So far I have:
93458,26,59
92960,59
92941,rc
92978,59,53?
92973,53?
Not sure if I should add last two with 53's since he did not complete. Thoughts/suggestions please?
INDICATIONS: ST elevation myocardial infarction, inferolateral leads.
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Left and right selective coronary angiogram.
3. Percutaneous intervention of mid-to-distal right coronary artery via drug-eluting stent,
Resolute 4.0 mm x 26 mm.
4. External DC cardioversion x1.
5. Attempted thrombectomy.
6. Attempted intravascular ultrasound.
7. Attempted temporary pacer wire placement.
8. Radiological supervision and interpretation.
DESCRIPTION OF PROCEDURE: The patient was brought in an emergent situation to the cardiac
catheterization lab for definition of coronary anatomy. She was prepped and draped as per
protocol. Conscious sedation was achieved by given Versed and fentanyl IV. The right groin was
then infiltrated with 20 mL of 2% lidocaine for local anesthesia. Using a modified Seldinger
technique and a micropuncture needle initially the right femoral vein access was obtained and
followed by a right femoral artery access; both sheaths were introduced without any resistance
with good backflow of blood. Both sheaths were flushed. The reason I got a right femoral vein
access, given the patient had inferior ST elevations, they are at high risk of getting
bradyarrhythmias. After flushing both sheaths, then diagnostic coronary angiogram was performed
by using a Judkins Left 4 catheter, getting the left coronary angiograms first given the
patient ST elevation in inferior leads. Then I went and cannulated the right coronary artery
using a Judkins Right 4 guide catheter. After defining her coronary anatomy, then an emergent
percutaneous intervention of the mid-to-distal right coronary artery was performed which will
be discussed in a later part of this report. The patient, during the course of percutaneous
intervention of the right coronary artery, had an episode of ventricular fibrillation arrest
which was successfully shocked by applying DC cardioversion of 360 joules x1. The patient was
subsequently started on IV amiodarone and did not have any hemodynamically unstable rhythm but
kept on having irregular ventricular rhythms which was consistent with <<__>> arrhythmias.
Overall the patient tolerated the procedure well. She was hemodynamically and neurologically
stable at the end of the procedure. Her right groin had both venous and arterial access in
place in the right femoral vein and the right femoral artery respectively which were placed on
a saline flush and resutured in place. At the end of the procedure the patient was chest-pain
free. She was then transferred to the Intensive Care Unit for further management in a
hemodynamically and neurologically stable condition with good hemostasis at the inguinal area
at the site of puncture with no change in her peripheral pulses.
DIAGNOSTIC CORONARY ANGIOGRAPHY FINDINGS:
1. Right dominant system.
2. Left main coronary artery was 4.0 mm vessel with no significant disease. It bifurcated in
the left anterior descending artery and the left circumflex artery.
3. The left anterior descending artery started off as a 3.0 mm vessel. After a very short
distance just before the take off of diagonal 1 and of the septal perforator there was
presence of an old stent with 20-30 in-stent restenosis. This stent was across the
diagonal 1 and appeared to have jailed the ostium the diagonal to some extent. After the
stent, the left anterior descending artery continued to be a 3.0 mm vessel until it gave
rise to diagonal 2, and after that it was a 2.5 mm vessel in the mid-to-distal portion
and distally becoming a small caliber vessel in a wraparound fashion. During its course
it gave rise to diagonal 1 which was a 2.25 mm vessel with evidence of 90% eccentric
stenosis at the ostium which is probably secondary to the stent in the past being
deployed across it and a proximal 60-70% stenosis. The diagonal 2nd was a 2.5 mm vessel
with no evidence of any obstructive disease, just 10-20% lumen irregularities.
4. The circumflex artery was 3.0 mm vessel from proximal to mid and distally continues as a
small caliber vessel in the atrioventricular groove. During its course it gave rise to
obtuse marginal 1 which was 2.0 mm vessel with no significant disease followed by obtuse
marginal 2 which was a 1.5 mm vessel with evidence of 10-20% lumen irregularities
throughout its course.
5. Right coronary artery was a 4.0 mm vessel proximally and after a short distance it became
a smaller caliber vessel around 3.0 mm and from that point onward there was presence of
old deployed stent which continued towards the distal portion of the right coronary
artery. There was about 20% in-stent restenosis in the amount of the stent which was
still patent, and then at the level of the mid-to-distal right coronary artery the right
coronary artery was totally occluded within the stented segment with evidence of
thrombus. During the left coronary injections there was presence of left-to-right
collaterals demonstrating fairly large territory and good caliber PDA/PLV.
