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Left heart catheterization with selective coronary angiography, second order selective peripheral thoracic angiography, complex peripheral artery disease requiring multiple wires and technique.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old with history of tobacco abuse, hypertension, previous CAD with multiple percutaneous interventions in the past. Most recently intervene on the ostial RCA lesion back approximately 3 months
prior. She presents with stuttering symptoms concerning and consistent with her previous angina and is referred for angiography with suspect restenosis or de novo lesion.
PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives 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 was accessed using modified Seldinger technique of which a 6 French sheath was attempted. Micropuncture technique was utilized initially and it was difficult to pass a
wire. Subsequently, a Terumo Glidewire was utilized eventually traversing the complex lesion seen in the common iliac artery on the right side and selective angiography demonstrated this. Eventually the wire was able to be traversed and catheters were
able to be deployed. A 5 French system was used to perform selective coronary angiography on the right which demonstrated patent stent seen.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg.
SELECTIVE CORONARY ANGIOGRAPHY:
LEFT MAIN: There was catheter dampening upon engagement of the left main coronary artery with the 5 French system. Patient experienced chest pain and ventricularization of pressures.
LAD: The left anterior descending artery had a patent stent with mild disease.
CIRCUMFLEX: There was a patent stent with mild disease as well as a high marginal that had about 30% proximal disease.
RCA: Diffuse disease and stents. There was an ostial stent that was patent, a midvessel stent that had about 20% stenosis and a distal stent with 50% in-stent restenosis.
Intravascular ultrasound was utilized to evaluate the ostial left main. Five thousand units of heparin were used and the sheath was up-sized to a 6 French system. An EBU 3.5 guide catheter was used to intubate the left main with the wire being placed
into the circumflex. An IVUS catheter was used to evaluate the reference diameter which was 16 m2 and the stenotic ostium measured 4.7 mm2 consistent with an approximately 70% area stenosis and a critical value of the stenosis to less than 6 mm2,
indicative of critical ostial left main.
SUMMARY: Multivessel coronary disease with high-grade lesion seen at the ostium of the left main as well as in the distal RCA with in-stent restenosis.
CLINICAL PATHWAY: The patient will be expedited for coronary artery bypass grafting by Dr. Ronald Kirshner with attention drawn to the left main as well as the RCA. Of note, due to the patient's severe peripheral artery disease, selective engagement of
the subclavian artery was performed. Selective angiography demonstrated tortuosity and mild stenosis seen in the proximal portion of the vessel. There is no pullback gradient. The vertebrals Were free of ostial disease. The wire was
then advanced into the main body of the subclavian and an IMA catheter was used to selectively engage the internal mammary artery. She had previous lung surgery and concern was whether or not the LIMA remained in situ. Selective engagement demonstrated
patency of this vessel and would be a useful conduit for bypass.
SUMMARY: Successful percutaneous evaluation of subclavian and internal mammary artery as potential conduits for coronary bypass.
Dr wants a LHC 93458-26
IVUS 92978-LC-26
and selective 2nd order pheripheral thoracic vessel
and subclavian S & I. I am not sure of the last two codes Thanks Nancy
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old with history of tobacco abuse, hypertension, previous CAD with multiple percutaneous interventions in the past. Most recently intervene on the ostial RCA lesion back approximately 3 months
prior. She presents with stuttering symptoms concerning and consistent with her previous angina and is referred for angiography with suspect restenosis or de novo lesion.
PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives 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 was accessed using modified Seldinger technique of which a 6 French sheath was attempted. Micropuncture technique was utilized initially and it was difficult to pass a
wire. Subsequently, a Terumo Glidewire was utilized eventually traversing the complex lesion seen in the common iliac artery on the right side and selective angiography demonstrated this. Eventually the wire was able to be traversed and catheters were
able to be deployed. A 5 French system was used to perform selective coronary angiography on the right which demonstrated patent stent seen.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg.
SELECTIVE CORONARY ANGIOGRAPHY:
LEFT MAIN: There was catheter dampening upon engagement of the left main coronary artery with the 5 French system. Patient experienced chest pain and ventricularization of pressures.
LAD: The left anterior descending artery had a patent stent with mild disease.
CIRCUMFLEX: There was a patent stent with mild disease as well as a high marginal that had about 30% proximal disease.
RCA: Diffuse disease and stents. There was an ostial stent that was patent, a midvessel stent that had about 20% stenosis and a distal stent with 50% in-stent restenosis.
Intravascular ultrasound was utilized to evaluate the ostial left main. Five thousand units of heparin were used and the sheath was up-sized to a 6 French system. An EBU 3.5 guide catheter was used to intubate the left main with the wire being placed
into the circumflex. An IVUS catheter was used to evaluate the reference diameter which was 16 m2 and the stenotic ostium measured 4.7 mm2 consistent with an approximately 70% area stenosis and a critical value of the stenosis to less than 6 mm2,
indicative of critical ostial left main.
SUMMARY: Multivessel coronary disease with high-grade lesion seen at the ostium of the left main as well as in the distal RCA with in-stent restenosis.
CLINICAL PATHWAY: The patient will be expedited for coronary artery bypass grafting by Dr. Ronald Kirshner with attention drawn to the left main as well as the RCA. Of note, due to the patient's severe peripheral artery disease, selective engagement of
the subclavian artery was performed. Selective angiography demonstrated tortuosity and mild stenosis seen in the proximal portion of the vessel. There is no pullback gradient. The vertebrals Were free of ostial disease. The wire was
then advanced into the main body of the subclavian and an IMA catheter was used to selectively engage the internal mammary artery. She had previous lung surgery and concern was whether or not the LIMA remained in situ. Selective engagement demonstrated
patency of this vessel and would be a useful conduit for bypass.
SUMMARY: Successful percutaneous evaluation of subclavian and internal mammary artery as potential conduits for coronary bypass.
Dr wants a LHC 93458-26
IVUS 92978-LC-26
and selective 2nd order pheripheral thoracic vessel
and subclavian S & I. I am not sure of the last two codes Thanks Nancy
