Marginal Artery Research Articles

PS01.035: ILEOCOLONIC INTERPOSITION GRAFT: A SAFE AND FEASIBLE CONDUIT AFTER ESOPHAGOGASTRECTOMY

Abstract Background Restoration of gastrointestinal tract continuity with a suitable conduit is a vital step in esophagectomy. An adequate length of conduit, preservation of a good blood supply and functionality are keys to a successful outcome Methods We report two cases of successful ileocolonic interposition graft after esophagogastrectomy for caustic injury. Results Both patients were female with mean age of 45. They presented with progressive dysphagia and weight loss after alleged corrosive ingestion. Both had good functional status with no significant comorbidities. OGDS revealed long complex esophageal stricture and biopsy showed acute on chronic esophagitis. CT scan showed diffuse thickening of mid-distal esophagus and gastric stenosis. Both patients had refractory strictures with unsuccessful serial endoscopic dilatation. One patient had endoscopic nasoenteric tube insertion for enteral feeding while the other had laparoscopic feeding jejunostomy placed due to tight strictures. A 3-stage esophagogastrectomy with ileocolonic interposition graft was performed after optimization. Intra-operatively findings were dense fibrotic esophagus with diffuse gastric strictures. Ileocolonic graft comprising of the distal 15cm of terminal ileum, ascending colon and transverse colon was constructed based on middle colic arterial supply via marginal artery of Drummond. Vascularity and length of graft were confirmed before transection. Graft pull through was done via orthotopic posterior mediastinal route and isoperistaltic end-to-side esophago-ileocolonic anastomosis was performed at the neck. Contrast studies showed no anastomotic leak and both patients were discharged well on postoperative day 10. They had good oral intake with satisfactory weight gain with no functional disorders during follow up. Conclusion Ileocolonic interposition graft is a safe and feasible option if a gastric conduit is not available. In addition to the advantages of long length, reflux resistance and good blood supply, the smaller caliber of the ileum eases the pull through and the anastomosis due to a smaller size discrepancy. Disclosure All authors have declared no conflicts of interest.

Establishment of an experimental model of small intestinal ischemia and reperfusion injuries in New Zealand rabbits

ABSTRACT: The present study aimed to establish a methodology capable to cause intestinal ischemia and reperfusion injuries, to perform clamping of the jejunal segment of the extramural peri-intestinal marginal artery branch. For this, 37, 10-week-old male New Zealand breed rabbits were used. One rabbit was used to establish the anatomic references for the procedure and was not part of the six experimental groups; the rest were allocated into six experimental groups: Sham group, negative control, subjected only to midline celiotomy; group I1H undergoing vascular occlusion for an hour; group I2H submitted to vascular occlusion for two hours; group I1H/R2H undergoing vascular occlusion for one hour followed by two hours of reperfusion; group I2H/R1H undergoing vascular occlusion for two hours, followed by reperfusion for one hour, and group I2H/R5H undergoing vascular occlusion for two hours followed by reperfusion for five hours. The rabbits were evaluated for the macroscopic aspects (color and peristalsis) of the jejunal segment, as well as the histological aspect, checking for presence or absence of mucosal destruction, edema, hemorrhaging, lymphatic vessel dilatation, and the presence of polymorphonuclear cells. It was observed that the macroscopic and histopathological lesions accentuated in larger employed ischemia and reperfusion times. Rabbits subjected to ischemia for two hours followed by reperfusion for five hours (I2H/R5H) made up the experimental group which was easily reproducible and showed moderate intestinal injury, different from the other groups.

Is topical epinephrine safe for hemostasis in endoscopic sinus surgery?

Is topical epinephrine safe for hemostasis in endoscopic sinus surgery?

