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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. Brown and C.S. White
a
b
Fig. 11.26 (a) Sagittal. Widespread metastatic bone dis-
ease from breast carcinoma (arrowheads). Status post vertebroplasty with injection of methylmethacrylate into a
vertebral body with a small amount of leakage of the
cement into the disc space (long arrows). (b) Sagittal.
B-cell lymphoma involving the thoracic spine (arrows).
(c) Sagittal. Widespread bony blastic metastases from
prostate carcinoma (arrowheads). Status post CABG. (d)
Sagittal. Expansile lytic lesion in the lower sternum
(arrows) incidentally found in a 91-year-old female with
intractable chest pain. Diagnosis: myeloma—Contributed
J. Lee and C. Smuclovisky
11 Extracardiac Findings on Cardiac CTA
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347
11.25 Case 11.24 Contributed by
Lee and C. Smuclovisky
J.
11.25.1 Extracoronary Disease
During the interpretation of cardiac CT, extracoronary findings are frequently identified.
a
It is important to evaluate the entire anatomy in
the field of view in order not to miss a clinically
relevant finding (Fig. 11.27a–h).
b
cd
Fig. 11.27 (a) Axial. Left renal upper pole carcinoma
(arrows). (b) Axial. Gastric carcinoma with ulceration of
the tumor (long arrow) and adjacent adenopathy (arrow-
heads). (c and d) Axial and coronal maximum intensity
projection. PFO closure device (arrow). (e and f) Coronal
and axial. Foreign body in the right pulmonary artery
from a wire lost during placement of an ICD device
(arrows). ICD wires in the SVC (f, long arrow). Status
post CABG. (g) Sluggish filling in the LA appendage;
questionable for clot (arrow). (h) Immediate delay acquisition demonstrates complete filling with no evidence of
thrombus (arrow)
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C. Brown and C.S. White
ef
g
Fig. 11.27 (continued)
h
11 Extracardiac Findings on Cardiac CTA
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349
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Abdom Imaging.
Structural Intervention:
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A Cardiologist’s Perspective
John J. Lee, Igor F. Palacios, and Alexander Llanos
12
12.1 Case 12.1
12.1.1 History
A 76-year-old male presenting with chest discomfort and shortness of breath.
12.1.2 Findings
Cardiac CT Angiogram (CCTA) demonstrated
multi-vessel coronary disease with a critical
lesion that was very short in length of the ostial
LAD (Fig. 12.1a–c).
Coronary angiography demonstrated a critical stenosis involving the ostial LAD involving
the bifurcation of a large first diagonal artery.
Mild non-obstructive disease involving the circumflex artery and the right coronary artery
(Fig. 12.1d, e).
12.1.3 Diagnosis
Critical ostial LAD disease (short lesion length
~3 mm).
12.1.4 Discussion
The ability for the interventional cardiologist to
know the distribution of coronary stenosis prior to
arrival to the cath lab facilitates better defining
lesion severity with invasive angiography. In particular, ostial coronary lesions of short length can
potentially be overlooked at the time of cardiac
catheterization due to overlapping of vessel segments. This patient underwent a minimally invasive
off-pump coronary bypass surgery consisting of a
LIMA to the LAD. Description of the coronary
anatomy by CCTA allows for more detailed discussion with our patients regarding options for therapy
prior to their arrival to the cath lab for invasive angiography where they may receive sedation agents.