6. Hemodynamics: Aortic pressure was 127 mmHg systolic and diastolic 60 mmHg with a mean of
87 mmHg. No left ventricular end-diastolic pressure was measured as the patient's
ventricle was very vulnerable to arrhythmias so I did not decide to put any hardware into
her left ventricle.
7. Left ventricular angiogram was not performed for the reason mentioned above, as the
patient had significant reperfusion arrhythmias and the plan is to get an echocardiogram
to assess that left ventricular function.
DECISION MAKING: Given the patient acute injury pattern in that territory the decision was made
to emergently intervene on this segment of the right coronary artery which was within the
stented portion in the region of mid-to-distal right coronary artery. This was communicated to
the patient and she gave her approval.
DESCRIPTION OF PERCUTANEOUS INTERVENTION OF THE RIGHT CORONARY ARTERY: Description of the
percutaneous intervention of the mid-to-distal right coronary artery totally occluded segment
of the in-stented portion of the vessel. In anticipation of percutaneous intervention of this
vessel, the patient was initiated on Angiomax as per protocol. She was given 180 mg of Brilinta
which is ticagrelor. The reason I used ticagrelor over Plavix is it has an immediate
antiplatelet activity and will give the most benefit during the thrombotic episode. Using a
Judkins Right 4 coronary catheter which I had used for diagnostic purposes as well, a Prowater
wire was introduced through the right catheter into the right coronary artery and placed
distally into the posterolateral ventricular branch of the right coronary artery. Attempt was
made initially to pass thrombectomy export catheter but after a couple attempts given the
patient's proximal-to-mid-to distal portion was so noncompliant secondary to presence of old
stent, it did not allow the thrombectomy device to go past the proximal portion of the right
coronary artery. At this point in time the plan was changed and using an Apex balloon, 3.0 x 8
mm, it was introduced into the totally occluded segment of the right coronary artery within the
stented portion and <<darted>> across the course and the <<dartering>> was very smooth
consistent with intraluminal passage. With passage of the balloon there was TIMI 2 blood flow
seen across the totally occluded segment within the stented portion of the right coronary
artery to the distal bed. Then this balloon was inflated within the totally occluded portion
which was in the old stented portion of the right coronary artery multiple times at 12
atmospheres. After successful desiccation of the thrombus burden in the stented portion of the
right coronary artery, this balloon was withdrawn and a Resolute stent 4.0 mm x 26 mm was
attempted to be introduced into the right coronary artery but we were unable to pass the stent
past the stented portion of the right coronary artery. After multiple attempts were made, the
guide and wire disengaged and the hardware was at this point removed and the right coronary
artery was then cannulated again and now I chose a different wire to get more support which was
a Mailman wire, 0.14 which was successfully traversed across the right coronary artery and
placed distally into the posterior descending artery branch of the right coronary artery. Then
this Resolute stent 4.0 mm x 26 mm was successfully introduced into the right coronary artery
through the stented portion into the distal portion of the old stented area and this was
deployed at high pressures of 14 atmospheres over 30 seconds. The stent balloon was removed and
post stent deployment was then performed by using a Quantum balloon, 4.5 mm x 12 mm which was
inflated on multiple times within the stented portion of the right coronary artery at around
16-17 atmospheres. During the course of intervention multiple injections of intracoronary
adenosine were given to improve the distal beds circulation and the patient also was started on
IV ReoPro bolus followed by infusion. Given the patient was having a lot of reperfusion
arrhythmias, IV amiodarone bolus 360 mg were given followed by IV infusion. After successful
post stent deployment dilatation was performed, I tried to introduce the intravascular catheter
to ascertain that the stent was well opposed, as there is another layer of stent beneath, by
doctor trying a couple of times, I was unable to advance the IVUS catheter past the proximal
portion of the right coronary artery just before the old stented portion of the artery started.
The guide would move out along with the wire. Given the <<__>> results angiographically after
the post stent deployment dilatation, I then did not attempt to IVUS the stented area as
angiographically there was no evidence of any <<__dissection>>, appeared to have well
deployment and TIMI 3 blood flow distally. At this point in time the procedure was stopped and
hardware was removed under fluoroscopic guidance. Thought was given to do a left ventricular
angiogram at the end of the procedure, but given the patient was having lots of reperfusion
arrhythmias I did not do any left ventricle hardware insertion and at this time the procedure
was stopped.