Allogenic mesenchymal stem cell intravenous infusion in reparation of mild intestinal ischemia/reperfusion injury in New Zealand rabbits

ABSTRACT: The present study aimed to evaluate the efficacy of mesenchymal stem cell (MSC) infusion, derived from adipose tissue, on reduction of local and remote tissue damage caused by the event of experimental intestinal I/R in New Zealand breed rabbits. For obtaining, characterization, and cultivation of MSC derived from adipose tissue (MSC-Adp), 3 juvenile animals (four months old) were used. The cells were considered to be viable for therapy after the fourth passage (in vitro phase). For the in vivo stage, 24 young adult animals (six months old) were used, weighing approximately 3.5 kg, in which were randomly divided into two groups, called: IR treated with MSC (I2H/R5H MSC 3D; I2H/R5H MSC 7D); IR treated with PBS (I2H/R5H PBS 3D; I2H/R5H PBS 7D). The animals were anesthetized and submitted to pre-retro-umbilical midline celiotomy. The extramural peri-intestinal marginal artery was located and clamped (predetermined and standardized region) with the aid of a vascular clip, promoting a 2 hour blood flow interruption. After this period, blood flow was reestablished, inhalatory anesthesia was suspended, and the animals awaken. After 5 hours of reperfusion, the treatments were performed by intravenous infusion according to the experimental groups. The animals were evaluated 72 hours and seven days after the treatment as for the macroscopic appearance (color and peristaltism) of the jejunal segment, and by histological evaluation of the ischemic segment for the presence or absence of destruction of the intestinal mucosa, edema, bleeding, dilation of lymph vessels, and presence of polymorphonuclear inflammatory cells, both in the mucosa and submucosa. The observed results revealed that the groups treated with MSC-Adp obtained smaller mucosal and submucosal lesions when compared to the groups treated with PBS. Also, MSC-Adp treated groups obtained controlled inflammatory response and higher mitotic rate, outcomes related to the therapeutic potential of MSC. Infusion of stem cells attenuated the lesions caused by intestinal I/R in both MSC groups when compared to the group treated with PBS.

Ultra-rapid progression of coronary artery disease or undiagnosed unstable plaque? A brief review from a case report

Coronary artery disease rarely manifests itself in the first decades of life, which explains why this population is underrepresented in clinical studies. The mechanisms and natural history of the disease seem to differ between this population and older patients. Recent studies suggest a more rapid disease progression in youth, presenting more unstable atherosclerotic plaques, although this correlation has yet to be proven. In this paper, we present the case of a 41-year-old man who presented with a non-ST elevation myocardial infarction, with percutaneous coronary intervention of the culprit lesion (70-90% lesion at bifurcation of the circumflex artery with the first marginal obtuse artery and a sub-occlusive lesion of the ramus intermedius). There was also a non-significant lesion (estimated at 30%) located in the left anterior descending coronary artery. Ten days after discharge, the patient suffered another non-ST elevation myocardial infarction. The coronary angiography revealed a surprising sub-occlusive lesion of the left anterior descending coronary artery. Regarding this case, the authors reviewed the literature on the pathophysiology of rapidly progressive coronary artery disease and the approach for non-significant lesions in patients with acute coronary syndrome, especially in the younger population.

The role of multislice computed tomography in the diagnosis of coronary artery fistulas

This study aims to investigate the frequency and the anatomical features of coronary artery fistulas in patients undergoing multislice computed tomographic angiography for various reasons. Between January 2009 and July 2015, a total of 40 coronary artery fistulas of 26 patients were retrospectively analyzed using multislice computed tomographic angiography in our clinic. The affected arteries and localizations of the fistulas were evaluated. Of the fistulas, 11 (27.5%) were originating from the circumflex artery, 10 (25%) from the left anterior descending artery, four (10%) from the diagonal arteries, three (7.5%) from the left main coronary artery, three (7.5%) from the right main coronary artery, three (7.5%) from the septal artery, three (7.5%) from the conus artery, one (2.5%) from the obtuse marginal artery, one (2.5%) from left anterior descending artery proper (dual LAD), and one (2.5%) from the ramus intermedius. One of the conus arteries was directly originating from the right coronary sinus. Twelve (30%) of the fistulas were draining into the pulmonary trunk, eight (20%) into the left ventricle, seven (17.5%) into the right ventricle, five (12.5%) into the superior vena cava, three (7.5%) into the right main pulmonary artery, two (5%) into the right atrium, one (2.5%) into the left atrium, one (2.5%) into the right internal thoracic artery, and one (2.5%) into the sinus coronarius. Compared to conventional angiography, multislice computed tomographic angiography is a non-invasive modality which allows enhancing coronary artery fistulas at a higher rate and visualizing the cardiac anatomy in detail.

