Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3676_Библиотеки_им_академика_М_И_Перельмана
.pdf
10 Cardiac CTA in the Evaluation of CABG
https://t.me/med1917
285
Fig. 10.7 (a–c) Volume rendering, cMPR, stretched
view: High-grade stenosis in the proximal segment of an
SVG (arrows). Note that the rest of the graft has no disease. (d, e) cMPR: Patent LIMA graft to distal LAD and
vein graft to the PDA. There is mild artifact in the body
and distal anastomosis of the mammary artery. (f, g)
Coronary angiogram: Confirms the high-grade stenosis in
the proximal segment of the SVG (arrows). (h) Coronary
angiogram: Excellent results following stenting of the
graft (arrow)
286
https://t.me/med1917
C. Smuclovisky
10.8 Case 7
10.8.1 History
A 59-year-old male presented with a history of
chest pain and status post CABG ×2 in the prior
10 years and subsequent percutaneous coronary
intervention (PCI) of a saphenous vein graft
(SVG).
10.8.2 Findings
There is a patent LIMA graft to the distal LAD
(not shown) and a proximally occluded SVG to
the second diagonal artery, which was previously
stented (Fig. 10.8a, b).
10.8.3 Diagnosis
The diagnosis is occluded SVG to a diagonal
artery.
10.8.4 Discussion
contrast opacification of only the proximal anastomosis, which is referred to as a stump or hood.
The rest of the graft is thrombosed, which has
low density throughout and has the appearance
of a phantom graft (Fig. 10.8b). Other times, the
occluded segments of the graft become atretic
and are not visualized.
Diseased vein grafts are commonly intervened
with balloon angioplasty and placement of stents.
The initial intervention success is similar among
native coronary arteries, internal mammary arteries, and SVGs. However, it has been reported that
the late patency rate after interventions on SVGs
is significantly lower than that for native coronary arteries.
10.8.5 Pearls and Pitfalls
It is commonly difficult to ascertain the targeted
native coronary artery of an occluded graft.
Careful evaluation of the coronary anatomy and
other grafts present as well as location of surgical
clips may provide sufficient clues to determine
where the graft was previously anastomosed.
The CTA demonstrates a proximally occluded
vein graft from the ascending aorta. There is
Fig. 10.8 (a) Volume
rendering: Proximal
SVG stump and
occluded stent in the
graft (long arrows).
Surgical cannulation
sites repair (short
arrows). (b) cMPR:
SVG–D2: Proximally
occluded SVG stump
(proximal arrow).
Occluded stent in the
SVG (mid-arrow).
Phantom graft (short
arrows). Native diagonal
coronary artery (lower
arrow)
10 Cardiac CTA in the Evaluation of CABG
https://t.me/med1917
287
10.9 Case 8
10.9.1 History
A 70-year-old female presented with a history of
atypical chest pain and status post CABG ×5 in
the previous 8 years and status post PCI of a graft
in the previous 2 years.
10.9.2 Findings
There is a patent sequential vein graft (SVG) to
the PDA and PLV. There is a patent stent in the
mid-body of the graft with a surrounding mostly
thrombosed hematoma. There is also a small
pseudoaneurysm (Fig. 10.9a–d).
10.9.3 Diagnosis
The diagnosis is patent sequential SVG to the
PDA and PLV, which contains a patent stent that
has an adjacent small pseudoaneurysm.
10.9.4 Discussion
The study demonstrates a mostly thrombosed
hematoma surrounding the mid-body of the
SVG. There is a small and subtle pseudoaneurysm that was previously undiagnosed. This finding was not considered to be clinically significant,
and it was decided to perform a follow-up study.
Pseudoaneurysms can occur as a complication of
coronary intervention secondary to balloon
angioplasty or wire perforation.
10.9.5 Pearls and Pitfalls
It is important to evaluate not only the lumen and
wall of the graft but also the adjacent soft tissues.
Fig. 10.9 (a) Volume
rendering: SVG 3D
volume rendered image
demonstrates a
hematoma surrounding
the mid-body of the
graft (arrow). (b–d)
Axial and cMPR: SVG:
Extra-luminal chronic
hematoma surrounding a
stent in the mid-body of
the graft (short arrows)
with a small
pseudoaneurysm (long
arrows)
288
https://t.me/med1917
C. Smuclovisky
10.10 Case 9
10.10.1 History
A 71-year-old male presented with a history of
recurrent right pleural effusion and status post
CABG ×4 in the previous 12 months, with a
stormy postoperative course.
