CTA coronary reporting

1. Introduction to Coronary CTA reporting
By
Mohammed Gibreel , FEBR
Cardiac Imager senior registrar ,,, AHC and NHI
With major contribution of our associate Prof Dr. Mohammed Ali Salem , Kasralainy

2. • Most of this lecture based on reports of the associate
professor Dr. Mohammed Ali Salem
Cardiac CT professional Radiologist .

3. Recommended coronary CT reporting drafts

4. • Patient full name.
• Date of study .
• Patient ID .
• BSA in certain cases.

5. MS ( 64/80/128/160/256/320D) CT CORONARY
ANGIOGRAPHY WITH CALCIUM SCORE
Clinical history and risk factors :-
• -- years old male /female with typical/atypical chest pain / dyspnea ,,,, HTN, DM,
Dyslipidemia, smoker for -- Years ( Smoking Index= ).
• Or failure of cannulation of RCA / non visualization of RCA.
• Or LCA ?? Spasm versus significant stenosis.
• Or Stanford type A dissection ,,, to assess origin of the coronaries.
Clinical question :- Assessment of coronary tree or RCA or LMA. Stents /Grafts.
Technique: using a [scanner type ,,, single source /Dual source], a preliminary scout
study was obtained, followed by coronary artery calcium score.

6. • Protocol:
[Prospective; Retrospective, semi-prospective , retrospective with mA modulation] ECG gating
was used with Heart rate of 00 B/M. Following administration of non-ionic intravenous
contrast 1.5ml/Kg, [0.5] mm collimated images were obtained through the coronary arteries.
Data were transferred off-line for 3D reconstructions including Curved MPR and multi-planar
reformatted images.
OR
Timed ECG-gated MSCT study of the coronary arteries was performed after IV
injection of 70/80/90/100 ml of non-ionic contrast media through an
antecubital vein followed by rapid acquisition of thin consecutive sections
through the heart to evaluate the coronary arteries that were studied in
different phases of the cardiac cycle using the different reformatting
procedures.

7. • MEDICATIONS:
[50 mg of oral atenolol was administered two hours before scanning].
[0.4 mg sublingual nitroglycerine was administered immediately prior
to scanning (just before contrast injection) ].[ 1.5 mg bromazepam as
anxiolytic 2 hours prior to exam].

8. EXAM QUALITY and SCAN LIMITATIONS: [excellent, with no artifacts;
good, with minor artifact but good diagnostic quality; acceptable,
with moderate artifacts; poor/suboptimal, with severe artifacts].
Artifacts
1)Respiratory motion,,, write (the patient did not comply completely with breath
holding instructions this led to respiratory motion artifacts that mainly affected PX
RCA/ mid LAD/ distal RCA ,,,,etc.,,,
2)Cardiac motion if there was acceleration of heart rate occurred during
acquisition.
The image quality partly degraded by the cardiac motion artifacts caused by
acceleration of the heart rate after IV contrast injection. However, review of the
coronary segments at different phases of the cardiac cycle allowed adequate
assessment of the coronary arterial system.
3)Image quality is partially degraded owing to High BMI (in cases of obese patient).

9. FINDINGS:
The total calcium score = zero / 00 .
The coronary arteries arise in normal position. There is ____ (right/ left/ co) coronary artery dominance.
Left main artery /trunk (LMA/LMT) or LCA : The left main coronary artery is a _____ ( medium/ large) size (short
/long ) vessel .
It (bifurcates in LAD and LCX /or trifurcates in LAD,RI and LCX).
The LMA is patent with no evidence of plaque or stenosis.
Or the LMA shows mild atherosclerotic changes with no significant stenosis.
Or the LMA show diffuse atherosclerotic changes .
Or the ostium /PX/distal segment shows (a concentric /an eccentric )( non-calcified /faintly calcified / partly
calcified /densely calcified) (non-vulnerable/ vulnerable ) plaque [as it shows ( positive remodeling / spots of
calcifications /Napkin ring sign/ necrotic core < 30 HU )] causing (minimal /mild /moderate /significant )stenosis.
Or very short artery ; the LAD & LCX arises from the left coronary sinus with common ostium.
Or Absent , the LAD & LCX arises directly from the left coronary sinus with separate ostia.
Or anomalous origin of the LCA from RCA or right CS with (interarterial /pre-pulmonic/retroaortic ) course .
Or high take-off LCA from the tubular ascending aorta ( --mm) above the STJ in continuity with LT CS.
Or ALCAPA ( we reported it in a 40 years adult female).