Limitation in Blood Flow of the Acute Marginal Artery During an Inferior ST-Elevation Myocardial Infarction is Associated With Poorer Clinical Prognosis

Limitation in Blood Flow of the Acute Marginal Artery During an Inferior ST-Elevation Myocardial Infarction is Associated With Poorer Clinical Prognosis

Obtuse Marginal Artery as the Final Branch of a Long Right Coronary Artery: A Rare Case of a Coronary Artery Anatomic Variant or Anomaly

Obtuse Marginal Artery as the Final Branch of a Long Right Coronary Artery: A Rare Case of a Coronary Artery Anatomic Variant or Anomaly

Silent coronary rupture treated with coronary emboliza-tion two years after total arch replacement

We experienced a case of asymptomatic coronary artery rupture two years after type A acute aortic dissection which was successfully treated with coronary embolization. A 51-year-old man underwent total arch replacement for type A acute aortic dissection two years ago. Although he had been followed uneventfully, follow-up computed tomography scan two years after the operation incidentally identified the hemopericardium compressing the posterolateral wall of the left ventricle. Echocardiography showed significant compression of the left ventricle due to the hemopericardium, but did not show any deterioration of cardiac function. ECG-gated 320-sliced multi-detector computed tomography (MDCT) revealed extravasation from the left circumflex artery. He was hemodynamically stable and asymptomatic despite this potentially life threating condition. After the admission, coronary angiography was performed which revealed coronary artery rupture from the distal part of the second obtuse marginal artery (OM2). The artery was successfully treated with coil embolization. However, four-dimensional computed tomography (4D-CT) three days after the embolization still showed persistent extravasation from the first obtuse marginal artery (OM1). As the artery dominated large areas, OM1 was treated with absorbable gelatin sponge particles. 6 months after the procedures, additional coil embolization was performed for recurrence bleeding from these arteries. After these coil embolization, cardiac enzymes were slightly elevated, but no deterioration of cardiac function was noted and successful hemostasis were achieved. Although considerably rare, asymptomatic coronary artery rupture could happen after the thoracic surgery. 4D-CT is efficient for identifying ruptured sites and coronary embolization is reasonable treatment to achieve hemostasis.

Variations in the Left Coronary Artery

Background : There is a large spectrum of variations in the disposition of coronary arteries. Many of these variations are 'normal' and not considered as 'anomalous'1. These variations mainly occur in the Left Coronary Artery (LCA)2. While some of these are benign and have no clinical consequences, other variants can cause important clinical manifestations including sudden death of the individual3. Lack of knowledge of such variations can pose difficulties in percuteneous coronary arteriography, coronary artery bypass surgery or prosthetic valve replacement. A cadaveric study in unsuspected population can help to understand the variations that will be useful to determine the prevalence of certain variations. Thus the objective of this study was to analyze the characteristics of LCA that may be used in the diagnosis and treatment of its pathologies.Methods: The study was carried out in the Department of Anatomy, Chittagong Medical College (CMC) Chittagong over a period between Jan 2012 to Dec 2013 with ethical clearance. A detailed dissection of LCA and its branches in 50 cadaveric human hearts, fixed in 10% formalin was carried out to study normal and variant anatomy of LCA. The length of the main stem of LCA was measured by slide calipers.Results: The LCA was found to arise from the Left Posterior Aortic Sinus (LPAS) of the ascending aorta in 100% cases. The level of the ostia (Opening of coronary artery) was above the free margin of the aortic cusps in 98% cases. In all samples ostia were present below sinutubular ridge (A slight circumferential thickening separating bulbar aortic sinus and proximal ascending aorta). The length of the main stem of LCA (From origin to the point of termination into main branches) was found to range from 0.5-2 cm. The LCA showed bifurcation in 74%, trifurcation in 26% of cases. Left Anterior Descending artery (LAD) was found to terminate at the apex of the heart in 68% and at the posterior interventricular groove in 32% cases. The Left Circumflex artery (LCx) was terminated at the crux of the heart in 52%, near the crux in 44% and by crossing the crux in 4% cases. The Left Marginal Artery (LMA) which was present only in 34% cases, found to terminate nearer to the apex of the heart. 0% Left dominance of heart was observed.Conclusion: Simple attention to potential variations in the origin, number, level of ostia, length of the main stem, branching pattern, termination and distribution of LCA can greatly enhance clinical outcomes.Chatt Maa Shi Hosp Med Coll J; Vol.16 (1); Jan 2017; Page 42-47

