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10 Cardiac CTA in the Evaluation of CABG
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10.19 Case 18
10.19.1 History
A 75-year-old male presented with atypical chest
pain.
a
c
10.19.2 Findings
There is a severe obstructing proximal mid LAD disease. There is a patent LIMA graft to the mid LAD
performed with minimally invasive direct coronary
artery bypass surgery (MIDCAB) (Fig. 10.19a–c).
b
Fig. 10.19 (a) Maximum Intensity Projection (MIP) (b) curved reformatted reconstruction (cMPR), (c) volume
rendered (VR)
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C. Smuclovisky
10.19.3 Diagnosis
Patent MIDCAB to the LAD.
10.19.4 Discussion
MIDCAB is a surgical option that is a less invasive
method than a traditional open medial sternotomy
CABG and also known as “keyhole surgery.” The
sternum is spared and the surgery can be performed
through a 4–6 cm fifth intercostal thoracotomy. The
surgery is performed “off- pump.” Although, all
myocardial territories can be accessed, MIDCAB
surgery is often reserved for single or double
obstructing left coronary tree disease. In general, a
single pedicle LIMA graft is used to anastomose
one or more branches of the LAD.
10.19.5 Pearls and Pitfalls
Clues that a MIDCAB has been performed is lack
of sternotomy wire sutures and a small left parasternal surgical defect in the chest wall. Follow
the course of the LIMA to assess the surgical
anastomosis.
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Extracardiac Findings on Cardiac
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CTA
Christopher Brown and Charles S. White
11
11.1 Introduction
Coronary computed tomographic angiography
(CCTA) is a powerful, noninvasive tool to evaluate coronary anatomy, plaque, and areas of stenosis in the coronary arteries. Technological
advancements have now given CCTA diagnostic
capabilities that approach those of invasive coronary angiography, which remains the gold standard for coronary artery imaging. CCTA is often
used in an outpatient setting to evaluate for coronary artery disease as well as graft patency following coronary artery bypass. Recent studies
have shown that CCTA can effectively rule out
acute coronary syndrome in low to intermediaterisk patients, who present with suspicious chest
pain. The use of CCTA is on the rise, and it is
important to recognize its diagnostic capabilities
not only related to the coronary arteries and heart,
but also with respect to extracardiac structures.
C. Brown, MD
Department of Radiology, Hahnemann University
Hospital, Drexel University School of Medicine,
Philadelphia, PA, USA
C.S. White, MD (*)
Department of Diagnostic Radiology, University of
Maryland Medical Center, 22 S Greene St, Baltimore,
MD 21201, USA
e-mail: cwhite@umm.edu
To visualize each of the coronary vessels on
CCTA, z-axis coverage must extend from the
upper mediastinum to the upper abdomen.
Depending on use of a wide or narrow field of
view, this will include variable portions of the
lungs, mediastinum, chest wall, thoracic spine,
and abdomen. Not surprisingly, incidental findings will often be identified that may or may
not be clinically significant. An incidental finding is classified as significant if it requires subsequent radiographic evaluation or therapeutic
intervention.
Patients undergoing cardiac imaging are not
necessarily representative of the general population because of the presence of cardiac disease,
additional associated risk factors, and ongoing
symptoms, all of which may affect the prevalence
and types of clinically significant incidental
findings.
In one of the earliest large studies to analyze
incidental findings on cardiac electron beam
CT in the context of calcium scoring, investigators found that 53% of all patients had one or
more incidental findings [1]. Most incidental
findings were limited to the heart or pericardium (38%). Extracardiac incidental findings
included pneumonia (1.7%), pulmonary malignancy (0.1%), pleural disease (8.9%), esophageal carcinoma (0.06%), lymphadenopathy
(4%), hiatal hernia (1%), hepatic tumors (2%),
and spinal degenerative disease (5.4%).
