28 hours ago Jones, J. Coronary artery bypass graft on chest x-ray. Case study, Radiopaedia.org. (accessed on 28 Nov 2021) https://doi.org/10.53347/rID-6456 >> Go To The Portal
Patients who have had coronary artery bypass grafts (CABG) will often have visible metallic vascular clips seen on their post-operative chest X-ray
Angiography was done for routine assessment of CABG, especially when the patient presented with recurrent angina. However, in the era of cardiac multidetector CT imaging, screening of grafts for patency is quite useful in the early (<1 month) as well as late (>1 month) post-operative period.
Recently, computed tomography (CT), particularly multidetector CT with electrocardiographic gating, has emerged as an important diagnostic tool for evaluation of CABGs in both the early (≤1 month) and late (>1 month) postoperative settings.
Chest radiography (CXR) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care. Aim To assess the influence of CXR on patient management in general practice. Design of study Prospective cohort study. Setting
Patients who undergo CABG surgery with severely compromized left ventricular function, postoperative MRI shows improved global and segmental cardiac function at mid-term follow-up. At the same time there is considerable clinical improvement.
Because the outlines of the large vessels near your heart — the aorta and pulmonary arteries and veins — are visible on X-rays, they may reveal aortic aneurysms, other blood vessel problems or congenital heart disease. Calcium deposits. Chest X-rays can detect the presence of calcium in your heart or blood vessels.
In most cases, merely 'eye-balling' a chest x-ray will be sufficient in detecting cardiomegaly (as the heart is either clearly normal in size or clearly abnormally enlarged). In equivocal cases, the cardiothoracic ratio (CTR) can be easily calculated on a PA chest x-ray.
The stents made of stainless steel can be better seen on the X-ray or fluoroscopy than the stents made of cobalt-chromium.
DiagnosisBlood tests. Blood tests may help confirm or rule out conditions that can cause heart enlargement. ... Chest X-ray. A chest X-ray can help show the condition of the lungs and heart. ... Electrocardiogram (ECG or EKG). ... Echocardiogram. ... Exercise tests or stress tests. ... Cardiac CT scan or MRI . ... Cardiac catheterization.
OBJECTIVE. Cardiac CT angiography (CTA) is commonly performed after coronary artery bypass grafting surgery (CABG) to assess graft patency, but the images also include parts of the lungs, abdomen, and mediastinum.
In short, the answer is no. Once a stent is opened in an artery, the tissue cells of the artery wall begin to grow over the stent. The stent becomes a part of the artery wall and cannot move.
“For a cardiac stent procedure to qualify as a medical necessity, it is generally accepted that a patient must have at least 70% blockage of an artery and symptoms of blockage,” Justice Department attorneys wrote.
A coronary artery bypass graft ( CABG or CAG) is placed during a surgical procedure to increase blood flow to the myocardium due to coronary stenoses, usually caused by coronary artery disease. Arteries or veins can be grafted during this procedure.
Left internal thoracic (or mammary) artery (ITA) grafts have emerged as the preferred bypass graft due to their excellent graft patency and close proximity to the left anterior descending artery (LAD). They are often referred to as LIMA grafts (left internal mammary artery grafts). The graft is directly seen on cross-sectional imaging or appears alongside a row of mediastinal surgical clips. Its proximal end arises from the normal anatomical origin (first part of the left subclavian artery for the LIMA), and its distal end is usually anastomosed to the LAD. The right ITA (RIMA) graft may be used in a similar way.
Other arterial grafts. radial artery: used after harvesting from the forearm. gastroepiploic artery : used by extended sternotomy and is dissected from the greater curvature of the stomach and anastomosed to the target vessel (difficult and rare surgery)
graft malposition or kinking. graft kinking can cause graft occlusion. it is especially common in longer grafts and graft with connector devices. graft spasm. this is common in radial artery grafts. it is seen in the early postoperative period.
Saphenous grafts are most convenient, however most prone to occlusion. In CT imaging, it may not be possible to see the distal anastomosis, however, a continuous contrast column in the graft can be read as the graft being patent.
