5:20

but I'm sure it's apparent.

5:22

Uh, and here we go. So I'm just gonna, um, orient you here.

5:26

So this is catheter going left, left main.

5:28

We knew that would be patent, I believe this

5:33

is our LAD

5:36

and you kind of have a series of

5:40

that proximal LED doesn't look as bad

5:42

or no focal disease, so at least there's that.

5:44

And then you have this lesion here, um,

5:46

and then that tubular kind

5:48

of ectatic segment and then a second lesion.

5:49

So, um, and there's another stenosis there,

5:53

which I think we kind of briefly laid eyes on

5:56

During the ct.

5:58

Um, these are septal perforators coming off, uh,

6:01

and then diagonals going this way.

6:03

So this might be called a diagonal or a dual LED,

6:05

but the labeling isn't as important as finding the stenosis.

6:09

A big lateral. Yeah, and there's that second lesion in the,

6:12

uh, of two marginal branch we were worried about.

6:13

So two vessels of disease, uh, in this view,

6:17

LED comes right at you,

6:19

so it's not gonna be great for laying that out.

6:21

But for the, uh, om it's kind of good a lot of ectasia.

6:24

If, if you told me this patient was chronically

6:26

hypertensive, I'd say that fits pretty well.

6:28

Uh, and then here's the RCA just confirmed to be negative.

6:31

Um, I did briefly look at this report and they didn't stent

6:36

and the reason was pretty careful.

6:38

Patient had GI bleeding issues.

6:39

It was several small lesions,

6:42

and once they confirmed the lesions,

6:44

a careful team discussion was held.

6:46

Um, and just to confirm, RCA, nothing ma major left main,

6:50

nothing major, LADA large bifurcating septal in small

6:54

diagonal where the LED becomes ectatic and then tortuous

6:57

and tapers 20 cent percent, proximal 50%, mid 70% distal,

7:02

and a 60% mid.

7:03

So you have several series of lesions.

7:05

So very likely the cause of the mi um, circumflex,

7:08

they call it a 40 and then a 70% distal om.

7:11

So with that not very proximal disease in the high risk

7:16

situation, uh, was pretty reasonable

7:17

to confirm a diagnosis and stop there.

7:20

So this is a, again, atypical use of CT in the setting

7:23

of known MI and high risk.