During the procedure, as mentioned in the first part of the report, the patient after we got
reperfusion she went into a brief episode of ventricular fibrillation arrest but
hemodynamically and clinically did not have any compromise. She was still awake and this was
successfully aborted by doing 1 DC cardioversion with 360 joules. This was followed by
introducing IV amiodarone bolus followed by infusion with marked improvement in her reperfusion
arrhythmias.
FINAL RESULTS:
Pre-stent deployment: Totally occluded mid-to-distal right coronary artery with areas of
thrombus burden.
Post-stent deployment: Well-deployed stent with 0 postresidual stenosis, no evidence of any
<<__dissection>> and TIMI 3 blood flow distally.
COMPLICATIONS: None.
CONTRAST AMOUNT USED: 160 mL of low osmolar contrast.
ESTIMATED BLOOD LOSS: Minimal.
MEDICATIONS USED DURING PROCEDURE:
1. Versed and fentanyl 1 mg and 50 micrograms for conscious sedation.
2. The patient was given ticagrelor which is Brilinta 180 mg p.o.
3. Intracoronary adenosine, total of 600 micrograms.
4. Amiodarone 300 mg IV bolus followed by infusion at 1 mg/kg/min.
5. ReoPro IV bolus followed by infusion.
6. Angiomax IV as per protocol.
EQUIPMENT USED DURING THE PROCEDURE: As per acute intervention of right coronary artery is
concerned.
1. JR4 guide catheter.
2. Prowater wire 0.14.
3. Mailman wire 0.14.
4. Apex balloon 3.0 mm x 8 mm for pre-stent deployment dilatation.
5. Resolute stent 4.0 mm x 26 mm.
6. Quantum balloon for postdilatation 4.5 x 12 mm.
7. Thrombectomy export device.
8. Intravascular ultrasound catheter from Volcano.
9. Temporary pacemaker wire.
DIAGNOSES:
1. Known case of coronary artery disease status post stenting in left anterior descending
artery/right coronary artery with presentation consistent ST elevation myocardial
infarction inferolateral leads, status post catheterization with patent left anterior
descending artery stent but totally occluded mid-to-distal right coronary artery within
the previously deployed stent from mid-to-distal, status post successful percutaneous
intervention with drug-eluting stenting.
2. Reperfusion arrhythmias requiring antiarrhythmics and external DC cardioversion.
LENGTH OF SERVICE: The critical care time spent with the patient apart from doing the
particular intervention of the right coronary artery was 30 minutes
93458,26,59
92960,59
92941,rc
92978,59,53?
92973,53?
Not sure if I should add last two with 53's since he did not complete. Thoughts/suggestions please?
INDICATIONS: ST elevation myocardial infarction, inferolateral leads.
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Left and right selective coronary angiogram.
3. Percutaneous intervention of mid-to-distal right coronary artery via drug-eluting stent,
Resolute 4.0 mm x 26 mm.
4. External DC cardioversion x1.
5. Attempted thrombectomy.
6. Attempted intravascular ultrasound.
7. Attempted temporary pacer wire placement.
8. Radiological supervision and interpretation.
DESCRIPTION OF PROCEDURE: The patient was brought in an emergent situation to the cardiac
catheterization lab for definition of coronary anatomy. She was prepped and draped as per
protocol. Conscious sedation was achieved by given Versed and fentanyl IV. The right groin was
then infiltrated with 20 mL of 2% lidocaine for local anesthesia. Using a modified Seldinger
technique and a micropuncture needle initially the right femoral vein access was obtained and
followed by a right femoral artery access; both sheaths were introduced without any resistance
with good backflow of blood. Both sheaths were flushed. The reason I got a right femoral vein
access, given the patient had inferior ST elevations, they are at high risk of getting
bradyarrhythmias. After flushing both sheaths, then diagnostic coronary angiogram was performed
by using a Judkins Left 4 catheter, getting the left coronary angiograms first given the
patient ST elevation in inferior leads. Then I went and cannulated the right coronary artery
using a Judkins Right 4 guide catheter. After defining her coronary anatomy, then an emergent
percutaneous intervention of the mid-to-distal right coronary artery was performed which will
be discussed in a later part of this report. The patient, during the course of percutaneous
intervention of the right coronary artery, had an episode of ventricular fibrillation arrest
which was successfully shocked by applying DC cardioversion of 360 joules x1. The patient was
subsequently started on IV amiodarone and did not have any hemodynamically unstable rhythm but
kept on having irregular ventricular rhythms which was consistent with <<__>> arrhythmias.
