Jane5711
Networker
Hi - Can someone help me with this report. I do not see where my provider did a distal abdominal aortogram. It is noted in the findings. I need some feedback before I ask him. Please note the PTCA to the LD was dictated on a different report.
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Selective bilateral renal artery angiography.
5. Distal abdominal aortogram using the right long sheath in the right
femoral artery.
6. Angioplasty of the distal left anterior descending artery with only
partial success with a 60 percent residual stenosis with a 3.0 x 15 mm
balloon.
7. Successful angioplasty and stent of the mid left anterior descending
artery with a 3.25 x 15 mm Xience Alpine Everolimus drug-eluting
stent.
8. Successful angioplasty and stent of the proximal left anterior
descending artery with a 3.5 x 12 mm Xience Alpine Everolimus
drug-eluting stent.
INDICATIONS:
1. Acute coronary syndrome and unstable angina pectoris with acute
non-ST-segment elevation myocardial infarction, peak troponin of
around 1.5.
2. Ischemic cardiomyopathy with anterior wall hypokinesis in the
echocardiogram and akinesis of the inferior wall.
3. Peripheral artery disease with a previous history of stenting of both
the common iliac arteries extensively including both the common iliac
arteries and external iliac arteries.
4. Renal artery atherosclerosis and renal artery stenosis bilaterally
with uncontrolled hypertension.
INDICATION: Unstable angina pectoris: After the informed consent was
obtained, the patient was prepped and draped in the usual sterile fashion.
Lidocaine 2 percent was used for local anesthesia in the right groin.
Vascular access was obtained in the right femoral artery. Over a
guidewire, a 6-French long angiographic sheath was placed in the right
femoral artery.
A 6-French JR4 catheter was used, followed by 5-French _____ JR4 catheter,
followed by 6-French IMA catheter to engage the right coronary artery. The
right coronary artery was totally occluded at the aortic ostium.
Then a 6-French JL4 catheter was introduced over a guidewire selectively
engaging the left coronary artery and selective left coronary angiography
was performed.
Then, over a guidewire, a 6-French JL4 catheter was withdrawn. A 6-French
JR4 catheter was used to selectively engage the left renal artery and
selective left renal artery angiography was performed.
A 6-French JR4 catheter was then used to selectively engage the right
renal artery and selective right renal artery angiography was performed.
Following this, angioplasty and stent of the left anterior descending
artery in 2 locations and angioplasty in the distal LAD was also performed
following which guidewire and guiding catheter removed and then over
guidewire, a 6-French pigtail catheter was introduced over a guidewire
into the left ventricle. Left ventricular hemodynamics were measured and
left ventriculography in the RAO projection was performed. The pigtail
catheter was removed under hemodynamic monitoring from the left ventricle
to the aorta.
Then at the end of the diagnostic cardiac catheterization, the guidewire,
diagnostic catheters, and the guiding catheters were removed and arterial
sheath was sutured in place and the patient was transferred in a stable
condition to the floor for further care with no complications.
FINDINGS:
HEMODYNAMIC DATA:
1. Left ventricular pressure 164/9/13 mmHg.
2. Heart rate 80 beats per minute.
3. Aortic pressure 171/71/111 mm mean.
ANATOMIC DATA:
LEFT VENTRICULOGRAPHY:
1. Anterobasal normal.
2. Anterolateral normal.
3. Apical normal.
4. Inferior severe hypokinesis/akinesis.
5. Posterobasal akinetic aneurysmal.
6. Left ventricular ejection fraction is approximately 50 percent by
visual estimate with no significant gradient across the aortic valve
noted, 1 to 2 plus mitral insufficiency noted.
CORONARY DATA:
RIGHT CORONARY ARTERY: Right coronary artery is heavily calcified in its
entire course and is totally occluded at the aortic ostium. The mid and
distal portion of the right coronary artery are noted to fill via grade 2
to grade 3 collaterals from the left anterior descending artery and the
left circumflex artery. It was noted that the posterolateral branch and
the PDA branch of the right coronary artery are patent with posterior
descending branch showing moderate diffuse disease and posterolateral
branch showing mild-to-moderate diffuse disease. Noted to fill via grade 3
collaterals from the distal portion of the left anterior descending artery
septal perforators and the left circumflex artery branches.
