INDICATIONS: This 62-year-old male with history of hypertension,
hyperlipidemia, coronary artery disease, status post coronary
artery bypass grafting is admitted to Methodist Medical Center in
the setting of unstable angina. He is referred for
catheterization, possible angioplasty. The patient was seen
recently in the Emergency Department with chest pain, found to be
in atrial fibrillation with rapid ventricular response. He was
treated with anticoagulation and started on sotalol. His left
ventricular function at that time was normal. Now for
catheterization, possible angioplasty.
NAME OF PROCEDURES: Left heart catheterization, coronary
arteriogram, ventriculography, arteriography of left internal
mammary artery graft, arteriography of saphenous vein graft to
the left anterior descending, ultrasound-guided right common
femoral artery access, and moderate conscious sedation. Start
time 12:09, stop time 12:47. Two mg of Versed used and 125 mcg
of fentanyl used.
DIAGNOSES: Unstable angina, coronary artery disease with
symptoms.
DESCRIPTION OF PROCEDURE: After informed consent was obtained,
the patient was brought to cardiac catheterization suite state,
prepped and draped in usual sterile fashion. A 6-French sheath
placed in right femoral artery. Using ultrasound guidance,
coronary arteriography was performed with 6-French JR4, 6-French
JL4. Engagement of the saphenous vein graft was accomplished
with a 6-French multipurpose catheter. Engagement of the IM
graft was accomplished with a 6-French JR4. Ventriculography was
performed using a 6-French pigtail catheter. A total of 24 mL of
Visipaque contrast was used. At the conclusion of the study,
right femoral sheath was removed. Hemostasis was obtained using
the Angio-Seal device. The patient tolerated the procedure well
without complication.
MEDICATIONS USED: 2 mg of Versed used and 125 mcg of fentanyl
used.
HEMODYNAMICS: Aortic pressure 157/80, left ventricular pressure
151/12, EDP equal 12.
CATHETERIZATION:
LEFT MAIN: The left main arose normally from the aorta giving
rise to LAD and circumflex. Left main was previously stented.
The stents were widely patent.
LEFT ANTERIOR DESCENDING: The LAD was totally occluded in its
ostial portion. There was a diagonal originating from ostial
vessel. This diagonal was patent with patent stents in the
proximal vessel.
CIRCUMFLEX: The circumflex arose normally from the left main.
Circumflex had been extensively stented from its proximal portion
extending into an OM1. The stents were patent with 10% luminal
irregularities. There is a stent extending into a small branch
of the marginal vessel and the stent had a 90% in-stent
restenosis. But this portion of the vessel was small.
RIGHT CORONARY ARTERY: The right coronary was totally occluded
in its proximal portion. There was left to right collateral
filling up to the mid right coronary artery. The right coronary
artery appeared to be a small caliber vessel.
GRAFTS:
1. LEFT INTERNAL MAMMARY ARTERY TO LEFT ANTERIOR DESCENDING:
The LIMA to LAD was widely patent. This graft was bypassed both
to the distal circumflex and the LAD anastomosis intact to both
vessels and the runoff was good.
2. SAPHENOUS VEIN GRAFT TO THE RIGHT CORONARY ARTERY: The
vessel graft was totally occluded in its proximal portion.
VENTRICULOGRAM: Single plane ventriculogram was performed and
revealed mild inferior wall hypokinesis, EF 55%.
IMPRESSION: Patent stents, left main. Patent stent in the
circumflex and OM1, 90% in-stent restenosis in the small branch
of the marginal vessel. Patent stent in left anterior descending
diagonal, totally occluded left anterior descending, totally
occluded right coronary artery, total occluded saphenous vein
graft to the right coronary artery, patent left internal mammary
artery to the left anterior descending and obtuse marginal.
hyperlipidemia, coronary artery disease, status post coronary
artery bypass grafting is admitted to Methodist Medical Center in
the setting of unstable angina. He is referred for
catheterization, possible angioplasty. The patient was seen
recently in the Emergency Department with chest pain, found to be
in atrial fibrillation with rapid ventricular response. He was
treated with anticoagulation and started on sotalol. His left
ventricular function at that time was normal. Now for
catheterization, possible angioplasty.
NAME OF PROCEDURES: Left heart catheterization, coronary
arteriogram, ventriculography, arteriography of left internal
mammary artery graft, arteriography of saphenous vein graft to
the left anterior descending, ultrasound-guided right common
femoral artery access, and moderate conscious sedation. Start
time 12:09, stop time 12:47. Two mg of Versed used and 125 mcg
of fentanyl used.
DIAGNOSES: Unstable angina, coronary artery disease with
symptoms.
DESCRIPTION OF PROCEDURE: After informed consent was obtained,
the patient was brought to cardiac catheterization suite state,
prepped and draped in usual sterile fashion. A 6-French sheath
placed in right femoral artery. Using ultrasound guidance,
coronary arteriography was performed with 6-French JR4, 6-French
JL4. Engagement of the saphenous vein graft was accomplished
with a 6-French multipurpose catheter. Engagement of the IM
graft was accomplished with a 6-French JR4. Ventriculography was
performed using a 6-French pigtail catheter. A total of 24 mL of
Visipaque contrast was used. At the conclusion of the study,
right femoral sheath was removed. Hemostasis was obtained using
the Angio-Seal device. The patient tolerated the procedure well
without complication.
MEDICATIONS USED: 2 mg of Versed used and 125 mcg of fentanyl
used.
HEMODYNAMICS: Aortic pressure 157/80, left ventricular pressure
151/12, EDP equal 12.
CATHETERIZATION:
LEFT MAIN: The left main arose normally from the aorta giving
rise to LAD and circumflex. Left main was previously stented.
The stents were widely patent.
LEFT ANTERIOR DESCENDING: The LAD was totally occluded in its
ostial portion. There was a diagonal originating from ostial
vessel. This diagonal was patent with patent stents in the
proximal vessel.
CIRCUMFLEX: The circumflex arose normally from the left main.
Circumflex had been extensively stented from its proximal portion
extending into an OM1. The stents were patent with 10% luminal
irregularities. There is a stent extending into a small branch
of the marginal vessel and the stent had a 90% in-stent
restenosis. But this portion of the vessel was small.
RIGHT CORONARY ARTERY: The right coronary was totally occluded
in its proximal portion. There was left to right collateral
filling up to the mid right coronary artery. The right coronary
artery appeared to be a small caliber vessel.
GRAFTS:
1. LEFT INTERNAL MAMMARY ARTERY TO LEFT ANTERIOR DESCENDING:
The LIMA to LAD was widely patent. This graft was bypassed both
to the distal circumflex and the LAD anastomosis intact to both
vessels and the runoff was good.
2. SAPHENOUS VEIN GRAFT TO THE RIGHT CORONARY ARTERY: The
vessel graft was totally occluded in its proximal portion.
VENTRICULOGRAM: Single plane ventriculogram was performed and
revealed mild inferior wall hypokinesis, EF 55%.
IMPRESSION: Patent stents, left main. Patent stent in the
circumflex and OM1, 90% in-stent restenosis in the small branch
of the marginal vessel. Patent stent in left anterior descending
diagonal, totally occluded left anterior descending, totally
occluded right coronary artery, total occluded saphenous vein
graft to the right coronary artery, patent left internal mammary
artery to the left anterior descending and obtuse marginal.