10.10.2 Findings
There is a retrosternal collection that has contrast
density. There is a right pleural effusion with
compressive atelectasis of the right lower lobe
(Fig. 10.10a). There is contrast leaking into the
anterior mediastinal collection (Fig. 10.10b, c)
from a patent sequential surgical Y saphenous
vein graft (SVG) to a diagonal and an obtuse
marginal artery. The other SVG limb to the RCA
is occluded. There is a patent LIMA graft to the
distal LAD (not shown).
10.10.4 Discussion
The anterior mediastinal collection has contrast
density thus indicating a pseudoaneurysm.
Figure 10.10b, c demonstrates a tiny leak from
the patent SVG limb that has a distal anastomosis
to an obtuse marginal artery. It is uncertain
whether the pseudoaneurysm is causing the
recurrent right pleural effusion. Without a
detailed surgical history, it would not have been
possible to determine that there was a leak at a
surgical Y anastomosis and with an occluded
SVG limb to the RCA. It may only have been
suspected since there was a chronic total occlusion of the RCA without visualization of a graft
or occluded stump in the aorta.
10.10.5 Pearls and Pitfalls
The most common cause of a pseudoaneurysm
originating from a graft is technical or breakdown of the suture anastomosis.
10.10.3 Diagnosis
The diagnosis is pseudoaneurysm from a leak at
a surgical Y vein graft anastomosis.
Fig. 10.10 (a) Axial. Hyperdense collection containing
contrast in the anterior mediastinum representing a pseudoaneurysm (long arrow). Right pleural effusion with
right lower lobe compressive atelectasis (short arrows).
(b, c) cMPR and oblique sagittal MPR: SVG: Contrast
leaking from the graft into the pseudoaneurysm is demonstrated (arrows)
10 Cardiac CTA in the Evaluation of CABG
https://t.me/med1917
289
10.11 Case 10
10.11.1 History
A 71-year-old male presented with a history of
new onset of exertional chest pain and stenting of
a saphenous vein graft (SVG) in the previous
3 months. His status was post CABG ×4 in the
previous 15 years.
10.11.2 Findings
There is a stent with high-grade restenosis in the
proximal segment of an SVG to the second obtuse
marginal artery. The graft has diffuse disease and
also high-grade obstruction just beyond the stent
and in the distal anastomosis (Fig. 10.11a–c). There
was a patent sequential LIMA graft to the distal
LAD and an occluded SVG to the RCA (not shown).
Fig. 10.11 (a–c) cMPR and stretched, SVG. High-grade
restenosis in a stent in the proximal SVG (upper arrow)
and also high-grade obstruction just distal to the stent.
There is a high-grade obstruction in the distal anastomosis
(lower arrow). (d, e) Coronary angiogram. Proximal and
distal SVG high-grade obstruction (arrows). (f) Coronary
angiogram. Successful intervention
290
https://t.me/med1917
C. Smuclovisky
10.11.3 Diagnosis
The diagnosis is diffusely diseased SVG containing a proximal stent with restenosis and also distal anastomosis high-grade obstruction.
10.11.4 Discussion
The patient underwent coronary angiography
with successful re-stenting of the proximal segment of the graft and balloon angioplasty of the
distal anastomosis (Fig. 10.11d–f). The chest
pain resolved.
10.11.5 Pearls and Pitfalls
Although there was no visible contrast density in
the lumen of the stent on the CTA, the visualization of the rest of the graft indicates that the SVG
was not occluded.
10.12 Case 11
10.12.1 History
An 81-year-old female presented with a history of
atypical chest pain and status post CABG ×2 and
LV aneurysmectomy in the previous 12 months.
10.12.2 Findings
There are surgical SVG Y grafts from the ascending aorta to the LAD and to the territory of the
left circumflex. The proximal segment of the
graft is occluded. The rest of the grafts have no
disease and retrograde flow (Fig. 10.12a–c).
10.12.3 Diagnosis
The diagnosis is proximal occlusion of an SVG Y
grafts and status post LV aneurysmectomy.
10 Cardiac CTA in the Evaluation of CABG
https://t.me/med1917
291
10.12.4 Discussion
The CTA clearly demonstrates an occlusion in
the proximal segment of the Y graft from the
ascending aorta, which has a stump in the proximal anastomosis (Fig. 10.12a). Note that otherwise the grafts have no disease and would
suggest that the proximal occlusion is likely
related to a surgical complication (Fig. 10.12d–e).
Coronary angiography was not performed since
the patient was stable. Although the direction of
flow cannot be determined with CTA, since there
was nonobstructing calcified plaque in the left
circumflex (Fig. 10.12d) and severe obstruction
Fig. 10.12 (a) Volume
rendering. Upper arrows
demonstrating proximal
occlusion of a surgical
SVG Y graft and a
stump in the ascending
aorta. Postsurgical
changes from an
aneurysmectomy (lower
arrow). (b) Axial.
