INDICATION FOR PROCEDURE:
1. Unstable angina pectoris.
2. Known history of coronary artery disease.
3. Status post coronary artery bypass grafting.
4. Prior PCI of saphenous vein graft to obtuse marginal.
PROCEDURES:
1. Left heart catheterization.
2. Selective coronary angiography of the native vessels.
3. Selective coronary angiography of the bypass vessels.
4. LIMA injection.
5. PTCA and stenting of the saphenous vein graft to the obtuse marginal.
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography of the native vessels.
3. Selective coronary angiography of the bypass vessels.
4. LIMA injection.
5. PTCA and stenting of the saphenous vein graft to the obtuse marginal.
COMPLICATIONS: None.
TOTAL FLUORO TIME: 10.3 minutes.
TOTAL CONTRAST: 90 mL of Isovue.
DESCRIPTION OF THE PROCEDURE: Informed consent was obtained. Standard sterile prep. The
patient was brought to the Catheterization Laboratory on an emergent basis because of chest
pain. She was prepped with 100 mg of IV hydrocortisone, 50 mg of IV Benadryl and 20 mg of IV
Pepcid as well as 50 mg p.o. prednisone due to her history of contrast allergy. In the
Catheterization Laboratory she was prepped and draped in the usual sterile fashion. Versed and
fentanyl were given for sedation; 2% topical lidocaine was infiltrated into the right common
femoral area for local anesthetic purpose. The pulse was weak and hardly palpable in the right
common femoral area. An SonoSite was used to access the right common femoral artery using a
modified Seldinger technique with the ultrasound guidance. After successful access with a
micropuncture needle eventually a 6-French sheath was placed. Through the 6-French sheath a
6-French JL4 and JR4 were advanced in succession over a guidewire for cannulation of the
coronary arteries. Left heart catheterization was also performed with the JR4. The JR4 was
then used for selective engagement of the saphenous vein graft to the obtuse marginals as well
as LIMA injection. At the completion of the diagnostic portion of the procedure it was decided
to proceed with PCI of the saphenous vein graft to the obtuse marginal. The ACT was checked
and it was 114. The patient was given 5000 unit bolus of heparin. A 6-French JR4 guide
catheter was used to engage the saphenous vein graft to the obtuse marginal. A 100 mcg of
Nipride was given intragraft. The ACT was redrawn and was 266. Thereafter, a filter wire
distal embolic protection device was advanced distal to the previously placed stent in the vein
graft and deployed within the body of the graft just proximal to the anastomosis. Thereafter,
an Apex 3.0 mm x 12 mm balloon was advanced to the stenosis and inflated to 8 atmospheres for
13 seconds. Thereafter the balloon was removed and a Resolute 3.5 mm x 15 mm drug-eluting
stent was advanced through the lesion and deployed to 15 atmospheres for 32 seconds and
reinflated to 21 atmospheres for 25 seconds. After this the wound was removed. There was
excellent TIMI-3 flow, no evidence of dissection and the filter retrieval device was advanced
and the filter was removed and all of the equipment was removed. The ACT at the end of the
case was 232. The sheath was sutured in place and the patient was transferred to the CV ICU in
stable condition. There were no immediate complications.
FINDINGS:
1. Hemodynamics: The aortic pressures was 149/51 with a mean aortic pressures of 84. LV
pressure was 148/-8 with LV end-diastolic pressure of 5. There was no significant
gradient on pullback across the aortic valve.
2. Left ventriculography was not performed given the patient's renal function.
3. Coronary angiography:
a. The left main. The left main gives off of the LAD, left circumflex and ramus
intermedius. The left main is severely diseased with distal 90% stenosis at the
trifurcation.
b. The ramus intermedius. The ramus intermedius is severely diseased and subtotally
occluded at the takeoff of the left main.
c. The left circumflex. The left circumflex is severely diseased at the takeoff of
the distal left main and is seen to give off a first marginal branch after which
the left circumflex was occluded.
d. LAD. The LAD comes off of the left main and is severely diseased in the proximal
portion and occluded after the second septal perforator. Some competitive flow is
visualized distal to the second septal perforator.
e. Saphenous vein graft to the 2nd obtuse marginal reveals a 95% focal stenosis in the
proximal portion of the graft. A 40-50% narrowing within the previously placed
stent is visualized in the mid portion and distally the anastomosis is intact with
excellent TIMI-3 flow. The distal marginal system is diffusely diseased.
f. Saphenous vein graft to the 3rd marginal system is widely patent with
retrograde flow seen into the circumflex to the point of occlusion in the mid
portion.
g. The LIMA to LAD is widely patent. Brisk flow is seen into the distal LAD and
septal perforators and left to right collaterals reconstituting the posterior
descending artery in a TIMI-3 fashion.
CONCLUSIONS:
1. Successful PCI of the saphenous vein graft to the 2nd obtuse marginal and placement of
a Resolute drug-eluting stent.
2. Patent LIMA to LAD.
3. Patent saphenous vein graft to the third obtuse marginal system.
4. Severely diseased native coronary arteries with occluded right coronary artery, occluded
LAD at the mid portion and occluded left circumflex in the proximal portion after takeoff
of a tiny first marginal.
PLAN:
1. The patient was advised to undergo aggressive cardiac risk factor modification and
continued medical management.
2. Twelve months of dual antiplatelet therapy was recommended, if not indefinitely given the
degree of disease that she has.
