em2177
Expert
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REASON FOR EVALUATION: Unstable angina.
HISTORY OF THE PRESENT ILLNESS: This patient is a very pleasant 65-year-old
gentleman who has had progressive type of symptoms. He has a history of
abnormal calcium score and hyperlipidemia. He has noted increasing fatigue and
increasing shortness of breath. The patient has noticed chest discomfort when
walking uphill, which is increasing in frequency. The patient went on to have
a stress test which showed severe inferior wall ischemia. The patient thus has
been explained the complete risks, benefits, and alternatives of coronary
angiography, plus/minus angioplasty and stenting, and agrees to proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the right common femoral
area, and a 6-French sheath was placed to the right common femoral artery using
Seldinger technique. Angiography of the groin was performed confirming common
femoral arterial placement and good flow. Next, left heart catheterization was
performed with a JL4 with multiple view angiography, followed by a Williams
right with multiple-view angiography.
At this point the short 6-French sheath was exchanged for a 7-French short
sheath. Heparin was given per weight-based protocol. At this point a 7-French
JR4 with side holes engaged the right coronary ostium. Angiography was
performed. A Luge wire was attempted to cross the right total occlusion at its
mid segment and was unsuccessful. Next a GuideLiner was used for extra support
at the level of the mid RCA, still unable to crass. Thus, we used a PT Graphix
wire, which was able to cross the total occlusion and be placed into the
posterolateral branch. There was good wire movement, confirming high
likelihood of intraluminal flow.
Next a 1.5 x 12 balloon was placed into the mid segment and had difficulty
crossing over through the total occlusion. However, it looked to be somewhat
distal. Thus, at this time we left the balloon in the mid-to-distal segment,
pulled the wire back and through the balloon, and we injected contrast by hand
injection, confirming intraluminal placement. A Luge wire was placed through
the balloon into the distal posterolateral branch. Serial inflations of the
1.5 balloon were performed.
Next 150 meg of nitroglycerin was given intracoronary and angiography was
performed. The GuideLiner and the 1.5 balloon were removed over the wire.
Then a 2.0 x 12 Apex balloon was able to cross easily through this segment.
This was brought back to the level of the occlusion and was inflated serially
to 14 atmospheres. The balloon was removed, and then a 2.5 x 12 apex balloon
was then placed to the area of the lesion and inflated to 14 atmospheres.
At this point the balloon was brought back with multiple-view angiography after
150 meg of nitroglycerin was given. There was significant improvement in
overall TIMI flow from TIMI-0 to TIMI-3 flow. However, there was a heavily
calcified 70% to 80% residual stenosis. There was difficulty in adequate
balloon inflation. At this point we attempted to cross the segment with a
cutting Flextome cutting balloon, 2.5, which would not cross.
At this point the balloon was brought back. Repeat angiography in multiple
views was performed. I felt at this point, since he has good flow through the
vessel and albeit severe residual stenosis, it would be more prudent to finish
today and proceed with Rotablator in the near future. Thus, wire and catheter
were removed. A pigtail was then placed across the aortic valve over the wire.
LVEDP was measured at 15 and LV angiography was performed. Pullback revealed
no significant aortic valve gradient. Pigtail was removed, and the Angio-Seal
was placed to the right common femoral artery using standard technique with
good groin hemostasis and no evidence of oozing, bruising, or hematoma. I then
reviewed my findings as well as my plan with patient, who agrees.
IMPRESSION:
1. Left main: No disease.
2. The LAD is a large vessel extending to the apex. In its mid segment it has
a 30% to 40% lesion. Diagonals are widely patent. The circumflex is
nondominant. However, it is a somewhat large vessel that is widely patent.
3. The RCA in the mid segment appears to be heavily calcified. It has a 100%
occlusion with grade 2 collaterals from the left side. This appears to be
heavily calcified. Status post balloon angioplasty reveals approximately
70% residual stenosis. However, there is now TIMI-3 flow
4. LVEDP0M6.
5. LVEF: 60% to 65% with no focal wall motion abnormalities.
6. No aortic valve gradient.
REASON FOR EVALUATION: Unstable angina.