The mid right coronary artery is heavily diseased with up to 80 percent
stenosis in its mid distal portion and it fills up to the total occlusion
in its early mid portion from grade 3 collaterals noted as above.
LEFT MAIN CORONARY ARTERY: The left main coronary artery is a short
vessel. It is a moderate-caliber vessel and it has mild diffuse
atherosclerosis. It divides into left anterior descending artery and left
circumflex artery. It has no high-grade focal stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery has
an 80 percent stenosis in its proximal portion after the origin of the
diagonal branch. The diagonal branch is a medium-caliber vessel with an
ostial 40 percent stenosis and the rest of the vessel with mild diffuse
disease.
Mid LAD after the origin of the diagonal branch has a severe calcific 80
percent stenosis just at the origin of the septal perforator. Distal to
this, the left anterior descending artery makes a U-shaped bend.
The left anterior descending artery after the origin of the diagonal
branch and at the origin of the septal perforator with 80 percent
stenosis. Also then gives rise to second septal perforator. Both first and
second perforator are medium-caliber branches of the left anterior
descending artery and _____ supply profuse grade 3 collaterals to the
distal portion of the left anterior descending artery.
After the 80 percent focal calcific stenosis of the LAD, the left anterior
descending artery continues on and has a widely patent stent in its mid
portion.
Distal to this, the left anterior descending artery has a calcific 80
percent eccentric stenosis.
Distal to this, the left anterior descending artery in the mid and distal
portion is a medium-caliber vessel with mild diffuse disease. It is a
transapical vessel curves around the apex.
It should be noted that the 2 septal perforators and the other septal
perforators of the left anterior descending artery give profuse grade 3
collaterals to the posterior descending branch of the right coronary
artery.
LEFT CIRCUMFLEX ARTERY: The left circumflex artery comes off at a
90-degree angle from the left main coronary artery. It has moderate
diffuse disease in its proximal portion with about 50 percent eccentric
stenosis in its proximal portion. The proximal portion of the left
circumflex artery gives rise to first obtuse marginal branch, which comes
off at a 90 degree angle from the left circumflex artery. It has moderate
diffuse disease in its proximal portion with a 30-40 percent diffuse
stenosis, it is very tortuous in its mid course with another 60 percent
stenosis, which is a focal stenosis at the bend in the mid portion of the
obtuse marginal branch. Distal to this, the obtuse marginal branch is a
medium-caliber vessel with mild diffuse disease.
After the origin of the left obtuse marginal branch, the left circumflex
artery makes another 90-degree bend and followed by another 90-degree bend
and continues on to the AV groove with mild-to-moderate diffuse disease.
The second obtuse marginal branch is a small vessel with mild diffuse
disease.
LEFT RENAL ARTERY: The left renal artery has a 40 percent stenosis in its
ostial proximal portion. The rest of the vessel has mild disease without
any high-grade focal stenosis.
RIGHT RENAL ARTERY: The right renal artery has a 50 percent proximal
calcific stenosis. The rest of the vessel has mild disease.
DISTAL ABDOMINAL AORTA: Distal abdominal aorta has stents, which are
criss-crossing with 2 stents noted and 1 stent extending into the right
common iliac artery and the second stent extending into the left common
iliac artery.
The distal abdominal aorta has moderate diffuse atherosclerosis.
ILIAC ARTERIES: Both right and left common iliac artery has patent stents
without any high-grade focal stenosis.
EXTERNAL ILIAC ARTERIES: Both right and left external iliac arteries have
patent stent without any significant in-stent restenosis.