J.J. Lee, MD
Department of Medicine,
University of Miami at Holy Cross Hospital,
Fort Lauderdale, FL, USA
I.F. Palacios, MD
Department of Medicine and Cardiology,
Massachusetts General Hospital,
Boston, MA, USA
© Springer International Publishing AG 2018
C. Smuclovisky (ed.), Coronary Artery CTA, https://doi.org/10.1007/978-3-319-66988-5_12
A. Llanos, MD (*)
Department of Cardiology, Holy Cross Hospital,
Jim Morgan Heart and Vascular Research Institute,
Fort Lauderdale, FL, USA
e-mail: alexander.llanos@holy-cross.com
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J.J. Lee et al.
a
c
b
Fig. 12.1 (a) cMPR of LAD (b) stretched MPR of LAD (c) coronary tree view (d and e) coronary angiograms
12 Structural Intervention: A Cardiologist’s Perspective
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12.2 Case 12.2
12.2.1 History
A 67-year-old male with previous history of coronary artery disease status post percutaneous
coronary intervention to the right coronary artery
and the left anterior descending, now presenting
with recurrent chest pain.
12.2.2 Findings
CCTA demonstrated hard and soft plaque in the
mid LAD past the first diagonal that appeared to
a
be hemodynamically significant with a stenosis
of at least 70% (Fig. 12.2a, b). There was an
occluded proximal RCA stent (Fig. 12.2c).
Coronary angiography demonstrated a wellcollateralized right coronary system from the left
coronary system. Moderate disease in the left
anterior descending system at the distal edge of a
previously placed stent: non-flow limiting lesion
as evaluated by both angiography and FFR (FFR
0.88) (Fig. 12.2d, e).
12.2.3 Diagnosis
Non-flow limiting lesion in the LAD.
b
c
Fig. 12.2 (a) cMPR of LAD (b) stretched MPR of LAD
(c) stretched MPR of RCA (d and e) LAD and LCX coronary angiogram (f) RCA Coronary angiogram demon-
strating proximal total occlusion (g) Coronary angiogram
demonstrating left to right collaterals
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J.J. Lee et al.
d
f
e
g
Fig. 12.2 (continued)
12.2.4 Discussion
Being able to understand the coronary anatomy
prior to arriving to the cath lab is helpful. The
planned addition of physiologic coronary assessment by means of flow evaluation is an exciting
future advancement that will help to further
enhance the utility of CT angiography to the
cardiologist.
This patient was found to have an occluded
proximal RCA and a 70% lesion in the LAD by
coronary CTA. He was further evaluated with
invasive angiography which verified the above
findings. FFR evaluation of the LAD determined
that the lesion was not significantly flow limiting
and the decision was made for medical therapy.
As detailed in previous chapter, the addition of
fractional flow reserve to CCTA imaging will
better allow us to determine care options.
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12.3 Case 12.3
12.3.1 History
A 52-year-old male with past medical history of
hyperlipidemia and hypertension who presented
with exertional chest discomfort.
12.3.2 Findings
CCTA demonstrated critical two vessel disease
involving the LAD and LCX. There was a chronic
total occlusion of the mid LAD with collateral
filling of the distal LAD. There was suspicion of
high-grade obstruction in the proximal to mid
circumflex (Fig. 12.3a, b).
Invasive coronary angiography was performed
and demonstrated a 50% proximal LAD lesion
followed by a total occlusion in the distal segment
of the LAD with a well-collateralized apical LAD
segment (anterograde bridging collateral). The
left circumflex had a mid 85% lesion and the right
coronary had a mid 70% lesion.
12.3.3 Diagnosis
Severe two vessel coronary artery disease of the
LAD and LCX.
12.3.4 Discussion
We performed three vessel fractional flow reserve
and found the RCA lesion to be non-flow limiting
(FFR = 0.90). Evaluation of the proximal LAD
50% lesion also demonstrated non-flow limiting
value (FFR = 0.88). FFR of the mid LCX 85%
lesion was found to be flow limiting (FFR = 0.69).
It was decided to proceed with percutaneous
intervention of the mid left circumflex. A bioabsorbable stent was placed without complication
(Fig. 12.3c). The remaining coronary disease was
medically managed.
Current advances in coronary CT angiography
are likely to involve the ability to evaluate a
noninvasive fractional flow reserve which will
help us to better evaluate patients and help guide
therapy.
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