em2177
Expert
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REASON FOR EVALUATION: Left subclavian steal.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion.
A 6-French sheath was placed to the right common femoral artery using Seldinger
technique. Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed.
At this point, we exchanged the short sheath for a 7-French sheath, and a
7-French jrf JR4 with side-hole guide catheter selectively engaged the left
ostial subclavian, and angiography was performed. Initial attempts to get a
Glide wire across were unsuccessful. Thus we used a CholCE PT2 cardiac wire,
which was placed into the left subclavian. Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed. Next the balloon was removed, and a stent
was attempted to be deployed to the proximal segment; however, this was
unsuccessful. Thus, the whole system was removed.
We exchanged the short sheath for an 8-French sheath and used an 8-French guide
catheter to the ostial left subclavian. A Glide wire was placed across the
vessel again, and an 8 x 40 Protege self-expanding stent was used to the
proximal left subclavian with the distal segment deployed prior to the
vertebral artery. We chose a self-expanding stent as opposed to a balloon
expandable stent due to the concern of a possible thrombus and the severity of
the lesion. Thus, once the stent was deployed, angiography was performed.
We had difficulty placing the postdilatation 7-0 balloon. Thus, we used a PT2
wire in the left subclavian and dilated the proximal portion of the stent with
a 5.0 x 30 Quantum Apex postdilatation balloon. Then we replaced the wire with
a Glide wire, and at this point a 7.0 x 40 postdilatation balloon was able to
be placed over the stented segment with postdilatation to 10 atmospheres.
Postdilatation balloon was removed, and repeat angiography was performed. At
this point, there was antegrade flow of the vertebral. There was brisk flow of
the left subclavian. Post blood pressure measurements showed no gradient and
no blood pressure difference.
The patient was asymptomatic, had a normal hemodynamic response to the
procedure, and felt quite well. The wire and catheter were removed. An
8-French Angio-Seal was placed at the right common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma.
IMPRESSION: Preprccedure proximal left subclavian had an 80% to 90% diffuse
severe stenosis. There was retrograde filling of the vertebral artery and a
blood pressure difference in the arms of 22 mmHg.
Post angioplasty and stenting as above with an 8 x 40 Protege self-expanding
stent and 7.0 postdilatation revealed 0% residual stenosis, brisk flow of the
left subclavian, and noW antegrade flow of the vertebral with zero gradient
across the stented segment.
REASON FOR EVALUATION: Left subclavian steal.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion.
A 6-French sheath was placed to the right common femoral artery using Seldinger
technique. Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed.
At this point, we exchanged the short sheath for a 7-French sheath, and a
7-French jrf JR4 with side-hole guide catheter selectively engaged the left
ostial subclavian, and angiography was performed. Initial attempts to get a
Glide wire across were unsuccessful. Thus we used a CholCE PT2 cardiac wire,
which was placed into the left subclavian. Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed. Next the balloon was removed, and a stent
was attempted to be deployed to the proximal segment; however, this was
unsuccessful. Thus, the whole system was removed.
We exchanged the short sheath for an 8-French sheath and used an 8-French guide
catheter to the ostial left subclavian. A Glide wire was placed across the
vessel again, and an 8 x 40 Protege self-expanding stent was used to the
proximal left subclavian with the distal segment deployed prior to the
vertebral artery. We chose a self-expanding stent as opposed to a balloon
expandable stent due to the concern of a possible thrombus and the severity of
the lesion. Thus, once the stent was deployed, angiography was performed.
We had difficulty placing the postdilatation 7-0 balloon. Thus, we used a PT2
wire in the left subclavian and dilated the proximal portion of the stent with
a 5.0 x 30 Quantum Apex postdilatation balloon. Then we replaced the wire with
a Glide wire, and at this point a 7.0 x 40 postdilatation balloon was able to
be placed over the stented segment with postdilatation to 10 atmospheres.
Postdilatation balloon was removed, and repeat angiography was performed. At
this point, there was antegrade flow of the vertebral. There was brisk flow of
the left subclavian. Post blood pressure measurements showed no gradient and
no blood pressure difference.
The patient was asymptomatic, had a normal hemodynamic response to the
procedure, and felt quite well. The wire and catheter were removed. An
8-French Angio-Seal was placed at the right common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma.
IMPRESSION: Preprccedure proximal left subclavian had an 80% to 90% diffuse
severe stenosis. There was retrograde filling of the vertebral artery and a
blood pressure difference in the arms of 22 mmHg.
Post angioplasty and stenting as above with an 8 x 40 Protege self-expanding
stent and 7.0 postdilatation revealed 0% residual stenosis, brisk flow of the
left subclavian, and noW antegrade flow of the vertebral with zero gradient
across the stented segment.