Presentation
Stable chest pain. Sweats. History of coronary stent placement.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
standard image reconstruction
Findings
normal coronary origins and proximal courses
coronary codominance
corkscrew-like tortuous terminal vessels
coronary stent in the second obtuse marginal branch
Plaque burden:
calcium score (according to Agatson, not shown): 750
segment involvement score (SIS): 7 segments
Right coronary artery (RCA): gives rise to PDA, two thin acute marginal branches
small calcified non-obstructing plaque in the transition zone of the proximal and middle segments
no relevant plaques or stenoses including the posterior descending artery (PDA)
Left main: short
-
calcified plaque with low-grade stenosis (25-49%)
Left anterior descending artery (LAD): (two diagonal branches)
multiple calcified plaques in the proximal and middle segments
plaque-related low-grade in the proximal and middle segments (25-49 %)
apical part of the distal segment partially truncated at the image edge
plaque-related low-grade stenosis at the origin of the first diagonal branch
Circumflex artery (CX): (two obtuse marginal branches, long distal segment/posterolateral branch)
few calcified plaques
low-grade plaque-related stenoses (25-49%) in the proximal segments
coronary stent in OM2 with hardly assessable stent lumen but well-perfused distal run-off vessel
Impression
coronary artery disease with multiple plaque-related low-grade stenoses
severe overall plague burden
limited assessability with regard to in-stent stenosis of the second obtuse marginal branch
corkscrew-like tortuous terminal vessels indicating hypertensive disease
Exam courtesy: Yvonne Kühn (radiographer)
Technique
sharp reconstruction algorithm without edge correction
wider window setting for the curved and straight multi-planar reconstruction
Findings
The stent lumen with a lumen diameter of slightly less than 1.5 mm is much better visible now, but the assessment with regard to in-stent stenosis is still difficult not only due to the stent but also due to the small stent lumen. However, there is no evidence of stent occlusion.
Case Discussion
A case of coronary artery disease with moderate stenoses of
According to the new version of the Coronary Artery Disease - Reporting and Data System 1 this case was classified CAD-RADS N/P3/S and functional assessment was recommended in this case, because of the following reasons:
we did not feel confident enough to exclude an in-stent stenosis in a coronary stent with a visible lumen diameter of <1.5 mm (even on the sharp image reconstruction algorithm)
the apical part of the distal segment partially truncated at the image edge
The patient received a nuclear stress test, which did not show any signs of myocardial ischemia. Management should also include aggressive risk factor modification and preventive therapy 1.