Overall the patient tolerated the procedure well. She was hemodynamically and neurologically
stable at the end of the procedure. Her right groin had both venous and arterial access in
place in the right femoral vein and the right femoral artery respectively which were placed on
a saline flush and resutured in place. At the end of the procedure the patient was chest-pain
free. She was then transferred to the Intensive Care Unit for further management in a
hemodynamically and neurologically stable condition with good hemostasis at the inguinal area
at the site of puncture with no change in her peripheral pulses.
DIAGNOSTIC CORONARY ANGIOGRAPHY FINDINGS:
1. Right dominant system.
2. Left main coronary artery was 4.0 mm vessel with no significant disease. It bifurcated in
the left anterior descending artery and the left circumflex artery.
3. The left anterior descending artery started off as a 3.0 mm vessel. After a very short
distance just before the take off of diagonal 1 and of the septal perforator there was
presence of an old stent with 20-30 in-stent restenosis. This stent was across the
diagonal 1 and appeared to have jailed the ostium the diagonal to some extent. After the
stent, the left anterior descending artery continued to be a 3.0 mm vessel until it gave
rise to diagonal 2, and after that it was a 2.5 mm vessel in the mid-to-distal portion
and distally becoming a small caliber vessel in a wraparound fashion. During its course
it gave rise to diagonal 1 which was a 2.25 mm vessel with evidence of 90% eccentric
stenosis at the ostium which is probably secondary to the stent in the past being
deployed across it and a proximal 60-70% stenosis. The diagonal 2nd was a 2.5 mm vessel
with no evidence of any obstructive disease, just 10-20% lumen irregularities.
4. The circumflex artery was 3.0 mm vessel from proximal to mid and distally continues as a
small caliber vessel in the atrioventricular groove. During its course it gave rise to
obtuse marginal 1 which was 2.0 mm vessel with no significant disease followed by obtuse
marginal 2 which was a 1.5 mm vessel with evidence of 10-20% lumen irregularities
throughout its course.
5. Right coronary artery was a 4.0 mm vessel proximally and after a short distance it became
a smaller caliber vessel around 3.0 mm and from that point onward there was presence of
old deployed stent which continued towards the distal portion of the right coronary
artery. There was about 20% in-stent restenosis in the amount of the stent which was
still patent, and then at the level of the mid-to-distal right coronary artery the right
coronary artery was totally occluded within the stented segment with evidence of
thrombus. During the left coronary injections there was presence of left-to-right
collaterals demonstrating fairly large territory and good caliber PDA/PLV.
6. Hemodynamics: Aortic pressure was 127 mmHg systolic and diastolic 60 mmHg with a mean of
87 mmHg. No left ventricular end-diastolic pressure was measured as the patient's
ventricle was very vulnerable to arrhythmias so I did not decide to put any hardware into
her left ventricle.
7. Left ventricular angiogram was not performed for the reason mentioned above, as the
patient had significant reperfusion arrhythmias and the plan is to get an echocardiogram
to assess that left ventricular function.
DECISION MAKING: Given the patient acute injury pattern in that territory the decision was made
to emergently intervene on this segment of the right coronary artery which was within the
stented portion in the region of mid-to-distal right coronary artery. This was communicated to
the patient and she gave her approval.
DESCRIPTION OF PERCUTANEOUS INTERVENTION OF THE RIGHT CORONARY ARTERY: Description of the
percutaneous intervention of the mid-to-distal right coronary artery totally occluded segment
of the in-stented portion of the vessel. In anticipation of percutaneous intervention of this
vessel, the patient was initiated on Angiomax as per protocol. She was given 180 mg of Brilinta
which is ticagrelor. The reason I used ticagrelor over Plavix is it has an immediate
antiplatelet activity and will give the most benefit during the thrombotic episode. Using a
Judkins Right 4 coronary catheter which I had used for diagnostic purposes as well, a Prowater
wire was introduced through the right catheter into the right coronary artery and placed
distally into the posterolateral ventricular branch of the right coronary artery. Attempt was
made initially to pass thrombectomy export catheter but after a couple attempts given the
patient's proximal-to-mid-to distal portion was so noncompliant secondary to presence of old
stent, it did not allow the thrombectomy device to go past the proximal portion of the right
coronary artery. At this point in time the plan was changed and using an Apex balloon, 3.0 x 8
mm, it was introduced into the totally occluded segment of the right coronary artery within the
stented portion and <<darted>> across the course and the <<dartering>> was very smooth
consistent with intraluminal passage. With passage of the balloon there was TIMI 2 blood flow
seen across the totally occluded segment within the stented portion of the right coronary
