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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
6.27 Case 6.27
6.27.1 History
A 63 year-old male with a 20-year history of a
myocardial infarction treated medically. The
patient did not have a coronary angiography.
The patient is an avid tennis player and underwent an echocardiogram showing questionable
mass in the left atrium. A cardiac CTA was
ordered for the evaluation of a cardiac mass.
6.27.2 Findings
There is a persistent left superior vena cava with
dilatation of the coronary venous sinus
(Fig. 6.27a, b).
There is a critical obstruction in the proximal
LAD, which has a small atherosclerotic aneurysm (Fig. 6.27c). There is a high-grade obstruction in the proximal RCA with appearance of a
chronic ruptured plaque and/or recanalized
thrombus (Fig. 6.27d). There is a diffuse multivessel disease.
6.27.3 Diagnosis
Severe obstructing multi-vessel coronary
artery disease.
6.27.4 Discussion
The patient was lucky to have a CCTA, which
was done to evaluate for a left atrial mass seen on
an echocardiography, which turned out to correspond to a dilated coronary venous sinus. There
was no mass in the left atrium.
There was a life-threatening multi-vessel coronary artery disease with poor collateral formation (Fig. 6.27f, g). It is incredible that the patient
was able to play competitive tennis for 4–5 days
a week without cardiac symptoms. The patient
underwent a surgical revascularization with double internal mammary grafts and within 6 weeks,
he was back playing tennis.
6.27.5 Pearls and Pitfalls
Congenital vascular anomalies are not infrequently confused with a cardiac mass on echocardiography. CCTA can easily identify and
definitively diagnose this type of vascular
anomaly.
Persistent left superior vena cava. Absence of a
right superior vena cava.
ab
Fig. 6.27 (a) Axial MIP showing persistent left SVC (b) Sagittal MIP (c) cMPR-LM (d) cMPR-RCA (e) stretched
cMPR (f) Left coronary angiogram (g) Right coronary angiogram
fg
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e
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Fig. 6.27 (continued)
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C. Smuclovisky
6.28 Case 6.28
6.28.1 History
A 49-year-old male with a past medical history of
hyperlipidemia, hypertension, and diabetes, presented to the hospital with atypical chest pain.
6.28.2 Findings
There is an advanced diffuse multi-vessel coronary artery disease without a flow limiting stenosis (Fig. 6.28a–d). Coronary circulation is right
dominant. There is an ovoid low-density nodule
in the right cardiophrenic angle fat pad consistent
with a pericardial cyst, which is of no clinical significance (Fig. 6.28e).
6.28.3 Diagnosis
Metabolic syndrome with advanced diffuse coronary artery disease.
6.28.4 Discussion
It is uncommon to see diffuse advanced coronary
artery disease in this age group, which should
raise the question of an underlying severe metabolic disorder.
Metabolic syndrome consists of five chronic
conditions: central obesity, hypertension, diabetes, hyperlipidemia, and hypertriglyceridemia, all
of which this patient had. Patients with metabolic
syndrome are at high risk of developing cardiovascular disease.
6.28.5 Pearls and Pitfalls
Patients with metabolic syndrome with stable
angina require aggressive optimal medical therapy in order to avoid a future cardiovascular
event.
Fig. 6.28 (a) cMPR-LCX (b) cMPR-LAD (c) cMPR-RCA (d) Coronary tree (e) Axial MIP demonstrating pericardial
cyst
cd
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Fig. 6.28 (continued)
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C. Smuclovisky
6.29 Case 6.29
6.29.1 History
A 52-year-old male admitted to the hospital with
an acute cerebrovascular accident (CVA). No
prior cardiovascular history. Standard testing was
performed, demonstrated a troponin of 0.04. A
CCTA was ordered.
6.29.2 Findings
There is a significant coronary artery disease.
There is a CTO of the mid-LAD (Fig. 6.29a, b).
Another CTO is seen in the RCA with recanalization of the proximal to mid-RCA (Fig. 6.29c, d).
There is a CTO in mid-LCX as well (Fig. 6.29e).
