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After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the left common femoral artery and vein. The left site was chosen
due to the palpation of aneurysmal right common femoral artery
obtained percutaneous in the left common femoral artery utilizing
the Seldinger technique and placed a #6 French sheath. I
obtained percutaneous access in the left common femoral vein
utilizing the Seldinger technique and placed a #7 French sheath. I
then advanced a Swan-Ganz balloon floatation catheter in the left
iliac and femoral veins, however, I was unable to pass the balloon
floatation catheter past the left common iliac vein. I then
advanced a 025 J wire and this also was unable to pass the left
common iliac vein. Decision was made at this time to perform
venogram. Through the Swan-Ganz balloon floatation catheter I
administered 8 cc of contrast. We saw an extrinsic mass
compressing the left common iliac vein that was calcified in the
location of the left common iliac artery and this was felt to be
consistent with left common iliac aneurysm. I therefore abandoned
venous access in the left common femoral vein and obtained venous
access in the right common femoral vein. I was unable to advance
my Swan-Ganz balloon floatation catheter unimpeded through the
heart and into the pulmonary artery. On the left side I advanced
a 035 J wire and pigtail cathter into the distal aorta at the
level above the bifurcation. I then performed aortography. I was
able to visualize the aneurysm in the left common iliac artery as
well as extreme tortuosity of the left iliac arterial system and
the aneurysmal dilatation of both femoral arteries. I removed the
pigtail catheter over an 035 wire and then exchanged my short #6
French sheath for a #6 French Arrow Superflex sheath with the
distal tip above the level of the aortic bifurcation. I then
advanced an AL-1 catheter over an 035 wire and performed left and
right coronary angiography. I crossed the aortic valve with the
AL-1 catheter and a Newton wire and exchanged the AL-1 catheter
for a Langston dual-lumen pigtail catheter. I performed
thermodilution cardiac outputs and then measured simultaneous left
and right heart pressures during a right heart pullback from wedge
position to the right atrium. I then performed power injection of
the left ventricle, flushed the catheter and measured simultaneous
left ventricular and aortic pressures through the dual lumen
pigtail catheter. I performed a pullback across the aortic valve.
I then turned by attention back to the peripheral arteries. I
carefully manipulated a Wholey wire from the left iliac system
down into the right external iliac artery and advanced the JR-4
catheter into the right external iliac artery. I then performed
angiography of the right femoral arterial system as well as
sequential pictures down the right lower extremity. The catheter
was then withdrawn. I performed angiography down the left lower
extremity by injecting through the arrow Superflex sheath which
had been withdrawn to the left external iliac artery. Following
completion of the imaging a StarClose was deployed in the right
common femoral artery with adequate achievement of hemostasis and
manual pressure was held for venous hemostasis.
FINDINGS:
HEMODYNAMICS:
Mean right atrial pressure is 4, RV pressure 44/4, PA pressure
44/15 with a mean pulmonary arterial pressure of 26, mean wedge
pressure is 18, left ventricular pressure 160/18, aortic pressure
143/63. The peak-to-peak gradient across the aortic valve is 17
with a mean gradient of 37. PA saturation is 64% with a femoral
arterial saturation of 92% yielding a Fick cardiac output of 5.7
liters per minute and calculated aortic valve area of 1.0.
Thermodilution cardiac output was 9.1 liters per minute with a
calculated aortic valve area of 1.5.
RAO LEFT VENTRICULOGRAM:
There is severe left ventricular dysfunction. Estimated ejection
fraction is 25% with global hypokinesis.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY ARTERY:
Originates from the left coronary cusp. It bifurcates into the
left anterior descending coronary artery and left circumflex
artery. The left main coronary artery is calcified but appears
otherwise of relatively normal caliber, about a 5.0 mm vessel.
LEFT ANTERIOR DESCENDING CORONARY ARTERY:
The LAD is a 3.5 mm vessel proximally. It has mild
atherosclerotic plaquing in its proximal segment with eccentric
20% plaque. The first diagonal vessel is a moderate size vessel
with an ostial 50% stenosis. The mid LAD has a second eccentric
20% plaque and minimal irregularities.