Percutaneous Interventional Repair of an Intraoperative Right Coronary Artery Tear

A 70-year-old Caucasian man with a history of coronary artery disease (CAD) 9 months status post–2-vessel coronary artery bypass grafting (left internal mammary artery to left anterior descending artery and saphenous vein graft to the first oblique marginal artery) performed at an outside hospital

Acute Simultaneous Thrombotic Occlusion of Multiple Coronary Arteries in Acute Myocardial Infarction: A Case Report

Introduction: Simultaneous multiple coronary artery thrombosis is a rare finding in ST segment elevation myocardial infarction (STEMI), and has a high mortality rate. Case Presentation: We report a case of myocardial infarction with cardiogenic shock, left bundle branch block, and multiple ST segment elevation on the electrocardiogram and thrombotic occlusion of the left circumflex, optus marginal, and left anterior descending arteries on emergency coronary angiography. Thrombus aspiration was performed at left circumflex, optus marginal, and left anterior descending arteries. Conclusions: In patients with STEMI, multiple coronary thrombosis is unusual and associated with high patient mortality. Keywords: Simultaneous Coronary Thrombosis, Acute Myocardial Infarction, Multiple Thrombosis, Acute ST Elevation Myocardial Infarction and Cardiogenic Shock

Interpretative Guidelines and Possible Indications for Indocyanine Green Fluorescence Imaging in Robot-Assisted Sphincter-Saving Operations.

Since the introduction of indocyanine green angiography more than 25 years ago, few studies have presented interpretative guidelines for indocyanine green fluorescent imaging. We aimed to provide interpretative guidelines for indocyanine green fluorescent imaging through quantitative analysis and to suggest possible indications for indocyanine green fluorescent imaging during robot-assisted sphincter-saving operations. This is a retrospective observational study. This study was conducted at a single center. A cohort of 657 patients with rectal cancer who consecutively underwent curative robot-assisted sphincter-saving operations was enrolled between 2010 and 2016, including 310 patients with indocyanine green imaging (indocyanine green fluorescent imaging+ group) and 347 patients without indocyanine green imaging (indocyanine green fluorescent imaging- group). We tried to quantitatively define the indocyanine green fluorescent imaging findings based on perfusion (mesocolic and colic) time and perfusion intensity (5 grades) to provide probable indications. The anastomotic leakage rate was significantly lower in the indocyanine green fluorescent imaging+ group than in the indocyanine green fluorescent imaging- group (0.6% vs 5.2%) (OR, 0.123; 95% CI, 0.028-0.544; p = 0.006). Anastomotic stricture was closely correlated with anastomotic leakage (p = 0.002) and a short descending mesocolon (p = 0.003). Delayed perfusion (>60 s) and low perfusion intensity (1-2) were more frequently detected in patients with anastomotic stricture and marginal artery defects than in those without these factors (p ≤ 0.001). In addition, perfusion times greater than the mean were more frequently observed in patients aged >58 years, whereas low perfusion intensity was seen more in patients with short descending mesocolon and high ASA classes (≥3). The 300 patients in the indocyanine green fluorescent imaging- group underwent operations 3 years before indocyanine green fluorescent imaging. Quantitative analysis of indocyanine green fluorescent imaging may help prevent anastomotic complications during robot-assisted sphincter-saving operations, and may be of particular value in high-class ASA patients, older patients, and patients with a short descending mesocolon.

Tentorial meningioma supplied by a marginal tentorial artery arising from the superior cerebellar artery: Anatomic and technical considerations

