debbyallen
Networker
Procedures Performed:
1. Right radial artery US-guided access with placement of a 6F sheath.
2. Coronary angiography.
3. Mechanical aspiration thrombectomy of the ramus branch using the Penumbra CAT RX mechanical aspiration system.
5. IVUS of the ramus branch, LAD, and left main.
6. IVUS-guided PCI of the LM/ramus/LAD using the Culotte technique, with placement of 3.5x28 Xience Skypoint DES and 3.5x15 Onyx Frontier DES from LM to mid LAD, and 3.5x23 Xience Skypoint DES and 3.0x12 Onyx Frontier DES from LM to ramus (post-dilated with a 5.0 NC in the LM, 5.0 NC ostial LAD, 4.0 NC proximal LAD, 4.0 NC ostial ramus, and 3.5 NC proximal-mid ramus).
7. Placement of a TR band to the R radial artery access site to achieve excellent hemostasis.
Anesthesia: Local and light sedation (fentanyl only).
Medications administered:
See McKesson
Total contrast: See McKesson
Coronary Angiography:
- Dominance: Right
- Left main: Large caliber vessel. The left main has no significant disease and trifurcates into the LAD, ramus, and LCx.
- LAD: Large caliber vessel, heavily calcified vessel. The ostial LAD has an eccentric 60-70% stenosis (best seen in LAO/CAU). The proximal to mid LAD has diffuse 50% calcific disease. The remainder of the LAD has no significant disease. The LAD gives rise to multiple small caliber diagonal branches. D2 is the most prominent (small-moderate caliber) and has 70% ostial disease.
- Ramus: Large ~4.0mm vessel. There is ostial 99% thrombotic occlusion with TIMI-2 flow in the vessel (STEMI culprit). There is an additional 80% calcific lesion in the mid vessel. The ramus gives rise to 3 daughter branches without significant disease.
- LCx: Moderate caliber vessel which has mild diffuse disease. Gives rise to 1 small caliber OM branch without significant disease.
- RCA: Normal caliber, heavily calcified vessel. The proximal-mid RCA has a diffuse 90-95% calcific stenosis. The mid-RCA has an additional 60-70% stenosis. The RCA gives rise to a moderate caliber R-PDA and moderate caliber RPL, neither with significant disease.
Procedure in Detail:
The indications, risks, benefits, and alternatives were explained to the patient in great detail and informed written consent was obtained. The patient was placed on the catheterization lab table in a non-sedated state. The right wrist and bilateral groins were prepped and draped in the usual sterile fashion. A time-out was performed. The right wrist was anesthetized using a 2% lidocaine solution. Using an Angiocath needle and US-guidance, access to the R radial artery was obtained and a 6F 10cm Glidesheath was inserted.
A 6F JR4 catheter was advanced over a wire under fluoroscopic guidance to the aortic root. The right coronary artery was engaged and angiography was performed in a single view. The catheter was exchanged for a 6F JL3.5 diagnostic catheter; the left coronary artery was engaged and selective angiography was performed in multiple views. Patient endorsed 10/10 chest pain and thus, given the
angiographic findings, I decided to proceed with intervention.
