Fluoroscopic “calcium sign” or reverse “c” sign of the aortic knuckle in a case of chronic total occlusion of left anterior descending coronary artery

We describe an interesting fluoroscopic calcification of the aortic knuckle assuming a reverse “C” shape in an atherosclerotic aorta in a 42-year-old male presenting with anterior wall ST-elevation myocardial infarction with dyslipidemia. Although calcification of the aortic knuckle and dilatation of the aorta is a common phenomenon in the elderly population, otherwise known as the “unfolding of aorta,” we observed this interesting pattern of calcification in a middle-aged person in an atherosclerotic aorta with calcification. The patient had double-vessel coronary artery disease with chronic total occlusion in the left anterior descending coronary artery and significant stenosis in the mid-segment of the right coronary artery, which we revascularized with drug-eluting stents and achieved TIMI III flow. Although calcium sign or C sign is described in aortic dissection and it is not specific to it, we observed this interesting pattern of calcification in a middle-aged person in the atherosclerotic aorta with dyslipidemia.