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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3676_Библиотеки_им_академика_М_И_Перельмана
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C. Smuclovisky
6.21 Case 6.21
6.21.1 History
A 53-year-old male presented with exertional
chest pain. No previous cardiac history.
6.21.2 Findings
There is a multi-vessel coronary artery disease
with a ruptured plaque in the mid-LAD causing
critical obstruction (Fig. 6.21a, b). There is also a
low-density lipid-rich appearing mixed plaque at
the ostium of the LAD.
6.21.3 Diagnosis
Critical obstruction in the proximal LAD from a
ruptured plaque.
6.21.4 Discussion
It is now better understood that atheromatous
plaque accumulation growth and ruptures are
multi-phasic, not a linear process. Plaques that
are non-obstructing are known to grow and
become obstructive in a relatively short period of
time, as little as few months [2].
6.21.5 Pearls and Pitfalls
Plaques that are predominantly non-calcified are
much easier to accurately quantify the degree of
obstruction.
a b
Fig. 6.21 (a) cMPR. (b) Coronary angiogram
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6.22 Case 6.22
6.22.1 History
A 51-year-old male with past medical history of
hypertension, presented with atypical chest pain
for 1 month. An EKG and a recent myocardial
perfusion scan were interpreted as normal.
6.22.2 Findings
High-grade obstruction at the ostium of the LAD
and chronic total occlusion (CTO) in the midLAD (Fig. 6.22a–c). There is a high-grade
obstruction in the mid-RCA (Fig. 6.22d, e).
6.22.3 Diagnosis
CTO of the LAD and high obstruction in the midRCA with epicardial collaterals.
6.22.4 Discussion
Since the patient had a CTO of the LAD without
a myocardial infarct, there was a retrograde flow
from the RCA collateralizing the distal LAD. The
high-grade obstruction in the RCA was likely the
cause of chest pain due to decreased perfusion to
a large territory of the myocardium, which placed
patient at a very high risk for a fatal cardiac event.
6.22.5 Pearls and Pitfalls
CTOs can easily be identified in major coronary
branches on the CCTA by observing a transition
of contrast density (transition zone) of high to
low between the non-occluded and occluded coronary segments.
It is helpful to report the length of the occlusion and the type of the plaque in the coronary
segment, in order to assess whether catheterbased revascularization may be attempted.
ab
Fig. 6.22 (a) cMPR (b) Axial. (c) Coronary angiogram—Left (d) cMPR (e) Coronary angiogram—Right
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e
Fig. 6.22 (continued)
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6.23 Case 6.23
6.23.1 History
A 60-year-old male presented to the hospital with
stable chest pain.
6.23.2 Findings
Presence of a significant multi-vessel coronary
artery disease. There is a critical obstruction in
the mid-RCA (Fig. 6.23a, b) as well as a very
short high-grade obstruction at the ostium of the
LAD confirmed with invasive coronary angiography (Fig. 6.23c–e).
6.23.3 Diagnosis
High-grade short-segment obstruction at the
ostium of the LAD and multiple obstructions in
the RCA.
6.23.4 Discussion
This case demonstrates multiple significant coronary obstructions. The short-segment obstruction
in the LAD can be easily missed with the CCTA
if one does not pay careful attention. The obstruction in the RCA was much easier to identify.
6.23.5 Pearls and Pitfalls
Short-segment ostial major coronary branch
obstructions are much easier to identify with the
CCTA than with invasive coronary angiography.
It is important to alert the angiographer of these
findings in order to not miss a critical finding. In
this case, the angiographer had a very difficult
time identifying the ostial LAD obstruction and
had to resort to FFR for confirmation, which
changed the management from catheter to surgical intervention.
a b
Fig. 6.23 (a) cMPR. Obstructions seen in RCA (arrow) (b) Coronary angiogram (c) cMPR; the ostial obstruction of
the left main coronary artery (arrow) (d and e) Coronary angiography
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e
C. Smuclovisky
Fig. 6.23 (continued)
ab
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6.24 Case 6.24
6.24.1 History
A 60-year-old male with acute severe epigastric
pain. History of hyperlipidemia and no previous
cardiac disease. Nonspecific ECG changes and
negative serial troponins. Initially, the atypical
chest pain was attributed to severe gastritis.
6.24.2 Findings
Numerous mixed plaques seen in the proximal
LAD with an acute thrombus in the mid-LAD
causing a total occlusion (Fig. 6.24a–d).
6.24.3 Diagnosis
Acute thrombus in the mid-LAD.
6.24.4 Discussion
CCTA was ordered, which demonstrated a thrombus with a complete occlusion in the LAD
(Fig. 6.24a–c). Note the contrast low-density
transition change in the occluded segment. The
patient was transported directly from the CT suite
to the catheterization lab for an emergency angiogram, which confirmed the findings on the
CCTA. The area of the obstruction in the midLAD was successfully stented with excellent
results (Fig. 6.24e).
6.24.5 Pearls and Pitfalls
This case highlights the importance of communicating critical findings in order to help improve
patient outcomes. This patient had immediate
intervention after the CCTA without having sustained a myocardial infarction. The patient is the
father of an employee of the hospital. To say the
least, they were extremely grateful for the service
provided.
The patient was thought to have acute severe gastritis with atypical chest symptoms. Luckily, the
Fig. 6.24 (a–c) Serial Axial MIP (d) Coronary angiogram: pre-intervention (e) Coronary angiogram: post-PCI
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e
Fig. 6.24 (continued)
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6.25 Case 6.25
6.25.1 History
A 62-year-old female presented with chest pain.
Normal EKG and stress test.
6.25.2 Findings
A critical short-segment ostial lesion at the left
circumflex artery with a separate ostium from the
LAD (Fig. 6.25a–c). No critical lesions in the
LAD. Coronary circulation is left dominant.
6.25.3 Diagnosis
A critical obstruction at the ostial LCX.
ab
6.25.4 Discussion
This is potentially a life-threatening lesion, in
this patient with a left dominant system. It is
important for the angiographer to know these
findings prior to the angiogram in order to avoid
occluding the LCX with the catheter tip. Again,
ostial short-segment stenosis can be easily missed
on angiography and may require, as in this case,
magnification views to better assess intervention
(Fig. 6.25c).
6.25.5 Pearls and Pitfalls
Short-segment critical lesions in the coronary
arteries can be easily missed on CCTA without
appropriate reconstruction and segmentation of
the coronary tree.
Fig. 6.25 (a) cMPR (b) Stretched cMPR (c) Coronary angiogram
c
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6.26 Case 6.26
6.26.1 History
A 61-year-old male with a mild area of ischemia
on exercise echocardiogram.
6.26.2 Findings
There is a significant coronary artery disease.
There are ischemic appearing changes in the
anteroseptal wall with hypokinesis (Fig. 6.26a).
There is an appearance of chronic total occlusion
of the mid-LAD (Fig. 6.26b–e).
6.26.3 Diagnosis
Chronic total occlusion of the LAD with ischemic changes seen on anteroseptal wall.
6.26.4 Discussion
Poorly collateralized segments of total coronary
occlusions can demonstrate hypoperfusion of the
effected myocardial segment and are seen as
areas of low density on the CCTA.
6.26.5 Pearls and Pitfalls
Ischemia in the myocardium can be inferred from
the CCTA in areas of low density with preserved
thickness of the myocardium.
Fig. 6.26 (a) Axial MIP. Areas of ischemia indicated by arrows. (b) Axial MIP demonstrating a chronic total occlusion
of the mid LAD. (c) cMPR. (d-e) Coronary angiogram
cd
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Fig. 6.26 (continued)
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