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WOULD 36215,75710 59, 37205,75960
thank you for any assistance on this!
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the left radial artery in the right common femoral artery.
Percutaneous access was obtained utilizing a modified Seldinger
technique and a micropuncture kit. I placed a #5 French sheath in
the left radial artery. In the right common femoral artery I
placed a #7 French sheath and then over a Wholey wire exchanged it
for a #7 French Destination catheter. I advanced a Wholey wire to
the occlusion in the LAD and then used a #5 French multipurpose
guide to perform angiography of the subclavian artery. I was able
to localize the occlusion in the ostial proximal segment of the
subclavian utilizing a #6 French mammary guide catheter through
the destination sheath. I was able to engage the origin of the
subclavian artery. I then proceeded with attempts to cross the
occlusion in the left subclavian artery. Initially this seemed to
be a small channel and I used a 300 length, run through wire and
then we also tried with a Whisper wire, a Crosset XT and with the
support of a valet catheter. I was subintimal in the right
subclavian and at this point terminated the intervention from that
approach and instead approached the femoral catheter. I initially
tried again with a Whisper wire and the run through wire, but I
was unable to cross and so I used a stiff angled glide wire and
was able to cross antegrade through the occlusion in the
subclavian artery. Having crossed the vessel, we proceeded with
angioplasty. I used a Boston Scientific 4.0 mm x 2.0 cm ultrathin
balloon and angioplastied the origin of the subclavian. Following
angioplasty I was able to wire into the aorta in a retrograde
approach from the subclavian. This was done in order to be able to
visualize the origin of the subclavian artery while deploying the
stent from the radial approach. I up-sized to a #7 French sheath
in the left radial artery and then advanced a atrium 10 x 38 mm
covered stent. We were able to cross the lesion with a covered
stent and carefully positioned it to cover the ostium of the
subclavian artery; however, I then placed a wire in the vertebral
artery, and noted that both the vertebral artery, and likely the
mammary artery would be compromised by the covered stent and the
decision was made to exchange the covered stent for a shorter
uncovered stent. The atrium stent was then withdrawn into the
radial artery sheath; however, as it crossed into the radial
arterial sheath the stent was dislodged from the balloon and it
was therefore free on the 0.035 wire in the right radial artery.
This stent could neither be removed nor deployed in that location,
as it was a 10 mm covered stent and I therefore carefully advanced
the stent delivery balloon into the stent and was able to gently
advance this back to the subclavian artery. However, it would not
cross the occlusion at the origin of the subclavian and I
therefore decided to deploy it in the axillary artery. The stent
was withdrawn into the axillary artery and then deployed at first
with a 4 mm SDS balloon and then an 8 mm SDS balloon. After the
second SDS this balloon we had appropriate apposition throughout
the length of the stent and decision was made to leave it at this
point. I was then able to cross through the occluded subclavian
with a 10 x 25 mm Express stent. This was carefully positioned and
then deployed covering the ostium of the subclavian without
encroaching on the mammary or vertebral arteries. It was deployed
at 12 atmospheres with excellent apposition. There was slight
staining in the roof of the ascending aorta, but no evidence of
perforation.
We then performed mammary angiography. The mammary arteries
remained widely patent with TIMI-2 flow now in an antegrade
direction. We did perform angiography of the axillary artery and
the left upper extremity down through the radial artery to ensure
that the vessel remains patent. The #7 French destination sheath
in the right groin was then exchanged for an #8 French short
sheath and the patient was transferred to holding. The patient was
given 5000 units of heparin at the beginning the procedure and we
monitored the ACT which remained above 250 throughout the length
of the case.
thank you for any assistance on this!
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the left radial artery in the right common femoral artery.
Percutaneous access was obtained utilizing a modified Seldinger
technique and a micropuncture kit. I placed a #5 French sheath in
the left radial artery. In the right common femoral artery I
placed a #7 French sheath and then over a Wholey wire exchanged it
for a #7 French Destination catheter. I advanced a Wholey wire to
the occlusion in the LAD and then used a #5 French multipurpose
guide to perform angiography of the subclavian artery. I was able
to localize the occlusion in the ostial proximal segment of the
subclavian utilizing a #6 French mammary guide catheter through
the destination sheath. I was able to engage the origin of the
subclavian artery. I then proceeded with attempts to cross the
occlusion in the left subclavian artery. Initially this seemed to
be a small channel and I used a 300 length, run through wire and
then we also tried with a Whisper wire, a Crosset XT and with the
support of a valet catheter. I was subintimal in the right
subclavian and at this point terminated the intervention from that
approach and instead approached the femoral catheter. I initially
tried again with a Whisper wire and the run through wire, but I
was unable to cross and so I used a stiff angled glide wire and
was able to cross antegrade through the occlusion in the
subclavian artery. Having crossed the vessel, we proceeded with
angioplasty. I used a Boston Scientific 4.0 mm x 2.0 cm ultrathin
balloon and angioplastied the origin of the subclavian. Following
angioplasty I was able to wire into the aorta in a retrograde
approach from the subclavian. This was done in order to be able to
visualize the origin of the subclavian artery while deploying the
stent from the radial approach. I up-sized to a #7 French sheath
in the left radial artery and then advanced a atrium 10 x 38 mm
covered stent. We were able to cross the lesion with a covered
stent and carefully positioned it to cover the ostium of the
subclavian artery; however, I then placed a wire in the vertebral
artery, and noted that both the vertebral artery, and likely the
mammary artery would be compromised by the covered stent and the
decision was made to exchange the covered stent for a shorter
uncovered stent. The atrium stent was then withdrawn into the
radial artery sheath; however, as it crossed into the radial
arterial sheath the stent was dislodged from the balloon and it
was therefore free on the 0.035 wire in the right radial artery.
This stent could neither be removed nor deployed in that location,
as it was a 10 mm covered stent and I therefore carefully advanced
the stent delivery balloon into the stent and was able to gently
advance this back to the subclavian artery. However, it would not
cross the occlusion at the origin of the subclavian and I
therefore decided to deploy it in the axillary artery. The stent
was withdrawn into the axillary artery and then deployed at first
with a 4 mm SDS balloon and then an 8 mm SDS balloon. After the
second SDS this balloon we had appropriate apposition throughout
the length of the stent and decision was made to leave it at this
point. I was then able to cross through the occluded subclavian
with a 10 x 25 mm Express stent. This was carefully positioned and
then deployed covering the ostium of the subclavian without
encroaching on the mammary or vertebral arteries. It was deployed
at 12 atmospheres with excellent apposition. There was slight
staining in the roof of the ascending aorta, but no evidence of
perforation.
We then performed mammary angiography. The mammary arteries
remained widely patent with TIMI-2 flow now in an antegrade
direction. We did perform angiography of the axillary artery and
the left upper extremity down through the radial artery to ensure
that the vessel remains patent. The #7 French destination sheath
in the right groin was then exchanged for an #8 French short
sheath and the patient was transferred to holding. The patient was
given 5000 units of heparin at the beginning the procedure and we
monitored the ACT which remained above 250 throughout the length
of the case.