# Return to Operating Room



## AshleyMartin (Feb 22, 2011)

Please help me code this:

A 75 year old Female went to the cath lab and had this procedure:

1. Coronary angiography
2. LIMA angiography
3. Saphenous vein graft angiography
4. Temporary venous pacer
5. Aspiration thrombectomy
6. PCI of left circumflex with bare metal stent

Access was obtained by the right femoral artery via modified Seldinger technique after 1% Lidocaine was used to anesthetize the area. There was some resistance met in the right iliac. We were able to cross using a glide wire. With the JR catheter a long 6-French sheath was then placed. Then used JR4 to selectively engage the right coronary artery as well as the stump of the vein graft as well as another vein graft to the diagonal. We used a JL4 diagnostic catheter to selectively engage the left coronary system. We were able to advance a JR4 into the subclavian. We used and exchanged the wires which offer a 4-French I-arm which was used to partially engage the LIMA. The patient became hypotensive and bradycardia. Angiography of the left coronary again was taken. The left circumflex seems to be down. We used an initially EBU 3.5 guide catheter. Integrilin was already going for anticoagulation. We added heparin. We were able to advance an whisper extra support wire down the circumflex. We were unable to pass a Pronto catheter. We ballooned the vessel using 2.5x15. This opened up the vessel. Then, stented using a 3-0x30 integrity bare metal stent. We post dilated with the 3.5 balloon more proximally. There was some thrombus noted at the proximal edge. We performed aspiration thrombectomy using an Export catheter. This was successful. The patient was started on Dopamine for low blood pressure. Temporary venous pacer was placed after Atropine failed to achieve adequate heart rate. The patient was transferred to the Intensive Care Unit in stable condition. 

Findings:
1. Left main is normal.
2. LAD is occluded.
3. The left circumflex is dominant with a long 90% to proximal mid lesion.
4. RCA was small and diffusely diseased.
5. SVC to diagonal is patent. 
6. LIMA to LAD small and has some ostial disease. 

Intervention details:
1. Left circumflex 90% lesion became a total occlusion which was reduced to zero percent by ballooning with a 2.5 balloon and placement of a 3.0x30 integrity bare metal stent which was post dilated to 3.5 proximally. Thrombus in the proximal portion was the aspirated using an Export catheter. Good result was achieved. 

Diagnosis:
1. Status post acute left circumflex closure.
2. Multi-vessel coronary artery disease status post bypass with failed graft.
3. Non-Stemi.
4. Bradycardia/hypotension.

Then while being observed in the ICU, she continued to develop tachycardia as well as hypotension requiring significant pressors. She was brought back for re-look angiography plus/minus PCI of the LIMA as well as to verify no active bleeding at the prior arterial access site in the groin. 

Procedure:
1. Triple lumen catheter placement
2. Intra-aortic balloon pump placement
3. Abdominal aortogram
4. PTA of the right common iliac artery.

Procedure in detail:
The patient was emergently brought back into the cath lab. She was prepped and drained in a sterile fashion. We exchanged a 6-French sheath in the right arterial access site for a 2-sheath under sterile technique. Angiography was performed at the right arterial access site showing no active extravasation of blood. The patient upon transfer to the table had also developed a bowel movement that was significantly bloody consistent with lower GI bleed. We then called GI emergently. Dr L came and placed an NG tube which aspirated no significant amount of blood. The patient was started on Protonix. We then exchanged the right venous access for a triple lumen and exchanged the 6-French arterial sheath for balloon pump sheath and placed a balloon pump after angiography was perfomed showing patency of the left main and the left circumflex. The balloon pump had some difficulty going up the iliac. There was a lesion of the right common iliac artery that was verified by abdominal aortogram. We then used a glide wire to pass it. A stiff Amplatz wire was exchanged over this 10x20 ultrathin SDS balloon was used to dilate the lesion. Then we were able to pass a balloon pump in the triple lumen as well as the balloon were sutured to the skin. Again, the patient was stable on pressors upon transfer the the ICU. 

Findings:
1. The is eccentric calcified plaque at the ostium of the right common iliac artery.

Intervention:
1. 80% lesion was reduced to less than 20% by PTA with a 10x20 millimeter ultra-thin SDS balloon.

Diagnosis:
1. Lower GI bleed
2. Patent stent in the left circumflex
3. Acute systolic heart failure status post intra-aortic balloon pump placement.


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