csorensen21@yahoo.com
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Can Someone help me on where to exactly start with this cath? I'm not sure if I've just been doing so much coding lately that I'm missing something so simple or what. But I'm drawing a blank on where to begin?
INDICATION: The patient is a 68-year-old gentleman who had coronary
artery bypass graft surgery 20 years ago with saphenous vein grafts to the
right coronary artery and obtuse marginal vessel as well as the left
internal mammary artery graft to the LAD. A few months ago, he underwent
stenting of the native circumflex coronary artery for myocardial
infarction. He was under the impression that both saphenous vein grafts
were occluded and his left internal mammary artery graft to the LAD was
patent. He presented with worsening symptoms of exertional angina. I
performed cardiac catheterization on him a few weeks ago, which revealed
patency of the circumflex stent and patency of the left internal mammary
artery graft to the LAD with collaterals from the LAD to the distal right
coronary artery branches. There were a couple of obtuse marginal branches
off the circumflex, which were severely diffusely diseased. Unfortunately,
the patient continued to complain of exertional angina despite
maximization of medical therapy with Ranexa, nitrates and beta blockers.
I asked for the films from Florida, which I personally reviewed and we
found out that he had a saphenous vein graft to an obtuse marginal branch,
which had severe disease throughout its proximal and mid portions. I felt
that we should proceed with intervention on this graft understanding that
there is an increased risk of complications and a higher risk of
restenosis given that the vein graft is degenerated and is 20 years old.
This was explained to the patient and the family in detail.
DESCRIPTION OF PROCEDURE: The patient was taken to the cath lab. The
right groin was prepped and draped in the usual manner and was
anesthetized with 1% lidocaine. A 6-French sheath was placed in the right
femoral artery using a modified Seldinger technique without any
difficulty. Angiography of the saphenous vein graft to the obtuse
marginal vessel was performed using a 6-French JR-4 diagnostic catheter.
This revealed evidence of a severely degenerated vein graft with subtotal
occlusion in the proximal and mid portions of the graft and significant
ectasia and had multiple areas of irregularities and thrombotic material.
Heparin bolus and Integrilin double bolus and drip were started. I did
not feel it was possible to pass a filter wire without predilation and so
a 0.014 BMW wire was advanced to the distal graft without difficulty. The
mid and proximal lesions were predilated using a 3.0 x 20 mm Trek balloon
at 10 to 12 atmospheres. I then placed a 4.0-mm filter wire along the
proximal aspect of the obtuse marginal vessel beyond the graft through the
BMW wire. I then proceeded with stenting of the mid saphenous vein graft
using a 5.0 x 18 mm Ultra stent deployed at 12 atmospheres. I then had to
place two 5.0 x 28 mm Ultra stent along the proximal to mid graft within
the degenerated segment and this was deployed at 12 to 16 atmospheres.
The most proximal portion of this graft was then also treated using a 5.0
x 13 mm Ultra stent deployed at 16 atmospheres. Unfortunately, we had no
choice with our stent length and this particular stent was too short as it
did not stretch well enough into the ostium. The ostium remained severely
diseased, so it was treated with a 4.0 x 13 mm Vision stent and was
post-dilated using a 5.0 x 13 mm Ultra stent balloon at 12 to 16
atmospheres (the 4.0 stent was deployed at 22 atmospheres). Repeat
angiography revealed evidence of extravasation of the ____ atherosclerotic
material through the stent along the mid graft and so this was treated
with prolonged balloon dilation with using a 5.0 to 38 mm stent balloon at
12 to 16 atmospheres. Final angiography revealed evidence of no residual
stenosis along the stented segment with no dissections. There was
evidence of extravasation of the graft atherosclerosis into the superior
aspect of the mid stent and there were some areas of severe ectasia just
distal to the distal stent. However, there was TIMI grade III flow along
the vessel and there were no flow-limiting dissection (there was
spontaneous, linear dissections throughout the graft even in the stented
segments). There was no visible thrombus. The obtuse marginal vessel had
great flow and was a moderate-sized vessel.
An ACT towards the end of the procedure was 233 and so I gave the patient
an additional 1000 units of heparin. Integrilin was kept in place and the
patient was given 180 mg at the end of the procedure. At the end of the
procedure, the sheath was removed and hemostasis of the right groin was
achieved using the Angio-Seal device.
TIMI grade flow before stenting was II. TIMI grade flow after stenting
was TIMI grade III. The lesion is a type C lesion. Estimated blood loss
was 20 mL.
CONCLUSION: Status post successful PCI and quadruple stenting of a very
degenerated saphenous vein graft to the obtuse marginal vessel. The
procedure was performed using filter wire and there was no evidence of
distal embolization.
