1. Introduction to Coronary CTA reporting
and plaque vulnerability CAD RADS based
By
Mohammed Gibreel , FEBR
Cardiac Imager senior registrar
AHC and NHI
2. CAD-RADS = Coronary Artery Disease
Reporting and Data System.
CAD-RADS is a standardized reporting system for coronary CTA results and
findings .
The main goal of CAD-RADS is to create report standardization terminology for
coronary CTA results and to improve communication of results to referring
physicians in a clear and consistent fashion with a final assessment and
suggestions for further management.
5. CAD-RADS reporting and data system for
patients presenting with stable chest pain
CAD-RADS will not apply for smaller vessels (<1.5 mm in diameter).
plaque with positive remodeling and no evidence of stenosis = CAD-RADS 1.
Coronary CTA has low accuracy for diagnosis of in-stent restenosis,
particularly in stents smaller than 3.0 mm diameter
6. Modifiers; N(non diagnostic study),S
(stent) ,G (graft) & V (vulnerable)
N:-
If the study is not fully diagnostic i.e. not all segments >1.5 mm diameter
can be interpreted with confidence).
Used when CAD-RADS is greater than 3 ( moderate and above).
Example, a patient with moderate stenosis (50-69%) in one segment with one
or more non-diagnostic remote segments CAD-RADS 3/N and not CAD-
RADS N, since further evaluation is needed.
7. Mid LAD Moderate stenosis + cardiac motion artifact of mid RCA so
CAD RADS is ?
CAD RADS 3/N or CAD RADS N ?
8. Answer is:
CAD RADS 3/N.
But if the mid LAD stenosis was mild so it will be
CAD RADS N .
9. Modifiers; N(non diagnostic study),S
(stent) ,G (graft) & V (vulnerable)
S:-
The modifier “S” indicates the presence of at least one coronary stent anywhere
in the coronary system.
Grading of in-stent stenosis should follow the grading of the coronary arteries.
For example, patent stent in Px LAD with no in-stent restenosis + mild non-
obstructive disease (25-49%) in LCX or RCA CAD-RADS 2/S.
If a patient demonstrates significant in-stent restenosis of a stent in the Px LAD
CAD-RADS 4A/S.
Patent stent in the Px LAD and a new severe stenosis in the RCA CAD-RADS
4A/S.
Finally, if a stent was non evaluable and no other lesions more than 50% in the
coronary tree CAD-RADS N/S.
11. Modifiers; N(non diagnostic study),S
(stent) ,G (graft) & V (vulnerable)
G:-
The modifier “G” indicates the presence of at least one coronary artery
bypass graft.
Stenosis bypassed by a fully patent graft is not considered for the CAD-RADS
classification.
Example , patent LIMA to mid LAD with free anastomotic site and segment
distal to anastomotic site + mild RCA or LCX stenosis (25-49%)
CAD-RADS 2/G.
Example , total occlusion of a saphenous vein graft (SVG) to the RCA, and a
patent LIMA to LAD and SVG to LCX CAD-RADS 5/G.
12. Modifiers; N(non diagnostic study),S
(stent) ,G (graft) & V (vulnerable)
V:-
Presence of “vulnerable” or high-risk plaque ,,,, associated with future ACS.
High-risk features include 4 items if 2 or more are present =Vulnerable
plaque :-
1) low attenuation plaque (less than 30 Hounsfield Units).
2) positive remodeling.
3) spotty calcification.
4) napkin ring sign.
13.
14.
15. Focal non-calcified plaque
in the mid RCA with 25-
49% diameter stenosis.
The plaque demonstrates
two high risk features,
low attenuation(<30 HU)
and positive remodeling,
thus coding with the
modifier “V.”
16. If more than one modifier is present, the symbol “/”(slash)
should follow each modifier in the following order:
i. First: modifier N (non-diagnostic).
ii. Second: modifier S (stent).
iii. Third: modifier G (graft).
iv. Fourth: modifier V (vulnerability).
17. Examples:
1) Non-interpretable coronary stent without evidence of other
obstructive coronary disease: Modifier S CAD-RADS N/S .
2) Presence of stent + new moderate stenosis showing a plaque
+ high-risk features: Modifiers S and V CAD-RADS 3/S/V .
3) Presence of stent, grafts and non-evaluable segments due to
metal artifacts: Modifiers S and G CAD-RADS N/S/G.
4) Presence of patent LIMA to the LAD + Mild non-obstructive
stenosis in the RCA and LCX. Modifier G CAD-RADS 2/G.
5) Severe stenosis (70-99%) in one segment and a non-diagnostic
area in another segment CAD-RADS 4/N.
22. MS ( 00 D) CT CORONARY ANGIOGRAPHY WITH CALCIUM SCORE
Clinical history and risk factors :-
Clinical question :-
TECHNIQUE: using a [scanner type], a preliminary scout study was obtained,
followed by coronary artery calcium.
Protocol: [Prospective; Retrospective>] ECG triggering was used with Heart
rate of 00 B/M. Following administration of 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 imaging.
MEDICATIONS: [100mg of oral metoprolol was administered two hours before
scanning]. [0.4mg sublingual nitroglycerine was administered immediately
prior to scanning].
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 ;respiratory motion if the patient did not comply completely with
breath holding instructions. Cardiac motion if there was acceleration of heart
rate occurred during acquisition. Image quality is partially degraded by high
BMI in cases of obese patient.
23. FINDINGS:
The total calcium score = zero / 00 .
The coronary arteries arise in normal position. There is ____ (right/ left/ co) coronary artery
dominance.
Left main: The left main coronary artery is a _____ (short/ medium/ large) size vessel and
(bifurcates in LAD and LCX /or trifurcates in LAD,RI and LCX). It is patent with no evidence of
plaque or stenosis.
LAD: The left anterior descending artery is patent with no evidence of plaque or stenosis. It
gives off ____ patent diagonal branches.
LCX: The left circumflex artery is patent with no evidence of plaque or stenosis. It gives off
____ patent obtuse marginal branches.
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.
Cardiac valves: There is no thickening or calcifications in the aortic and mitral valves.
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 and mediastinum.
24. IMPRESSION:
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: [ ].
