NEED HELP POSTING TWO PTCA'S AND Thoracic aortogram.

Jane5711

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INDICATIONS:
1. Acute inferior wall and posterior wall myocardial infarction with ST
elevation in leads II, III, aVF and ST-segment depression in leads aVL
and V2 consistent with acute inferior and posterior wall myocardial
infarction.
2. Coronary artery disease.
3. History of thoracic aortic aneurysm.


PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Thoracic aortogram.
5. Percutaneous transluminal coronary angioplasty and stenting of the mid
left circumflex artery with a 3.5/12 mm Xience Alpine Everolimus
drug-eluting stent.
6. Percutaneous transluminal coronary angioplasty and stenting of the mid
distal left circumflex artery with a 3.0/33 mm Xience Alpine Everolimus
drug-eluting stent.

DESCRIPTION OF PROCEDURE: After the informed consent was obtained, the
patient was prepped and draped in the usual sterile fashion. Lidocaine 2
percent was used for local anesthesia in the right groin. Vascular access
was obtained in the right femoral artery. Over a guidewire, a 6-French
angiographic sheath was placed in the right femoral artery.

It was noticed that the patients abdominal aorta is very tortuous and the
thoracic aorta was very widened and a bovine aortic arch noted. Hence for
better support, a 6-French arterial sheath was removed from the groin and
over a guidewire, a 6-French long was advanced over _____. Then, a 6-French
JL4 catheter was used to engage the left coronary artery, but the engagement
was not optimal and left coronary artery angiography was performed.

Then, the 6-French JR4 catheter was introduced, _____ with the right
coronary artery was performed and selective right coronary angiography was
performed.

At the end of this angioplasty, stenting of the left circumflex artery was
performed, following which a 6-French pigtail catheter was introduced over a
guidewire into the left ventricular, left ventricular hemodynamics were
measured, and left ventriculography was performed. The pigtail catheter was
then removed under hemodynamic monitoring from the left _____ to the aorta.
Then, the 6-French pigtail catheter was used to perform the thoracic
aortogram in the LAO projection. Then, at the end of the angioplasty
procedure and diagnostic procedure, the guidewire and guiding catheter was
removed.

The 6-French long arterial sheath was removed over a guidewire. A 6-French
arterial sheath was placed in the right femoral artery over a guidewire and
arterial sheath was sutured in place and the patient was transferred in a
stable condition to the floor for further care with no complications.

RESULTS:

HEMODYNAMIC DATA:
1. Left ventricular pressure 119/7/14 mmHg.
2. Heart rate 79 beats per minute.
3. Aortic pressure 108/67/85 mm mean.

ANATOMIC DATA:

LEFT VENTRICULOGRAPHY:
1. Anterobasal normal.
2. Anterolateral normal.
3. Apical normal.
4. Inferior distally normal and mid inferior moderate hypokinesis.
5. Posterobasal: Severe hypokinesis.
6. Left ventricular ejection fraction is approximately 45 percent visual
estimate with no significant gradient across the aortic valve noted and
no significant mitral insufficiency noted.

CORONARY DATA:
1. Left main coronary artery: The left main coronary artery has moderate
diffuse atherosclerosis. Ostium of the left main coronary artery is not
well visualized. The entire left main coronary artery, otherwise has
mild diffuse atherosclerosis without any high-grade focal stenosis.
Distally, the left main coronary artery bifurcates into left anterior
descending artery and left circumflex arteries.
2. Left anterior descending artery: The left anterior descending artery has
mild-to-moderate disease in its proximal portion, diffuse
atherosclerosis noted. Mild-to-moderate diffuse calcification noted in
the left anterior descending artery in its proximal to mid portion. The
left anterior descending artery gives rise to small first diagonal
branch and the patient has mild-to-moderate diffuse disease throughout
its course and this tapers distally to a small caliber vessel.
3. Mid LAD: After the origin of this first diagonal branch it gives rise to
major septal perforator. Prior to the origin of the major septal
perforator, early mid LAD has a 40 percent stenosis.
a. Just after the origin of the major septal perforator, the LAD gives

