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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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ac
b
Fig. 12.3 (a) cMPR of LCX (b) stretched MPR of LCX (c) optical coherence tomography (OCT) of LCX showing
bioabsorbable stent; arrows indicating bioabsorbable stent struts
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12.4 Case 12.4
12.4.1 History
A 75-year-old male with coronary artery disease
status post CABG and aortic stenosis undergoing
evaluation for possible transcatheter aortic valve
replacement.
12.4.2 Findings
CCTA demonstrated a calcified aortic valve. The
bypass anatomy was defined as a saphenous vein
graft to the right coronary artery, saphenous vein
graft to an obtuse marginal and a left internal mammary artery (LIMA) graft to LAD (Fig. 12.4a–c).
12.4.3 Diagnosis
Previous history of CABG with new severe
symptomatic aortic stenosis.
12.4.4 Discussion
In the evaluation of patients for transcatheter aortic
valve therapy, cardiac CT scanning has many roles.
In addition to evaluation of aortic valve characteristics, it can also be used for defining coronary artery
bypass grafting anatomy in patients with remote
history of coronary arterial bypass grafting surgery
for whom the surgical report is not available. This
is particularly important in setting of renal insufficiency. Significant amounts of contrast volume can
be used in trying to define bypass anatomy in individuals in whom the operative report/bypass anatomy is not available at the time of invasive coronary
angiography. Also, it is also possible in the same
setting with CTA to evaluate the thoracic, abdominal, and pelvic vasculature to determine access
routes for a transcatheter procedure with use of
minimal contrast.
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a
c
b
Fig. 12.4 (a–c) Volume rendered
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12.5 Case 12.5
12.5.1 History
A 82-year-old male presents with progressive
exertional chest discomfort.
12.5.2 Findings
CCTA demonstrated a critical stenosed and heavily calcified lesion in the mid LAD (Fig. 12.5a, b).
12.5.3 Diagnosis
Critical mid calcified mid LAD lesion.
a
12.5.4 Discussion
In addition to determining the presence of critically stenotic lesions, CCTA also allows for
morphologic characteristics of coronary lesions
that can be useful to determining the best treatment modality. In particular, the distribution
and extent of calcium in coronary lesions is
important in choosing the treatment options.
The presence of heavy, and in particular, circumferential calcium in coronary lesions is an
important consideration for use of plaque modification techniques (rotablator, orbital atherectomy, etc.) that lead to improved percutaneous
intervention results.
b
Fig. 12.5 (a) cMPR of LAD (b) stretched MPR of LAD
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12.6 Case 12.6
12.6.1 History
A 46-year-old male presents with progressive
shortness of breath on exertion.
12.6.2 Findings
Transthoracic echo demonstrated a patent ductus
arteriosus (PDA) with coronary CTA demonstrated a PDA (Type B) (Fig. 12.6a, b).
12.6.3 Diagnosis
Type B PDA.
12.6.4 Discussion
CCTA with inclusion of the aortic arch is useful
for planning of percutaneous intervention for
closure of PDAs. Defining of the shape, length,
and width of the PDA facilitates choosing the
appropriate device for closure. In this case, an
Amplatzer PDA occlude was chosen. In contrast, a type C PDA (Fig. 12.6c) in a separate
patient was occluded with an Amplatzer vascular plug 2.
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a
b
c
Fig. 12.6 (a) Sagittal view of type B PDA (b) volume rendered (c) sagittal view of type C PDA
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12.7 Case 12.7
12.7.1 History
A 66-year-old female presented with atypical
chest discomfort. She was evaluated in the emergency room and found to have normal cardiac
biomarkers.
12.7.2 Findings
CCTA demonstrated non-obstructive coronary
disease. She was found to have a secundum atrial
septal defect with enlargement of the right atrium
and right ventricle (Fig. 12.7).
12.7.3 Diagnosis
Ostium secundum atrial septal defect.
12.7.4 Discussion
It allows for evaluation of associated congenital
defects (Anomalous pulmonary venous return,
ventricular septa defects, etc.). It also facilitates
decisions as to the feasibility of percutaneous
closure versus surgical intervention (as in the
case of an ostium primum ASD or sinus venosus
defect which are usually corrected with surgical
intervention).
The pairing of CT with transesophageal echo
helps to plan an effective closure of secundum
atrial septal defects.
The benefits of CCTA to the cardiologist in this
setting are numerous. The CT scan allows for
evaluation of the septal defect anatomy and can
be used to planning of percutaneous closure.
Fig. 12.7 Axial MIP showing ASD
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12.8 Case 12.8
12.8.1 History
An 84-year-old female with significant past medical history of aortic stenosis presented with
complaints of progressive shortness of breath on
exertion.
12.8.2 Findings
Severe aortic stenosis with numerous comorbidities and significant frailty. She was deemed not
an ideal candidate for surgical aortic valve
replacement and was referred to transcatheter
aortic valve replacement (TAVR).
CCTA was performed as part of her evaluation.
Significant aortic annular calcification was noted
that extended 2.5 cm into the left ventricle (Fig. 12.8).
12.8.3 Diagnosis
Severe aortic stenosis.
12.8.4 Discussion
Anatomic information regarding the distribution
and extent of calcification in patients with aortic stenosis aids in choosing an optimal transcatheter aortic valve technology. In this case, it was decided to
use a self-expanding transcatheter valve technology
instead of using a balloon expandable transcatheter
to minimize the risk of disruption of the aortic annulus due to the calcification pattern seen on CT.
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Fig. 12.8 Cardiac CT angiography showing severe nodular aortic annular calcification extending into the left
ventricle
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12.9 Case 12.9
12.9.1 History
A 67-year-old male presents with new onset chest
discomfort.
12.9.2 Findings
Coronary angiography demonstrated a saphenous vein graft pseudoaneurysm.
Coronary CTA defined the dimensions of the
pseudoaneurysm that developed from the proximal segment a saphenous vein bypass conduit
(Fig. 12.9b).
12.9.3 Diagnosis
Expanding saphenous vein graft pseudoaneurysm (Fig. 12.9c).
12.9.4 Discussion
Invasive angiography demonstrated the existence of a saphenous vein graft pseudoaneurysm, but did not define well the expansion that
had occurred over the 2-year interval between
the invasive angiograms. Invasive angiography
is limited in its nature to define a pseudoaneurysm as it provides a “luminogram” of the
lesion. Lesions such as this saphenous vein
graft pseudoaneurysm benefit from imaging
using CCTA to better determine their true size
and interval changes that may cause symptoms
and require invasive therapy. Coronary CTA
was also performed and clearly demonstrated
the expansion of the saphenous vein graft pseudoaneurysm that had occurred in the 2-year
interval (Fig. 12.9a, b). This patients pseudoaneurysm was subsequently treated percutaneously (Fig. 12.9d).
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