Coronary artery bypass graft (CABG) surgery is the standard of care in the treatment of advanced coronary artery disease. It is well known that the long-term clinical outcome after myocardial revascularization depends on the patency of the bypass grafts. In the past, invasive coronary angiography was used to assess the status of the grafts and check for graft occlusion. Recently, computed tomography (CT), particularly multidetector CT with electrocardiographic gating, has emerged as an important diagnostic tool for evaluation of CABGs in both the early (≤1 month) and late (>1 month) postoperative settings. A variety of postoperative complications may manifest as dyspnea and chest pain, thereby mimicking recurrent angina secondary to graft occlusion. Owing to its improved spatial resolution compared with that of earlier-generation CT scanners and its ability to produce three-dimensional and multiplanar images, multidetector CT has assumed an integral role in characterization of graft patency while allowing investigation of alternative postoperative complications. In addition, the expanded capabilities of volumetric imaging may provide valuable information in preoperative planning for repeat CABG surgery.
The various conduits used for CABG surgery may be divided into arterial and venous grafts. Venous grafts have demonstrated a tendency to develop partial or complete occlusions with time, whereas arterial grafts have shown relative resistance to plaque formation and obstruction. However, arterial conduits are more limited in their availability and ease of procurement compared with venous grafts, specifically the saphenous vein. Therefore, saphenous vein grafts (SVGs) remain the most commonly used conduits.
Occlusion after the first month following CABG surgery is primarily due to thrombosis resulting from progressive pathologic changes related to exposure of the SVG to systemic blood pressure (, Fig 21 ). After surgery, the vein graft undergoes a process of arterialization. This results from progressive thickening of the media and neointimal formation, which begins within days of implantation and continues over months to years. These changes form a foundation for eventual atherosclerotic narrowing, which may ultimately lead to late graft occlusion.
True aneurysms typically arise more than 5 years after bypass and occur in the body of the graft. The dominant mechanism is related to accelerated atherosclerosis (, 44,, 45 ). Pseudoaneurysms more commonly occur within 6 months after surgery, although they may also arise several years later. Pseudoaneurysms arise at either proximal or distal anastomotic sites (, Fig 22, ). Earlier-onset cases may be related to wound infection or to tension at the anastomosis that leads to suture rupture; the pathogenesis of later pseudoaneurysms most likely involves progressive atherosclerosis (, 43,, 44,, 46 ). Less common graft body pseudoaneurysms have been reported secondary to host vessel degeneration and technical factors involved in harvesting the SVG (, 44 ).
Patients are generally asymptomatic, and the effusion usually resolves spontaneously over several weeks (, 31 ). Only 1%–4% of CABG surgery patients proceed to develop clinically significant effusions that manifest with chest pain and dyspnea and require thoracentesis.
A segment of the saphenous vein was used to perform the first CABG operation in 1962. Since then, the susceptibility of SVGs to occlusive failure in both early and late postoperative settings has been well documented and extensively investigated. Early graft occlusion is primarily due to vascular damage that can occur at surgery, whereas vessel wall changes resulting from exposure to systemic blood pressure may predispose to occlusion in later stages. A large angiographic study of CABGs ( n = 5,065; 91% venous, 9% arterial) performed to assess graft disease found that 88% of grafts were patent perioperatively, 81% were patent at 1 year, and 75% were patent at 5 years, with a further decline to 50% at 15 years or later (, 7 ). Nevertheless, continued improvements in surgical techniques, combined with use of antiplatelet or anticoagulant agents and lipid-lowering drug therapy, have allowed SVGs to remain an important, convenient, and readily available choice for bypass grafting (, 8 ).
Left-sided grafts are typically anastomosed distally to the LAD artery, diagonal artery, circumflex artery, or the obtuse marginal branches of the circumflex artery (, Figs 2 –,, 4 ). Right-sided grafts are usually connected to the distal right coronary artery or posterior descending artery.
Most often, the reader of the radiology report is the individual responsible for providing direct patient care. In some cases, the reader will be the patient.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers the radiology report to be part of the medical record because it documents the results of a radiologic test or procedure. 13 In addition, hospitals have specific policies regarding the radiology report as part of the medical record.
The written radiology report is the critical service of radiology and should provide clear and concise communication that is understandable by the intended reader. Since increasingly more often the patient is the reader of the report, it is even more important to keep the report clear and concise.
Impression. The abstract is the summary of a scientific report. In a radiology report, the summary has been referred to as the "Impression," "Conclusion," or "Diagnosis" section. Sometimes this summary is an impression, sometimes it is a conclusion or diagnosis, and sometimes it is a concise statement of the findings.
One of the 3 most common reasons for malpractice suits against radiologists is failure to communicate results clearly and effectively. 2,3 Poor communication is a common reason patients choose to sue the doctor. 5,6 In some situations, such as mammograms, it is helpful to give a copy of the report directly to the patient, which makes it even more important that the report is clear and understandable. 6,7 If a report is written so that a patient can understand what is said, it is much more likely that a healthcare provider, who depends upon the report to make decisions concerning patient management, will also understand the report. 8
Therefore, recapitulation of the indication for the study at the time of the report dictation is appropriate because it will document the actual reason the study was performed. In addition, many third-party payers and Medicare now require an appropriate indication before they will reimburse for a study.
