em2177
Expert
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REASON FOR EVALUATION: Cardiogenic shock.
HISTORY OF THE PRESENT ILLNESS: This patient is a 60-year-old gentleman who
came in with acute onset of chest discomfort. He has known coronary artery
disease. The patient then had progressive shortness of breath and evidence of
congestive heart failure and volume overload. The patient then had progressive
respiratory failure. His troponin continued to elevate. He had signs and
symptoms of cardiogenic shock.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Using a Seldinger technique, a
6-French sheath was placed to the right common femoral artery. However, there
was some difficulty in crossing the wire up into the aorta area. Then a
6-French sheath was also placed into the right common femoral vein for central
access in case needed, as also the patient had bradycardia. Angiography of the
right common femoral artery showed a significant external iliac stenosis,
approximately 50% to 70%, with significant dilatation and possible narrowing as
well in the common iliac portion. Thus, due to this, it was felt more prudent
to proceed with Seldinger technique. A 6-French sheath was placed to the left
common femoral artery. Then angiography of that site concluded that there was
likely a distal abdominal aortic aneurysm extending into the bilateral iliac.
There was no evidence of significant dissection.
Next, an over-the-wire JL4 was placed into the ascending aorta and then into
the left main. Multiple-view angiography was performed. Over the wire the JL4
was exchanged for a Williams right, and multiple-view angiography was
performed. Next I reviewed the findings. Then, over the wire, a pigtail was
placed into the infrarenal abdominal aorta, and an aortic angiography with
runoff down bilateral groins was performed to evaluate the benefit of
intraaortic balloon pump. There was significant aortic aneurysm, questionable
ostial iliac stenosis of approximately 70% with significant aneurysmal
dilatation of common iliacs as well as the right external iliac, and thus we
preferred for not intraaortic balloon pump. At this point there was concern
regarding an obtuse marginal 3 as the infarct-related artery, although there
was severe diffuse coronary artery disease. All other vessels appeared to be
chronic. Thus, at this point heparin was given per weight-based protocol, and
the 6-French sheath on the left common femoral artery was exchanged for a
7-French short sheath. Then a 7-French XB 3.5 guide engaged the left main.
Multiple attempts to cross into the OM3 were attempted with a Luge wire as well
as a PT2 wire. These were unsuccessful, even with the portable balloon.
Thus, wire and balloons were removed. Catheter was removed. Sheaths were
sutured into place.
At this point the patient's blood pressure was in the 100s. Pulse was in the
50 range.
IMPRESSION:
1. Left main: No significant disease.
2. The LAD in its proximal and mid segment has long diffuse 80% to 90% disease
with evidence of significant in-stent restenosis of a mid stent distally.
This is otherwise widely patent. Diagonals appear to be fairly patent.
3. The left circumflex has a very large proximal obtuse marginal which in the
RAO cranial view appears to have a focal severe proximal-to-mid 80% lesion.
4. The circumflex proper, just prior to an obtuse marginal, has a mid 80%
lesion. Then there is the obtuse marginal. Then in the distal circumflex
proper there is more diffuse disease. There does appear to be an obtuse
marginal 3 branch with 90% lesion and TIMI-1 flow. We were unable to cross
wire to see vessel caliber size.
5. The RCA in the mid segment has a 60% to 70% lesion and then in the PDA has
a 70-80% somewhat long lesion.
6. The distal abdominal aorta is aneurysmal. These extend into the bilateral
iliac segment. In the right external iliac artery there is a 50% to 70%
lesion, and on the left system there is a 50% to 70% ostial common iliac
REASON FOR EVALUATION: Cardiogenic shock.
HISTORY OF THE PRESENT ILLNESS: This patient is a 60-year-old gentleman who
came in with acute onset of chest discomfort. He has known coronary artery
disease. The patient then had progressive shortness of breath and evidence of
congestive heart failure and volume overload. The patient then had progressive
respiratory failure. His troponin continued to elevate. He had signs and
symptoms of cardiogenic shock.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Using a Seldinger technique, a
6-French sheath was placed to the right common femoral artery. However, there
was some difficulty in crossing the wire up into the aorta area. Then a
6-French sheath was also placed into the right common femoral vein for central
access in case needed, as also the patient had bradycardia. Angiography of the
right common femoral artery showed a significant external iliac stenosis,
approximately 50% to 70%, with significant dilatation and possible narrowing as
well in the common iliac portion. Thus, due to this, it was felt more prudent
to proceed with Seldinger technique. A 6-French sheath was placed to the left
common femoral artery. Then angiography of that site concluded that there was
likely a distal abdominal aortic aneurysm extending into the bilateral iliac.
There was no evidence of significant dissection.
Next, an over-the-wire JL4 was placed into the ascending aorta and then into
the left main. Multiple-view angiography was performed. Over the wire the JL4
was exchanged for a Williams right, and multiple-view angiography was
performed. Next I reviewed the findings. Then, over the wire, a pigtail was
placed into the infrarenal abdominal aorta, and an aortic angiography with
runoff down bilateral groins was performed to evaluate the benefit of
intraaortic balloon pump. There was significant aortic aneurysm, questionable
ostial iliac stenosis of approximately 70% with significant aneurysmal
dilatation of common iliacs as well as the right external iliac, and thus we
preferred for not intraaortic balloon pump. At this point there was concern
regarding an obtuse marginal 3 as the infarct-related artery, although there
was severe diffuse coronary artery disease. All other vessels appeared to be
chronic. Thus, at this point heparin was given per weight-based protocol, and
the 6-French sheath on the left common femoral artery was exchanged for a
7-French short sheath. Then a 7-French XB 3.5 guide engaged the left main.
Multiple attempts to cross into the OM3 were attempted with a Luge wire as well
as a PT2 wire. These were unsuccessful, even with the portable balloon.
Thus, wire and balloons were removed. Catheter was removed. Sheaths were
sutured into place.
At this point the patient's blood pressure was in the 100s. Pulse was in the
50 range.
IMPRESSION:
1. Left main: No significant disease.
2. The LAD in its proximal and mid segment has long diffuse 80% to 90% disease
with evidence of significant in-stent restenosis of a mid stent distally.
This is otherwise widely patent. Diagonals appear to be fairly patent.
3. The left circumflex has a very large proximal obtuse marginal which in the
RAO cranial view appears to have a focal severe proximal-to-mid 80% lesion.
4. The circumflex proper, just prior to an obtuse marginal, has a mid 80%
lesion. Then there is the obtuse marginal. Then in the distal circumflex
proper there is more diffuse disease. There does appear to be an obtuse
marginal 3 branch with 90% lesion and TIMI-1 flow. We were unable to cross
wire to see vessel caliber size.
5. The RCA in the mid segment has a 60% to 70% lesion and then in the PDA has
a 70-80% somewhat long lesion.
6. The distal abdominal aorta is aneurysmal. These extend into the bilateral
iliac segment. In the right external iliac artery there is a 50% to 70%
lesion, and on the left system there is a 50% to 70% ostial common iliac