Presentation
Stable chest pain. History of hypertension and diabetes.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
image reconstruction with edge correction
Findings
normal coronary origins and proximal courses
right coronary dominance strong double intermedius branch
corkscrew-like tortuous terminal vessels
Plaque burden:
calcium score (according to Agatson, not shown): 1601
segment involvement score (SIS): 10 segments
Right coronary artery (RCA): gives rise to PDA and RPLB
multiple calcified plaques and severe calcifications in the distal segment
low-grade stenosis (25-49%) in the proximal segment by an odd-looking plaque versus artifact in the transition zone of the cranial and middle sequential axial scan rotations
calcified hardly assessable stenosis in the middle segment and moderate stenosis (50-69%) in the distal segment
no relevant plaques or stenoses in the posterior descending artery (PDA) and posterolateral branch (RPLB)
Left main: quadrifurcation with a strong and a thin ramus intermedius branch
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no plaques or stenosis
Left anterior descending artery (LAD): one diagonal branch
multiple calcified plaques
plaque-related moderate stenosis in the proximal segment (50-69 %)
small diagonal branch with a thin lumen and no relevant plaques or stenoses
Ramus intermedius: duplicate with a thin proximal and strong branching distal branch
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plaque-related moderate stenosis (50-69%) proximally at the origin of the dominant branch
Circumflex artery (CX): two obtuse marginal branches
multiple calcified plaques
low-grade plaque-related stenoses (25-49%) in the proximal and distal thirds
obtuse marginal branches with no plaque or stenoses
Impression
moderate coronary stenoses (50-69%) in the proximal LAD and the origin of the dominant ramus intermedius branch and questionable further significant stenosis in the distal part of the RCA
extensive overall plague burden
quadrifurcation of the left main with duplicate ramus intermedius artery
corkscrew-like tortuous terminal vessels indicating hypertensive disease
Exam courtesy: Yvonne Kühn (radiographer)
Technique
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image reconstruction without edge correction and without motion correction
Findings
Without edge correction, the transition of the three sequential axial steps can be identified clearly as a sharp edge, visible in the coronal and sagittal multiplanar and 3D reconstructions.
The odd-looking plaque in the proximal third of the right coronary artery with possible high-risk features looks much less conspicuous in this image reconstruction. It is consistent with an artifact in the standard reconstruction mode. The plaque-related stenosis in the middle segment of the right coronary artery can now be better assessed in the area of the transition zone and rated as moderate stenosis.
In the standard algorithm with 'edge correction', it looks rather blurry.
Case Discussion
A case of coronary artery disease with moderate stenoses in the proximal left anterior descending artery, the middle segment of the right coronary artery and at the ostium of the dominant ramus intermedius in the setting of a quadrifurcation of the left main stem.
This case demonstrates that different image reconstruction algorithms can clarify or obscure findings and artifacts depending on the chosen algorithm. Edge correction can help to create more beautiful 3D reconstructions in a prospective gated coronary CTA by covering up stair-step artifacts. On the other hand, image reconstruction without edge correction can clarify findings and artifacts created by the correcting algorithm.
According to the 2.0 version of the Coronary Artery Disease - Reporting and Data System 2 this case is classified CAD-RADS 3/P4.
Management recommendations include functional assessment to look for signs of myocardial ischemia 2,3 as well as aggressive risk factor modification and preventive therapy 2.