I would like to thank Dr. for allowing me to participate
in the care of the patient.
INDICATION: The patient is a 68-year-old gentleman who had coronary
artery bypass graft surgery 20 years ago with saphenous vein grafts to the
right coronary artery and obtuse marginal vessel as well as the left
internal mammary artery graft to the LAD. A few months ago, he underwent
stenting of the native circumflex coronary artery for myocardial
infarction. He was under the impression that both saphenous vein grafts
were occluded and his left internal mammary artery graft to the LAD was
patent. He presented with worsening symptoms of exertional angina. I
performed cardiac catheterization on him a few weeks ago, which revealed
patency of the circumflex stent and patency of the left internal mammary
artery graft to the LAD with collaterals from the LAD to the distal right
coronary artery branches. There were a couple of obtuse marginal branches
off the circumflex, which were severely diffusely diseased. Unfortunately,
the patient continued to complain of exertional angina despite
maximization of medical therapy with Ranexa, nitrates and beta blockers.
I asked for the films from Florida, which I personally reviewed and we
found out that he had a saphenous vein graft to an obtuse marginal branch,
which had severe disease throughout its proximal and mid portions. I felt
that we should proceed with intervention on this graft understanding that
there is an increased risk of complications and a higher risk of
restenosis given that the vein graft is degenerated and is 20 years old.
This was explained to the patient and the family in detail.
DESCRIPTION OF PROCEDURE: The patient was taken to the cath lab. The
right groin was prepped and draped in the usual manner and was
anesthetized with 1% lidocaine. A 6-French sheath was placed in the right
femoral artery using a modified Seldinger technique without any
difficulty. Angiography of the saphenous vein graft to the obtuse
marginal vessel was performed using a 6-French JR-4 diagnostic catheter.
This revealed evidence of a severely degenerated vein graft with subtotal
occlusion in the proximal and mid portions of the graft and significant
ectasia and had multiple areas of irregularities and thrombotic material.
Heparin bolus and Integrilin double bolus and drip were started. I did
not feel it was possible to pass a filter wire without predilation and so
a 0.014 BMW wire was advanced to the distal graft without difficulty. The
mid and proximal lesions were predilated using a 3.0 x 20 mm Trek balloon
at 10 to 12 atmospheres. I then placed a 4.0-mm filter wire along the
proximal aspect of the obtuse marginal vessel beyond the graft through the
BMW wire. I then proceeded with stenting of the mid saphenous vein graft
using a 5.0 x 18 mm Ultra stent deployed at 12 atmospheres. I then had to
place two 5.0 x 28 mm Ultra stent along the proximal to mid graft within
the degenerated segment and this was deployed at 12 to 16 atmospheres.
The most proximal portion of this graft was then also treated using a 5.0
x 13 mm Ultra stent deployed at 16 atmospheres. Unfortunately, we had no
choice with our stent length and this particular stent was too short as it
did not stretch well enough into the ostium. The ostium remained severely
diseased, so it was treated with a 4.0 x 13 mm Vision stent and was
post-dilated using a 5.0 x 13 mm Ultra stent balloon at 12 to 16
atmospheres (the 4.0 stent was deployed at 22 atmospheres). Repeat
angiography revealed evidence of extravasation of the ____ atherosclerotic
material through the stent along the mid graft and so this was treated
with prolonged balloon dilation with using a 5.0 to 38 mm stent balloon at
12 to 16 atmospheres. Final angiography revealed evidence of no residual
stenosis along the stented segment with no dissections. There was
evidence of extravasation of the graft atherosclerosis into the superior
aspect of the mid stent and there were some areas of severe ectasia just
distal to the distal stent. However, there was TIMI grade III flow along
the vessel and there were no flow-limiting dissection (there was
spontaneous, linear dissections throughout the graft even in the stented
segments). There was no visible thrombus. The obtuse marginal vessel had
great flow and was a moderate-sized vessel.
An ACT towards the end of the procedure was 233 and so I gave the patient
an additional 1000 units of heparin. Integrilin was kept in place and the
patient was given 180 mg at the end of the procedure. At the end of the
procedure, the sheath was removed and hemostasis of the right groin was
achieved using the Angio-Seal device.
TIMI grade flow before stenting was II. TIMI grade flow after stenting
was TIMI grade III. The lesion is a type C lesion. Estimated blood loss
was 20 mL.
CONCLUSION: Status post successful PCI and quadruple stenting of a very
degenerated saphenous vein graft to the obtuse marginal vessel. The
procedure was performed using filter wire and there was no evidence of
distal embolization.
I would like to thank Dr. for allowing me to participate
in the care of the patient.