10. • LAD: The left anterior descending artery is patent with no evidence of plaque or stenosis. It
gives off ____ patent diagonal branches& many septal perforators.
• Long artery that reaches (& wraps around )the apex. It supplies
(one/two/three/four/five/six/seven/eight/nine) Diagonal branches and many septal
perforators . ( the D1 is an early branch / D3 is a large bifurcating artery/D1&2 are large
branches ).
• Or short artery that barely reaches the apex.
• The ostium /para-ostial (1st 5 mm of the vessel )/ proximal /mid /distal LAD shows shows (a
concentric /an eccentric )( non-calcified /faintly calcified / partly calcified /densely calcified)
(non-vulnerable/ vulnerable ) plaque [as it shows ( positive remodeling / spots of
calcifications /Napkin ring sign/ necrotic core < 30 HU )] causing (minimal /mild /moderate
/significant )stenosis.
• The mid LAD shows a (superficial/deep) (long /short) segment of intramyocardial course ;
likely myocardial bridge ; its depth = mm , length = mm with (significant /non-significant)
caliber attenuation & (significant /non-significant )systolic milking .
• The PX /mid D1/D2 shows an eccentric non-calcified plaque causing significant stenosis ; the
average calibers of D1/D2 = 3 mm .
• The proximal / mid LAD is ectatic as its average calibers mounts to >5 mm .
• The rest of the LAD & its branches show mild atherosclerotic changes with no significant
stenosis.

11. CTO
• Or the LAD shows a segment of CTO ( Chronic Total Occlusion). It starts from
PX /mid segment , its length = mm with (central or eccentrically tapered /
blunt ) (proximal/distal )cap or entry side.
• No side branch adjacent to the proximal entry side / side branch adjacent to
the proximal entry side is present.
• (Significant {> 50% lumen encroachment or >180° wall circumference or
central calcification} / non significant {< 50% encroachment or <180° wall
circumference or no calcification } ) wall calcification .
• Bending angle of the CTO segment (<45°/>45°).
• Occlusion duration > 12 month or unknown (clinical data )
• Reattempt of previously failed CTO PCI = (clinical data )
• KCCT score = or CT RECTOR score =

12. • Or anomalous origin of the LAD from (Px RCA / right CS) with
(interarterial/pre-pulmonic course )to join the anterior IV groove.
• Or duplicated LAD type I/II/III/IV. Two LAD ,,,, short LAD arises from
the LCA & supplies the Px IV groove with D1,2 ,,, SP 1,2 ,,,,,,the long
LAD arises from LCA /RCA suppling the mid , distal IV groove & D3.

13. • LCX: The left circumflex artery is patent with no evidence of plaque or
stenosis. It gives off ____ patent obtuse marginal branches.
Or
• Dominant /non-dominant artery that supplies SAN , high lateral = high
OM / one/ two / three OM branches , +- PDA & small /large PLA.
• The proximal LCX ( before /at /after) OM1/ OM2/OM3 shows an
eccentric non-calcified ( vulnerable / non-vulnerable )plaque causing
,,,,,etc.
• The proximal LCX is ectatic as its average cross sectional diameters
mounts to >5mm.
• The rest of the LCX & its branches show mild atherosclerotic changes
with no significant stenosis.

14. • The SNA branch of the LCX shows fistulous communication with the
RA the average calibers = 10mm , the neck of the fistula = --mm.
• Coronary cameral fistula / aorta RA tunnel if present as above.
Or
• Anomalous origin of the dominant/non-dominant LCX from the right
CS / Px RCA with retro-aortic course to join the left AV groove where
it supplies OM branches and small PLA / Long PDA .