IMPRESSION:
1. Severe 3-vessel coronary artery disease; with proximal left anterior
descending, 80 percent stenosis; 80 percent focal stenosis of mid left
anterior descending at the origin of the septal perforator with
moderate diffuse disease in the mid left anterior descending and
patent stent in the left anterior descending without significant
in-stent restenosis; distal left anterior descending with 80 percent
calcific eccentric stenosis; left circumflex artery with moderate
diffuse disease in its proximal portion with a 50 percent eccentric
stenosis and a major obtuse margin major first obtuse marginal branch
showing moderate diffuse disease in its proximal portion with a 40-50
percent diffuse proximal stenosis and a focal 60-70 percent stenosis
at the acute bend in the midportion of the obtuse marginal branch and
mild-to-moderate diffuse disease of the rest of the left circumflex
artery and the second obtuse marginal branch; right coronary artery
totally occluded with grade 3 collaterals from the left anterior
descending and the left circumflex artery with the septal perforators
supplying the distal portion of the posterior descending branch, which
are medium-caliber vessels with mild disease and posterolateral
branch, which is a small-to-medium caliber vessel with mild disease.
The right coronary artery fills up to the mid portion with a grade 3
collaterals.
2. Mildly decreased left ventricular systolic function with inferior wall
severely hypokinetic. Posterobasal wall akinetic aneurysmal.
3. Patent renal arteries bilaterally with a 50 percent stenosis of the
proximal left renal artery and 50 percent calcific stenosis of the
right renal artery.
4. Severe peripheral artery disease with a patent stent in both common
iliac arteries and both external iliac artery with the stents in the
common iliac artery extending into the distal portion of the abdominal
aorta.
RECOMMENDATIONS:
1. Recommend angioplasty of the distal left anterior descending.
Recommend angioplasty and stent of the proximal and mid left anterior
descending. The distal left anterior descending appears to have a
calcific lesion. If the angioplasty is only partially successful, then
consider atherectomy in a future time.
2. The patient has multiple comorbidities and hence staged procedures are
recommended.
3. Maximum medical management of renal artery disease and renal arteries
atherosclerosis.
4. With regards to lesions in the left circumflex artery and obtuse
marginal branch, maximal medical management to continue. Right
coronary artery being totally occluded, it is filled by grade 3
collaterals from left-to-right.
Thanks!
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Selective bilateral renal artery angiography.
5. Distal abdominal aortogram using the right long sheath in the right
femoral artery.
6. Angioplasty of the distal left anterior descending artery with only
partial success with a 60 percent residual stenosis with a 3.0 x 15 mm
balloon.
7. Successful angioplasty and stent of the mid left anterior descending
artery with a 3.25 x 15 mm Xience Alpine Everolimus drug-eluting
stent.
8. Successful angioplasty and stent of the proximal left anterior
descending artery with a 3.5 x 12 mm Xience Alpine Everolimus
drug-eluting stent.
INDICATIONS:
1. Acute coronary syndrome and unstable angina pectoris with acute
non-ST-segment elevation myocardial infarction, peak troponin of
around 1.5.
2. Ischemic cardiomyopathy with anterior wall hypokinesis in the
echocardiogram and akinesis of the inferior wall.
3. Peripheral artery disease with a previous history of stenting of both
the common iliac arteries extensively including both the common iliac
arteries and external iliac arteries.
4. Renal artery atherosclerosis and renal artery stenosis bilaterally
with uncontrolled hypertension.
INDICATION: Unstable angina pectoris: After the informed consent was
obtained, the patient was prepped and draped in the usual sterile fashion.
Lidocaine 2 percent was used for local anesthesia in the right groin.
Vascular access was obtained in the right femoral artery. Over a
guidewire, a 6-French long angiographic sheath was placed in the right
femoral artery.
A 6-French JR4 catheter was used, followed by 5-French _____ JR4 catheter,
followed by 6-French IMA catheter to engage the right coronary artery. The
right coronary artery was totally occluded at the aortic ostium.
Then a 6-French JL4 catheter was introduced over a guidewire selectively
engaging the left coronary artery and selective left coronary angiography
was performed.
Then, over a guidewire, a 6-French JL4 catheter was withdrawn. A 6-French
JR4 catheter was used to selectively engage the left renal artery and
selective left renal artery angiography was performed.