LEFT CIRCUMFLEX CORONARY ARTERY:
The left circumflex and obtuse marginal vessels are mildly
calcified with mild atherosclerotic plaquing up to 10%.
RIGHT CORONARY ARTERY:
Originates from the right coronary cusp. It is a anatomically
dominant vessel with an ostial 20% stenosis and a proximal 30%
stenosis. The rest of the right coronary and its branches have
nonobstructive irregularities.
AORTOGRAPHY:
Abdominal aortography demonstrates the distal aorta to be
calcified and measures 2.8 cm in diameter in its internal
dimension. The proximal iliac arteries are both dilated and
aneurysmal. The right common iliac artery proximally measures 2.2
cm in its internal lumen and in the distal right common iliac
artery measures 2.3 cm on its internal lumen. The right
hypogastric artery appears to have aneurysmal dilatation although
it not well laid out in this anterior view. The right external
iliac artery has diffuse mild atherosclerotic plaquing. The right
common femoral artery is aneurysmal. It is a long fusiform
aneurysm measuring 2.5 cm on its internal lumen. The right
profunda femoris is patent. The right superficial femoral artery
throughout its length has diffuse mild atherosclerotic plaquing
with no high-grade stenosis noted. The right popliteal artery has
mild ectasia. The right anterior tibial artery is occluded
proximally. The tibioperoneal trunk is occluded with bridging
collaterals. There is faint reconstitution of the peroneal artery
and there is no flow seen to the foot on the right. On the left
side the common iliac artery is aneurysmal. It measures at its
maximal diameter 3.7 cm on its internal lumen. The left
hypogastric artery is patent. The left common femoral artery is
aneurysmal. Its maximal internal luminal diameter is 1.6 cm. The
profunda femoris is patent. The left superficial femoral artery
is patent with mild diffuse atherosclerotic plaquing throughout
its length. There is slow flow noted throughout the left femoral
system. The left popliteal artery is seen to fill and appears to
have mild atherosclerotic plaquing and then the left anterior
tibial artery and tibioperoneal trunk are occluded.
............
thank you very much for your help on this it is greatly appreciated!
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the left common femoral artery and vein. The left site was chosen
due to the palpation of aneurysmal right common femoral artery
obtained percutaneous in the left common femoral artery utilizing
the Seldinger technique and placed a #6 French sheath. I
obtained percutaneous access in the left common femoral vein
utilizing the Seldinger technique and placed a #7 French sheath. I
then advanced a Swan-Ganz balloon floatation catheter in the left
iliac and femoral veins, however, I was unable to pass the balloon
floatation catheter past the left common iliac vein. I then
advanced a 025 J wire and this also was unable to pass the left
common iliac vein. Decision was made at this time to perform
venogram. Through the Swan-Ganz balloon floatation catheter I
administered 8 cc of contrast. We saw an extrinsic mass
compressing the left common iliac vein that was calcified in the
location of the left common iliac artery and this was felt to be
consistent with left common iliac aneurysm. I therefore abandoned
venous access in the left common femoral vein and obtained venous
access in the right common femoral vein. I was unable to advance
my Swan-Ganz balloon floatation catheter unimpeded through the
heart and into the pulmonary artery. On the left side I advanced
a 035 J wire and pigtail cathter into the distal aorta at the
level above the bifurcation. I then performed aortography. I was
able to visualize the aneurysm in the left common iliac artery as
well as extreme tortuosity of the left iliac arterial system and
the aneurysmal dilatation of both femoral arteries. I removed the
pigtail catheter over an 035 wire and then exchanged my short #6
French sheath for a #6 French Arrow Superflex sheath with the
distal tip above the level of the aortic bifurcation. I then
advanced an AL-1 catheter over an 035 wire and performed left and
right coronary angiography. I crossed the aortic valve with the
AL-1 catheter and a Newton wire and exchanged the AL-1 catheter
for a Langston dual-lumen pigtail catheter. I performed
thermodilution cardiac outputs and then measured simultaneous left
and right heart pressures during a right heart pullback from wedge
position to the right atrium. I then performed power injection of
the left ventricle, flushed the catheter and measured simultaneous
left ventricular and aortic pressures through the dual lumen
pigtail catheter. I performed a pullback across the aortic valve.
