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| Cardiac catheterization | |
90-95% proximal right iliac stenosis. 95% mid LAD stenosis. Long up to 95% stenosed lesion in the mid RCA, severely calcified. . Intervention: Percutaneous intervention of 95% right common iliac stenosis with 5.5 mm shockwave lithoplasty balloon and 6.0 mm balloon angioplasty PCI of mid LAD stenosis with resolute Onyx 2.75 x 15 mm drug-eluting stent, postdilated with a 2.75 x 12 mm NC balloon to 24 atm. PCI of mid RCA stenosis with a 2.5 x 12 mm SC balloon to 20 atm. . Plan: Continue inpatient and post NSTEMI care. Dual antiplatelet therapy. Monitor for symptoms and possibly return for PCI of RCA with rotational atherectomy, and possible intervention on remainder of the lesion in right common iliac Procedures performed: Distal aortogram with bilateral runoff Percutaneous intervention of right common iliac artery Coronary angiography PCI of LAD with DES x1 PCI of RCA with POBA Procedure details: Patient was brought down to the Cath Lab in a fasting state. Conscious sedation was formed with Versed and fentanyl. The right common femoral artery was accessed under ultrasound guidance with a micropuncture needle and a 5 French sheath was placed. An attempt to advance a JR4 up over wire, the wire would not pass the common iliac area. Hand-injection showed a severe stenosis of the common iliac artery. A soft angled Glidewire was advanced beyond the lesion followed by a pigtail catheter. A distal aortogram with bilateral runoff was performed showing greater than 90% lesion in the right common iliac artery and complete occlusion of the left common iliac artery. A miracle Brothers 3 wire was advanced and the pigtail catheter was catheter was removed, and a was advanced to the distal aorta where the angiogram was performed to see the result. Then a J-wire was advanced an Abbott Armada 6.0 x 20 mm balloon was then used to perform angioplasty of the stenosis up to 14 atm. Repeat angiography showed some improvement in the stenosis although there is at least an 80% residual stenosis. Since there was enough room to get through with guide catheters I proceeded with the coronary angiography next. A JR4 diagnostic was used to perform angiography of the right coronary artery. A JL 4.0 diagnostic catheter was used to engage the left main and perform left coronary angiography. Next an EBU 3.75 guide catheter was used to engage the left main coronary artery. A Prowater guidewire was advanced down the LAD beyond the mid LAD lesion. Angioplasty of the LAD lesion was performed with a 2.5 x 12 mm SC balloon to 12 atm. Lesion was then stented with a resolute Onyx 2.75 x 15 mm drug-eluting stent to 14 atm. Stent was then postdilated with a 2.75 x 8 mm NC balloon up to 24 atm. Repeat angiography showed no residual stenosis of the stented region there was a slight ostial pinching of the first diagonal branch but there was good flow. Next, JR4 guide was used to engage the right coronary artery. A Prowater wire was advanced down the vessel beyond the lesion. Angioplasty of the lesion was performed with a 2.5 x 12 mm SC balloon to 16-20 atm. There is little change in the RCA lesion therefore I advanced a 2.75 x 12 mm NC balloon, however this would not advance down to the lesion. A 6 French guide liner was inserted as well for support however could not pass the NC balloon. At this point I decided to stop the case given the patient had receive a significant amount of the dye due to the need for the peripheral intervention as well as the LAD intervention. Patient was comfortable therefore the procedure was ended. The wires and catheters were removed and the sheath was later removed using manual pressure for hemostasis. Findings: Right common iliac: 90 to 95% stenosis. Right internal iliac: Mild nonobstructive disease Right external iliac: Mild nonobstructive disease Right common femoral: 60% stenosis Left common iliac: Occluded Left internal iliac: Occluded Left external iliac: Occluded Left common femoral: Reconstituted with collaterals, at least moderate disease. LMCA: Large caliber vessel arising from the left sinus of Valsalva. Angiographically patent. Trifurcates into the LAD and left circumflex. LAD: Moderate caliber vessel arising from the left main coronary artery. There is a 95% stenosis of the mid LAD just distal to the diagonal 1 branch. 30% ostial D1 branch stenosis. The remainder of the LAD has mild nonobstructive disease. Ramus intermedius: Small caliber vessel arising from the LMCA. There is a 60% ostial stenosis. LCx: Large caliber vessel arising from the left main coronary artery. Gives off 2 obtuse marginal branches. There are mild luminal irregularities in left circumflex and its branches. RCA: Moderate caliber vessel arising from the right sinus of Valsalva. The bifurcates into a small to moderate PDA and a small to moderate PLB. There is a long mid RCA stenosis which is calcified and up to 95% stenosed. |