A 6-French JR4 catheter was then used to selectively engage the right
renal artery and selective right renal artery angiography was performed.
Following this, angioplasty and stent of the left anterior descending
artery in 2 locations and angioplasty in the distal LAD was also performed
following which guidewire and guiding catheter removed and then over
guidewire, a 6-French pigtail catheter was introduced over a guidewire
into the left ventricle. Left ventricular hemodynamics were measured and
left ventriculography in the RAO projection was performed. The pigtail
catheter was removed under hemodynamic monitoring from the left ventricle
to the aorta.
Then at the end of the diagnostic cardiac catheterization, the guidewire,
diagnostic catheters, and the guiding catheters were removed and arterial
sheath was sutured in place and the patient was transferred in a stable
condition to the floor for further care with no complications.
FINDINGS:
HEMODYNAMIC DATA:
1. Left ventricular pressure 164/9/13 mmHg.
2. Heart rate 80 beats per minute.
3. Aortic pressure 171/71/111 mm mean.
ANATOMIC DATA:
LEFT VENTRICULOGRAPHY:
1. Anterobasal normal.
2. Anterolateral normal.
3. Apical normal.
4. Inferior severe hypokinesis/akinesis.
5. Posterobasal akinetic aneurysmal.
6. Left ventricular ejection fraction is approximately 50 percent by
visual estimate with no significant gradient across the aortic valve
noted, 1 to 2 plus mitral insufficiency noted.
CORONARY DATA:
RIGHT CORONARY ARTERY: Right coronary artery is heavily calcified in its
entire course and is totally occluded at the aortic ostium. The mid and
distal portion of the right coronary artery are noted to fill via grade 2
to grade 3 collaterals from the left anterior descending artery and the
left circumflex artery. It was noted that the posterolateral branch and
the PDA branch of the right coronary artery are patent with posterior
descending branch showing moderate diffuse disease and posterolateral
branch showing mild-to-moderate diffuse disease. Noted to fill via grade 3
collaterals from the distal portion of the left anterior descending artery
septal perforators and the left circumflex artery branches.
The mid right coronary artery is heavily diseased with up to 80 percent
stenosis in its mid distal portion and it fills up to the total occlusion
in its early mid portion from grade 3 collaterals noted as above.
LEFT MAIN CORONARY ARTERY: The left main coronary artery is a short
vessel. It is a moderate-caliber vessel and it has mild diffuse
atherosclerosis. It divides into left anterior descending artery and left
circumflex artery. It has no high-grade focal stenosis.
LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery has
an 80 percent stenosis in its proximal portion after the origin of the
diagonal branch. The diagonal branch is a medium-caliber vessel with an
ostial 40 percent stenosis and the rest of the vessel with mild diffuse
disease.
Mid LAD after the origin of the diagonal branch has a severe calcific 80
percent stenosis just at the origin of the septal perforator. Distal to
this, the left anterior descending artery makes a U-shaped bend.
The left anterior descending artery after the origin of the diagonal
branch and at the origin of the septal perforator with 80 percent
stenosis. Also then gives rise to second septal perforator. Both first and
second perforator are medium-caliber branches of the left anterior
descending artery and _____ supply profuse grade 3 collaterals to the
distal portion of the left anterior descending artery.
After the 80 percent focal calcific stenosis of the LAD, the left anterior
descending artery continues on and has a widely patent stent in its mid
portion.
Distal to this, the left anterior descending artery has a calcific 80
percent eccentric stenosis.
Distal to this, the left anterior descending artery in the mid and distal
portion is a medium-caliber vessel with mild diffuse disease. It is a
transapical vessel curves around the apex.
It should be noted that the 2 septal perforators and the other septal
perforators of the left anterior descending artery give profuse grade 3
collaterals to the posterior descending branch of the right coronary
artery.
