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Angina pectoris, coronary artery disease.
Left heart catheterization with coronary angiography, bypass graft angiography and attempted percutaneous intervention of the distal left main with unsuccessful balloon angioplasty
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old with history of coronary bypass graft x5, hypertension, dyslipidemia presenting with reminiscent syndrome concerning for his typical angina. He is able to perform his typical activities, However,
he raises great concern as his typical anginal warning system was poor as prior to his 5 vessel bypass. He had a previous stress test that was otherwise acceptable, however, with escalating symptoms, he requested angiography.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused
subcutaneously until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique. A 6 French 11 cm sheath was placed without complication. Diagnostic JL4 and JR4 catheters and IMA catheter were used to
perform selective coronary angiography, bypass graft angiography and left heart catheterization. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 8 mmHg. There was no transaortic gradient on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN: 90% eccentric distal highly calcified stenosis leading into the trifurcation of an LAD, ramus and left circumflex system.
LAD: Subtotally occluded proximally. The previously described diagonal system was not visualized on antegrade angiography. The distal LAD was seen with mild disease seen from a patent bypass graft. The diagonals were not visualized with angiography
as the bypass graft subtending it was totally occluded.
LEFT CIRCUMFLEX: The ramus intermedius was a diffuse 80% proximal stenosis and was fed by a patent bypass graft. The left circumflex gave off a prominent first marginal. The circumflex itself was diffusely diseased. The marginal had mild disease and
was compromised by the distal left main stenosis. There was no bypass graft to it.
RCA: Dominant vessel with a prominent RPDA and PL system with 100% proximal stenosis being fed by a patent bypass grafts distally.
GRAFTS: The vein graft to the right PDA was patent with mild disease. The vein graft to the ramus was patent with mild proximal disease. The vein graft to the diagonal 1, diagonal 2 was totally occluded. The LIMA to LAD was patent with mild disease.
SUMMARY: Severe multivessel coronary artery disease with 3/5 patent bypass grafts. It appears that the region feeding the left circumflex subtended by the distal left main is compromised perhaps maybe reporting his symptoms and therefore it was decided
to proceed with.
INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. The lesion itself was greater than 90 degree takeoff in order to wire the marginal. Significant mental
effort was engaged in order to try to wire with multiple wires being utilized. Eventually a PILOT was able to be navigated to the left circumflex and 1.5 Apex push was used to dilate. Subsequently a 2.5 Apex balloon was used to dilate to 12 atmospheres
to the distal left main. There was a residual waist. Thereafter, rewiring into the marginal with buddy wire technique, other multiple wires and balloons were utilized as well as a noncompliant balloon of 2.5 and 3.5 variety as well as a 2.5 compliant
balloon were not able to pass the residual lesion. It was decided at that point to abandon the procedure.
SUMMARY: Unsuccessful balloon angioplasty of the distal left main with 80% residual stenosis.
CLINICAL PATHWAY: We will focus on medical therapy in light of this very difficult to traverse the lesion. Rotablation atherectomy could be considered in the future should his symptoms dictate, however, would greatly maximize medical therapy prior to
pursuing this. We thank you for the opportunity to participate in the care of this fine gentleman.
I have 93459-26-59
92920-LM-22
Thanks Nancy
Angina pectoris, coronary artery disease.
Left heart catheterization with coronary angiography, bypass graft angiography and attempted percutaneous intervention of the distal left main with unsuccessful balloon angioplasty
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old with history of coronary bypass graft x5, hypertension, dyslipidemia presenting with reminiscent syndrome concerning for his typical angina. He is able to perform his typical activities, However,
he raises great concern as his typical anginal warning system was poor as prior to his 5 vessel bypass. He had a previous stress test that was otherwise acceptable, however, with escalating symptoms, he requested angiography.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused
subcutaneously until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique. A 6 French 11 cm sheath was placed without complication. Diagnostic JL4 and JR4 catheters and IMA catheter were used to
perform selective coronary angiography, bypass graft angiography and left heart catheterization. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 8 mmHg. There was no transaortic gradient on pullback.
CORONARY ANGIOGRAPHY:
LEFT MAIN: 90% eccentric distal highly calcified stenosis leading into the trifurcation of an LAD, ramus and left circumflex system.
LAD: Subtotally occluded proximally. The previously described diagonal system was not visualized on antegrade angiography. The distal LAD was seen with mild disease seen from a patent bypass graft. The diagonals were not visualized with angiography
as the bypass graft subtending it was totally occluded.
LEFT CIRCUMFLEX: The ramus intermedius was a diffuse 80% proximal stenosis and was fed by a patent bypass graft. The left circumflex gave off a prominent first marginal. The circumflex itself was diffusely diseased. The marginal had mild disease and
was compromised by the distal left main stenosis. There was no bypass graft to it.
RCA: Dominant vessel with a prominent RPDA and PL system with 100% proximal stenosis being fed by a patent bypass grafts distally.
GRAFTS: The vein graft to the right PDA was patent with mild disease. The vein graft to the ramus was patent with mild proximal disease. The vein graft to the diagonal 1, diagonal 2 was totally occluded. The LIMA to LAD was patent with mild disease.
SUMMARY: Severe multivessel coronary artery disease with 3/5 patent bypass grafts. It appears that the region feeding the left circumflex subtended by the distal left main is compromised perhaps maybe reporting his symptoms and therefore it was decided
to proceed with.
INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. The lesion itself was greater than 90 degree takeoff in order to wire the marginal. Significant mental
effort was engaged in order to try to wire with multiple wires being utilized. Eventually a PILOT was able to be navigated to the left circumflex and 1.5 Apex push was used to dilate. Subsequently a 2.5 Apex balloon was used to dilate to 12 atmospheres
to the distal left main. There was a residual waist. Thereafter, rewiring into the marginal with buddy wire technique, other multiple wires and balloons were utilized as well as a noncompliant balloon of 2.5 and 3.5 variety as well as a 2.5 compliant
balloon were not able to pass the residual lesion. It was decided at that point to abandon the procedure.
SUMMARY: Unsuccessful balloon angioplasty of the distal left main with 80% residual stenosis.
CLINICAL PATHWAY: We will focus on medical therapy in light of this very difficult to traverse the lesion. Rotablation atherectomy could be considered in the future should his symptoms dictate, however, would greatly maximize medical therapy prior to
pursuing this. We thank you for the opportunity to participate in the care of this fine gentleman.
I have 93459-26-59
92920-LM-22
Thanks Nancy