rise to a medium caliber branch, which could be classified as a
second diagonal branch.
b. This branch in its distal portion is a small caliber vessel with
diffuse disease.
c. The mid LAD after the origin of this second diagonal branch
continues on as a medium caliber vessel with mild disease and then
gives rise to a third diagonal branch.
d. Just after the origin of the third diagonal branch, the LAD has a 90
percent eccentric stenosis.
e. The third diagonal branch is a small vessel with mild disease with
an ostial 60-80 percent stenosis.
f. The fourth diagonal branch is a small vessel with mild diffuse
disease.
g. The mid distal LAD beyond the origin of the fourth diagonal branch
is a medium caliber vessel with mild disease. It is a transapical
vessel and curves around the apex.
4. Left circumflex artery: The left circumflex artery is a large ectatic
vessel. Proximal left circumflex artery has moderate ectasia with
calcification along its wall and moderate diffuse disease noted.
a. The left circumflex artery then gives rise to first obtuse marginal
branch, which is also ectatic in its proximal portion with a 40
percent stenosis in its mid portion with the rest of the vessel
shows moderate diffuse disease.
b. Just after the origin of the first obtuse marginal branch, the left
circumflex artery makes a 90 degree bend. Just after the bend, the
left circumflex artery has a moderate diffuse disease with moderate
ectasia. Distal to this, at the mid portion of this left circumflex
artery gives rise to a second obtuse marginal branch. Just distal
to the origin of the second obtuse marginal branch, the left
circumflex artery is totally occluded with a flush occlusion.
c. It should be noted that after the angioplasty and stent of the left
circumflex artery, this appears to be a dominant vessel with the mid
and distal left circumflex artery being supplied by the circumflex
artery as well as the PDA branch of the left circumflex artery. It
appears to be a medium caliber vessel with moderate diffuse disease
beyond the total occlusion of the mid left circumflex artery.
d. It should be noted after angioplasty and stent, the mid left
circumflex artery and the mid distal left circumflex artery, the PDA
branch is a medium caliber vessel with mild-to-moderate diffuse
disease with another subbranch.
5. Right coronary artery: The right coronary artery is possibly
codominant/nondominant vessel. Proximal right coronary artery has 50
percent stenosis in its proximal portion.
a. The mid portion of the right coronary artery is totally occluded
after the origin of the RV branch.
6. There are no collaterals from left-to-right or right-to-right supplying
the PDA branch.
7. Thoracic aortogram: The aorta is diffusely dilated in the thoracic
portion. The aortic root is dilated. The ascending aorta, arch of

aorta, and the thoracic aorta are dilated. The size could not be
measured on this study, but probably is in the range of 4 to 5 cm
diffusely. There was no focal aneurysmal dilatation.

IMPRESSION:
1. Acute inferior and posterior wall myocardial infarction with the culprit
vessel, possibly dominant/codominant large ectatic mid left circumflex
artery with a total occlusion.
2. Severe three-vessel coronary artery disease with a total occlusion of
the mid left circumflex artery, total occlusion of the mid right
coronary artery, possibly nondominant vessel, 95 percent stenosis of the
mid left anterior descending artery.
3. Mild-to-moderately decreased left ventricular systolic function with
severe posterobasal hypokinesis and moderate mid inferior wall
hypokinesis with left ventricular ejection fraction in the range of 40
to 45 percent.
4. Severe ectasia of the thoracic aorta with a bovine arch with no focal
aneurysmal segment. There was diffuse widening of the thoracic aorta
noted.
5. Significant tortuosity of the entire mid abdominal aorta.
6. It was very difficult to engage the left main coronary artery with an
ectatic left circumflex artery and ectatic obtuse marginal branch of the
left circumflex artery.

Please help!! Thanks!
 
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