HISTORY OF THE PRESENT ILLNESS: This patient is a very pleasant 65-year-old
gentleman who has had progressive type of symptoms. He has a history of
abnormal calcium score and hyperlipidemia. He has noted increasing fatigue and
increasing shortness of breath. The patient has noticed chest discomfort when
walking uphill, which is increasing in frequency. The patient went on to have
a stress test which showed severe inferior wall ischemia. The patient thus has
been explained the complete risks, benefits, and alternatives of coronary
angiography, plus/minus angioplasty and stenting, and agrees to proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the right common femoral
area, and a 6-French sheath was placed to the right common femoral artery using
Seldinger technique. Angiography of the groin was performed confirming common
femoral arterial placement and good flow. Next, left heart catheterization was
performed with a JL4 with multiple view angiography, followed by a Williams
right with multiple-view angiography.
At this point the short 6-French sheath was exchanged for a 7-French short
sheath. Heparin was given per weight-based protocol. At this point a 7-French
JR4 with side holes engaged the right coronary ostium. Angiography was
performed. A Luge wire was attempted to cross the right total occlusion at its
mid segment and was unsuccessful. Next a GuideLiner was used for extra support
at the level of the mid RCA, still unable to crass. Thus, we used a PT Graphix
wire, which was able to cross the total occlusion and be placed into the
posterolateral branch. There was good wire movement, confirming high
likelihood of intraluminal flow.
Next a 1.5 x 12 balloon was placed into the mid segment and had difficulty
crossing over through the total occlusion. However, it looked to be somewhat
distal. Thus, at this time we left the balloon in the mid-to-distal segment,
pulled the wire back and through the balloon, and we injected contrast by hand
injection, confirming intraluminal placement. A Luge wire was placed through
the balloon into the distal posterolateral branch. Serial inflations of the
1.5 balloon were performed.
Next 150 meg of nitroglycerin was given intracoronary and angiography was
performed. The GuideLiner and the 1.5 balloon were removed over the wire.
Then a 2.0 x 12 Apex balloon was able to cross easily through this segment.
This was brought back to the level of the occlusion and was inflated serially
to 14 atmospheres. The balloon was removed, and then a 2.5 x 12 apex balloon
was then placed to the area of the lesion and inflated to 14 atmospheres.
At this point the balloon was brought back with multiple-view angiography after
150 meg of nitroglycerin was given. There was significant improvement in
overall TIMI flow from TIMI-0 to TIMI-3 flow. However, there was a heavily
calcified 70% to 80% residual stenosis. There was difficulty in adequate
balloon inflation. At this point we attempted to cross the segment with a
cutting Flextome cutting balloon, 2.5, which would not cross.
At this point the balloon was brought back. Repeat angiography in multiple
views was performed. I felt at this point, since he has good flow through the
vessel and albeit severe residual stenosis, it would be more prudent to finish
today and proceed with Rotablator in the near future. Thus, wire and catheter
were removed. A pigtail was then placed across the aortic valve over the wire.
LVEDP was measured at 15 and LV angiography was performed. Pullback revealed
no significant aortic valve gradient. Pigtail was removed, and the Angio-Seal
was placed to the right common femoral artery using standard technique with
good groin hemostasis and no evidence of oozing, bruising, or hematoma. I then
reviewed my findings as well as my plan with patient, who agrees.
IMPRESSION:
1. Left main: No disease.
2. The LAD is a large vessel extending to the apex. In its mid segment it has
a 30% to 40% lesion. Diagonals are widely patent. The circumflex is
nondominant. However, it is a somewhat large vessel that is widely patent.
3. The RCA in the mid segment appears to be heavily calcified. It has a 100%
occlusion with grade 2 collaterals from the left side. This appears to be
heavily calcified. Status post balloon angioplasty reveals approximately
70% residual stenosis. However, there is now TIMI-3 flow
4. LVEDP0M6.
5. LVEF: 60% to 65% with no focal wall motion abnormalities.
6. No aortic valve gradient.