Regarding clinical significance, 9% of these
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C. Smuclovisky (ed.), Coronary Artery CTA, https://doi.org/10.1007/978-3-319-66988-5_11
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findings required further evaluation, and only
1% resulted in therapeutic intervention.
More recent investigations with modern
multi- detector CT scanners have found similar
results, with a prevalence of significant findings
as high as 23%. One important difference is
that CCTA requires contrast administration,
which enhances the ability to detect additional
pathology such as pulmonary embolism and
aortic dissection. For example, in a study
looking at patients who underwent CCTA after
coronary artery bypass grafts, incidental pulmonary embolism was found in 1.9% of patients
in the immediate postoperative period.
There has been considerable debate about the
necessity to look for and report incidental findings.
Many studies have confirmed that incidental findings are common and have the potential to influence treatment; identifying such findings should
be a component of the image interpretation.
ab
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11.2 Case 11.1
11.2.1 History
A 56-year-old male screened for coronary artery
disease. History is significant for hypertension,
hyperlipidemia, and family history of coronary
artery disease.
11.2.2 Findings
There is a solitary pulmonary nodule in the left
upper lobe of the lung measuring approximately
1 cm in diameter. There is no associated lymphadenopathy or calcification (Fig. 11.1).
11.2.3 Diagnosis
Incidental solitary pulmonary nodule.
11.2.4 Discussion
Solitary pulmonary nodules (SPN) are relatively
common findings that must not be overlooked
because they may represent malignancy. Most often,
patients are asymptomatic, and these lesions are
found incidentally or in screening studies for lung
cancer in high-risk populations.
By definition, a pulmonary nodule is a discrete opacity that is less than 3 cm; any lesion
that is greater than 3 cm is termed a mass. The
differential diagnosis of a SPN is large and can be
divided into benign and malignant etiologies.
Benign causes include infection or abscess,
inflammatory disease (e.g., sarcoidosis), vascular
abnormalities (e.g., AVM, aneurysm), and benign
neoplasms (e.g., hamartoma, lipoma, fibroma).
Malignant causes include primary lung cancer or
metastasis.
Certain radiographic features help to distinguish
a benign versus malignant etiology of SPN. Several
patterns of calcification are associated with a benign
SPN including complete calcification, laminated
calcification, popcorn calcification, and central calcification. Margins that are smooth and well defined
are more likely benign. The growth rate of a SPN
can be highly predictive of a benign or malignant
cause. SPNs that double in less than 1 month usually have an infectious etiology. SPNs that are stable
over 2 years are usually benign although ground
glass nodules may have longer doubling times and
those that double in less than 2 years (and greater
than 1 month) are usually malignant.
Fig. 11.1 (a) Axial. There is solitary pulmonary nodule in the left upper lobe (arrow). (b) Axial. A different patient
with a spiculated nodule suspicious for malignancy (long arrow) with an associated satellite nodule (short arrow)
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C. Brown and C.S. White
Management of SPNs can be difficult because
physicians must consider risks of further radiation from follow-up imaging and possible tissue
sampling versus the likelihood of diagnosing or
missing a lung cancer. The predictable growth
rate of malignant and benign SPNs is the basis
for the Fleischner Society recommendations for
follow-up of lung nodules [2]. These recommendations outline scheduled CT follow-up, PET
imaging, and/or biopsy based on the size of the
SPN and risk stratification of the patient.
11.2.5 Pearls and Pitfalls
When available, prior imaging studies should be
carefully studied to assess for changes in the size
or morphology of any nodules. Solid nodules that
are stable over 2 years or those that are completely calcified can be considered benign.
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11.3 Case 11.2 Contributed by
Lee and C. Smuclovisky
J.