15. RCA: The right coronary artery is patent with no evidence of plaque or stenosis. It gives off a patent posterior
descending artery and a patent posterior left ventricular branch.
Or
• Dominant artery that supplies Conus , SAN , acute marginal or RV branches & ends at the crux by giving a long
PDA and PLA/ multiple PLAs.
• Dominant artery that supplies Conus , SAN , acute marginal or RV branches & an early PDA at the acute margin
of the heart . The RCA ends at the crux by giving a second long PDA and PL arteries / multiple PLA.
• Separate origin of the Conus artery from the right CS (Conus artery may be cannulated instead of RCA during
coronary angiography).
Or
• Non-dominant artery that supplies Conus , SAN , acute marginal or RV branches & ends at the acute margin of
the heart .
Or
Anomalous origin of the dominant /non-dominant RCA from the LCA /left CS with interarterial course of the
attenuated /slit Px segment between the RVOT/MPA &Aorta to join the right AV groove where it supplies RV
branches ,,,,etc.
Or
Acute take-off of the RCA showing a 25º angle with the aortic wall , no significant compression nor significant
stenosis. No congenital coronary ostial valve-like ridges.
Or
High take-off RCA from the tubular ascending aorta ( --mm) above the STJ in continuity with RT CS.

16. In cases of moderate or severe multi vessel disease & possibility of cath / CABG
• The aorta measures 32x31x30 mm at the sinus level , left sided aortic arch with normal branching pattern.
• The visualized LIMA & RIMA appears free from stenotic lesions ; its average calibers = - mm& -mm respectively.
• In cases of post CABG ,,, full assessment of grafts ostia , body , Px & distal anastomotic sites.
General items start with it in your way of reporting as these are frequently forgotten
• Cardiac Chambers : Dilated LV & LA . No apical LV thrombi / or present .
No LAA filling defects / or present ( slow flow as in AF versus thrombi , for TEE correlation).
Accessory LAA / chicken wing noted with no thrombi .
Persistent LT SVC which seen draining into the dilated CS>>RA.
• PAs: average calibers central pulmonary arteries / prominent /dilated with no filling defects /filling defects seen in the MPA
/central 1st /2nd order branches.
• PVs: normal appearance of the PVs , no ostial stenosis , no APVD (anomalous pulmonary venous drainage).
• Cardiac valves: There is no thickening or calcifications in the aortic and mitral valves.
BAV / dilated aortic root / calcifications of LVOT ,,, Stanford type A ,B aortic dissection , aneurysmal dilatation of the
ascending aorta with maximum diameters of the ascending aorta –x– mm in Diastole & --x– mm in Systole., no peri-aneurysmal
leak ,,,,,etc.
• Pericardium: The pericardial contour is preserved with no effusion, thickening or calcifications.
• Extra-cardiac findings: There are no significant extra-cardiac findings in the available limited views of the lungs , mediastinum
and upper abdominal cuts.

17. IMPRESSION / CONCLUSION
Within normal MSCT coronary angiography ,,, CAD-RADs 0.
Or
Mild atherosclerotic CAD with no significant stenotic plaques ,, CAD-RADs 1.
Or
Atherosclerotic CAD with significant stenotic plaques seen at Px LAD , mid RCA proximal D2 (large branch ),, CAD-RADs
4B
Or
Atherosclerotic CAD with CTO RCA /LAD ,,, CAD-RADs 5.
Or
1- Total calcium score of 00.
2- No evidence of coronary stenosis or plaque by Coronary CT Angiography.
CAD RADS [0] - Management recommendation: Reassurance. Consider other non- atherosclerotic causes of chest
pain.
Other: [ ].

18. Tips & tricks
• Review ,,, Axial (source) images.
• Multi - planner reformatted images (Sagittal, Coronal, Oblique, Curved) with cardiac axes.
• Thin Maximum intensity projection (MIP).
• Volume rendering.
• Consider bloom effect of dense calcium ,,, the proper estimate of degree stenosis could be
affected by Bloom effect of dense Ca,,, write this when u see densely calcified plaque .
• The lesion should be interpreted in the best phase.
* The lesion severity (diameter reduction) is calculated at the narrowest plane.
* Severity of the concentric lesions are calculated either by area or diameter reduction.
* Severity of the eccentric lesions are calculated by diameter reduction.
• Thin MIP for plaque detection , cMPR for quantification .
Revise all phases in all planes if possible.
• Use sharp filters in stents.
• The FoV should be about 180 mm.

20. Thank U
GIPRIANO@YAHOO.COM
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