Intervention Narrative
This was a complex STEMI PCI as it appeared that the culprit was a rather large ramus branch (which actually appeared to come off the LAD very proximally, but essentially behaved as a high rising OM), with ostial ~99% thrombotic occlusion and TIMI-2 flow. Given the ostial location, I did not feel that PCI could be performed without also treating the LAD/distal LM, as the LAD appeared to have significant, calcific ostial disease, with more diffuse disease in the its proximal-mid segments. The LCA was engaged using a 6F EBU 3.5 guide. Loaded with heparin. Wired ramus initially with a Runthrough wire. Given the large thrombotic burden, I opted to proceed with upfront mechanical aspiration thrombectomy using the Penumbra CAT RX mechanical aspiration system. The catheter was prepped and advanced over the wire. Two passes were performed at the ostium of the ramus, however the catheter could not be advanced further into the ramus branch. Subsequent angiogram demonstrated restoration of TIMI-3 flow down the ramus, however with significant residual ostial disease. The ostial to mid ramus was then serially pre-dilated using a 2.5 balloon with good balloon expansion. There was TIMI-3 flow in the ramus and LAD. Patient still reported ongoing 8/10 chest pain. As discussed above, I deliberated for a while on the best PCI strategy, as PCI of the ramus would effectively involve PCI of the distal LM and LAD as well. I did not feel that patient would be a surgical candidate given her multiple myeloma. I did not feel the RCA was the culprit vessel as the disease appeared chronic, there was TIMI-3 flow in the vessel, and the ECG ST-elevation distribution fit more with a ramus/OM culprit. I thus decided to proceed with ramus/LAD PCI using a Culotte strategy and to manage LCx provisionally (relatively modest caliber vessel). A second Runthrough was placed in the LAD. IVUS of the ramus demonstrated a 3.0mm DRV, and 3.5-4.0mm PRV with severe ostial disease. IVUS of the LM/LAD was also performed; the LM was a nearly 7.0mm vessel (media to media); after giving off the LCx, the ostial LAD/ramus confluence was a ~5.8mm vessel. The LAD itself (proximally) was a 4.5mm vessel and 3.5mm vessel in the mid LAD. The ostial/proximal ramus was serially pre-dilated with a 3.5 NC with good balloon expansion. The balloon was also used to pre-dilate the LAD, with good balloon expansion. The ramus was stented first with a 3.5x23 Xience Skypoint DES, with the proximal edge extending slightly into the distal LM. The LAD was re-wired using another Runthrough wire and jailed Runthrough was removed. The struts were dilated using a 2.0 balloon and a 3.5x28 Xience Skypoint DES was deployed in Culotte fashion from the distal LM into the LAD. Subsequent angiograms demonstrated that there was still residual disease beyond the stent edge in the ramus, and the LAD stent had also landed in a diseased segment. The LAD stent was post-dilated with a 4.0 NC, which was also used to POT the proximal edge. The jailed ramus was then re-wired through the LAD stent struts with another Runthrough wire and jailed Runthrough in the ramus was removed. The ramus ostium was dilated using a 2.0 Takeru balloon. The residual disease in the ramus was covered with an additional 3.0x12 Onyx Frontier DES in overlapping fashion, while the residual disease in the LAD was covered using a 3.5x15 Onyx Frontier DES in overlapping fashion. Additional POT of the LM/ostial LAD was performed with a 5.0 NC. The ramus stents were then serially post-dilated with a 3.5 NC and the first kissing balloon inflation was performed with a 4.0 SC in the LM-LAD and the 3.5 NC from LM to ramus. At this point, IVUS of both ramus and LAD was performed, which demonstrated good stent expansion and apposition throughout most of the stented segments. The neo-carina (as a result of Culotte stenting) had some mild under-expansion at both ostia and it appeared by IVUS that only a very small amount of stent extended proximally beyond the neo-carina. A final kissing inflation was performed with the 5.0 NC in the LM-LAD and a 4.0 SC from LM-ramus at 8 atm. Final angiograms demonstrated a very satisfactory angiographic result, TIMI-3 flow in all three vessel, 0% residual disease in the stented segments, and no dissection/perforation. The ostial LCx appeared somewhat pinched, however I suspect there was a component of spasm present in all of her vessels. 200mcg IC nitroglycerin was given. I opted to leave the LCx alone as it was a relatively small caliber vessel with diffuse disease proximally. There was also TIMI ~2 flow in the D2 branch however this was also a small caliber vessel which I opted to leave alone.
The wires and guide were removed. I attempted to advance a Pigtail catheter however there was significant radial spasm, and thus, I decided not to cross into the LV. At the end of the procedure, all wires and catheters were removed; the sheath was removed and hemostasis was achieved using a TR band. The patient tolerated the procedure well without any apparent complications. The patient will be transferred to the ICU for further management.
Summary:
1. Lateral STEMI with posterior extension, with culprit 99% thrombotic occlusion of the ostial ramus branch, s/p mechanical aspiration thrombectomy (using the Penumbra CAT RX) and complex LM/LAD/ramus IVUS-guided PCI using the Culotte bifurcation technique, with placement of 3.5x28 Xience Skypoint DES and 3.5x15 Onyx Frontier DES from LM to mid LAD, and 3.5x23 Xience Skypoint DES and 3.0x12 Onyx Frontier DES from LM to ramus (post-dilated with a 5.0 NC in the LM, 5.0 NC ostial LAD, 4.0 NC proximal LAD, 4.0 NC ostial ramus, and 3.5 NC proximal-mid ramus).
2. Severe residual 90-95% calcific proximal-mid RCA disease, to be staged in the next few days.
3. R radial access; successful hemostasis with a TR band. Of note, there was significant R subclavian/innominate tortuosity, requiring a soft angled glidewire to traverse.