I then turned by attention back to the peripheral arteries. I
carefully manipulated a Wholey wire from the left iliac system
down into the right external iliac artery and advanced the JR-4
catheter into the right external iliac artery. I then performed
angiography of the right femoral arterial system as well as
sequential pictures down the right lower extremity. The catheter
was then withdrawn. I performed angiography down the left lower
extremity by injecting through the arrow Superflex sheath which
had been withdrawn to the left external iliac artery. Following
completion of the imaging a StarClose was deployed in the right
common femoral artery with adequate achievement of hemostasis and
manual pressure was held for venous hemostasis.
FINDINGS:
HEMODYNAMICS:
Mean right atrial pressure is 4, RV pressure 44/4, PA pressure
44/15 with a mean pulmonary arterial pressure of 26, mean wedge
pressure is 18, left ventricular pressure 160/18, aortic pressure
143/63. The peak-to-peak gradient across the aortic valve is 17
with a mean gradient of 37. PA saturation is 64% with a femoral
arterial saturation of 92% yielding a Fick cardiac output of 5.7
liters per minute and calculated aortic valve area of 1.0.
Thermodilution cardiac output was 9.1 liters per minute with a
calculated aortic valve area of 1.5.
RAO LEFT VENTRICULOGRAM:
There is severe left ventricular dysfunction. Estimated ejection
fraction is 25% with global hypokinesis.
CORONARY ANGIOGRAPHY:
LEFT MAIN CORONARY ARTERY:
Originates from the left coronary cusp. It bifurcates into the
left anterior descending coronary artery and left circumflex
artery. The left main coronary artery is calcified but appears
otherwise of relatively normal caliber, about a 5.0 mm vessel.
LEFT ANTERIOR DESCENDING CORONARY ARTERY:
The LAD is a 3.5 mm vessel proximally. It has mild
atherosclerotic plaquing in its proximal segment with eccentric
20% plaque. The first diagonal vessel is a moderate size vessel
with an ostial 50% stenosis. The mid LAD has a second eccentric
20% plaque and minimal irregularities.
LEFT CIRCUMFLEX CORONARY ARTERY:
The left circumflex and obtuse marginal vessels are mildly
calcified with mild atherosclerotic plaquing up to 10%.
RIGHT CORONARY ARTERY:
Originates from the right coronary cusp. It is a anatomically
dominant vessel with an ostial 20% stenosis and a proximal 30%
stenosis. The rest of the right coronary and its branches have
nonobstructive irregularities.
AORTOGRAPHY:
Abdominal aortography demonstrates the distal aorta to be
calcified and measures 2.8 cm in diameter in its internal
dimension. The proximal iliac arteries are both dilated and
aneurysmal. The right common iliac artery proximally measures 2.2
cm in its internal lumen and in the distal right common iliac
artery measures 2.3 cm on its internal lumen. The right
hypogastric artery appears to have aneurysmal dilatation although
it not well laid out in this anterior view. The right external
iliac artery has diffuse mild atherosclerotic plaquing. The right
common femoral artery is aneurysmal. It is a long fusiform
aneurysm measuring 2.5 cm on its internal lumen. The right
profunda femoris is patent. The right superficial femoral artery
throughout its length has diffuse mild atherosclerotic plaquing
with no high-grade stenosis noted. The right popliteal artery has
mild ectasia. The right anterior tibial artery is occluded
proximally. The tibioperoneal trunk is occluded with bridging
collaterals. There is faint reconstitution of the peroneal artery
and there is no flow seen to the foot on the right. On the left
side the common iliac artery is aneurysmal. It measures at its
maximal diameter 3.7 cm on its internal lumen. The left
hypogastric artery is patent. The left common femoral artery is
aneurysmal. Its maximal internal luminal diameter is 1.6 cm. The
profunda femoris is patent. The left superficial femoral artery
is patent with mild diffuse atherosclerotic plaquing throughout
its length. There is slow flow noted throughout the left femoral
system. The left popliteal artery is seen to fill and appears to
have mild atherosclerotic plaquing and then the left anterior
tibial artery and tibioperoneal trunk are occluded.
............
thank you very much for your help on this it is greatly appreciated!