Background and importance The marginal tentorial artery runs over the free edge of the tentorium. Different origins have been described, always involving branches of the carotid artery. We report the superior cerebellar artery as an unknown origin of this artery. We developed our strategy in a case of a tentorial meningioma mainly supplied by this artery. Clinical presentation A 53-year-old man was admitted in our institution for the surgical treatment of a large tentorial and petroclival meningioma. A 2D conventional angiogram was insufficient to detect the tumoral blush. A 3D digital subtraction angiogram (DSA) of the vertebral artery highlighted a blush arising from a marginal tentorial artery fed by the superior cerebellar artery. Selective embolization of this branch led to significant devascularization of the tumor. A total tumor resection was performed 24 h after embolization without complication. The dural medial tentorial artery of the superior cerebellar artery is relatively unknown and courses at the inferior surface of the tentorium. We report the first case in which the marginal tentorial artery arises from this artery. Major bleeding may result from its section or its avulsion from the superior cerebellar artery during surgery; its preoperative diagnosis is thus essential. In this case, a 3D-DSA with dual volume visualization was more sensitive than a 2D conventional angiogram to detect such an anatomic variant. Conclusion The marginal tentorial artery may originate from the superior cerebellar artery. The recognition of this anatomic variant may be essential to avoid hemorrhagic complications during surgery of hypervascular tumors of the tentorium.

Anatomic variations of inferior mesenteric artery and left colic artery evaluated by 3-dimensional CT angiography: Insights into rectal cancer surgery – A retrospective observational study

ObjectiveTo demonstrate the clinical applicability of 3-dimensional CT angiography (3D-CTA) in evaluating the anatomic variations of inferior mesenteric artery (IMA) and left colic artery (LCA), to help make pre-operative strategies of rectal cancer surgery. Methods188 patients with abdominal and pelvic contrast-enhanced CT scan were retrospectively enrolled and 3D-CTA was reconstructed. The origin and branching patterns of IMA, tracking patterns of LCA, intersectional patterns among IMA, LCA and inferior mesenteric vein (IMV) were examined, and their associations with clinical features were analyzed. ResultsThe origin of IMA was located 42.1 ± 7.7 mm above iliac artery bifurcation, 64.4% within the area of the 3rd lumbar vertebra. 47.3% of LCA arose independently from IMA, 27.1% arose at the root of sigmoid artery (SA), 20.7% shared a common trunk with SA while 4.8% of LCA was absent. As for track of LCA before anastomosis with marginal artery, 53.2% went straight upward while medial to the inner border of left kidney (Type A), 27.1% traveled diagonally across left kidney (Type B) and14.9% went infero-laterally to the lower border of left kidney (Type C). Short IMA trunk was independently associated with type A LCA and lower site of IMA origin. At the horizontal level of IMA origin, 29% of the LCA went distant from IMV, while 71% (21% medial, 50% lateral) were mutually close, and the close type was independently associated with type A LCA. ConclusionPreoperative understanding of the vascular variations and the mutual relationship among LCA, IMA and IMV could be obtained by 3D-CTA, which would further help surgeons to set detailed plans for laparoscopic rectal cancer surgery.

Multiple myocardial abscesses secondary to late stent infection

A 53-year-old woman presented to our hospital with dizziness and low-grade fever. She underwent percutaneous coronary intervention to the obtuse marginal artery with a drug-eluting stent 20 months prior to this presentation. Physical examination was remarkable for bradycardia. Electrocardiogram showed a junctional rhythm with heart rate of 35 bpm. Blood and urine cultures were negative. Despite successful urgent pacemaker placement, she had cardiac arrest the following day with unsuccessful cardiopulmonary resuscitation attempt. Cardiac autopsy report revealed multiple abscesses involving the obtuse marginal and left anterior descending arteries as well as the adjacent myocardial regions.

What is the commonest site of coronary artery involvement in diabetic patients with coronary artery disease?

Introduction Diabetes is a complex metabolic disease with different targets of vascular endothelial injury. This study concentrates on locating the common areas of insult in the coronary vascular tree among diabetic patients. Objectives To evaluate the frequent sites of coronary artery involvement in diabetic patients and to compare with non-diabetic patients with Coronary Artery Disease (CAD). Methods Retrospective observational study was conducted on all patients with coronary angiographic evaluation for CAD at Cardiology Unit, Kandy. Results Among 1531 patients reviewed, 37.5% were diabetics (69% males) with a mean age of 56.76±8.5 years. Among them 54.3% had hypertension and 13.3% had dyslipidaemia. Single vessel disease (SVD) was the commonest (30.3%) pattern, whereas 27.6% had dual vessel disease and 26.9% had triple vessel disease. There were 35.6% with significant (stenosis >70%) proximal Left Anterior Descending (LAD) lesions, 17.4% with proximal Left Circumflex (LCX) lesions and 26.7% with proximal Right Coronary Artery (RCA) lesions. There were 13.4%, 13.5% and 10% with distal LAD, LCX and RCA involvement respectively. There were 56.5% with at least one proximal vessel involvement and 35.8% with at least one distal vessel involvement. There were 35.4% and 25.4% with significant diagonal and obtuse marginal vessel involvement respectively, among diabetics. There was a significant involvement of diagonal and obtuse marginal branches in diabetics compared to non-diabetics (p=0.001). Conclusion Single vessel disease and proximal LAD involvement were the commonest patterns observed among diabetic patients and they showed significant involvement of diagonal and obtuse marginal arteries compared to non-diabetic patients.

Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography.

This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC). Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal. Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21cm giving a sensitivity of 100% and a specificity of 83.3%. The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.

Coronary Steal by LIMA Bypass Graft Side-Branches: Physiologic Functional Evaluation and Coil Embolisation

Thoracic side branches of the left internal mammary artery (LIMA) has been reported to cause a coronary steal phenomena if not ligated at the time of surgery. The haemodynamic significance of the unligated side branches remains controversial. We present a case of coronary steal phenomena with an objective evidence of ischaemia that resolved after coil embolisation. A 61-year-old male underwent CABG in 1999 for unstable angina. The LAD received a LIMA graft, vein grafts to the diagonal, obtuse marginal and right coronary artery. His presenting symptom prior to CABG was shortness of breath. He remained symptom free until a year ago where he presented with progressive shortness of breath on minimal exertion despite medical therapy. He underwent a diagnostic coronary angiogram, which revealed severe narrowing in the left main stem, ostial circumflex and proximal LAD as well as occluded right coronary artery. All his grafts were patent. The LIMA was also patent but two unligated thoracic branches were noted. The possibility of coronary steal phenomena was entertained and the patient was brought back to the catheterisation laboratory for fractional flow reserve (FFR) study with a view of coiling the unligated side branches if the FFR was positive. After maximal hyperaemia using intravenous adenosine infusion at 140 mcg/kg/min, maximal FFR was calculated at 0.74 in the distal LAD. Both LIMA branches were occluded with balloons and FFR increased to 0.94. Therefore both branches were coiled and repeat FFR was 0.94 after coil embolisation. Six months later, the patient is off his anti-anginal therapy and is symptom free.

Outcomes after coronary computed tomography angiography of patients at low to intermediate risk for acute coronary syndrome

Background: Coronary computed tomography angiography (CTA) has recently been shown to enjoy a high negative predictive value for ruling out coronary heart disease and risk stratifying patients with acute coronary syndrome (ACS). Hence, we assessed the 1-year outcome associated with a CTA-guided strategy in patients presenting to the emergency department with low to intermediate risk for ACS graded according to the GRACE score. Methods: In this case-series study, 77 consecutive patients (mean age = 49.7 ± 10.1 and 53.2% female) who presented to the emergency department with ischemic-type chest pain and low to intermediate risk for ACS were evaluated prospectively. The patients underwent coronary CTA after the measurement of troponin I. Those with nonobstructive plaques and mild stenoses ( 70% narrowing) underwent coronary angiography. The discharged patients were contacted and their medical records were reviewed to determine the rates of major adverse cardiovascular events (MACE)—comprising death, myocardial infarction, stroke, hospital admission, and revascularization. Results: A total of 89.6% of the patients were in the low-risk ACS group. There was no significant association between MACE and the subscales and the GRACE score (P > 0.05). There was no relationship between the GRACE score and the severity of coronary stenosis (P > 0.05) and the high-severity plaques (P > 0.05). However, the severity of stenoses in the proximal part of the left anterior descending artery (LAD) (P = 0.00), the mid part of the LAD (P = 0.004), and the first part of the obtuse marginal artery (P = 0.004) was associated with MACE. Furthermore, there were no relationships between MACE and the high-risk plaques and the risk factors (P > 0.05). Conclusions: CTA ruled out significant lesions and optimal treatment was accompanied by good prognoses in our patients. CTA may, therefore, be an optimal cost-benefit modality for the determination of the diagnosis and the therapeutic modality in patients at low to intermediate risk for ACS presenting to the emergency department.