Presentation
Heavy smoker, h/o hypertension and esophageal cancer on opioids for thoracic pain.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
Findings
normal coronary origins and proximal courses
right coronary dominance with a thin circumflex artery and a strong intermedius branch
Plaque burden:
calcium score (according to Agatson, not shown): 909
segment involvement score (SIS): 7 segments
Right coronary artery (RCA): gives rise to PDA and small PLB
small calcified plaques without relevant stenosis in the proximal and middle segments
plaque-related mild stenosis (25-49%) in the distal segment
no relevant plaques or stenoses in the posterior descending artery (PDA) and posterolateral branch (PLB)
Left main: short, strong
-
small calcified plaque, no stenosis
Left anterior descending artery (LAD): two diagonal branches
some calcified plaques without stenosis in the proximal segment
plaque-related moderate stenosis (~50%) with high-risk features in the middle segment as well as plaque-related mild stenosis in the first diagonal branch (D1)
myocardial bridge in the middle segment with no stenosis
distal segment and second diagonal branch with no plaques or stenoses
Ramus intermedius: strong lumen (~4 mm)
-
plaque-related moderate stenosis (50-69%) proximally
Circumflex artery (CX): (thin luminal diameter <2mm, one obtuse marginal branch)
proximal and distal segments with no plaque or stenoses
obtuse marginal branch with no plaque or stenoses
Other findings:
status post esophagectomy with gastric pull-up
peribronchial thickening
Impression
moderate coronary stenosis of the ramus intermedius and in the middle segment of the LAD with a high-risk plaque as well as mild stenoses of the D1 and the distal RCA
severe overall plague burden
modifiers: high-risk plaque
Exam courtesy: Sven Winzler (radiographer)
Curved multiplanar images for better evaluation of the stenoses in the middle left anterior descending artery (LAD) and the ramus intermedius artery.
Case Discussion
A case of coronary artery disease with moderate stenosis of a strong ramus intermedius artery and the middle left anterior descending artery and a severe overall plaque burden with a high-risk plaque in a heavy smoker taking opioid pain medication after esophagectomy.
According to the new version of the Coronary Artery Disease - Reporting and Data System 1 this case should be classified CAD-RADS 3/P3/HRP.
Functional assessment should be considered in this patient such as nuclear stress testing, stress echo or stress MRI (CT stress perfusion and CT-FFR were not available in this case) to look for myocardial ischemia 1,2. Management should also include aggressive risk factor modification and preventive therapy 1.