artery to the distal bed. Then this balloon was inflated within the totally occluded portion
which was in the old stented portion of the right coronary artery multiple times at 12
atmospheres. After successful desiccation of the thrombus burden in the stented portion of the
right coronary artery, this balloon was withdrawn and a Resolute stent 4.0 mm x 26 mm was
attempted to be introduced into the right coronary artery but we were unable to pass the stent
past the stented portion of the right coronary artery. After multiple attempts were made, the
guide and wire disengaged and the hardware was at this point removed and the right coronary
artery was then cannulated again and now I chose a different wire to get more support which was
a Mailman wire, 0.14 which was successfully traversed across the right coronary artery and
placed distally into the posterior descending artery branch of the right coronary artery. Then
this Resolute stent 4.0 mm x 26 mm was successfully introduced into the right coronary artery
through the stented portion into the distal portion of the old stented area and this was
deployed at high pressures of 14 atmospheres over 30 seconds. The stent balloon was removed and
post stent deployment was then performed by using a Quantum balloon, 4.5 mm x 12 mm which was
inflated on multiple times within the stented portion of the right coronary artery at around
16-17 atmospheres. During the course of intervention multiple injections of intracoronary
adenosine were given to improve the distal beds circulation and the patient also was started on
IV ReoPro bolus followed by infusion. Given the patient was having a lot of reperfusion
arrhythmias, IV amiodarone bolus 360 mg were given followed by IV infusion. After successful
post stent deployment dilatation was performed, I tried to introduce the intravascular catheter
to ascertain that the stent was well opposed, as there is another layer of stent beneath, by
doctor trying a couple of times, I was unable to advance the IVUS catheter past the proximal
portion of the right coronary artery just before the old stented portion of the artery started.
The guide would move out along with the wire. Given the <<__>> results angiographically after
the post stent deployment dilatation, I then did not attempt to IVUS the stented area as
angiographically there was no evidence of any <<__dissection>>, appeared to have well
deployment and TIMI 3 blood flow distally. At this point in time the procedure was stopped and
hardware was removed under fluoroscopic guidance. Thought was given to do a left ventricular
angiogram at the end of the procedure, but given the patient was having lots of reperfusion
arrhythmias I did not do any left ventricle hardware insertion and at this time the procedure
was stopped.
During the procedure, as mentioned in the first part of the report, the patient after we got
reperfusion she went into a brief episode of ventricular fibrillation arrest but
hemodynamically and clinically did not have any compromise. She was still awake and this was
successfully aborted by doing 1 DC cardioversion with 360 joules. This was followed by
introducing IV amiodarone bolus followed by infusion with marked improvement in her reperfusion
arrhythmias.
FINAL RESULTS:
Pre-stent deployment: Totally occluded mid-to-distal right coronary artery with areas of
thrombus burden.
Post-stent deployment: Well-deployed stent with 0 postresidual stenosis, no evidence of any
<<__dissection>> and TIMI 3 blood flow distally.
COMPLICATIONS: None.
CONTRAST AMOUNT USED: 160 mL of low osmolar contrast.
ESTIMATED BLOOD LOSS: Minimal.
MEDICATIONS USED DURING PROCEDURE:
1. Versed and fentanyl 1 mg and 50 micrograms for conscious sedation.
2. The patient was given ticagrelor which is Brilinta 180 mg p.o.
3. Intracoronary adenosine, total of 600 micrograms.
4. Amiodarone 300 mg IV bolus followed by infusion at 1 mg/kg/min.
5. ReoPro IV bolus followed by infusion.
6. Angiomax IV as per protocol.
EQUIPMENT USED DURING THE PROCEDURE: As per acute intervention of right coronary artery is
concerned.
1. JR4 guide catheter.
2. Prowater wire 0.14.
3. Mailman wire 0.14.
4. Apex balloon 3.0 mm x 8 mm for pre-stent deployment dilatation.
5. Resolute stent 4.0 mm x 26 mm.
6. Quantum balloon for postdilatation 4.5 x 12 mm.
7. Thrombectomy export device.
8. Intravascular ultrasound catheter from Volcano.
9. Temporary pacemaker wire.
DIAGNOSES:
1. Known case of coronary artery disease status post stenting in left anterior descending
artery/right coronary artery with presentation consistent ST elevation myocardial
infarction inferolateral leads, status post catheterization with patent left anterior
descending artery stent but totally occluded mid-to-distal right coronary artery within
the previously deployed stent from mid-to-distal, status post successful percutaneous
intervention with drug-eluting stenting.
2. Reperfusion arrhythmias requiring antiarrhythmics and external DC cardioversion.
LENGTH OF SERVICE: The critical care time spent with the patient apart from doing the
particular intervention of the right coronary artery was 30 minutes
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