1. Right radial artery US-guided access with placement of a 6F sheath.
2. Coronary angiography.
3. Mechanical aspiration thrombectomy of the ramus branch using the Penumbra CAT RX mechanical aspiration system.
5. IVUS of the ramus branch, LAD, and left main.
6. IVUS-guided PCI of the LM/ramus/LAD using the Culotte technique, with placement of 3.5x28 Xience Skypoint DES and 3.5x15 Onyx Frontier DES from LM to mid LAD, and 3.5x23 Xience Skypoint DES and 3.0x12 Onyx Frontier DES from LM to ramus (post-dilated with a 5.0 NC in the LM, 5.0 NC ostial LAD, 4.0 NC proximal LAD, 4.0 NC ostial ramus, and 3.5 NC proximal-mid ramus).
7. Placement of a TR band to the R radial artery access site to achieve excellent hemostasis.
Anesthesia: Local and light sedation (fentanyl only).
Medications administered:
See McKesson
Total contrast: See McKesson
Coronary Angiography:
- Dominance: Right
- Left main: Large caliber vessel. The left main has no significant disease and trifurcates into the LAD, ramus, and LCx.
- LAD: Large caliber vessel, heavily calcified vessel. The ostial LAD has an eccentric 60-70% stenosis (best seen in LAO/CAU). The proximal to mid LAD has diffuse 50% calcific disease. The remainder of the LAD has no significant disease. The LAD gives rise to multiple small caliber diagonal branches. D2 is the most prominent (small-moderate caliber) and has 70% ostial disease.
- Ramus: Large ~4.0mm vessel. There is ostial 99% thrombotic occlusion with TIMI-2 flow in the vessel (STEMI culprit). There is an additional 80% calcific lesion in the mid vessel. The ramus gives rise to 3 daughter branches without significant disease.
- LCx: Moderate caliber vessel which has mild diffuse disease. Gives rise to 1 small caliber OM branch without significant disease.
- RCA: Normal caliber, heavily calcified vessel. The proximal-mid RCA has a diffuse 90-95% calcific stenosis. The mid-RCA has an additional 60-70% stenosis. The RCA gives rise to a moderate caliber R-PDA and moderate caliber RPL, neither with significant disease.
Procedure in Detail:
The indications, risks, benefits, and alternatives were explained to the patient in great detail and informed written consent was obtained. The patient was placed on the catheterization lab table in a non-sedated state. The right wrist and bilateral groins were prepped and draped in the usual sterile fashion. A time-out was performed. The right wrist was anesthetized using a 2% lidocaine solution. Using an Angiocath needle and US-guidance, access to the R radial artery was obtained and a 6F 10cm Glidesheath was inserted.
A 6F JR4 catheter was advanced over a wire under fluoroscopic guidance to the aortic root. The right coronary artery was engaged and angiography was performed in a single view. The catheter was exchanged for a 6F JL3.5 diagnostic catheter; the left coronary artery was engaged and selective angiography was performed in multiple views. Patient endorsed 10/10 chest pain and thus, given the
angiographic findings, I decided to proceed with intervention.
Intervention Narrative
This was a complex STEMI PCI as it appeared that the culprit was a rather large ramus branch (which actually appeared to come off the LAD very proximally, but essentially behaved as a high rising OM), with ostial ~99% thrombotic occlusion and TIMI-2 flow. Given the ostial location, I did not feel that PCI could be performed without also treating the LAD/distal LM, as the LAD appeared to have significant, calcific ostial disease, with more diffuse disease in the its proximal-mid segments. The LCA was engaged using a 6F EBU 3.5 guide. Loaded with heparin. Wired ramus initially with a Runthrough wire. Given the large thrombotic burden, I opted to proceed with upfront mechanical aspiration thrombectomy using the Penumbra CAT RX mechanical aspiration system. The catheter was prepped and advanced over the wire. Two passes were performed at the ostium of the ramus, however the catheter could not be advanced further into the ramus branch. Subsequent angiogram demonstrated restoration of TIMI-3 flow down the ramus, however with significant residual ostial disease. The ostial to mid ramus was then serially pre-dilated using a 2.5 balloon with good balloon expansion. There was TIMI-3 flow in the ramus and LAD. Patient still reported ongoing 8/10 chest pain. As discussed above, I deliberated for a while on the best PCI strategy, as PCI of the ramus would effectively involve PCI of the distal LM and LAD as well. I did not feel that patient