bhargavi
Guru
Conclusion
64-year-old male with history of aggressive premature coronary disease status post bypass surgery, multiple stenting with repeated interventions presenting with accelerated angina. He was referred for coronary angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 9:07 AM and monitoring period Ended 9:56 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main was a diffusely diseased calcific vessel with a mid area of 70% stenosis..
2: The left anterior descending artery 100% occluded shortly after the takeoff of a small to moderate-sized diagonal branch and a septal branch. Long delay of stenting distally in an occluded vessel seen.
3: Left circumflex: The left circumflex artery is 100% occluded.
4: Right coronary artery: Is known to be 100% occluded. It was not injected.
5: Left heart catheterization with left ventricular angiogram showed moderate to severe inferior wall hypokinesis overall estimated ejection fraction 45%.
6: Vein graft to the right coronary artery is patent. The previously inserted stent in its mid part shows 50% in-stent restenosis.
7: Vein graft to a large obtuse marginal branch/S circumflex artery system is patent. There is an ostial 80% stenosis. At the most proximal edge of a previously inserted stent, there is 50% stenosis. Right distal to the distal edge of the stent, there is an area of 80% stenosis.
*
Impression:
1. Severe native coronary artery disease.
2. In-stent restenosis in the vein graft to the right coronary artery at 50%.
3. New disease at the ostium of the vein graft to the obtuse marginal branch as well as the proximal as well as the distal edge of previously inserted stent in the vein graft
Plan: Proceed with percutaneous intervention to the vein graft to the obtuse marginal branch.
*
Intervention:
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Using a L CB guiding catheter and a ATW marker wire I was able to cross to severe stenosis in the vein graft to the obtuse marginal branch. The area was treated with a 3.0 x 12 mm balloon. Repeat angiogram showed excellent result in the ostium of the proximal edge. The distal edge of the stent still had residual 50% stenosis. A 3.5 x 12 mm balloon was then used with excellent result and no residual stenosis. Given the fact that the patient had frequent in-stent restenosis in the past I elected to stop at the balloon angioplasty and try to avoid stenting
*
Final impression:
*
1. Severe native coronary artery disease.
2. In-stent restenosis in the vein graft to the right coronary artery at 50%.
3. New disease at the ostium of the vein graft to the obtuse marginal branch as well as the proximal as well as the distal edge of previously inserted stent in the vein graft
The vein graft was successfully treated with balloon angioplasty alone as mentioned above
*
Plan:
Continue aggressive medical treatment. Surveillance of the progression of disease in the vein graft to the right coronary artery as well as in the areas of balloon angioplasty as mentioned above.
*
I am thinking of 93459-xu,92937?
thanks in advance
64-year-old male with history of aggressive premature coronary disease status post bypass surgery, multiple stenting with repeated interventions presenting with accelerated angina. He was referred for coronary angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 9:07 AM and monitoring period Ended 9:56 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main was a diffusely diseased calcific vessel with a mid area of 70% stenosis..
2: The left anterior descending artery 100% occluded shortly after the takeoff of a small to moderate-sized diagonal branch and a septal branch. Long delay of stenting distally in an occluded vessel seen.
3: Left circumflex: The left circumflex artery is 100% occluded.
4: Right coronary artery: Is known to be 100% occluded. It was not injected.
5: Left heart catheterization with left ventricular angiogram showed moderate to severe inferior wall hypokinesis overall estimated ejection fraction 45%.
6: Vein graft to the right coronary artery is patent. The previously inserted stent in its mid part shows 50% in-stent restenosis.
7: Vein graft to a large obtuse marginal branch/S circumflex artery system is patent. There is an ostial 80% stenosis. At the most proximal edge of a previously inserted stent, there is 50% stenosis. Right distal to the distal edge of the stent, there is an area of 80% stenosis.
*
Impression:
1. Severe native coronary artery disease.
2. In-stent restenosis in the vein graft to the right coronary artery at 50%.
3. New disease at the ostium of the vein graft to the obtuse marginal branch as well as the proximal as well as the distal edge of previously inserted stent in the vein graft
Plan: Proceed with percutaneous intervention to the vein graft to the obtuse marginal branch.
*
Intervention:
*
Using a L CB guiding catheter and a ATW marker wire I was able to cross to severe stenosis in the vein graft to the obtuse marginal branch. The area was treated with a 3.0 x 12 mm balloon. Repeat angiogram showed excellent result in the ostium of the proximal edge. The distal edge of the stent still had residual 50% stenosis. A 3.5 x 12 mm balloon was then used with excellent result and no residual stenosis. Given the fact that the patient had frequent in-stent restenosis in the past I elected to stop at the balloon angioplasty and try to avoid stenting
*
Final impression:
*
1. Severe native coronary artery disease.
2. In-stent restenosis in the vein graft to the right coronary artery at 50%.
3. New disease at the ostium of the vein graft to the obtuse marginal branch as well as the proximal as well as the distal edge of previously inserted stent in the vein graft
The vein graft was successfully treated with balloon angioplasty alone as mentioned above
*
Plan:
Continue aggressive medical treatment. Surveillance of the progression of disease in the vein graft to the right coronary artery as well as in the areas of balloon angioplasty as mentioned above.
*
I am thinking of 93459-xu,92937?
thanks in advance