Every radiologic study has a procedure associated with performing the examination. For most routine studies, the procedure is implied by the title. For example, a routine study such as a "PA & LAT Chest," by accepted use, implies the procedure (posteroanterior and lateral chest radiograph), and a separate "Procedure" section of the report is not necessary. However, a separate "Procedure" section may be convenient to document informed consent, technical limitations, drugs, and isotopes or contrast material associated with the study. Frequently, reports for invasive procedures are best organized in a separate "Procedure" section.
There are 2 types of bypass graft aneurysms: true aneurysms and pseudo aneurysms. True aneuryms are usually found 5 to 7 years after CABG surgery and are related to atherosclerotic disease. 42 On the other hand, occurrences of pseudoaneurysms are more variable, although these lesions are usually found at the anastomotic site (Figure 9). Pseudo-aneurysm cases that are found earlier may be related to infection or tension at the anastomotic site, resulting in suture rupture. In late-onset pseudoaneurysms, similar to true aneurysms, atherosclerotic changes likely played a role. 43
Another important complication of the CABG procedure is sternal infection, with a prevalence of 1% to 20%. 48,49 Risk factors include diabetes mellitus, obesity, complexity of surgery, length of surgical time, and blood transfusions. Three different compartments may be affected: the presternal (cellulitis, sinus tracts, abscess), sternal (osteomyelitis, dehiscence), or retrosternal (mediastinitis, hematoma, abscess) compartments. 50 The mortality rate is high; a recent study reported a 1-year mortality rate of approximately 22%. 51 Thus, CTA is important in revealing the extent and depth of infection, which, in turn, will help guide treatment planning. 52 Usually, the preservation of mediastinal fat planes in CTA excludes surgical intervention. On the other hand, obliteration of mediastinum fat planes and diffuse soft tissue infiltration without or with gas collection, or low-density ﬂuid collections within the mediastinum, are concerning for sternal infection. 53
The use of the RA in CABG surgery was first described in 1973. 34 The RA is usually harvested from the nondominant arm and is used as a third arterial graft, either as a free or composite graft or to avoid using a venous graft (Figure 4). As a muscular artery from the forearm, the RA has a prominent medial layer and elevated vasoreactivity, which results in a lower patency rate than that of IMA grafts. On CTA, the caliber of the RA is similar to the IMA, but it typically is visualized coursing from the ascending aorta to the native coronary artery (Figures 1 and 2). In the early postoperative period, the RA may be reduced in caliber and may be difficult to identify because of vasospasm. In addition, because the RA is a muscular artery, a larger number of surgical clips may be needed to ligate collaterals as compared with IMA grafts. These clips may limit a full CTA evaluation of an RA graft.
During the early phase, usually within 1 month after CABG surgery, the most common cause of graft failure is thrombosis from platelet dysfunction at the site of focal endothelial damage during surgical harvesting and anastomosis. 20 Additionally, other factors (such as the hypercoagulability state of the patient and the high-pressure distension or stretching of the venous graft, with its intrinsically weaker antithrombotic features) further initiate early venous graft failure, resulting in a 3% to 12% occlusion rate within 1 month postoperatively. 21
Saphenous grafts tend to appear as large contrast-filled vessels. An SVG to the right side is attached to the distal right coronary artery (RCA), posterior descending artery (PDA), or distal LAD artery (Figure 1). The distal anastomosis may lie on the phrenic wall of the heart (Figure 2).
The graft is usually divided into 3 different segments: the origin or proximal anastomosis of the graft, the body of the graft, and the single (or sequential) distal anastomosis. 18 During the CTA evaluation of bypass grafts, the proximal anastomosis is usually better visualized than the distal anastomosis.
35-37 In rare instances, the right gastroepiploic artery may be used in situ to the PDA. These instances require that the surgical history be conveyed to the radiologist so the CTA protocol can be modified to include the upper abdomen, because the gastroepiploic artery is freed to course anteriorly to the liver and through the diaphragm to reach the target vessel (Figure 5).
The automatic generation of radiology reports given medical radiographs has significant potential to operationally and clinically improve patient care. A number of prior works have focused on this problem, employing advanced methods from computer vision and natural language generation to produce readable reports.
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