Proximal graft occlusion
(arrow). (c)
cMPR. Proximal
occlusion (short arrow).
Otherwise, the limbs of
the grafts are open
(double arrows). The
limb in the upper picture
is to the territory of the
left circumflex. The limb
in the lower picture is to
the LAD. (d) cMPR
LCX. Scattered
nonobstructive calcified
plaque in the left
circumflex. Graft
anastomosis (arrow). (e)
cMPR LAD. Severe
obstruction in the
proximal LAD and SVG
anastomosis (arrows)
of the proximal LAD (Fig. 10.12e), it was presumed that the retrograde flow was likely from
the left circumflex limb to the LAD. Note the
postsurgical aneurysmectomy changes in the left
ventricle. When a ventricular aneurysm is
resected, felt strips (large pledgets) are commonly used to suture the myocardium.
10.12.5 Pearls and Pitfalls
Grafts that are anastomosed to the aorta cannot
be presumed to be patent unless they are visualized in their entirety.
292
https://t.me/med1917
C. Smuclovisky
10.13 Case 12
10.13.1 History
A 65-year-old male presented with a history of
multiple prior myocardial infarctions over many
years. His status post CABG in the previous
30 years and repeat CABG ×1 in the previous
3 years.
10.13.2 Findings
There is a diffusely diseased but otherwise patent
saphenous vein graft (SVG) to the LAD. There is
a patent SVG to the territory of the left circumflex that was proximally grafted to the descending aorta. There are multiple chronic left
ventricular myocardial infarcts and a thrombus in
the left ventricle apex (Fig. 10.13a–e).
10.13.3 Diagnosis
The diagnosis is patent SVG proximally grafted
to the descending aorta.
10.13.4 Discussion
Saphenous veins are most commonly grafted to
the ascending aorta. Rarely, as in this case, are
these proximally grafted to the descending aorta
(Fig. 10.13b–d). The most common surgical
approach to anastomosing a graft to the descending aorta is via a left thoracotomy approach. This
surgical technique is occasionally used in repeat
cardiac surgical revascularization to the left circumflex territory without having to perform
another median sternotomy. The patient had
extensive previous myocardial infarcts involving
the territory of the LAD and left circumflex,
which was dominant. There was also a small
thrombus in the LV apex (Fig. 10.13e).
10.13.5 Pearls and Pitfalls
Since a full surgical history at the time of interpretation of a CTA might not always be available,
it is therefore important to examine carefully the
native coronary anatomy and the entire thoracic
aorta in order not to exclude reporting additional
grafts.
10 Cardiac CTA in the Evaluation of CABG
https://t.me/med1917
Fig. 10.13 (a) cMPR
SVG to the LAD
SVG.
has diffuse disease but is
patent (upper arrow).
Extensive anterior and
apical chronic
myocardial infarct
(middle arrow).
Thrombus in the LV
apex (lower arrow). (b,
c) cMPR and volume
rendering. SVG
proximally grafted to the
descending aorta and
distally to an obtuse
marginal artery. (d)
Axial. Proximal
anastomosis of the SVG
from the descending
aorta (arrow). (e)
Sagittal MPR
LV.
Extensive chronic
myocardial infarcts and
thrombus in the left
ventricle apex. (Case
courtesy of Dr. William
Bugni, Tampa, FL)
293
294
https://t.me/med1917
C. Smuclovisky
10.14 Case 13
10.14.1 History
A 74-year-old male presented with a history of
shortness of breath and chronic ischemic cardiomyopathy and status post CABG ×4 in the previous 10 years.
10.14.2 Findings
Coronary circulation is right dominant. There is a
patent LIMA to the distal LAD and a saphenous
vein graft (SVG) to D2. There is also a patent
SVG to the PDA and with distal runoff chronic
total occlusion. There is a stump in the ascending
aorta from an occluded SVG to the territory of
the left circumflex (Fig. 10.14a–d).
10.14.3 Diagnosis
There are three patent grafts and one occluded
graft. The SVG to the PDA has chronic total
occlusion of the distal runoff.
10.14.4 Discussion
In the evaluation of grafts, it is important to evaluate and comment on the proximal anastomosis,
body of the graft, distal anastomosis, and runoff.
Although the SVG to the PDA is patent, the targeted artery is occluded just beyond the anastomosis, with retrograde flow into the proximal
PDA (Fig. 10.14b–d).
10.14.5 Pearls and Pitfalls
The grafting of coronary targets that are diseased
beyond the anastomosis has a significant worse
patency rate than nondiseased arteries.
Соседние файлы в папке Библиотека им академика М.И. Перельмана