LEFT CIRCUMFLEX ARTERY: The left circumflex artery comes off at a
90-degree angle from the left main coronary artery. It has moderate
diffuse disease in its proximal portion with about 50 percent eccentric
stenosis in its proximal portion. The proximal portion of the left
circumflex artery gives rise to first obtuse marginal branch, which comes
off at a 90 degree angle from the left circumflex artery. It has moderate
diffuse disease in its proximal portion with a 30-40 percent diffuse
stenosis, it is very tortuous in its mid course with another 60 percent
stenosis, which is a focal stenosis at the bend in the mid portion of the
obtuse marginal branch. Distal to this, the obtuse marginal branch is a
medium-caliber vessel with mild diffuse disease.
After the origin of the left obtuse marginal branch, the left circumflex
artery makes another 90-degree bend and followed by another 90-degree bend
and continues on to the AV groove with mild-to-moderate diffuse disease.
The second obtuse marginal branch is a small vessel with mild diffuse
disease.
LEFT RENAL ARTERY: The left renal artery has a 40 percent stenosis in its
ostial proximal portion. The rest of the vessel has mild disease without
any high-grade focal stenosis.
RIGHT RENAL ARTERY: The right renal artery has a 50 percent proximal
calcific stenosis. The rest of the vessel has mild disease.
DISTAL ABDOMINAL AORTA: Distal abdominal aorta has stents, which are
criss-crossing with 2 stents noted and 1 stent extending into the right
common iliac artery and the second stent extending into the left common
iliac artery.
The distal abdominal aorta has moderate diffuse atherosclerosis.
ILIAC ARTERIES: Both right and left common iliac artery has patent stents
without any high-grade focal stenosis.
EXTERNAL ILIAC ARTERIES: Both right and left external iliac arteries have
patent stent without any significant in-stent restenosis.
IMPRESSION:
1. Severe 3-vessel coronary artery disease; with proximal left anterior
descending, 80 percent stenosis; 80 percent focal stenosis of mid left
anterior descending at the origin of the septal perforator with
moderate diffuse disease in the mid left anterior descending and
patent stent in the left anterior descending without significant
in-stent restenosis; distal left anterior descending with 80 percent
calcific eccentric stenosis; left circumflex artery with moderate
diffuse disease in its proximal portion with a 50 percent eccentric
stenosis and a major obtuse margin major first obtuse marginal branch
showing moderate diffuse disease in its proximal portion with a 40-50
percent diffuse proximal stenosis and a focal 60-70 percent stenosis
at the acute bend in the midportion of the obtuse marginal branch and
mild-to-moderate diffuse disease of the rest of the left circumflex
artery and the second obtuse marginal branch; right coronary artery
totally occluded with grade 3 collaterals from the left anterior
descending and the left circumflex artery with the septal perforators
supplying the distal portion of the posterior descending branch, which
are medium-caliber vessels with mild disease and posterolateral
branch, which is a small-to-medium caliber vessel with mild disease.
The right coronary artery fills up to the mid portion with a grade 3
collaterals.
2. Mildly decreased left ventricular systolic function with inferior wall
severely hypokinetic. Posterobasal wall akinetic aneurysmal.
3. Patent renal arteries bilaterally with a 50 percent stenosis of the
proximal left renal artery and 50 percent calcific stenosis of the
right renal artery.
4. Severe peripheral artery disease with a patent stent in both common
iliac arteries and both external iliac artery with the stents in the
common iliac artery extending into the distal portion of the abdominal
aorta.
RECOMMENDATIONS:
1. Recommend angioplasty of the distal left anterior descending.
Recommend angioplasty and stent of the proximal and mid left anterior
descending. The distal left anterior descending appears to have a
calcific lesion. If the angioplasty is only partially successful, then
consider atherectomy in a future time.
2. The patient has multiple comorbidities and hence staged procedures are
recommended.
3. Maximum medical management of renal artery disease and renal arteries
atherosclerosis.
4. With regards to lesions in the left circumflex artery and obtuse
marginal branch, maximal medical management to continue. Right
coronary artery being totally occluded, it is filled by grade 3
collaterals from left-to-right.
Thanks!