11.3.1 History
A 75-year-old male presented with new onset of
left-sided chest pain.
a
d
bc
e f
11.3.2 Findings
There is a mass in the left upper lobe of the lungs
infiltrating the adjacent mediastinum and with
adenopathy (Fig. 11.2a–c).
g
Fig. 11.2 (a) Axial. Left upper lobe adenocarcinoma infil-
trating the mediastinum (double arrows). Left hilar metastatic lymph node (single arrow). (b) Axial. Delayed images
again demonstrating the infiltrating tumor (arrows). (c)
Axial. Metastatic adenopathy adjacent to the left subclavian
artery and vein (arrow). (d) Axial. Incidental small lung can-
cer (different patient) adjacent to the right hilum with a metastatic lymph node (arrows). (e and f) Axial. Incidental
13-mm lung cancer (different patient) in the left upper lobe
adjacent to the aortic arch. Lung window (f) demonstrating
spiculated borders of the tumor (arrows). (g) Axial. Incidental
5.5-cm left upper lobe lung cancer (different patient) incidentally found on the cardiac CTA and previously missed on
plain radiographs over a period of 3 years. Note that the
tumor is posterior to a cardiac pacemaker and would be difficult to suspect on a plain radiograph (Murphy’s law)
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C. Brown and C.S. White
11.3.3 Diagnosis
The diagnosis is adenocarcinoma of the lung.
11.3.4 Discussion
Lung cancer is the leading cause of cancer-related
mortality in both men and women. The prevalence
of lung cancer is second only to that of prostate
cancer in men and breast cancer in women. Nonsmall cell lung cancer (NSCLC) accounts for
approximately 75% of all lung cancers. NSCLC is
divided further into adenocarcinoma, squamous
cell carcinoma, and large cell carcinoma.
Extracardiac findings are frequently encountered on cardiac CTA. Primary lung cancer typically appears as a noncalcified soft tissue mass
with irregular or spiculated borders. The tumors
have variable size and may be located anywhere
in the thorax.
11.3.5 Pearls and Pitfalls
Careful attention to the extracardiac structures is
of paramount importance in order not to miss
reporting a neoplasm in the field of view.
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11.4 Case 11.3
11.4.1 History
A 40-year-old male, who presented with chest
pain after using cocaine.
11.4.2 Findings
There is a focal consolidation in the right middle
lobe (Fig. 11.3).
11.4.3 Diagnosis
Pneumonia, possibly secondary to aspiration
given patient’s history of drug abuse.
11.4.4 Discussion
Pneumonia develops when pathologic organisms
invade lung parenchyma and initiate a host
immune response. This manifests as inflammatory
exudate in the airspaces, which causes the radiographic appearance of consolidation. Spread of
organisms can occur through the airways via inhalation or aspiration, through vasculature (hematogenous spread) or by direct contact with infected
adjacent structures such as the mediastinum or
abdomen. Pneumonia can be caused by bacteria,
viruses, fungi, and parasites. The integrity of the
immune system plays an important role in the susceptibility of infections from various organisms.
There are three radiographic patterns of
pneumonia: lobar, lobular or bronchopneumonia, and interstitial. Lobar pneumonia usually
involves inflammation in the distal airways first,
which then spreads proximally along the airways to involve the whole lobe. S. pneumoniae
and Klebsiella pneumoniae often produce lobar
pneumonia.
Lobular or bronchopneumonia is caused by
inflammation in the bronchi, which then spreads distally to involve the pulmonary lobule. S. aureus and
H. influenza often produce bronchopneumonia.
Interstitial pneumonia is caused by inflammation in the bronchioles and pulmonary interstitium, which causes radiographic thickening of
airways and reticulonodular opacities. Viral
infections and mycoplasma often produce interstitial pneumonia.
Although each organism has predilection for a
specific radiographic appearance, there is
considerable overlap. Other complications of
infection that can occur with pneumonia are
abscess and empyema.
Fig. 11.3 Axial. Right middle lobe consolidation indicative of airspace disease (arrow)
11.4.5 Pearls and Pitfalls
In an erect patient, aspiration pneumonia is most
common in the right middle lobe or bilateral
lower lobes because the bronchi are oriented
more vertically.
A chest radiograph may require 4–6 weeks to
normalize after pneumonia.
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