would be a surgical candidate given her multiple myeloma. I did not feel the RCA was the culprit vessel as the disease appeared chronic, there was TIMI-3 flow in the vessel, and the ECG ST-elevation distribution fit more with a ramus/OM culprit. I thus decided to proceed with ramus/LAD PCI using a Culotte strategy and to manage LCx provisionally (relatively modest caliber vessel). A second Runthrough was placed in the LAD. IVUS of the ramus demonstrated a 3.0mm DRV, and 3.5-4.0mm PRV with severe ostial disease. IVUS of the LM/LAD was also performed; the LM was a nearly 7.0mm vessel (media to media); after giving off the LCx, the ostial LAD/ramus confluence was a ~5.8mm vessel. The LAD itself (proximally) was a 4.5mm vessel and 3.5mm vessel in the mid LAD. The ostial/proximal ramus was serially pre-dilated with a 3.5 NC with good balloon expansion. The balloon was also used to pre-dilate the LAD, with good balloon expansion. The ramus was stented first with a 3.5x23 Xience Skypoint DES, with the proximal edge extending slightly into the distal LM. The LAD was re-wired using another Runthrough wire and jailed Runthrough was removed. The struts were dilated using a 2.0 balloon and a 3.5x28 Xience Skypoint DES was deployed in Culotte fashion from the distal LM into the LAD. Subsequent angiograms demonstrated that there was still residual disease beyond the stent edge in the ramus, and the LAD stent had also landed in a diseased segment. The LAD stent was post-dilated with a 4.0 NC, which was also used to POT the proximal edge. The jailed ramus was then re-wired through the LAD stent struts with another Runthrough wire and jailed Runthrough in the ramus was removed. The ramus ostium was dilated using a 2.0 Takeru balloon. The residual disease in the ramus was covered with an additional 3.0x12 Onyx Frontier DES in overlapping fashion, while the residual disease in the LAD was covered using a 3.5x15 Onyx Frontier DES in overlapping fashion. Additional POT of the LM/ostial LAD was performed with a 5.0 NC. The ramus stents were then serially post-dilated with a 3.5 NC and the first kissing balloon inflation was performed with a 4.0 SC in the LM-LAD and the 3.5 NC from LM to ramus. At this point, IVUS of both ramus and LAD was performed, which demonstrated good stent expansion and apposition throughout most of the stented segments. The neo-carina (as a result of Culotte stenting) had some mild under-expansion at both ostia and it appeared by IVUS that only a very small amount of stent extended proximally beyond the neo-carina. A final kissing inflation was performed with the 5.0 NC in the LM-LAD and a 4.0 SC from LM-ramus at 8 atm. Final angiograms demonstrated a very satisfactory angiographic result, TIMI-3 flow in all three vessel, 0% residual disease in the stented segments, and no dissection/perforation. The ostial LCx appeared somewhat pinched, however I suspect there was a component of spasm present in all of her vessels. 200mcg IC nitroglycerin was given. I opted to leave the LCx alone as it was a relatively small caliber vessel with diffuse disease proximally. There was also TIMI ~2 flow in the D2 branch however this was also a small caliber vessel which I opted to leave alone.
The wires and guide were removed. I attempted to advance a Pigtail catheter however there was significant radial spasm, and thus, I decided not to cross into the LV. At the end of the procedure, all wires and catheters were removed; the sheath was removed and hemostasis was achieved using a TR band. The patient tolerated the procedure well without any apparent complications. The patient will be transferred to the ICU for further management.
Summary:
1. Lateral STEMI with posterior extension, with culprit 99% thrombotic occlusion of the ostial ramus branch, s/p mechanical aspiration thrombectomy (using the Penumbra CAT RX) and complex LM/LAD/ramus IVUS-guided PCI using the Culotte bifurcation technique, with placement of 3.5x28 Xience Skypoint DES and 3.5x15 Onyx Frontier DES from LM to mid LAD, and 3.5x23 Xience Skypoint DES and 3.0x12 Onyx Frontier DES from LM to ramus (post-dilated with a 5.0 NC in the LM, 5.0 NC ostial LAD, 4.0 NC proximal LAD, 4.0 NC ostial ramus, and 3.5 NC proximal-mid ramus).
2. Severe residual 90-95% calcific proximal-mid RCA disease, to be staged in the next few days.
3. R radial access; successful hemostasis with a TR band. Of note, there was significant R subclavian/innominate tortuosity, requiring a soft angled glidewire to traverse.