3. Continued measures for renal protection.
4. The sheath will be pulled when the ACT is less than 180.
5. Bed rest for a minimum of 6 hours.
1. Unstable angina pectoris.
2. Known history of coronary artery disease.
3. Status post coronary artery bypass grafting.
4. Prior PCI of saphenous vein graft to obtuse marginal.
PROCEDURES:
1. Left heart catheterization.
2. Selective coronary angiography of the native vessels.
3. Selective coronary angiography of the bypass vessels.
4. LIMA injection.
5. PTCA and stenting of the saphenous vein graft to the obtuse marginal.
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography of the native vessels.
3. Selective coronary angiography of the bypass vessels.
4. LIMA injection.
5. PTCA and stenting of the saphenous vein graft to the obtuse marginal.
COMPLICATIONS: None.
TOTAL FLUORO TIME: 10.3 minutes.
TOTAL CONTRAST: 90 mL of Isovue.
DESCRIPTION OF THE PROCEDURE: Informed consent was obtained. Standard sterile prep. The
patient was brought to the Catheterization Laboratory on an emergent basis because of chest
pain. She was prepped with 100 mg of IV hydrocortisone, 50 mg of IV Benadryl and 20 mg of IV
Pepcid as well as 50 mg p.o. prednisone due to her history of contrast allergy. In the
Catheterization Laboratory she was prepped and draped in the usual sterile fashion. Versed and
fentanyl were given for sedation; 2% topical lidocaine was infiltrated into the right common
femoral area for local anesthetic purpose. The pulse was weak and hardly palpable in the right
common femoral area. An SonoSite was used to access the right common femoral artery using a
modified Seldinger technique with the ultrasound guidance. After successful access with a
micropuncture needle eventually a 6-French sheath was placed. Through the 6-French sheath a
6-French JL4 and JR4 were advanced in succession over a guidewire for cannulation of the
coronary arteries. Left heart catheterization was also performed with the JR4. The JR4 was
then used for selective engagement of the saphenous vein graft to the obtuse marginals as well
as LIMA injection. At the completion of the diagnostic portion of the procedure it was decided
to proceed with PCI of the saphenous vein graft to the obtuse marginal. The ACT was checked
and it was 114. The patient was given 5000 unit bolus of heparin. A 6-French JR4 guide
catheter was used to engage the saphenous vein graft to the obtuse marginal. A 100 mcg of
Nipride was given intragraft. The ACT was redrawn and was 266. Thereafter, a filter wire
distal embolic protection device was advanced distal to the previously placed stent in the vein
graft and deployed within the body of the graft just proximal to the anastomosis. Thereafter,
an Apex 3.0 mm x 12 mm balloon was advanced to the stenosis and inflated to 8 atmospheres for
13 seconds. Thereafter the balloon was removed and a Resolute 3.5 mm x 15 mm drug-eluting
stent was advanced through the lesion and deployed to 15 atmospheres for 32 seconds and
reinflated to 21 atmospheres for 25 seconds. After this the wound was removed. There was
excellent TIMI-3 flow, no evidence of dissection and the filter retrieval device was advanced
and the filter was removed and all of the equipment was removed. The ACT at the end of the
case was 232. The sheath was sutured in place and the patient was transferred to the CV ICU in
stable condition. There were no immediate complications.
FINDINGS:
1. Hemodynamics: The aortic pressures was 149/51 with a mean aortic pressures of 84. LV
pressure was 148/-8 with LV end-diastolic pressure of 5. There was no significant
gradient on pullback across the aortic valve.
2. Left ventriculography was not performed given the patient's renal function.
3. Coronary angiography:
a. The left main. The left main gives off of the LAD, left circumflex and ramus
intermedius. The left main is severely diseased with distal 90% stenosis at the
trifurcation.
b. The ramus intermedius. The ramus intermedius is severely diseased and subtotally
occluded at the takeoff of the left main.
c. The left circumflex. The left circumflex is severely diseased at the takeoff of
the distal left main and is seen to give off a first marginal branch after which
the left circumflex was occluded.
d. LAD. The LAD comes off of the left main and is severely diseased in the proximal
portion and occluded after the second septal perforator. Some competitive flow is
visualized distal to the second septal perforator.
e. Saphenous vein graft to the 2nd obtuse marginal reveals a 95% focal stenosis in the
proximal portion of the graft. A 40-50% narrowing within the previously placed
stent is visualized in the mid portion and distally the anastomosis is intact with
excellent TIMI-3 flow. The distal marginal system is diffusely diseased.
f. Saphenous vein graft to the 3rd marginal system is widely patent with
retrograde flow seen into the circumflex to the point of occlusion in the mid
portion.
g. The LIMA to LAD is widely patent. Brisk flow is seen into the distal LAD and
septal perforators and left to right collaterals reconstituting the posterior
descending artery in a TIMI-3 fashion.
CONCLUSIONS:
1. Successful PCI of the saphenous vein graft to the 2nd obtuse marginal and placement of
a Resolute drug-eluting stent.
2. Patent LIMA to LAD.
3. Patent saphenous vein graft to the third obtuse marginal system.
4. Severely diseased native coronary arteries with occluded right coronary artery, occluded
LAD at the mid portion and occluded left circumflex in the proximal portion after takeoff
of a tiny first marginal.
PLAN:
1. The patient was advised to undergo aggressive cardiac risk factor modification and
continued medical management.
2. Twelve months of dual antiplatelet therapy was recommended, if not indefinitely given the
degree of disease that she has.
3. Continued measures for renal protection.
4. The sheath will be pulled when the ACT is less than 180.
5. Bed rest for a minimum of 6 hours.