Angiograms were then obtained with the 5 French pigtail in the ascending aorta and the thoracic aorta. Aortopulmonary collaterals were observed arising from the right subclavian artery, the intercostal arteries and from the aortic isthmus. The pigtail was removed, and a 4F angled Glide catheter and 0.035" Wholey wire were advanced retrograde and used to enter three right-sided intercostal arteries and two left-sided intercostal arteries. Hand angiograms were performed in each vessel; the most superior right intercostal artery that was entered was the only vessel with aortopulmonary collateralization visualized. The the 4F angled Glide in the intercostal artery, the Wholey was removed and a 4 mm x 7 cm Azur CX 35 coil was selected and advanced into the intercostal artery. The coil was deployed, and follow up hand angiogram was performed. The 4F Glide was then removed, and a 4F IMA catheter was advanced into the LIMA with the aid of an 0.030" straight wire. The straight wire was removed, and a hand angiogram was performed in the LIMA which demonstrated no flow through the previously occluded vessel. The IMA was then removed.
The 4F angled Glide was then advanced into the right subclavian artery where hand angiogram was performed and a large aortopulmonary collateral was identified coursing torturously to the right lung field. During catheter manipulation, an additional aortopulmonary collateral adjacent to the previously identified collateral was entered. Hand injection in this collateral also demonstrated collateralization to the left lung field. A 2.8F Progreat catheter was then advanced through the Glide catheter into the distal collateral.The collateral was then occluded with two 5 mm x 16 mm Azur CX 18 coils and a 6 mm x 20 cm Azur CX 18 coil. The Progreat was removed and a follow up hand injection was then performed; this demonstrated filling of the initial subclavian collateral, was entered with manipulation of the Glide catheter. The 2.8F Progreat catheter was then advanced through the Glide catheter into the distal collateral.The collateral was then occluded with a 4 mm x 13 cm Azur CX 18 coil. The Progreat was removed, and additional 4 mm x 5 cm 35 Helical Hydrocoil and 4 mm x 7 mm CX 35 coil were used to occlude the vessel. A follow up hand angiogram was performed.
Further inspection of the thoracic aortic angiogram demonstrated a moderate sized collateral in the vicinity of the left coronary artery vs the aorta. A 5F JL4 catheter was advanced into the aortic root with the help of the 0.030" straight wire. The straight wire was removed and the left coronary artery was engaged. A hand angiogram was performed in the left coronary artery demonstrating normal left coronary anatomy and no apparent AP collateralization. The catheter was pulled back slowly into the ascending aorta with hand angiogram performed that demonstrated no collateralization from the proximal left coronary or the ascending aorta. The collateral appears to be arising from a meshwork of tiny collaterals from the lesser curvature of the aorta that reconstitute into a larger collateral. Attempts were made to enter this vessel with a 4F JR4 catheter and the 4F angled Glide catheter, which were unsuccessful. The procedure was then completed