Incidentally noted is extensive bilateral pulmonary embolism (PE) (Fig. 6.29f).
6.29.3 Diagnosis
6.29.4 Discussion
The combination of acute CVA, PE, multiple
coronary thrombosis should raise suspicions for
systemic causes of coagulopathy or other metabolic dysfunction. This patient was found to have
a lipoprotein A level of 500 nmol/L (normal is
less than 75 nmol/L). Patient underwent a plasmapheresis and successful cardiac surgical revascularization. He was eventually discharged home
in stable condition.
6.29.5 Pearls and Pitfalls
The severity of coronary artery disease findings
with additional new onset of PE and CVA should
alert an underlying systemic disease beyond the
usual atherosclerotic disease seen in this age
group.
Lipoproteinemia causing PE, CVA, and MI.
Fig. 6.29 (a) Axial MIP demonstrating occluded LAD (b) Left coronary angiogram (c) cMPR (d) Right coronary
angiogram (e) Axial MIP showing occluded LCX (f) Axial MIP showing bilateral pulmonary embolism
ef
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Fig. 6.29 (continued)
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C. Smuclovisky
6.30 Case 6.30
6.30.1 History
A 49-year-old male with a history of hypertension presented to the hospital with atypical chest
pain.
6.30.2 Findings
Right dominant coronary circulation. There is a critical obstruction in the proximal LAD (Fig. 6.30a, b).
No plaques in the RCA (Fig. 6.30c, d) and no
plaques in the LCX (Fig. 6.30e).
6.30.3 Diagnosis
Critical obstruction in the proximal segment of
the LAD.
6.30.4 Discussion
Atherosclerotic events are usually thought to be
linearly correlated to plaque burden; meaning the
greater the plaque burden, the greater the chance
of a coronary event. However, as this case delineates, it can take only one plaque to cause a major
cardiac event.
6.30.5 Pearls and Pitfalls
It only takes one plaque rupture in a major proximal coronary branch to ruin your day.
ab
Fig. 6.30 (a) cMPR: LAD (b) Left coronary angiogram (c) cMPR: RCA (d) Right coronary angiogram (e) cMPR:
LCX
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e
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Fig. 6.30 (continued)
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C. Smuclovisky
6.31 Case 6.31
6.31.1 History
A 54-year-old presented to the hospital with
chest pain.
6.31.2 Findings
Right dominant coronary circulation. There is a
thrombus in the ostium of the ramus intermedius
(RI) artery (Fig. 6.31a–d).
6.31.3 Diagnosis
Acute thrombus in the ramus intermedius artery.
6.31.4 Discussion
The RI is typically a small branch, but sometimes
as in this case, it can be a large branch and cause
significant ischemia to a large segment of the
myocardium.
6.31.5 Pearls and Pitfalls
Significant obstructive CAD can be subtle and
the reader needs to pay careful attention to the
proximal branches. The critical finding was initially missed by another reviewer.
Fig. 6.31 (a) Axial MIP (b) Volume rendered (c) Left coronary angiogram (d) Post PCI left coronary angiogram
cd
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6.32 Case 6.32
(Fig. 6.32a, b). There is a total occlusion of the
LAD (Fig. 6.32c, d) with a collateral (Fig. 6.32e, f).
6.32.1 History
There is a subtotal occlusion of the ramus intermedius artery at the ostium.
A 50-year-old male presented with left-sided
chest discomfort.
6.32.3 Diagnosis
6.32.2 Findings
Right dominant coronary circulation. The anteroseptal and apical regions have ischemic changes
ab
Critical obstruction of the LAD.
Fig. 6.32 (a) Axial MIP: Arrows demonstrating areas of
ischemia (b) Axial MIP: Note different Hounsfield Unit
(HU). Previously denoted ischemia areas have less HU
compared to non-ischemic areas (c) Axial MIP showing a
total occlusion of the LAD. (d) cMPR (e) Axial MIP
delineating collateral from the RCA (f) Right coronary
angiogram showing collateral from the RCA (g) Left coronary angiogram showing a subtotal occlusion in the
ostium of the ramus
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